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Nursing Intervention and Management in Head Injuries

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Head Injury Has reached epidemic proportions due to motor vehicle accidents :Other causes include Falls, assaults, sports injuries -

.Two thirds of patients are under 30 yrs, most are males Head injuries often cause damage to the brain from bleeding or swelling which results in .increased intracranial pressure Intracranial Pressure The cranial skull contains three components: brain , blood, and cerebrospinal fluid ((CSF The cranial skull is a closed system, and if one of the three components increases in volume, at least one of the other two must decrease in volume, or the pressure increases. Any bleeding or swelling within the skull increases the volume of contents .within the skull and therefore causes increased intracranial pressure Normal ICP is 10 20 mm Hg Increased ICP - Pathophysiology If the pressure increases enough, it can cause displacement of the brain through or against the rigid structures of the skull. This causes restriction of blood flow to the brain , decreasing oxygen delivery and waste removal. Cells in the brain become anoxic and cannot metabolize properly, producing ischemia, infraction, irreversible brain damage, .and eventually brain death

Clinical Manifestations Depends on the severity and anatomic location of the underlying brain injury. Localized pain usually suggests that a fracture is present. Fracture of the cranial skull may or may not produce swelling in the region of the fracture. But frequently produce hemorrhage. .Therefore, an x-ray is needed for diagnosis Early signs of Increased ICP Earliest sign is change in LOC Slowing of speech, delay in responding to questions Restlessness, Confusion Pupillary changes Weakness in one extremity Headache constant, aggravated by movement, increasing in intensity Late signs of increased ICP LOC deteriorates to comatose Bradycardia, fluctuating to tachycardia Decreased respiratory rate (Altered respiratory pattern ( Cheyne-Stokes BP and temperature rises (Widening pulse pressure ( difference between systolic and diastolic pressure Projectile vomiting Decorticate or decerebrate posturing, followed by bilateral flaccidity Loss of brainstem reflexes (pupils, corneal, gag, swallowing ) are ominous signs Hematoma Most serious brain injury -

Collection of blood : Types Epidural (between the skull and the dura ) this can result from a skull fracture that causes a rupture or laceration in the artery between the skull and the dura Subdural (between the dura and the brain ) this can cause from trauma, but can also occur as a result of rupture of an aneurysm Intracerebral (into the substance of the brain) result from: systemic hypertension rupture of aneurysm intracranial tumors when force is exerted to the head e.g. bullet wound Management of Increased ICP True emergency requiring prompt treatment Monitor ICP Intraventricular catheter, subarachnoid bolt, epidural catheter Reduce Cerebral Edema (Osmotic diuretics (mannitol (Corticosteroids ( dexamethasone Maintain cerebral perfusion Maintain cardiac output with fluids and dobutamine Reduce CSF and blood volume Drain CSF Hyperventilation results in vasoconstriction Control Fever Fever increases cerebral metabolism and edema Antipyretics, cooling blanket Avoid shivering which increases ICP Reduce metabolic demands Barbiturates decrease ICP Muscle relaxants to paralyze patient Head Injury Classification Scalp Skull Brain Scalp trauma causes abrasion, contusion, laceration or hematoma beneath the layers .of tissue of the scalp .Skull Fracture- break in the continuity of the skull caused by forceful trauma .Classified as linear, depressed or basilar Skull fracture may be open or closed Open tear in the dura Closed dura is intact Brain Injury .Closed damage to brain tissue, but no opening through skull and dura Open occurs when object penetrates the skull, enters the brain opens the scalp, .skull, dura to enter the brain Common reactions .Minor Injury client rapidly regains mental function -

Concussion temporary loss of neurologic function with brief loss of consciousness few seconds to few minutes Contusion bruising and hemorrhaging at brain surface unconsciousness for more .than a few seconds to few minutes Loss of neurological function paralysis, speech and visual disturbances Increased ICP brain compression Intracranial Hemorrhage hematomas (collection of blood) that develops within the .cranial vault most serious of brain injuries (Hematoma epidural (above the dura (subdural (below the dura (Intracerebral (within the dura Management ,Based on physical and neurological examination Xray CT Scan MRI Treatment of increased ICP Supportive measures Ventilatory Support Fluid and Electrolyte maintenance Nutritional support .Pain and Anxiety management Nursing Assessment History of Trauma Time, cause, direction and force of the blow Loss of consciousness, duration Assess LOC - Glasgow Coma Scale Response to verbal commands or tactile stimuli Pupillary response to light Motor Function Vital Signs Monitor for signs of increased ICP Motor Function Move extremities, hand grasp, pedal push, speech Ineffective airway clearance related to accumulation of secretions and decreased LOC Maintain patient airway Suction carefully (Discourage coughing (causes increase in ICP Elevate HOB 30 degrees Guard against aspiration Monitor ABGs to assess ventilation Ineffective breathing pattern related to neurological dysfunction Monitor constantly for respiratory irregularities ,Cheyne Stokes, hyperventilation -

Effective suctioning HOB 30 degrees Position patient lateral or semi prone Altered cerebral tissue perfusion related to increased intracranial pressure : Position patient to reduce ICP head in midline position to promote venous drainage Elevate HOB 30 degrees Avoid extreme rotation or flexion of neck Avoid extreme hip flexion Prevent straining Stool Softeners High Fibre diet Space Nursing activities Maintain calm atmosphere, reduce stimuli Risk for fluid volume deficit related to dehydration procedures and decreased LOC Monitor electrolytes Brain damage can produce metabolic and hormonal dysfunctions Monitor intake and output Monitor IV fluids carefully Monitor urine for acetone, osmolality Record daily weights .Altered nutrition related to metabolic changes, inadequate intake Start enteral feedings when patient stabilized NG feeding unless CSF rhinorrhea Elevate HOB 30 degrees Aspirate for residual before feeding to prevent distention and aspiration Use pump to regulate feeds .Risk for injury related to disorientation, restlessness and brain damage Assess for cause of restlessness Often present as patient emerges from coma May be due to hypoxia, fever, pain, full bladder Use padded side rails or wrap hands in mitts Avoid restraints as straining against them increases ICP Minimize environmental stimuli Low lights, limit visitors, speak calmly Orient patient frequently Risk for altered body temperature related to damage to temperature -regulating mechanism .Monitor temperature every 4 hrs :Can be increased as result of Damage to hypothalmus Cerebral irritation from hemorrhage Infection Reduce temperature with acetaminophen and cooling blankets

 If infection suspected Culture potential sites Start antibiotics Potential for impaired skin integrity related to bed rest, immobility, unconsciousness .Assess all body surfaces every 8 hrs Turn every 2-4 hrs Provide skincare every 4 hrs (Assist patient to chair (if possible
Posted in: Neurology,Nursing Intervention,Nursing Management

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May 3, 2011 10:32 AM

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