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-» Nursing Care of Patients with Head Injuries

Nursing Care of Patients with Head Injuries


P1. Motor/Sensory deficit due to cervical spine injury (may accompany head injury):

N.I.:
 Immobilize head and neck until cervical injury ruled out by examination/x-ray (cervical collar, sand bag, spine board).
 Avoid flexion, hyperextension, rotation of neck.
 If respiratory resuscitation needed, use jaw thrust maneuver.
 Assess/ document leg, hand, arm and shoulder movement and strength q hr and P.R.N.
 Assess sensory deficits.
 Assess for hypertension and bradycardia.


P2. Inadequate airway/ ventilation due to obstruction, absence gag reflex, chest trauma, phrenic nerve injury, aspiration, neurogenic pulmonary edema:
N.I.:
 Maintain a patent airway.
 Clear mouth/ oropharynx of foreign bodies.
 Suction oropharynx and trachea q 1-2 hrs and P.R.N. (suction nasopharynx after basilar # ruled out).
 Assess respiratory rate, rhythm q 1-2 hr.
 Check breath sounds q 1-2 hr.
 Monitor ABG (initially daily and P.R.N.).
 Position person semiprone, lateral position to facilitate drainage of secretions and prevent aspiration after cervical spine stabilized.
 Administer humidified O2 as indicated.
 Assist/ maintain endotracheal intubation, tracheostomy, and mechanical ventilation as needed.


P3. Inadequate cerebral circulation due to  B.P., cardiovascular instability, hypovolemia, hemorrhagic shock, ruptured spleen, long bone fracture.:
N.I.:
 Monitor B/P and pulse q hr or as ordered.
 Monitor EKG pattern continuously.
 Urine output every hr.
 Assess for signs of bleeding, abdomen, chest, pelvis, long bones, extremities.
 Control active bleeding from scalp by compression.
 Monitor Hgb and Hct.
 Check for hematuria.
 Administer blood/ blood products.

P4. Alteration in level of consciousness due to concussion, contusion, laceration, intracranial hemorrhage, cerebral edema, IICP, herniation, fat embolism:

N.I.:
 Assess level of consciousness/ responsiveness q hr or PRN, including alterness, orientation, verbal response, eye opening, motor response.
 Report/ record/ assess more frequently if any deterioration.
 Monitor temperature q 2hr, report temperature greater than 38.5°C and maintain normothermia with antipyretic agents, tepid sponge bath.
 Keep side rails up at all time.
 Anticipate emergency diagnostic procedures.


P5.  ICP due to edema, intracranial hemorrhage, hematoma:
N.I.:
 Note alteration in level of consciousness.
 Assess pupillary size, position.
 Note verbalization and response to verbal command by checking hand grip and release, leg movement, dorsiflexion and plantar flexion q 1-4 hrs.
 In unconsciousness person, note spontaneous movement, withdrawal to pain q 1-4 hrs.
 Vital signs q 1-4 hrs.
 Maintain head of bed elevation at least 30°C or as prescribed.
 Monitor I&O q 1-4 hrs.



P6. Impaired mobility due to motor, sensory deficits, depressed conscious level:
N.I.:
 Early range-of-motion exercises.
 Reposition every 2 hrs.
 Footboard and/or foot supports.
 Maintain functional alignment of extremities.
 Prevent contractures: splints to maintain functional position of hands, arms, legs and feet.
 Check signs of skin redness, especially over ears, shoulders, elbows, sacrum, hips, heels, and toes.
 Massage over bony prominence q 2-4 hrs.
 Eye care every 4 hrs.
 Mouth care q 4 hrs; check for infection (Thrush).

P7. Alterations in elimination (bladder, bowel) bladder distention, paralytic ileus, distention, impaction:
N.I.:
 I&O q 8 hrs.
 Assess person for urinary retention, overflow, incontinence.
 Intermittent catheterization, preferred to indwelling urinary catheter.
 Monitor daily for signs of UTI.
 Bladder training program as soon as possible.
 Check person for impaction daily.
 Administer stool softeners, laxatives, suppositories, and/or enemas as needed.

P8. CSF leak due to dural tear:
N.I.:
 Observe for otorrhea or rhinorrhea.
 Apply a drip pad, change when wet.
 Do not suction nasally if anterior fossa fracture present or if basilar fractures have not ruled out.
 Instruct not to blow nose or cough.

P9. Fluid volume alterations due to diabetes insipidus syndrome, inappropriate ADH secretion, diuretic therapy, fluid restriction, GI suction, hyperthermia, and inadequate intake:
N.I.:
 Monitor I&O q 1-8 hrs.
 Assess skin turgor daily.
 Daily weights if indicated.
 Report urine output under 30ml/hr and over 200ml/hr for 2 consecutive hours.
 Monitor electrolyte and urine specific gravity