- Head injuries can be classified as OPEN (skull integrity is compromised - penetrating trauma) or CLOSED (skull integrity is maintained - blunt trauma).
- are classified as Mild, Moderate or Severe, depending on GCS ratings & length of time pt was unconscious.
- Open-head injuries pose "HIGH RISK" for infection.
- Skull fractures are often accompanied by brain injury. Dmg to the brain tissue may be the result of decreased O2 supply, or the direct impact from the skull fracture, which caused the trauma. The glucose levels in the brain are negatively affected, resulting in an alteration in neurological synaptic ability.
- Head injuries may or may not be associated w/ hemorrhage (epidural, subdural, & intracerebral). CSF leakage is also possible. Any collection of fluid, or foreign objects, that occupies space w/in the skull consequently poses a risk for cerebral edema, cerebral hypoxia, & brain herniation.
*A Cervical Spine injury should always be suspected when a head injury occurs. A cervical spine injury must be ruled out prior to removing any devices used to stabilize the cervical spine.
- The following interventions help to do what??
*Elevate head to reduce ICP & promote venous drainage.
*Avoid extreme flexion, extension or rotation of the head, &
maintain the body in a midline neutral position, with the HOB
*Maintain a patent airway. Provide mechanical ventilation as
*Administer oxygen as indicated to maintain an O2 saturation
level of > 92.
*Hyperventilate pt to keep the PaCO2 b/w 30-35 mm Hg (this
reduces cerebral bloodflow).
*Maintain cervical spine stability until cleared by an xray.
*Report presence of CSF from nose or ears to the provider.
*Provide a calm & restful environment (limit visitors, minimize
*Implement measures to prevent complications of immobility
(turn pt every 2hr, footboard, & splints). Specialty beds can be
*Monitor fluid & electrolyte values & osmolarity to detect changes
in sodium regulation, the onset of diabetes insipidus, or severe
*Provide adequate fluids to maintain Cerebral perfusion. When
large amounts of IV fluids are prescribed, monitor the pt
carefully for EFV which could increase ICP.
*Maintain pt safety & seizure precautions (side rails up, padded
side rails, call light w/in the pts reach).
*Even if the LOC is decreased, explain to the pt the actions being
taken & why. 'Hearing' is the last sense affected by a head
- what complication of head injuries involves a downward shift of brain tissue due to cerebral edema??
- The brain consists of brain matter, CSF, & intravascular blood.
- The "Monroe-Kellie Doctrine" states that any alteration in the volume of one of these results in a compromise in the other components.
- when trauma creates a shift in these components, & the other components are unable to accomodate, the brain shifts from the cranial vault, or herniates.
- this can result in brain tissue moving downward, through the "Foramen Magnum".
- Clinical signs include fixed, Dilated pupils, deteriorating LOC, Cheyne-strokes respirations, Hemodynamic instability, & abnormal posturing.
*Recovery after this occurrence is rare. Urgent medical Mannitol (Osmitrol) &/or surgical (debulking) txt is indicated.
- Severe Neurological impairment usually persists.
- NURSING ACTIONS -
*This situation should be prevented before txt is needed.
*Close monitoring of the pt vital signs & neurological status will
allow early reporting of changes in the GCS, an increase in BP,
& an alteration in respiratory pattern & effort.
- PATIENT EDUCATION -