This guide is about head injury, head injury assessment, head injury nursing diagnosis, and head injury nursing care plan. It can be employed in the formulation of head injury nursing care plans for educational purposes.
What is a head injury?
A head injury is a broad term that describes a vast array of injuries that occur to the scalp, skull, brain, and underlying tissue and blood vessels in the head. Head injuries are also commonly referred to as brain injury, or traumatic brain injury (TBI), depending on the extent of the head trauma.
A traumatic brain injury may vary in degree of damage to brain tissue. As a result of injury, Primary impact to the brain may occur as skull fracture, concussion, contusion, and cerebral vessel damage. Secondary problems are hematoma, rupture of blood vessels, ischemia to brain tissue, infection, and increased intracranial pressure.
Before planning any care nurses first assess the condition of the patient.
Head injury nursing assessment
How do I know if my head injury is serious?
Glasgow coma scale (GCS)
What is GCS P Glasgow Coma Scale?
GCS assesses the conscious level of the patient. GCS 13-15 is considered as mild, 9-12 is moderate and 3-8 level indicates a decrease in the severe level of consciousness. It is considered the most sensitive indicator of the brain.
In the assessment, we will discuss how to assess the patient in each type of injury.
What are the 3 grades of concussions?
It is a mild most common brain injury. It takes a few days to get back to normal condition. Brain imaging such as CT scans and MRIs show no changes in the structure of the brain.
Concussion has three grades based on the severity of the injury. Grades with symptoms are given below:
Grade-I: There is no loss of consciousness. There may be little confusion. Symptoms disappear and it becomes normal within 15 minutes of injury.
Grade-2: in grade-2 also there is no loss of consciousness. A little confusion, symptoms remain more than 15 minutes. Persistent symptoms after 1 week of injury need immediate imaging of the brain and doctor consultation.
Grade-3: If there is loss of consciousness, it is considered a severe form of concussion.
Symptoms of concussion are headache, dizziness, nausea, lethargy, difficulty in focusing, irritability to bright light, loud noises, sleep disturbances, difficulty in concentration and attention.
Diffuse Axonal Injury
What are the levels of diffuse axonal injury?
It is stretching and tearing of neurons due to rotational injury. No significant focal legion is found like ischemia, infarction, and intracerebral bleeding. But there may be a loss of consciousness for at least 6 hours.
CT scan may have small hepatoma or hemorrhagic areas near corpus callous and cerebral oedema may be seen.
The grade of Diffuse axonal injury (DAI) is like follows:
- Mild DAI: Coma lasts 6-24 hrs
- Moderate DAI: More than 24 hrs
- Severe DAI: Prolonged coma, possible vegetative state, or death
What is a contusion injury?
It is bruising of brain tissue. More severe than a concussion. A bruise or small venous hemorrhage is seen in a CT scan. Sometimes amnesia may occur for which the patient forgets not only traumatic events but also past events.
Contusion symptoms like loss of consciousness, agitation, and confusion may last for long hours. General symptoms in contusion are nausea, vomiting, headache, lethargy, motor paralysis may occur. Recovery depends on the extent of the injury.
What is brain laceration?
It is tearing or injury to the cortical surface of the brain resulting in mechanical disruption of neural function. It forms hepatoma and oedema. It mostly occurs due to penetrating injury or rotational shearing injury inside the brain.
If there is any penetrating injury, the penetrating object should be left there in the wound to control bleeding. It can be removed during surgery.
What are 4 types of skull fractures?
It is a situation in which the skull is torn in the injury. A skull fracture can be open or closed. The skull fracture can be classified into three categories like linear (Hairline), comminuted (fragmented), depressed (pushed towards brain tissue).
Most of the brain injury causes an increase in Intracranial pressure (ICP). Let us discuss what are the symptoms that occur during an increase in intracranial pressure.
Symptoms of Increased Intracranial Pressure (ICP)
What are the clinical symptoms of increased intracranial pressure ICP in a child?
Early symptoms of increased intracranial pressure
- Alteration in loss of consciousness
- Pupillary dysfunction like diplopia and blurred vision
Late symptoms of increased intracranial pressure
- Continuous deterioration in consciousness
- Stupor or coma
- Projectile vomiting
- Increased blood pressure
- Widening of pulse pressure
- Decrease in pulse rate
- Cheyne-Stokes breathing
- Dilated pupil
- Non-reactive to light
- Impaired brain system reflexes
Head Injury Nursing Diagnosis and Head Injury Nursing Care Plan Examples
What are the nursing interventions for a head injury?
Nursing care plan of head injury includes nursing diagnosis, intervention, and rationale. Let us discuss nursing diagnoses one by one.
Nursing diagnosis-1: Decreased intracranial adaptive capacity
- injury with cerebral edema
- intracranial hemorrhage
- increased cerebral blood flow.
as evidenced by
- increase in intracranial pressure more than 10 mm Hg
- Elevated ICP waveform
- Baseline ICP greater than 10 mm Hg
Expected outcomes: Patient maintains optimal cerebral tissue perfusion, ICP less than 10 mm Hg.
|Assess the patient’s GCS level, pupil size, reactive to light or not.||A decrease in neurological signs indicates cerebral ischemia. It is also a sign of increased ICP.|
|Report immediately after finding deterioration in neurological status.||Surgical intervention may be required to reduce the potential damage to brain tissue.|
|Assess. for Rhinorrhea, otorrhea, Battle’s sign (Ecchymosis over mastoid process), and raccoon eyes (periorbital ecchymosis.||These may indicate a fracture of the frontal, orbital, or basal skull.|
|Assess for protective reflex-like swallowing, gagging, and coughing.||Loss of protective reflex may increase the risk of aspiration.|
|Monitor vital signs.||An increase in ICP is a life-threatening condition. Early recognition is essential for survival.|
|Monitor ICP through corneal catheter device. Inform immediately if it is more than 15 mm Hg.||An increase in ICP may cause brain stem compression or herniation. There may be compression of the respiratory center which may result in apnea and cardiac arrest.|
|Monitor oxygen saturation regularly. If required assess arterial blood gases as ordered.||To avoid cerebral ischemia.|
What is the intervention for decreased intracranial adaptive capacity in head injury?
|Elevate bed up to 30 degrees and keep head in neutral alignment.||It promotes venous outflow and decreases ICP.
Neutral head alignment facilitates venous flow.
|Limit nursing and medical procedures.||Any stimuli can contribute to increasing ICP.|
|Little loose tapes should be there to secure the endotracheal tube.||Tight tape may compress jugular venous flow.|
|Reorient the patient about the environment. Provide psychological support.||It decreases anxiety and maintains ICP at a normal level.|
|Avoid Valsalva maneuvers.||It increases intrathoracic pressure and increases ICP.|
|Administer mannitol as per order.||Mannitol must be used cautiously because it can also induce cerebral ischemia.|
|Hyperventilate before suctioning through the trachea.||This method avoids hypoxemia, hypotension, and hypercapnia which results in an increase in ICP.|
Nursing diagnosis-2: Risk for electrolyte imbalance (excess fluid volume)
related to the compromised regulatory mechanism with an increase in Anti-diuretic hormone (ADH)
as evidenced by
- increase in weight
- decrease in urine specific gravity
- pressence of edema in sternum
Expected outcomes are: decrease in weight to normal, increase in output to 30ml/hr, urine specific gravity in 1.010-1.030. BP within baseline limit.
|Monitor Na+ level, weight and notify health care provider in case of significant findings.||In presence of a syndrome of inappropriate ADH secretion (SIADH), the Patient has inappropriate urinary concentration causes excessive water retention.
If the Na+ level reaches below 118 mEq/L there may be seizure activity.
|Check for fingerprint oedema on the sternum.||It indicates cellular oedema.|
|Fluid intake may be restricted to 500ml-1000ml per 24 hrs.||Fluid restriction helps to achieve homeostasis.|
|Free use of Na+ may be advised.||It normalizes Na+ levels.|
|Elevate the head of the bed to 10-20 degrees, in case of hypervolemia is present.||It promotes venous return and reduces ADH release.|
|The regular specimen should be sent for evaluating electrolytes levels especially Na+.||To check the improvement in Na+ level due to treatment.|
Nursing diagnosis-3: Risk for seizures
- Cortical lacerations
- Intracranial bleeding
- Penetrating injury to the brain
Expected outcomes: The patient does not sustain injury due to seizure activity. The patient does not experience any seizure activity.
|Observe the patient for any seizure activity. Record and report on the following basis:
Time of onset, Body part involved, tonic-clonic stage, Incontinence, duration of seizure, post-seizure state.
|Around 5% of patients with non-penetrating head trauma suffers from seizure.
Seizure activity can aggravate seizure-inducing hypoxia.
Documentation of seizure helps to recognize the type of seizure.
|Monitor any signs of airway obstruction.||If the tongue falls back it may lead to hypoxia.|
|Take seizure precautions: like raising bedside rails, padding up bed.||To prevent injury from seizure activity. The safety of the patient is very necessary.|
|Administer anti-convulsant as per doctors’ advice.||It is necessary to follow the rights of administration of medication.|
|During a seizure, don’t try to put anything in the patient’s mouth, and maintain the airway.||Inserting objects may cause aspiration or more harm to the patient like broken teeth, soft tissue injury.|
|After the seizure, turn the patient to one side, suction, and administer oxygen if needed.||To clear the airway and prevent hypoxia.|
Nursing Diagnosis-4: Risk for imbalanced nutrition, less than body requirements
- Facial trauma
- Restriction of intake
- Impaired level of consciousness
- Multisystem trauma
|Regularly monitor patients’ electrolytes, proteins, and glucose.||These investigations indicate the nutritional state of the patient.|
|Assess for muscle mass, skin color, and turgor.||Decreased muscle mass and dry, flaky skin is a clear indication of a decrease in nutritional intake.|
|Assess the rate and quality of wound healing.||Extra calories are required to heal wounds.|
|Regular check weights.||Changes in weight indicate a change in nutritional status.|
|Administer tube feedings.||Head injury patients need around 2000 kcal/day. Multiple injuries require more. Nutritional support can be provided through the IV route by placing a central venous catheter.|
|Maintain the head of the bed at 30 degrees.||It prevents the risk of aspiration through tube feedings.|
|Avoid inserting a feeding tube through the nose in case of basilar fractures.||In basilar fracture, insertion of a feeding tube could penetrate the brain tissue through the fracture site.|
Patients with head injuries require critical care and constant observation. Timely treatment and adequate care can minimize the risk of morbidity and mortality.
- Strategies nurses use to care for patients with head injuries.
- Nursing management of adults with severe head injuries