Head Injury

  1. General information
    1. Usually caused by car accidents, falls, assaults
    2. Types
      1. Concussion: severe blow to the head jostles brain, causing it to strike the skull; results in temporary neural dysfunction
      2. Contusion: results from more severe blow that bruises the brain and disrupts neural function
      3. Hemorrhage
        1. epidural hematoma: accumulation of blood between the dura mater and skull; commonly results from laceration of middle meningeal artery during skull fracture; blood accumulates rapidly
        2. subdural hematoma: accumulation of blood between the dura and arachnoid; venous bleeding that forms slowly; may be acute, subacute, or chronic
        3. subarachnoid hematoma: bleeding in subarachnoid space
        4. intracerebral hematoma: accumulation of blood within the cerebrum
      4. Fractures: linear, depressed, comminuted, compound
  2. Assessment findings (depend on type of injury)
    1. Concussion: headache, transient loss of consciousness, retrograde or posttraumatic amnesia, nausea, dizziness, irritability
    2. Contusion: neurologic deficits depend on the site and extent of damage; include decreased LOC, aphasia, hemiplegia, sensory deficits
    3. Hemorrhages
      1. Epidural hematoma: brief loss of consciousness followed by lucid interval; progresses to severe headache, vomiting, rapidly deteriorating LOC, possible seizures, ipsilateral pupillary dilation
      2. Subdural hematoma: alterations in LOC, headache, focal neurologic deficits, personality changes, ipsilateral pupillary dilation
      3. Intracerebral hematoma: headache, decreased LOC, hemiplegia, ipsilateral pupillary dilation
    4. Fractures
      1. Headache, pain over fracture site
      2. Compound fractures: rhinorrhea (leakage of CSF from nose); otorrhea (leakage of CSF from ear)
    5. Diagnostic tests
      1. Skull x-ray: reveals skull fracture or intracranial shift
      2. CT scan: reveals hemorrhage
  3. Nursing interventions (see also Care of the Unconscious Client and Care of the Client with Increased ICP)
    1. Maintain a patent airway and adequate ventilation.
    2. Monitor vital signs and neuro checks; observe for changes in neurologic status, signs of increased ICP, shock, seizures, and hyperthermia.
    3. Observe for CSF leakage.
      1. Check discharge for positive Testape or Dextrostix reaction for glucose; bloody spot encircled by watery, pale ring on pillowcase or sheet.
      2. Never attempt to clean the ears or nose of a head-injured client or use nasal suction unless cleared by physician
    4. If a CSF leak is present
      1. Instruct client not to blow nose.
      2. Elevate head of bed 30° as ordered.
      3. Observe for signs of meningitis and administer antibiotics to prevent meningitis as ordered.
      4. Place a cotton ball in the ear to absorb otorrhea; replace frequently.
      5. Gently place a sterile gauze pad at the bottom of the nose for rhinorrhea; replace frequently.
    5. Prevent complications of immobility.
    6. Prepare the client for surgery if indicated.
      1. Depressed skull fracture: surgical removal or elevation of splintered bone; debridement and cleansing of area; repair of dural tear if present; cranioplasty (if necessitated for large cranial defect)
      2. Epidural or subdural hematoma: evacuation of the hematoma
    7. Provide psychologic support to client/significant others.
    8. Observe for hemiplegia, aphasia, and sensory problems, and plan care accordingly (see Cerebrovascular Accident)
    9. Provide client teaching and discharge planning concerning rehabilitation for neurologic deficits; note availability of community agencies.