Head Injury
- General information
- Usually caused by car accidents, falls, assaults
- Types
- Concussion: severe blow to the head jostles brain, causing it to strike the skull; results in temporary neural dysfunction
- Contusion: results from more severe blow that bruises the brain and disrupts neural function
- Hemorrhage
- 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
- subdural hematoma: accumulation of blood between the dura and arachnoid; venous bleeding that forms slowly; may be acute, subacute, or chronic
- subarachnoid hematoma: bleeding in subarachnoid space
- intracerebral hematoma: accumulation of blood within the cerebrum
- Fractures: linear, depressed, comminuted, compound
- Assessment findings (depend on type of injury)
- Concussion: headache, transient loss of consciousness, retrograde or posttraumatic amnesia, nausea, dizziness, irritability
- Contusion: neurologic deficits depend on the site and extent of damage; include decreased LOC, aphasia, hemiplegia, sensory deficits
- Hemorrhages
- Epidural hematoma: brief loss of consciousness followed by lucid interval; progresses to severe headache, vomiting, rapidly deteriorating LOC, possible seizures, ipsilateral pupillary dilation
- Subdural hematoma: alterations in LOC, headache, focal neurologic deficits, personality changes, ipsilateral pupillary dilation
- Intracerebral hematoma: headache, decreased LOC, hemiplegia, ipsilateral pupillary dilation
- Fractures
- Headache, pain over fracture site
- Compound fractures: rhinorrhea (leakage of CSF from nose); otorrhea (leakage of CSF from ear)
- Diagnostic tests
- Skull x-ray: reveals skull fracture or intracranial shift
- CT scan: reveals hemorrhage
- Nursing interventions (see also Care of the Unconscious Client and Care of the Client with Increased ICP)
- Maintain a patent airway and adequate ventilation.
- Monitor vital signs and neuro checks; observe for changes in neurologic status, signs of increased ICP, shock, seizures, and hyperthermia.
- Observe for CSF leakage.
- Check discharge for positive Testape or Dextrostix reaction for glucose; bloody spot encircled by watery, pale ring on pillowcase or sheet.
- Never attempt to clean the ears or nose of a head-injured client or use nasal suction unless cleared by physician
- If a CSF leak is present
- Instruct client not to blow nose.
- Elevate head of bed 30° as ordered.
- Observe for signs of meningitis and administer antibiotics to prevent meningitis as ordered.
- Place a cotton ball in the ear to absorb otorrhea; replace frequently.
- Gently place a sterile gauze pad at the bottom of the nose for rhinorrhea; replace frequently.
- Prevent complications of immobility.
- Prepare the client for surgery if indicated.
- 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)
- Epidural or subdural hematoma: evacuation of the hematoma
- Provide psychologic support to client/significant others.
- Observe for hemiplegia, aphasia, and sensory problems, and plan care accordingly (see Cerebrovascular Accident)
- Provide client teaching and discharge planning concerning rehabilitation for neurologic deficits; note availability of community agencies.
Tuesday, May 20, 2008
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nervous disorder
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This entry was posted on Tuesday, May 20, 2008
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