Friday, September 23, 2011

Nursing Care Plan For Acute Head Injury

Acute head injury result from a trauma to the head leading to brain injury or bleeding within the brain, It's can make edema and hypoxia. Head injury cases is the leading cause of death in the first four decades of life. A head injury also called Traumatic Brain Injury (TBI) is classified by brain injury type; fracture, hemorrhage (epidural, subdural, intracerebral or subarachnoid) and trauma.

The management or nursing care plan (NCP) for patient with an acute head injury are divided on the several levels including prevention, pre-hospital care, immediate hospital care, acute hospital care, and rehabilitation.

In order to give accurate nursing care plan to the patients, The nurses should understand the principles behind medical treatments. It focuses on the evidence based practice that nurses use in assessing, intervening and managing a severe head injury.
A. Assessment Findings on Acute Head Injury

Possible causes of acute head injury are assault, automobile accident, blunt trauma, fall and penetrating trauma. The medical team should be perform serious and critical care to handle this cases, So that they can finding correct assessment may happened to the patients such as:
  • Disorientation to time, place or person
  • Unequal pupil size, loss of pupillary reaction
  • Decreased LOC
  • Paresthesia
  • Otorrhea, rhinorea, frequent swallowing.
To quickly asses a patient's level of consciousness and to uncover baseline change, use the Glasgow Coma Scale. If the patient has already applied with an endotracheal tube and can't response verbally, use the abbreviation "T" score.


B. Diagnostic Evaluation for Acute Head Injury

The doctors are who responsible to the patient in the emergency department, they will order some examination trough CT scan or MRI (possible for hemorrhage, cerebral edema, or shift of midline structure), EEG (may reveal seizure activity), ICP monitoring (possible increased of ICP) and skull X-ray (may be fracture).


C. Nursing Diagnose in Acute Head Injury

  • Ineffective tissue perfusion (cerebral)
  • Risk for Injury
  • Decreased intracranial adaptive capacity.

D. Treatment of Acute Head Injury

  • Cervical collar (until neck injury is ruled out)
  • Craniotomy; surgical incision into te cranium (may be necessary to evacuate a hematoma or evacuate contents to make room for swelling to prevent herniation)
  • Oxygen (O2) Therapy; intubation and mechanical ventilation (to provide controlled hyperventilation to decrease elevate ICP)
  • Restricted oral intake for 24 to 48 hours
  • Ventriculostomy; insertion of a drain into the ventricles (to drain CSF in the presence of hydrocephalus, which may occur as a result of head injury; can also be used to monitor ICP).

E. Drug Therapy Options for Head Injury Cases
  • Analgesic; codein phosphate
  • Anesthetic; Lidocin (Xylocaine)
  • Anticonvulsant; Phenytoin (Dilantin)
  • Barbiturate; pentobarbital (Nembutal), if unable to control ICP with diuresis
  • Diuretic; mannitol (Osmitrol), furosemide (Lasic) to combat cerebral edema
  • Dopamine (Intropin) to maintain cerebral perfusion pressure above 50 mmHg (if blood pressure is low and ICP is elevated)
  • Glucocorticoid; dexamethasone (Decadron) to reduce cerebral edema
  • Histamin-2 (H2) receptor antagonist such as cimetidine (tagamet), ranitidine (Zantag), famotidine (Pepcid), nizatidine (Axid)
  • Mucosal barriel fortifier; sucralfate (Carafate)
  • Posterior pituitary : vasopressin (Pitressin) if client develops diabetes insipidus.

F. Planing and Goal on Nursing Care Plan
  • The patient will have improved cerebral perfusion
  • The patient will have decreased ICP
  • The patient will have remain free from injury.

G. Implementation of Nursing Care Plan Procedure
  1. Assest neurologic and respiratory status to monitor for sign of increased ICP and respiratory distress
  2. Monitor and record vital sign and intake and output, hemodynamic variables, ICP, cerebral perfusion pressure, specific gravity, laboratory studies, and pulse oximetry to detect early sign of compromise.
  3. Observe for sign of increasing ICP to avoid treatment delay and prevent neurologic compromise
  4. Assess for CSF leak as evidenced by otorhea or rinorrhea. CSF leak could leave the patient at risk for infection
  5. Assess for pain. Pain may cause anxiety and increase ICP
  6. Check cough and gag reflex to prevent aspiration
  7. Check for sign of diabetes insipidus (low urine specific gravity, high urine output) to maintain hydration
  8. Administer I.V fluids to maintain hydration
  9. Administer Oxygen to maintain position and patency of endotracheal tube if present, to maintain airway and hyperventilate the patient and to lower ICP
  10. Provide suctioning; if patient is able, assist with turning, coughing, and deep breating to prevent pooling of secretions
  11. Maintain postion, patency and low suction of NGT to prevent vomiting
  12. Maintain seizure precautions to maintain patient safety
  13. Administer medication as prescription to decrease ICP and pain
  14. Allow a rest period between nursing activities to avoid increase in ICP
  15. Encourage the patient to express feeling about changes in body image ot allay anxiety
  16. Provide appropriate sensory input and stimuli with frequent reorientation to foster awarness of the environtment
  17. Provide means of communication, such as a communcation board to prevent anxiety
  18. Provide eye, skin, and mouth care to prevent tissue damage
  19. Turn the patient every 2 hours or maintain in a rotating bed if condition allows to prevent skin breakdown.

H. Evaluation of Goals in the Nursing Care Plan
  • The patient has improved LOC
  • The patient hasdoest not exhibit signs of increased ICP
  • The patient hasremains free from injury

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