Head Injury Nursing Diagnosis & Care Plan

Contents: 

• Head Injury Overview 
• Nursing Diagnosis 
• Care Plans

Pathophysiology

Head injury involves trauma to the skull leading to temporary or permanent brain damage. There are several different types of traumatic brain injuries (TBIs):

Causes

The Mayoclinic includes the following events causing the most traumatic brain injuries, with falls being the most common accident. 

• Falls (from a ladder or down the stairs) 
• Vehicle-related collisions (cars, bicycles) 
• Violence (shootings, domestic violence) 
• Sports injuries (football, boxing, etc.) 
• Combat injuries (military) 

Signs and Symptoms 

•  Symptoms of Increased intracranial pressure (ICP) 
  • Decreased level of consciousness (LOC) 
    • Restlessness 
    • Changes in behavior
    • Irritability 
    • Confusion  
  • Headache 
  • Nausea and projectile vomiting 
  • Pupillary changes 
  • Changes in vital signs: (Cushing’s triad) 
    • Severe hypotension 
    • Widened pulse pressure 
    • Bradycardia
• Seizures 
• Ataxia 
• Abnormal posturing 
  • Decerebrate (extension) 
  • Decorticate (flexion) 
• Cerebrospinal fluid leakage from the nose or ears 

Secondary Injuries from TBI

• Increased intracranial pressure
• Hypotension 
• Hypoxia 
• Hemorrhage 
• Hydrocephalus 
• Brain herniation 

Diagnosis 

• Arterial blood gas – to determine oxygen-carrying capacity 

• CBC – to identify hemodynamic stability and infection 

• CT scan – to identify scope of injury such as identifying subdural or epidural hematoma, and to rule out fractures 

• MRI – provides a more specific picture about brain tissue changes

• Electroencephalogram (EEG) – to detect seizure activity 

Treatment

• Non- surgical 
  • targeted temperature treatment: cooling the body down to a temperature of 32 to 34 degrees Fahrenheit to protect the brain
  • drug therapy 
• Surgical 
  • Craniotomy 
  • decompressive craniectomy 

Nursing Diagnosis for Head Injury: 

• Decreased Intracranial Adaptive Capacity r/t increased intracranial pressure 
• Risk for Seizures 
• Acute Confusion r/t increased intracranial pressure 
• Deficient Knowledge r/t lack of experience with head injury 

Nursing Care Plans for Head Injury

Expected Outcome: The patient will have an optimal cerebral tissue perfusion as evidenced by stable ICP and LOC 

Monitor the patient’s neurological status, meaning the LOC, pupils, and Glasgow coma scale scores continuously.  Subtle changes such as irritability, increased confusion, and restlessness can indicate a deterioration in status. A change in LOC may be a sign of an increased ICP (intracranial pressure).

Monitor vital signs continuously or at least every hour. Changes in vital signs may be a sign of increased pressure in the brain. An increased ICP causes bradycardia, a widening pulse pressure, and irregular respirations (Cushing’s triad).

Assess for fluid leakage from the ears and nose.  Leakage from the nose (rhinorrhea)  and ears (otorrhea) might be cerebrospinal fluid (CSF) after head trauma caused by fractures. Because there is no accumulation of fluid in the brain, there might be no signs of ICP.

Keep Po2 between 80 and 100 mmHg and Pco2 between 35 and 38 mmHg. The goal is to prevent prolonged states of hypoxemia (decreased blood level of oxygen) and hypercarbia (increased amount of carbon dioxide in arterial blood). Hypercarbia can cause cerebral vasodilation, which could cause an increased intracranial pressure.

Avoid any activities and symptoms that increase ICP.  Position changes (keep head straight)  Endotracheal suctioning  Coughing, vomiting Bending at the waist Valsalva maneuvers  Pain  Fever Shivering These factors can increase cerebrospinal fluid and, therefore, intracranial pressure. Elevation of the head of the bed and maintaining a neutral alignment help reduce venous pressure and thus decrease ICP. Limiting suctioning and hyperoxygenation before suctioning helps keep ICP at bay. Treating pain, fever and shivering helps lower ICP as well.

Use an intracranial monitoring system.  This equipment allows for real-time, continuous monitoring.  An ICP that is greater than 15 mmHg should be reported right away.

Administer medication as ordered to decrease ICP.  Hyperosmotic agents (Mannitol)  Steroids  Barbiturates Antipyretics  Muscle relaxants  Anticonvulsants  Medications such as Mannitol are used to draw fluid from interstitial spaces into the intravascular space reducing cerebral edema. Steroids help reduce brain swelling. Barbiturates are used to reduce brain metabolism and blood pressure. Antipyretics lower body temperature, which lowers metabolism, which lowers cerebral blood flow – decreasing ICP. Muscle relaxants prevent shivering. Seizures might increase metabolic demands and cerebral blood flow, increasing ICP. Anticonvulsants are administered to avoid seizure activity.

Risk for Seizures 

Expected Outcome: The patient will remain free from seizure activity and injury thereof. 

Risk factors: 

• Intracranial Bleeding 
• Contusion 
• Hyponatremia 
• Open and closed brain injuries 
• Hypoxia 

Protect the patient’s airway during seizure activity.  The patient might not be able to control muscle movement during a seizure. The tongue might pose an airway obstruction by falling back into the upper airway.

Note characteristics during the seizure:  Onset  Duration  Type of seizure  Behavior at the onset, during, and after the seizure.  Documenting these characteristics can help to identify the type of seizure and allows for more specific treatment options.

Maintain seizure precautions. Reduce environmental stimuli Pad side rails Place the bed in the lowest position  Have suction set up and ready if needed Provide head protection  These implementations reduce the risk of injury during a seizure.

Assist the patient during the seizure.  Turn the patient’s head to the side  Suction if necessary  Administer oxygen  These measures protect the patient’s airway during and after the seizure.

Administer anticonvulsants as ordered and check therapeutic levels regularly.  Phenytoin (Dilantin) can only be mixed with NS. Its therapeutic level is 10 to 20 mcg/mL.  Close monitoring for medication toxicity is essential. Signs include but are not limited to nausea, vomiting, restlessness, drowsiness, and visual changes.

Acute Confusion r/t increased intracranial pressure 

Expected Outcome: The patient will demonstrate a stable cognitive status as evidenced by intact LOC. 

Assess the patient’s level of consciousness frequently as ordered.  A change in mental status might indicate an increase in cerebral pressures.

Reorient the patient to person, time, place, and situation frequently.   Memory might be affected that requires frequent repetition of the same information. Informing the patient about their situation might reduce anxiety levels and bring their cognitive status back to baseline.

Treat the underlying cause of the confusion.  For increased intracranial pressure, implement measures to reduce this pressure. (See care plan above)

Introduce yourself before any interaction and procedures. Explain care in short and simple sentences before and throughout the process.  These measures are part of reorientation. Too much information at once might increase confusion and make the patient more irritable.

Promote continuity of care.  Frequent changes in staff and environment might further worsen the patient’s confused state. Keep the staff and environment consistent as much as possible.

If possible, have the family communicate with the patient via facetime.  Seeing familiar faces and recognizing familiar voices might stimulate memory and helps with reorientation.

Deficient Knowledge r/t lack of experience with head injury 

Expected Outcome: The patient will demonstrate knowledge about the disease process, treatment, and prognosis as evidenced by verbalizing correct information and posing appropriate and relevant questions. 

Assess the patient’s cognitive ability and receptiveness to learning information.  Brain injury might affect short-term memory and cause behavior and mood changes.  Ability to focus and learn new information might be difficult and take more time.

Assess the patient’s knowledge about the injury and treatment plan.  Most patients and families have no prior experience with head trauma injuries. In most cases, these types of injuries arise from very sudden and unexpected events.

Update patients and family members regularly about changes in health status.  Family members and caregivers are a vital part of the healthcare team. They can provide unique information about the patient’s baseline before the head injury.

Prepare the patient and family for possible need for physical, occupational,  speech therapy, and ongoing home support.  Rehabilitation can be a long process that goes beyond the hospital stay. Patients and families need to be aware of all members of the healthcare team. The roles of significant others might turn into primary caregiver roles after the patient is discharged. Families need help to adjust to their new roles and situation.

More Care Plans:

Risk for Falls Nursing Diagnosis & Care Plan

Activity Intolerance Nursing Diagnosis & Care Plan

Ineffective Airway Clearance Nursing Diagnosis & Care Plan

Ineffective Breathing Pattern Nursing Diagnosis & Care Plan

Ineffective Coping

Impaired Gas Exchange Nursing Diagnosis & Care Plan

Risk for Infection Nursing Diagnosis & Care Plan

Risk for Bleeding Nursing Diagnosis & Care Plan

References: 

Traumatic brain injury – Symptoms and causes. (2021). Retrieved from https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557

Deglin, J., Vallerand, A., & Sanoski, C. (2014). Davis’s Drug Guide for Nurses (14th ed.) (14th ed.). FA Davis Company.

Blair, M., Ignatavicius, D., Rebar, C., Winkelman, C., & Workman, M. Medical-surgical nursing (8th ed.). Elsevier.

Silvestri, L. (2014). Saunders comprehensive review for the NCLEX-RN examination (6th ed.). St. Louis, Mo.: Elsevier/Saunders.