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.
Nursing Diagnose in Acute Head Injury
- Risk for Injury
- Decreased intracranial adaptive capacity.
- Ineffective tissue perfusion (cerebral)
Nursing Care and Intervention in Acute Head Injury
- Observe for sign of increasing ICP to avoid treatment delay and prevent neurologic compromise
- Assess for CSF leak as evidenced by otorhea or rinorrhea. CSF leak could leave the patient at risk for infection
- Assess for pain. Pain may cause anxiety and increase ICP
- Check cough and gag reflex to prevent aspiration
- Check for sign of diabetes insipidus (low urine specific gravity, high urine output) to maintain hydration
- Administer I.V fluids to maintain hydration
- Assest neurologic and respiratory status to monitor for sign of increased ICP and respiratory distress
- 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.
- Administer Oxygen to maintain position and patency of endotracheal tube if present, to maintain airway and hyperventilate the patient and to lower ICP
- Provide suctioning; if patient is able, assist with turning, coughing, and deep breating to prevent pooling of secretions
- Maintain postion, patency and low suction of NGT to prevent vomiting
- Maintain seizure precautions to maintain patient safety
- Administer medication as prescription to decrease ICP and pain
- Allow a rest period between nursing activities to avoid increase in ICP
- Encourage the patient to express feeling about changes in body image ot allay anxiety
- Provide appropriate sensory input and stimuli with frequent reorientation to foster awarness of the environtment
- Provide means of communication, such as a communcation board to prevent anxiety
- Provide eye, skin, and mouth care to prevent tissue damage
- Turn the patient every 2 hours or maintain in a rotating bed if condition allows to prevent skin breakdown.
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Ditulis oleh: Shahzad Khan - 4 May 2012