Head injuries are a significant concern in healthcare, requiring prompt and comprehensive nursing care. A head injury can range from a mild concussion to a severe traumatic brain injury (TBI), each presenting unique challenges for both the patient and the healthcare team.
This article will explore the nursing diagnosis of head injuries, including causes, signs and symptoms, expected outcomes, nursing assessments, nursing interventions, and detailed care plans. By understanding these essential elements, nurses can provide optimal care and improve outcomes for patients with head injuries.
Causes (Related to)
The following are common causes of head injuries:
- Motor vehicle accidents
- Falls, especially in the elderly and young children
- Sports-related injuries
- Assault or violence
- Workplace accidents
- Penetrating injuries (gunshot wounds)
- Explosive blast injuries
Signs and Symptoms (As evidenced by)
The following are common signs and symptoms of head injuries. Based on patient reports and nurse assessments, they are categorized into subjective and objective data.
Subjective: (Patient reports)
- Headache
- Dizziness or vertigo
- Confusion or disorientation
- Memory loss, especially of events surrounding the injury
- Nausea
- Blurred vision
- Ringing in the ears (tinnitus)
- Sensitivity to light or noise
Objective: (Nurse assesses)
- Altered level of consciousness
- Unequal pupil size or reactivity
- Weakness or paralysis on one side of the body
- Seizures
- Clear or bloody fluid draining from ears or nose
- Bruising around the eyes (raccoon eyes) or behind the ears (Battle’s sign)
- Irregular breathing patterns
- Changes in vital signs (increased blood pressure, decreased heart rate)
- Vomiting, especially projectile
- Slurred speech
- Agitation or combativeness
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for head injury patients:
- The patient will maintain a stable neurological status as evidenced by the Glasgow Coma Scale (GCS) score.
- The patient will demonstrate improvement in cognitive function and orientation.
- The patient will maintain stable vital signs within normal limits.
- The patient will remain free from complications such as increased intracranial pressure or seizures.
- Patient and family will verbalize understanding of the injury, treatment plan, and potential long-term effects.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, neurological, and diagnostic data. The following section will cover critical aspects of the nursing assessment for head injury patients.
- Perform a thorough neurological assessment.
Use the Glasgow Coma Scale (GCS) to evaluate the level of consciousness, pupil reactivity, and motor responses. Repeat assessments at regular intervals to monitor for changes. - Assess vital signs.
Monitor blood pressure, heart rate, respiratory rate, and temperature. Be alert for signs of increased intracranial pressure, such as widening pulse pressure or bradycardia. - Evaluate cognitive function.
Assess orientation, memory, and ability to follow commands. Note any confusion, agitation, or changes in behavior. - Check for signs of basilar skull fracture.
Look for raccoon eyes, Battle’s sign, or cerebrospinal fluid leakage from ears or nose. - Assess pain level.
Use an appropriate pain scale based on the patient’s ability to communicate. For non-verbal patients, observe for nonverbal signs of pain or discomfort. - Review diagnostic test results.
Interpret CT scans, MRIs, or other imaging studies to understand the extent of the injury and potential complications.
Nursing Interventions
Nursing interventions and care are essential for the patient’s recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with a head injury.
- Maintain a patent airway and adequate oxygenation.
Ensure proper positioning and suction as needed to prevent aspiration. Administer oxygen therapy as ordered. - Monitor and manage intracranial pressure (ICP).
Keep the head of the bed elevated at 30 degrees, minimize stimulation, and avoid activities that may increase ICP, such as coughing or straining. - Administer medications as ordered.
This may include analgesics, anticonvulsants, osmotic diuretics, or sedatives. Monitor for side effects and effectiveness. - Prevent secondary injury.
Maintain normothermia, ensure adequate cerebral perfusion pressure, and manage blood glucose levels. - Provide neurological checks at regular intervals.
Document and report any changes in GCS score, pupil reactivity, or motor function. - Implement seizure precautions.
Pad bed rails, keep suction equipment readily available, and educate family members on seizure first aid. - Promote rest and minimize stimulation.
Create a calm environment, cluster care activities, and allow uninterrupted rest periods. - Provide emotional support to the patient and family.
Offer clear, concise information about the injury and treatment plan. Address concerns and fears as they arise. - Initiate early mobilization as appropriate.
Collaborate with physical and occupational therapy to prevent complications of immobility and promote recovery. - Provide patient and family education.
Teach about the injury, recovery process, potential long-term effects, and strategies for coping with cognitive or physical changes.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find examples of nursing care plans for patients with head injuries.
Nursing Care Plan 1: Risk for Increased Intracranial Pressure
Nursing Diagnosis Statement: Risk for Increased Intracranial Pressure related to head injury.
Related factors/causes:
- Cerebral edema
- Hematoma formation
- Altered cerebral blood flow
Nursing Interventions and Rationales:
- Monitor neurological status using GCS every 1-2 hours or as ordered.
Rationale: Frequent neurological assessments allow for early detection of increased ICP. - Maintain the head of the bed at 30 degrees unless contraindicated.
Rationale: This position promotes venous drainage and helps reduce ICP. - Avoid activities that may increase ICP, such as coughing, straining, or Valsalva maneuver.
Rationale: These activities can temporarily increase ICP and potentially worsen the injury. - Administer osmotic diuretics as ordered (e.g., mannitol).
Rationale: Osmotic diuretics help reduce cerebral edema and lower ICP. - Monitor and record input and output strictly.
Rationale: Fluid balance is crucial in managing ICP and preventing complications.
Desired Outcomes:
- The patient will maintain stable ICP within normal limits (< 15 mmHg).
- The patient will demonstrate stable or improving neurological status as evidenced by the GCS score.
Nursing Care Plan 2: Impaired Physical Mobility
Nursing Diagnosis Statement: Impaired Physical Mobility related to neurological deficits secondary to head injury.
Related factors/causes:
- Altered muscle tone or strength
- Impaired balance or coordination
- Pain or discomfort
Nursing Interventions and Rationales:
- Assess the patient’s level of mobility and strength at least once per shift.
Rationale: Regular assessments help track progress and identify areas needing intervention. - Implement a turning schedule every 2 hours while in bed.
Rationale: Frequent position changes prevent pressure ulcers and promote circulation. - Collaborate with physical and occupational therapy for early mobilization.
Rationale: Early mobilization can improve outcomes and prevent complications of immobility. - Provide assistive devices as needed (e.g., walker, cane).
Rationale: Assistive devices promote safe mobility and independence. - Educate patient and family on safe transfer techniques.
Rationale: Proper transfer techniques prevent falls and promote patient safety.
Desired Outcomes:
- The patient will demonstrate improved mobility and strength within individual limitations.
- The patient will participate in prescribed therapy sessions without complications.
Nursing Care Plan 3: Acute Pain
Nursing Diagnosis Statement: Acute Pain related to head injury and increased intracranial pressure.
Related factors/causes:
- Tissue damage from initial injury
- Cerebral edema
- Muscle tension and anxiety
Nursing Interventions and Rationales:
- Assess pain level using an appropriate pain scale every 4 hours and as needed.
Rationale: Regular pain assessments guide pain management strategies. - Administer analgesics as ordered, avoiding those that may mask neurological changes.
Rationale: Proper pain management promotes comfort and healing while maintaining neurological assessment accuracy. - Provide non-pharmacological pain relief measures (e.g., quiet environment, relaxation techniques).
Rationale: These measures can complement medication and reduce overall pain perception. - Monitor for signs of increased ICP when administering pain medication.
Rationale: Some pain medications can affect ICP, requiring close monitoring. - Document the effectiveness of pain interventions and any changes in neurological status.
Rationale: This information guides ongoing pain management and helps detect potential complications.
Desired Outcomes:
- The patient will report a pain level of 3 or less on a 0-10 scale.
- The patient will demonstrate the use of non-pharmacological pain relief techniques.
Nursing Care Plan 4: Risk for Aspiration
Nursing Diagnosis Statement: Risk for Aspiration related to decreased level of consciousness and impaired gag reflex.
Related factors/causes:
- Altered mental status
- Weakened or absent gag reflex
- Presence of a feeding tube
Nursing Interventions and Rationales:
- Assess gag reflex and swallowing ability before administering oral intake.
Rationale: This assessment helps determine the risk of aspiration and guides feeding decisions. - Keep the head of the bed elevated at least 30 degrees during and after feeding.
Rationale: This position reduces the risk of reflux and aspiration. - Suction the airway as needed using a sterile technique.
Rationale: Proper suctioning helps maintain a clear airway and prevent aspiration of secretions. - Collaborate with speech therapy for swallowing evaluation and exercises.
Rationale: Speech therapy can help improve swallowing function and reduce aspiration risk. - Educate the family on signs of aspiration and proper feeding techniques.
Rationale: Family education promotes safe feeding practices and early recognition of aspiration.
Desired Outcomes:
- The patient will maintain a clear airway without signs of aspiration.
- The patient will demonstrate improved swallowing ability as appropriate to injury severity.
Nursing Care Plan 5: Disturbed Thought Processes
Nursing Diagnosis Statement: Disturbed Thought Processes related to cerebral injury and altered neurological function.
Related factors/causes:
- Brain tissue damage
- Altered cerebral blood flow
- Medication side effects
Nursing Interventions and Rationales:
- Assess cognitive function, including orientation, memory, and attention, every shift.
Rationale: Regular assessments help track cognitive recovery and identify areas of deficit. - Provide a structured, calm environment with minimal stimulation.
Rationale: A quiet environment reduces confusion and promotes cognitive rest. - Use simple, clear communication and provide frequent reorientation.
Rationale: Clear communication helps the patient process information more effectively. - Encourage family involvement in care and cognitive stimulation activities.
Rationale: Family involvement can provide familiar stimuli and support cognitive recovery. - Collaborate with occupational therapy for cognitive rehabilitation exercises.
Rationale: Cognitive exercises can help improve thought processes and functional abilities.
Desired Outcomes:
- The patient will demonstrate improved cognitive function as appropriate to injury severity.
- The patient will show increased orientation periods to person, place, and time.
By implementing these nursing care plans, nurses can provide comprehensive, individualized care to patients with head injuries, promoting optimal recovery and preventing complications.
References
- American Association of Neuroscience Nurses. (2019). Core curriculum for neuroscience nursing (6th ed.). AANN.
- Bader, M. K., & Littlejohns, L. R. (2019). AANN core curriculum for neuroscience nursing (6th ed.). Elsevier.
- Bradshaw, M., & Lowenstein, A. (2020). Innovative teaching strategies in nursing and related health professions (8th ed.). Jones & Bartlett Learning.
- Hickey, J. V. (2021). Clinical practice of neurological and neurosurgical nursing (8th ed.). Wolters Kluwer.
- Mauk, K. L. (2021). Gerontological nursing: Competencies for care (5th ed.). Jones & Bartlett Learning.
- Urden, L. D., Stacy, K. M., & Lough, M. E. (2022). Critical care nursing: Diagnosis and management (9th ed.). Elsevier.
