Head Injury Nursing Diagnosis and Nursing Care Plan

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Head Injury Nursing Care Plans Diagnosis and Interventions

Head Injury NCLEX Review and Nursing Care Plans

Any concussion to the brain, skull, or scalp is considered a head injury. A traumatic brain injury can range from a minor bump or bruise to severe head trauma.

The implications and therapeutic interventions differ tremendously depending on what caused the head injury and its severity.

There are two common kinds of head injuries: closed and open.

Any head injury that does not damage the skull is referred to as a closed head injury.

An open (penetrating) head injury occurs when something permeates the scalp and skull, entering the brain.

It is hard to ascertain how severe a head injury is just by looking at it. Some minor head injuries bleed profusely, while others do not bleed at all.

All head injuries should be addressed medically and evaluated by a physician.

Types of Head Injury

  1. Hematoma. A hematoma is a blood clot formation outside the blood vessels. A hematoma in the brain can be incredibly dangerous. Pressure can build up inside the skull as a result of the clotting. It is indeed possible that the patient may lose consciousness or suffer permanent neurological damage.
  1. Hemorrhage. Uncontrolled bleeding is referred to as a hemorrhage. Subarachnoid hemorrhage is bleeding in the space around the brain, while intracerebral hemorrhage is bleeding within the brain tissue. Moreover, headaches and nausea are common symptoms of subarachnoid hemorrhages. The amount of bleeding measures the intensity of intracerebral hemorrhages, but any volume of blood can end up causing fluid to accumulate over time.
  1. Concussion. When an impact to the head is strong enough to cause brain trauma, it is called a concussion. A concussion transpires when the brain collides with the skull’s formidable walls or by sudden acceleration and deceleration forces. In most cases, the impairment of body functions caused by a concussion is only temporary. Multiple concussions, on the other hand, can cause irreversible damage.
  1. Edema. Also known as swelling, edema can result from any brain injury. Swelling of the surrounding tissues is joint in many injuries, but it is hazardous in the brain. As a result, the affected person cannot stretch the skull to accommodate the swelling. Edema leads to the accumulation of pressure in the brain, causing it to press against the skull.
  1. Fracture of the skull. Dissimilar to other bones in the body, the skull lacks bone marrow. As a result, the skull is highly resilient and tough to break. Since a broken skull cannot absorb the force of a blow, it is more highly probable that the brain will be damaged as well.
  1. Diffuse axonal injury. A diffuse axonal injury, commonly known as sheer injury, is a type of brain injury that does not result in hemorrhage but damages cells in the brain. Since the brain cells are severely damaged, they cannot function effectively. It can also lead to inflammation, aggravating the situation. Furthermore, a diffuse axonal injury is one of the most threatening head injuries. Thus, even though this is not as noticeable as other types of brain injury, it has a higher possibility to cause irreparable brain damage, as well as fatality.

Signs and Symptoms of Head Injury

Since the head has more blood vessels than any other part of the body, bleeding on the surface or within the brain during a head injury is a significant concern. However, not all head injuries result in bleeding.

The following are common symptoms of a minor head injury:

  • Dizziness
  • Migraine
  • Mild disorientation
  • Temporary ringing in the ears
  • Whirling sensation
  • Vertigo

Many of the symptoms of a severe head injury are similar to those of a minor head injury. They may also include the following:

  • State of unconsciousness
  • Convulsions
  • Vomiting
  • Balance or coordination impairment
  • Severe confusion
  • Inability to focus one’s eyes for a moment
  • Unusual eye movements
  • Deterioration in muscle control
  • Headache that persists or worsens
  • Memory lapses
  • Alterations in mood
  • Clear fluid leaking from the ear or nose

Causes of Head Injury

The following are the most common causes of head injuries:

  • Violent behavior
  • Accidents involving cars or motorcycles
  • Child abuse
  • Fall incidents

When two athletes collide, or a player was hit in the head with a piece of sporting equipment, a concussion or other head injury can also occur.

As a result, the following sports-related activities cause the most significant number of head injuries in people of all ages:

  • Riding powered recreational vehicles such as dune buggies, go-karts, and mini bikes
  • Cycling
  • Softball and baseball
  • Basketball
  • Football

Head injuries are not always the result of sports or trauma. Other causes of concussions or brain hemorrhages include:

Risks Factors to Head Injury

The following groups are the most vulnerable to traumatic brain injury:

  • Children, particularly newborn babies to four-year-olds
  • Young adults, particularly those aged 15 to 24,
  • Adults aged 60 and up
  • Males of any age are eligible.

Diagnosis of Head Injury

  • Glasgow Coma Scale (GCS) – This 15-point test assists a doctor, or other urgent care personnel in determining the initial intensity of a brain injury by assessing a person’s ability to follow commands and the movement of their eyes and limbs. The consistency of speech also gives valuable data. The Glasgow Coma Scale rates abilities on a scale of three to fifteen. Higher scores indicate less severe injuries.
  • Patient Interview – Evaluating the details about the injury and its symptoms. The answers to the following questions may be critical in identifying the intensity of the head injury:
  • What caused the head injury?
    • Did the individual pass out?
    • How long was the individual unconscious?
    • Did someone notice any other changes in alertness, speech, coordination, or other signs of the patient’s injury?
    • What parts of the body, if any, were struck?
    • Provide necessary information about the severity of the injury. For instance, what struck the person’s head, how far did he or she fall, or was the person thrown from a vehicle?
    • Was the individual’s body thrown around or grievously shaken?
  •  Imaging tests
    • Computerized Tomography (CT scan). This test is performed in an emergency room for a suspected traumatic brain injury. A CT scan creates a detailed image of the brain using a sequence of X-rays. A CT scan can accurately identify fractures as well as proof of internal bleeding (hemorrhage), blood clots (hematomas), lacerated brain tissue (contusions), and inflammation of brain tissue.
    • Magnetic Resonance Imaging (MRI).  An MRI provides a comprehensive image of the brain using powerful radio waves and magnets. This test is beneficial once the patient’s condition has stabilized or if clinical manifestations do not rectify within a few days of the injury.

Treatment for Head Injury

  1. Medications. The following medications are used to treat various types of head injuries:

  • Anti-seizure medication – may be prescribed within the first week of treatment to prevent any additional brain damage inflicted by a seizure. Seizures are only treated with anti-seizure medications as long as they occur.
  • Coma-inducing medications – used to induce momentary comas since an unconscious brain requires less oxygen to function. This medication is incredibly beneficial if blood vessels in the brain are constricted by tremendous pressure and cannot deliver average amounts of essential nutrients and oxygen to brain cells.
  • Diuretics – decrease the amount of fluid in the body tissue while increasing urine output. Diuretics minimize pressure within the brain if administered intravenously to people suffering from brain trauma.
  1. Surgery. Surgery may be an excellent choice to treat the following health issues:

  • Removal of coagulated blood (hematomas) – Hemorrhage from the outside or inside the brain can cause blood clot collection, putting much pressure on the brain and damaging brain tissue.
  • Repair of fracture/s in the skull – Surgery may be required to fix severe skull fractures or remove skull fragments from the brain.
  • Cessation of bleeding in the brain – Head trauma that results in brain hemorrhage may necessitate surgery to cease the bleeding.
  • Reduction of intracranial pressure (ICP) – Surgery may alleviate the pressure within the skull by depleting aggregated cerebrospinal fluid in the brain.

3. Rehabilitation. The majority of people who have suffered substantial brain trauma will need rehabilitation. They may need to relearn essential skills like walking and talking. The focus of rehabilitation is to enhance their ability to carry out daily tasks.

Prevention of Head Injury

Depending on the extent of damage, brain injury symptoms can be minor, tolerable, or severe. Sometimes even minor injuries can affect how the brain functions. Follow these prevention tips to lower the risk of traumatic brain injury:

  • Put on the seat belt all the time when driving.
  • Do not drive while intoxicated in liquor or drugs.
  • Avoid using a cellular phone while driving.
  • Always put on a helmet while riding a motorcycle.
  • Perform actions to prevent slips and falls at home.
  • Take good care of children to avoid head injuries at all costs.

Nursing Diagnosis for Head Injury

Nursing Care Plan for Head Injury 1

Risk for Bleeding

Nursing Diagnosis: Risk for Bleeding related to tissue trauma or disturbance of the standard blood clotting mechanisms secondary to head injury as evidenced by petechiae, bruises, blood clot formation, or overflowing of blood.

Desired Outcome: The patient will learn how to prevent bleeding and recognize clinical manifestations of hemorrhage that must be disclosed to a health care professional instantaneously.

Nursing Interventions for Head InjuryRationale
Instruct the at-risk patient on how to take precautions to avoid tissue trauma or disruption of standard clotting mechanisms.  The knowledge of safety precautions minimizes the incidence of bleeding.    
Inform the patient and family members on the manifestations of bleeding that must be disclosed to a health care provider right away.  The earlier a health care provider evaluates and treats bleeding, the lower the associated complications from blood loss.    
Advise the female patient that an increase in menstrual periods, as indicated by an increase in the number of sanitary pads used, should be mentioned to the healthcare professional.  Changes in blood clotting may result in higher blood loss during regular menstruation.  
Inform the patient and family members about the health hazards of using natural supplements that have been associated with a higher likelihood of hemorrhage.  A large percentage of herbal remedies impede platelet activation by inhibiting serotonin release from the platelet. Other herbs enhance the impact of antiplatelet and anticoagulant medications, raising the risk of bleeding.    
Instruct family and friends to participate in decision-making regarding the diagnosis and treatment of who is at risk for bleeding complications.    Full engagement of the family and friends promotes a better comprehension of the rationale and adherence to the intervention.

Nursing Care Plan for Head Injury 2

Acute Confusion

Nursing Diagnosis: Acute Confusion related to a pattern of memory impairment secondary to head injury as evidenced by changes in cognition, heightened agitation, or alterations in one’s level of consciousness.

Desired Outcome: The patient will have diminished hallucinations and recover normal reality orientation and consciousness.

Nursing Interventions for Head InjuryRationale
Determine the presence of risk factors such as substance misuse, seizure episodes, current Electroconvulsive Therapy (ECT) therapy, incidents of fever/pain, the presence of acute infection, especially urinary tract infection in elderly patients, exposure to potentially harmful substances, traumatic experiences, and changes in the external environment such as unfamiliar noises and excessive visitors.    This intervention is beneficial since baseline data aids in developing a specific plan.    
Sustain a regular sleep-wake cycle for the patient as possible. For example, avoid allowing the patient to nap during the day, avoid trying to wake patients at night, give tranquilizers but not diuretics prior to sleep, and provide pain medicine and sensual massages.  The sleep-wake cycle is disrupted in people who have acute confusion. As a result, this approach will assist the patient in resuming a typical sleeping pattern.    Carry out a thorough mental health examination that includes the following: Overall appearance, mannerisms, and personalityEvaluation of behavior, attitude, and level of motor coordinationMood and affect (the existence of suicidal or homicidal thought patterns as witnessed by others and disclosed by the patient)Interpretation and decision-making capabilitiesLevel of consciousness, orientation (to time, place, and person), way of thinking, and content are all indicators of cognition. Attention  An excellent diagnostic feature of delirium is confused thinking. Delirium is a mental state, whereas agitation is a behavioral symptom. Some patients may be delirious without being agitated and may exhibit withdrawn habits. These symptoms manifest a type of delirium that is hypoactive. However, some patients have delirium that is both hypoactive and hyperactive. Therefore, this approach is beneficial in assessing the patient’s mental health status.    
As necessary, ensure the patient’s cognitive performance systematically and regularly during the day and night.    Delirium always involves an acute change in mental status; consequently, recognizing the patient’s benchmark mental status is crucial for determining delirium.        
Examine the degree of impairment in orientation, ability to focus, capacity to grasp directions, send or receive communication, and response appropriateness.  This approach should be conducted to identify the severity of the impairment.    

Nursing Care Plan for Head Injury 3

Nausea

Nursing Diagnosis: Nausea related to acute concussion secondary to head injury as evidenced by headache and vomiting.

Desired Outcome: The patient will report a reduction in the intensity or complete elimination of nausea.

Nursing Interventions for Head InjuryRationale
Make an emesis basin easily accessible to the patient.  Vomiting and nausea are directly connected. If the nausea is psychogenic, keep the emesis basin out of sight but still within reach of the patient.    
Allow the patient to utilize non – pharmacologic nausea management techniques such as resting, mental imagery, music education, diversionary tactic, or deep breathing techniques.    These techniques have assisted patients in resolving the condition, but they must be used before it occurs.    
Analyze the patient’s response to antiemetics or other treatments to alleviate the condition.  This method is essential for evaluating the efficacy of such interventions.  
Teach the patient or nurse how to use accu-stimulation bands or acupressure.  If the intervention was beneficial and practical, patients and nurses might intend to continue with it.    
Educate the patient on the significance of shifting positions slowly and gently.    Excessive or erratic movement may exacerbate the condition.

Nursing Care Plan for Head Injury 4

Acute Pain (Headache)

Nursing Stat Facts
Nursing Stat Facts

Nursing Diagnosis: Acute Pain related to traumas and illnesses secondary to head injury as evidenced by severe migraine.

Desired Outcome: The patient will be able to cope with acute pain.

Nursing Interventions for Head InjuryRationale
Understand and acknowledge the patient’s pain.    Nurses have a responsibility to question their patients about their pain and to presume their patients’ reports of pain. Challenging or undermining their pain reports leads to an undesirable therapeutic relationship, impeding pain treatment and degrading rapport.
Nonpharmacologic pain management can be another option to relieve a patient’s pain.    Physiological, cognitive-behavioral techniques and lifestyle pain management are nonpharmacologic pain control strategies.    
Examine the effectiveness of painkillers as prescribed and keep an eye out for any clinical manifestations of side effects.    Pain medications must be evaluated separately for each patient because they are absorbed and metabolized differently.    
Ascertain pain-relieving factors.  Ask if the patients have done anything to relieve their pain. Contemplation, breathing techniques, exercises, praying, and other similar practices may be included. Information on these pain-relieving techniques can be incorporated into pain-management planning.
During the peak effect of analgesics, deliver nursing care.  Oral painkillers typically reach their full potential in sixty minutes, while intravenous analgesics peak in twenty minutes. When nursing tasks are performed during the maximum effect of analgesics, client comfort and compliance in care are maximized.    

Nursing Care Plan for Head Injury 5

Risk for Seizure

Nursing Diagnosis: Risk for Seizure related to unwanted electrical firing or discharges from cerebral cortex nerve fibers secondary to head injury as evidenced by short, brief episodes of altered state of consciousness, motor functions, and sensory manifestations.

Desired Outcome: The patient will execute safety measures when seizure episodes occur suddenly.

Nursing Interventions for Head InjuryRationale
Investigate and explain seizure warning signs as well as the typical seizure pattern. Educate the family on how to acknowledge and recognize warning signs and how to care for the patient during and after seizure episodes.  This intervention allows the patient to guard himself against harm and recognize disturbances that require notification of the physician and further intervention. Understanding what to do if a seizure happens can prevent injury or complications and reduce a patient’s feelings of helplessness.    
Do not leave patients while he or she is experiencing seizure symptoms.    This approach encourages safety precautions.
Reorient the patient after seizure attacks.  After the seizure, the patient may be bewildered, disorganized, and potentially amnesic and require assistance to regain control and relieve anxiety.  
Examine the patient’s reports of pain.    Pain could result from repetitive muscle contractions or a clinical sign of an injury that necessitates further assessment or treatment.
Instruct the patient not to smoke unless carefully monitored.  If a cigarette is dropped unintentionally during aura or seizure activity, it may lead to burns.    

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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