Head Injury
Head Injury
• Any trauma to the scalp, skull, or brain
Setiap
Setiap trauma pada kulit kepala, tengkorak, atau otak
otak
• Head trauma includes an alteration in
consciousness no matter how brief
Trauma
Trauma kepala
kepala termasuk
termasuk perubahan
perubahan kesadaran tidak peduli
peduli seberapa
seberapa
singkat
Head Injury
• Causes
– Penyebab
– Kecelakaan kendaraan bermotor
– Cedera yang berhubungan dengan senjata api
– Air terjun
– Assaults
– Cedera terkait olahraga
– Kecelakaan rekreasi
Head Injury
• Potensi tinggi untuk hasil yang buruk
• Kematian terjadi pada tiga titik waktu
setelah cedera:
– Segera setelah cedera
– Dalam 2 jam setelah cedera
– 3 minggu setelah cedera
Head Injury
Types of Head Injuries
• Laserasi kulit kepala
– Jenis trauma kepala yang paling ringan
– Kulit kepala adalah pendarahan yang sangat
vaskular
– Komplikasi utama adalah infeksi
Head Injury
Types of Head Injuries
• Skull fractures
– Linear or depressed
– Simple, comminuted, or compound
– Closed or open
– Direct & Indirect
– Coup & Contrecoup
Head Injury
Types of Head Injuries
• Skull fractures
– Location of fracture alters the
presentation of the manifestations
– Facial paralysis
– Conjugate deviation of gaze
– Battle’s sign
Head Injury
Types of Head Injuries
• Basal Skull fractures
– CSF leak (extravasation) into ear (Otorrhea)
or nose (Rhinorrhea)
– High risk infection or meningitis
– “HALO Sign (Battle Sign)” on clothes of
linen
– Possible injury to Internal carotid artery
– Permanent CSF leaks possible
Battle’s Sign
Fig. 55-13
Nursing Care of Skull
Fractures
• Minimize CSF leak
– Bed
Bed flat
flat
– Never
Never suction
suction orally;
orally; never
never insert
insert NG
NG tube;
tube; never
never use
use Q-Tips
Q-Tips
in
in nose/ears;
nose/ears; caution
caution patient
patient not
not to blow nose
• Place sterile gauze/cotton ball around area
• Verify CSK leak:
– DEXTROSTIX:
DEXTROSTIX: positive
positive for
for glucose
glucose
• Monitor closely: Respiratory status+++
Head Injury
Types of Head Injuries
• Minor head trauma
– Concussion
• A sudden transient mechanical head
injury with disruption of neural activity
and a change in LOC
• Brief disruption in LOC
• Amnesia
• Headache
• Short duration
Head Injury
Types of Head Injuries
• Minor head trauma
– Postconcussion syndrome
• 2 weeks to 2 months
• Persistent headache
• Lethargy
• Personality and behavior changes
Head Injury
Types of Head Injuries
• Major head trauma
– Includes cerebral contusions and
lacerations
– Both injuries represent severe trauma
to the brain
Head Injury
Types of Head Injuries
• Major head trauma
– Contusion
• The bruising of brain tissue within a focal
area that maintains the integrity of the pia
mater and arachnoid layers
– Lacerations
• Involve actual tearing of the brain tissue
• Intracerebral hemorrhage is generally
associated with cerebral laceration
Head Injury
Pathophysiology
• Diffuse axonal injury (DAI)
– Widespread axonal damage occurring
after a mild, moderate, or severe TBI
– Process takes approximately 12-24
hours
Head Injury
Pathophysiology
• Diffuse axonal injury (DAI)
– Clinical signs:
LOC
ICP
• Decerebration or decortication
• Global cerebral edema
Head Injury
Complications
• Epidural hematoma
– Results from bleeding between the
dura and the inner surface of the skull
– A neurologic emergency
– Venous or arterial origin
Head Injury
Complications
• Subdural hematoma
– Occurs from bleeding between the
dura mater and arachnoid layer of the
meningeal covering of the brain
Epidural and Subdural Hematomas
Epidural Hematoma
Subdural Hematoma
Fig. 55-15
Head Injury
Complications
• Subdural hematoma
– Usually venous in origin
– Much slower to develop into a mass
large enough to produce symptoms
– May be caused by an arterial
hemorrhage
Head Injury
Complications
• Subdural hematoma
– Acute subdural hematoma
• High mortality
• Signs within 48 hours of the injury
• Associated with major trauma (Shearing
Forces)
• Patient appears drowsy and confused
• Pupils dilate and become fixed
Head Injury
Complications
• Subdural hematoma
– Subacute subdural hematoma
• Occurs within 2-14 days of the
injury
• Failure to regain consciousness may
be an indicator
Head Injury
Complications
• Subdural hematoma
– Chronic subdural hematoma
• Develops over weeks or months after
a seemingly minor head injury
Head Injury
Diagnostic Studies and
Collaborative Care
• CT scan considered the best diagnostic test to
determine craniocerebral trauma
• MRI
• Cervical spine x-ray
• Glasgow Coma Scale (GCS)
• Craniotomy
• Craniectomy
• Cranioplasty
• Burr-hole
Head Injury
Nursing Management
Nursing Assessment
– GCS score
– Neurologic status
– Presence of CSF leak
Head Injury
Nursing Management
Nursing Diagnoses
– Ineffective tissue perfusion
– Hyperthermia
– Acute pain
– Anxiety
– Impaired physical mobility
Head Injury
Nursing Management
Planning
– Overall goals:
• Maintain adequate cerebral perfusion
• Remain normothermic
• Be free from pain, discomfort, and
infection
• Attain maximal cognitive, motor, and
sensory function
Head Injury
Nursing Management
Nursing implementation
Health Promotion
• Prevent car and motorcycle accidents
• Wear safety helmets
Head Injury
Nursing Management
Nursing implementation
Acute Intervention
• Maintain cerebral perfusion and
prevent secondary cerebral ischemia
• Monitor for changes in neurologic
status
Head Injury
Nursing Management
Nursing implementation
Ambulatory and Home Care
• Nutrition
• Bowel and bladder management
• Spasticity
• Dysphagia
• Seizure disorders
• Family participation and education
Head Injury
Nursing Management
Evaluation
Expected Outcomes
• Maintain normal cerebral perfusion
pressure
• Achieve maximal cognitive, motor, and
sensory function
• Experience no infection, hyperthermia,
or pain
