A head injury involves trauma to the scalp, skull, or brain, ranging from a minor bump to a severe traumatic brain injury (TBI). Even seemingly mild head injuries can lead to complications, as symptoms may not appear immediately. Nurses play a central and multifaceted role throughout the patient’s journey, from the initial impact through recovery, guiding the patient toward optimal recovery. Their specialized care is important in preventing further damage.
Initial Nursing Care
Upon a patient’s arrival with a head injury, nurses prioritize immediate, life-sustaining actions. The primary assessment focuses on ensuring a patent airway, adequate breathing, and stable circulation (ABCs). Compromised airways can worsen brain injury, so nurses may assist with positioning or ventilation to optimize respiratory function. Establishing intravenous access and assessing blood pressure are performed to maintain stable blood flow to the brain, preventing secondary brain injury.
Nurses assess the patient’s level of consciousness using the Glasgow Coma Scale (GCS), a standardized tool evaluating eye opening, verbal response, and motor response. Scores range from 3 to 15, with lower scores indicating more severe brain injury, such as a severe TBI classified as a GCS of 3-8. This GCS score helps establish a baseline and guides immediate medical care. Nurses also perform a head-to-toe assessment to check for external injuries, such as lacerations, bruising, or signs of skull fractures like bruising behind the ear (Battle’s sign) or around the eyes (raccoon eyes).
Stabilization of the cervical spine is a concurrent consideration, especially if a spinal injury is suspected, maintaining the neck in a neutral position or applying a cervical collar. This comprehensive initial assessment and stabilization prevent further neurological damage and minimize the risk of secondary brain injury from factors like oxygen deprivation or unstable blood pressure.
Ongoing Assessment and Monitoring
Following initial stabilization, nurses maintain continuous assessments throughout the acute care phase. Frequent neurological assessments are performed, including repeated GCS evaluations to track changes in consciousness. Pupil checks are conducted for size, shape, and reactivity to light, as changes can indicate increasing intracranial pressure (ICP) or specific areas of brain damage. Motor and sensory responses are also evaluated, as dysfunction often appears on the opposite side of the injury.
Monitoring of vital signs, including blood pressure, heart rate, respiratory rate, and temperature, is performed. Nurses observe for specific patterns like Cushing’s triad—characterized by increased blood pressure, a slowed heart rate, and irregular respirations—which can indicate rising ICP. Recognizing changes allows for early detection of neurological deterioration, enabling rapid intervention.
In severe cases, monitoring ICP is important to prevent brain herniation and further damage. ICP is the pressure exerted by the brain tissue, cerebrospinal fluid, and blood within the skull. Normal ICP is typically less than 20 mmHg. Nurses monitor ICP using devices like intraventricular or intraparenchymal monitors, and they help manage it by elevating the head of the bed to 30 degrees and maintaining the patient’s neck in a neutral position to promote cerebrospinal fluid drainage.
Cerebral perfusion pressure (CPP) is another important indicator, reflecting the blood flow to the brain, calculated as Mean Arterial Pressure (MAP) minus ICP. Maintaining CPP above 60 mmHg is generally desired to ensure adequate blood supply to brain tissue. Nurses monitor these pressures and promptly communicate any changes to the medical team, as interventions are often required to optimize cerebral blood flow and prevent complications.
Addressing Complications and Daily Needs
Nurses manage common complications and ensure basic needs are met for patients with head injuries. Pain management is addressed, as uncontrolled pain can increase intracranial pressure and agitation. Nurses administer prescribed analgesics and continuously assess pain levels, recognizing it as a significant vital sign. Seizure precautions are implemented, and nurses are prepared to manage seizures if they occur, which can be a complication of head injury.
Maintaining fluid and electrolyte balance is important, as imbalances can affect brain swelling. Nurses monitor intake and output, and administer intravenous fluids as ordered, often with caution to prevent fluid overload. Regulating body temperature is also a nursing responsibility, as fever can worsen brain injury outcomes. Nurses use interventions such as cooling blankets or antipyretics to maintain a normal body temperature.
Preserving skin integrity is achieved through frequent repositioning and skin care, preventing pressure injuries, especially in immobile patients. Adequate nutrition is ensured, often through enteral feeding, to support healing and metabolic needs. Nurses also manage bowel and bladder function, implementing strategies to prevent constipation and urinary tract infections. Finally, infection prevention measures, such as maintaining asepsis for invasive lines and promoting respiratory hygiene, are important to prevent complications like ventilator-associated pneumonia.
Preparing for Recovery and Discharge
As patients stabilize, nurses play a role in facilitating their transition toward recovery and eventual discharge. Early mobilization and activity are promoted as appropriate, which can include assisting with range of motion exercises or helping patients out of bed when medically cleared. Nurses collaborate with a multidisciplinary team, including physical, occupational, and speech therapists, to integrate rehabilitation goals into daily care. This team approach helps address physical, cognitive, and communication challenges.
Comprehensive education is provided to patients and their families, covering ongoing care needs, potential long-term cognitive or physical effects, and medication management. Nurses explain what to expect during recovery, including possible changes in memory, concentration, or behavior. They also identify resources for support post-discharge, such as outpatient rehabilitation services or community support groups.
Discharge planning begins early in the patient’s hospital stay, ensuring a smooth and well-planned transition from acute care to rehabilitation or home. This includes reviewing the home environment for safety, arranging necessary equipment, and scheduling follow-up appointments. Nurses advocate for the patient and family, ensuring they are prepared for the next phase of recovery.