BRAIN INJURIES

HEAD AND BRAIN INJURIES

Overview of the Disease
Head Injuries
Overview of the Disease
Head Injury is a broad classification that includes injury to the scalp,

skull, or brain. A head injury may lead to conditions ranging from mild concussion to

coma and death.

Most common causes are Falls (35.2%), Motor Vehicle Crashes (17.3%),

Being stuck by objects (16.5%) and Assaults (10%)

Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical

Nursing 13th Edition. Philippines: Lippincott Williams & Wilkins. Pg. 1996
Pathophysiology
Damage to the brain from traumatic injury takes two forms: Primary Injury:

initial damage that results from traumatic event and Secondary Injury: ensuing hours

and days after the initial injury and results from inadequate delivery of nutrients and

oxygen to the cells.

The Monro-Kellie hypothesis, explains dynamic equilibrium of

cranial contents. Cranial Vault: Brain, Blood, and Cerebrospinal fluid (CSF).
If the pressure increases enough, it can cause displacement of the brain

through or against the rigid structures of the skull. Cells within the brain become

anoxic and cannot metabolize properly.

Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical

Nursing 13th Edition. Philippines: Lippincott Williams & Wilkins. Pg. 1996
Scalp Injury
Isolated scalp trauma-generally classified as minor injury, because its many blood

vessels constrict poorly, the scalp bleeds profusely when injured. Trauma may

result in an abrasion (brush wound), contusion, laceration, or hematoma beneath

the layers of tissue in the scalp (subgaleal hematoma).

A large avulsion (tearing away) of the scalp may be potentially threatening and is

true emergency.
Diagnosis is based on physical examination, inspection, and palpation.
BRAIN INJURIES

Wound are potential portal of entry for organisms that cause intracranial

infections, the area is irrigated before the laceration is sutured to remove foreign

material and to reduce the risk for infection.

Subgaleal hematoma usually reabsorb and do not require any specific treatment.
Skull Fractures
A break in the continuity of the skull caused by forceful trauma.
A simple (linear) fracture is a break in the continuity of the bone.
A comminuted skull fracture refers to a splintered or multiple fracture line
Depressed skull fractures occur when the bone of the skull are forcefully

displaced downward and can vary from the slight depression to bones of the skull

being splintered and embedded within brain tissue.

A fracture of the base of the skull is refered to as a basilar skull fracture.
A fracture may be open, indicating a scalp laceration of tear in the dura (e.g.,from

bullet or an ice pick) or closed in case the dura is intact.

Clinical manifestations
Localized pain
Cranial vault may or may not produce swelling in the region of the fracture
Fracture of the base of the skull tend to traverse the paranasal sinus of the frontal

bone or the middle ear located in the temporal bone. Therefore, they frequently

produce hemorrhage from the nose, pharynx, or ears and blood may appear under

the conjuctiva.
An area of ecchymosis (bruising) may be seen over the mastoid (Battles sign).
Basillar skull fractures are suspected when CSF escapes from the ears (CSF

onorhea) and the nose (CSF rhinorhea).

Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical

Nursing 13th Edition. Philippines: Lippincott Williams & Wilkins. Pg. 1996

Medical Management

Test Purpose Nursing Management

Computed It is used to detect size Instruct the patient to take

Tomography and location of bone off some or all of the the

BRAIN INJURIES

(CT) Scan trauma. clothing and wear a hospital

gown.
Instruct the patient to remove

any metal objects, such as

beltor jewelry.
Intruct the patient to stop

eating for a few hours before

scan.

Magnetic Provides superior Patient may be asked not

Resonance information as compared to eat or drink anything

Imaging (MRI) to CT scans to confirm for 4-6 hours before the

diagnosis. scan.
Instruct the patient to

remove any metal

objects, such as beltor

jewelry.
Monitor the patient.

Position some trauma centers for Asked the patient if

emission assessing brain functions he/she has any allergies

tomography or adverse reactions to

(PET) medications.
If the patient is pregnant

or may be pregnant,

please tell to the doctor

or technologist.
Instruct the patient not to
BRAIN INJURIES

eat or drink anything,

except water, for 6 hours

before the exam. Patient

may drink water, as much

water as he/she can

would be helpful.

After the Procedure

Instruct the patient to

drink about 5 glasses of

water.
Nursing mothers should

wait for 24 hours before

resuming breast-feeding.
Asked the patient if

he/she feel any

symptoms such as nasal

congestion, itchy eyes,

hives, rashes, sneezing,

restlessness, tremors,

pain, nausea, vomiting,

dizziness, please notify

the physician

immediately.
BRAIN INJURIES

Common causes of secondary injury are cerebral edema, hypotension, and

respiratory depression that may lead to hypoxemia and electrolyte imbalance.

Treatment includes stabilization of cardiovascular and respiratory function.

Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical

Nursing 13th Edition. Philippines: Lippincott Williams & Wilkins. Pg. 1996

Medical management
Nondepressed skull fractures do not require surgical treatment, however, close

observation is essential.
Depressed skull fracture usually require surgery with elevation of the skull and

debridement, usually within 24 hrs of injury.

Associated injuries include concurrent scalp lacerations, dural tears, and brain

injury directly below the fracture from compression of the tissue below the bony

injury and from lacerartions produced by the bony fragments.

Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical

Nursing 13th Edition. Philippines: Lippincott Williams & Wilkins. Pg. 1997

BRAIN INJURY
The most important consideration in any head injury is whether the brain is

injured. Even seemingly minor injury can cause significant brain damage secondary to

obstructed blood flow and decreased tissue perfusion.

Closed (blunt) brain injury occurs when the head accelerates and then

rapidly decelerates or collides with another object (eg, a wall, the dashboard of a car)

and brain tissue is damaged but there is no opening through the skull and dura.
Open brain injury occurs when an object penetrates the skull, enters the

brain, and damages the soft brain tissue in its path (penetrating injury), or when blunt
BRAIN INJURIES

trauma to the head is so severe that it opens the scalp, skull, and dura to expose the

brain.
Traumatic brain injury (TBI) is a major cause of death and disability in the

United States, contributing to about 30% of all injury deaths.1 Every day, 138 people

in the United States die from injuries that include TBI. Those who survive a TBI can

face effects lasting a few days to disabilities which may last the rest of their lives.

Effects of TBI can include impaired thinking or memory, movement, sensation (e.g.,

vision or hearing), or emotional functioning (e.g., personality changes, depression).

These issues not only affect individuals but can have lasting effects on families and

communities.
Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical

Nursing 13th Edition. Philippines: Lippincott Williams & Wilkins. Pg. 1997

TYPES OF BRAIN INJURY

Concussion
A temporary loss of neurologic function with no apparent structural damage to

the brain. The mechanism of injury is usually blunt trauma from acceleration-

deceleration force, direct blow, or a blast injury.If brain tissue in the frontal lobe is

affected, the patient may experience bizzare behavior, whereas involvement of the

temporal bone can produce amnesia or disorientation.

Grades of Concussion

Grade of Symptoms Mental Status

Concussion

Grade 1 transient confusion duration of

no loss of
Concussion mental status
consciousness
abnormalities on

examination

resolve in less
BRAIN INJURIES

than 15 mins.

Grade 2 transient confusion concussion

no loss of
Concussion symptoms and
consciousness
mental status

abnormalities on

examination

resolve in more

than 15 mins.

Grade 3 there is any loss of last from seconds

Concussion consciousness to minutes.

Diagnostic studies may show no apparent structural sign of injury. The

duration of mental status is an indicator of the grade of the concussion. Monitoring

includes observing the patient decreased level of LOC, worsening headache,

dizziness, seizures, abnormal pupil response, vomiting, irritability, slurred speech, and

numbness or weakness of arms and legs.

CONTUSION
In cerebral contusion, a moderate to severe head injury, the brain is bruised

and damaged in a specific area because of severe acceleration-deceleration force or

blunt trauma.

Contusions are characterized:

Loss of consciousness associated with stupor and confusion.

BRAIN INJURIES

Tissue alteration and neurologic deficit without hematoma formation

Alteration in consciousness without localizing signs
Hemorrhage into the tissue that varies in size and is surrounded by edema.

The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours.

Temporal lobe contusions carry a greater risk of swelling, rapid deterioration, and

brain herniation. Deep contusions are more often associated with hemorrhage and

destruction of the reticular activating fibers altering arousal.

Diffuse Axonal Injury (DAI) results from widespread shearing and rotational

forces that produce damage throughout the brain to axons in the cerebral

hemispheres, corpus callosum, and brain stem. Associated with prolonged traumatic

coma. Clinically, with severe injury, the patient has no lucid intervals and experiences

immediate coma, decorticate and decerebrate posturing. Diagnosis is made by clinical

signs in conjunction with a CT scan or MRI.

Intracranial hemorrhage

Collections of blood in the brain, that may be epidural (above the dura), subdural

(below the dura), or intracerebral (within the brain).

Major symptoms are frequently delayed until the hematomas is large enough to

cause distortion of the brain and increased ICP.

The sign and symptoms of cerebral ischemia resulting from compression by a

hematoma are variable and depend on the speed with which the vital area are

affected and the area is injured.

Epidural Hematoma
After a head injury, blood may collect in the epidural (extradural) space

between the skull and the dura. This can result from a skull fracture that causes a

rupture or laceration of the middle meningeal artery, the artery that runs between the

dura and the skull inferior to a thin portion of temporal bone. Symptoms are caused by
BRAIN INJURIES

the expanding hematoma. Usually, there is a momentary loss of consciousness at the

time of injury, followed by an interval of apparent recovery (lucid interval).

During the lucid interval, compensation for the expanding hematoma takes

place by rapid absorption of CSF and decreased intravascular volume, both of which

help maintain a normal ICP. Treatment consists of making openings through the skull

(burr holes) and Craniotomy.

Subdural hematoma
Is a collection of blood between the dura and the brain. The most common

cause of subdural hematoma is trauma, but it may also occur from coagulopathies or

rupture of an aneurysm. A subdural hemorrhage is more frequently venous in origin

and is due to the rupture of small vessels that bridge the subdural space. A subdural

hematoma may be acute, subacute, or chronic.

Intracerebral hemorrhage
Bleeding into the parenchyma of brain. Commonly seen in head injuries when

force is exerted to the head over a small area (e.g., missile injures, bullet wounds, stab

injuries)
These hemorrhages within the brain may result from the ff:

Systemic hypertension, which causes degeneration and ruptured of

vessels
Ruptured of aneurysm
Vascular anomalies
Intracranial tumors
Bleeding disorders
Complication of anticoagulant therapy

The onset may be insidious, beginning with the development of neurologic deficit

followed by headache.
Management includes supportive care, control of ICP and careful administration

of fluids, electrolytes and antihypertensives medications.

Craniotomy is a surgical removal of part of the bone from the skull to expose the

brain. Specialized tools are used to remove the section of bone called the bone flap.
BRAIN INJURIES

The bone flap is temporarily removed, then replaced after the brain surgery has been

done.
Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical

Nursing 13th Edition. Philippines: Lippincott Williams & Wilkins. Pg. 1998-2000
BRAIN INJURIES
Assessment

Assessment
Acute and Subacute Subdural Hematoma
Acute subdural hematomas are associated with major head injury involving

contusion.
Signs and symptoms:

changes in the level of consciousness (LOC),

pupillary signs
hemiparesis.
There may be minor or even no symptoms with small collections of blood.
Coma
increasing blood pressure, decreasing heart rate
slowing respiratory rate
Subacute subdural hematomas

Subacute subdural hematomas are the result of less severe contusions and head

trauma. Clinical manifestations usually appear between 48 hours and 2 weeks after

the injury. Signs and symptoms are similar to those of an acute subdural hematoma.
If the patient can be transported rapidly to the hospital, an immediate craniotomy

is performed to open the dura, allowing the subdural clot to be evacuated. Successful

outcome also depends on the control of ICP and careful monitoring of respiratory

function.
Chronic Subdural Hematoma
Chronic subdural hematomas can develop from seemingly minor head injuries

and are seen most frequently in the elderly. The elderly are prone to this type of head

injury secondary to brain atrophy, which is a frequent consequence of the aging

process. Seemingly minor head trauma may produce enough impact to shift the brain

contents abnormally. The time between injury and onset of symptoms can be lengthy

(eg, 3 weeks to months), so the actual injury may be forgotten.

CLINICAL MANIFESTATIONS

severe headache, which tends to come and go;

alternating focal neurologic signs;
BRAIN INJURIES
Assessment
personality changes;
mental deterioration;
focal seizures.

The patient may be labeled neurotic or psychotic if the cause is overlooked.

Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical

Nursing 13th Edition. Philippines: Lippincott Williams & Wilkins. Pg. 2001
Brain Death
The nurse may assist in the clinical examination for determination of brain death

and in process of organ procurement. All 50 states is recognize the Uniform

Determination Of Death Act that indicates irreversible loss of brain function,

including the brain stem.

Cardinal signs of brain death:

Coma
Absence of brain stem
Reflexes
Apnea

Adjunctive tests, such as cerebral blood flow studies, electroencephalogram (EEG),

transcranial Doppler, and brain stem auditory evoked potential, are often used to

confirm brain death. The health care team provides information to the family and

assists them with the decision making process about end-of-life care.
Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical Nursing

13th Edition. Philippines: Lippincott Williams & Wilkins. Pg. 2001

Name of Dosage Classification Indication/Co Mode of Nursing

Drug ntraindication Action Responsibil

ty

Generic 2-4mg CNS agent, Indication: Antiaxiety -Do not

Used for
Name: (0.5mg/k anxyolytic, agent that Drive or
paresthetic
BRAIN INJURIES
Assessment

Lorazepa g) at sedative- medication to also causes engage in

m least 2hrs hypnotic, produce mild dangerous

Brand
before benzodiazepin sedstion and to supression activities
Name:
Ativan the e reduce anxiety of REM untill full

surgery and recall of sleep, while effects of

IV-
events related increasing drugs is
0.044mg/
to day of total time known
kg up to -Dot drink
surgery, for
2mg 15- large
management of
20 min amounts of
status
before coffee,
epilepticus.
surger Side anxiolytic

Effects:Drowsi effect can be

ness,sedation, altered
-Do not
weakness,
consume
Sleep
alcohol for
disturbances,
atleast 24-
Halluciantions
48 hours

after an

injection,

avoid when

taking orally
-Do not stop

abruptly the

medication,
BRAIN INJURIES
Assessment

stop

gradually to

avoid

withdrawal

symptoms
-Do not self

medicate

with OTC

drugs
Reference:h

ttps://www.s

cribd.com/d

oc/104041/

Ativan

Name of Dosage Classification Indication/Co Mode of Nursing

Drug ntraindication Action Responsibil

ty

Generic 1mg/ IV Anxiolytic/Hy Indication: Increased -Assess

Sedating
Name: pnotic, CNS level of
antidepressants,
Midazola Sedatives, depression sedation and
antiepileptic
m Anticonvulsa with level of
Brand drugs such as
nt alcohol, consciousne
Name: phenobarbital
Versed Contraindicatio opiods, ss

n: barbiturates throughout
Acute narrow-
other and for 2-6
BRAIN INJURIES
Assessment

angle sedatives hr following

glaucoma; and administrati

coma patients anesthetics. on

-Monitor
in shock; acute
BP, pulse,
alcoholic
and
intoxication;
respiration
intrathecal and
continously
epidural admin.
during IV

administrati

on
-Maintain

patent

airway and

assists

ventilation

as needed. If

hypertention

occurs,

treatment

includes IV

fluids

repositionin

g and

vasopressors
BRAIN INJURIES
Assessment

.
-The effects

of

midazolam

can be

reversed

with

flumazeni

Name of Dosage Classification Indication/Co Mode of Nursing

Drug ntraindication Action Responsibil

ty

Generic 40mg by sedative- Indication: Short acting -Monitor

Induction and
Name: injection hypnotic anesthetic HR, ECG,
maintenace of
Propofol or agent given for Pulse Oxi,
Brand general
infusion induction BP
Name: anesthesia and -Abrupt
Diprifol every 10 and
used for discontinuat
seconds maintenance
sedation ion of
Contraindicatio of general
infusion
n: anesthesia
Electroconvulsi may result

ve therapy in rapid

obstetics, awakening

Pregnancy, with

Hypotensive agitation,
BRAIN INJURIES
Assessment

patients anxiety
Discard

tubing bottle

after 12hrs
-Maintain

strict aseptic

technique
-document

neuro

assessment

on

awakening

Supportive measures
Ventilatory support, seizures prevention, fluid and electrolyte maintenance,

nutritional support, and management of pain and anxiety.

Patient who are comatose are intubated and mechanically ventilated to ensure

adequate oxygenation and protect airway.

Antiseizure may be administered
If the patient is agitated, benzodiazepines are the most commonly used

sedative agents and do not affect cerbral blood flow or ICP.

Lorazepam and midazolam are used but have active metabolites that may

cause prolonged sedation, making it diffucult to conduct a neurologic

assessment
Propofol a sedative-hypnotic agent that supplied in an intralipid emulsion for

intravenous use, is the sedative of choice.

BRAIN INJURIES
Assessment
A nasogastric tube may be inserted, because reduced gastric motility and

reversed peristalsis are associated with head injuries, making regurgitation and

aspiration common in the first few hours.

Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical Nursing

13th Edition. Philippines: Lippincott Williams & Wilkins. Pg. 2001

BRAIN INJURIES
Assessment

Nursing Diagnosis
Ineffective airway clearance and impaired gas exchange related to brain injury
Risk for ineffective cerebral tissue perfusion related to increased ICP, decreased

CPP, and possible seizures

Deficient fluid volume related to decreased LOC and hormonal dysfunction
Imbalanced nutrition: less than body requirements related to increased metabolic

demands, fluid restriction, and inadequate intake

Risk for injury related to seizures, disorientation, restlessness, or brain damage
Risk for imbalanced body temperature related to damaged temperature-regulating

mechanisms in the brain

Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia,

immobilty, restlessness
Ineffective coping related to brain injury
Disturbed sleep pattern related to brain injury and frequent neurologic checks

Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical Nursing

13th Edition. Philippines: Lippincott Williams & Wilkins. Pg. 2002

BRAIN INJURIES
Nursing Diagnosis
 BRAIN INJURIES
Nursing Management

Nursing Management
Maintaining Body Temperature
Monitor temperature every 2 to 4 hours.
If temperature rises, try to identify the cause and administer acetaminophen and

cooling blankets as prescribed to achieve normothermia.

Monitor for infection related to fever.
Maintaining Skin Integrity

Assess all body surfaces, and document skin integrity every 8 hours.
Turn patient and reposition every 2 hours.
Provide skin care every 4 hours.
Assist patient to get out of bed three times a day (when appropriate).

Improving Cognitive Functioning

Develop patients ability to devise problem-solving strategies through cognitive

rehabilitation over time; use a multidisciplinary approach.

Be aware that there are fluctuations in orientation and memory and that these

patients are easily distracted.

Do not push to a level greater than patients impaired cortical functioning allows

because fatigue, anger, and stress (headache, dizziness) may occur; the Rancho

Los Amigos Level of Cognitive Function scale is frequently used to assess

cognitive function and evaluate ongoing recovery from head injury.

Preventing Sleep Pattern Disturbance

Group nursing activities so that patient is disturbed less frequently.

Decrease environmental noise, and dim room lights.

Provide strategies (eg, back rubs) to increase comfort.
BRAIN INJURIES
Nursing Management
Supporting Family Coping

Provide family with accurate and honest information.

Encourage family to continue to set well-defined, mutual,short-term goals.
Encourage family counseling to deal with feelings of loss and helplessness, and

provide guidance in the management of inappropriate behaviors.

Refer family to support groups that provide a forum for networking, sharing

problems, and gaining assistance in maintaining realistic expectations and hope.

The Brain Injury Association provides information and other resources.

Assist patient and family in making decisions to end life support and permit

donation of organs.

Monitoring and Managing Potential Complications

Take measures to control CPP (eg, elevate the head of the bed and increase

intravenous [IV] fluids).

Take measures to control ICP
Monitor for a patent airway, altered breathing pattern, and hypoxemia and

pneumonia. Assist with intubation and mechanical ventilation.

Provide enteral feedings, IV fluids and electrolytes, or insulin as prescribed.
Initiate PN as ordered if patient is unable to eat.
Assess carefully for development of posttraumatic seizures.

Controlling Intracranial Pressure in Patients With Severe Brain Injury

Promoting Home- and Community-Based Care

TEACHING PATIENTS SELF-CARE

Reinforce information given to family about patients condition and prognosis

early in the course of head injury.

BRAIN INJURIES
Nursing Management
As patients status changes over time, focus teaching on interpretation and

explanation of changes in patients responses.

Instruct patient and family about limitations that can be expected and

complications that may occur if patient is to be discharged.

Explain to the patient and family, verbally and in writing, how to monitor for

complications that merit contacting the neurosurgeon.

Teach about self-care management strategies, if patients status indicates.
Instruct about side effects of medications and importance of taking them as

prescribed.

CONTINUING CARE
Encourage patient to continue rehabilitation program after discharge.

Improvement

may take 3 or more years after injury, during which time the family and their

coping skills need frequent assessment.

Encourage patient to return to normal activities gradually.

Remind the patient and family of the need for continuing health promotion and

screening practices after the initial phase of care.

Others (Nursing Management)

Motor Function
Observing spontaneous movements, asking the patient to raise and lower the

extremities, and comparing the strength and equality of the hand grasp and pedal

push at periodic intervals.

The nurse assesses lower extremity motor strength (pedal push)
The presence or absence of spontaneous movement of each extremity is also

noted, and speech and eye signs are assessed.

BRAIN INJURIES
Nursing Management
Reference: Hinkle, J. & Cheever, K. 2014. Brunner and Suddarths Textbook of Medical-Surgical

Nursing 13th Edition. Philippines: Lippincott Williams & Wilkins.