Nursing Care Plan For Acute Head Injury
Nursing Care Plan For Acute Head Injury
Nursing Care Plan For Acute Head Injury
The management or nursing care plan (NCP) for patient with an acute head injury are divided on the several levels
including prevention, pre-hospital care, immediate hospital care, acute hospital care, and rehabilitation.
In order to give accurate nursing care plan to the patients, The nurses should understand the principles behind medical
treatments. It focuses on the evidence based practice that nurses use in assessing, intervening and managing a severe
head injury.
A. Assessment Findings on Acute Head Injury
Possible causes of acute head injury are assault, automobile accident, blunt trauma, fall and penetrating trauma. The
medical team should be perform serious and critical care to handle this cases, So that they can finding correct
assessment may happened to the patients such as:
To quickly asses a patient's level of consciousness and to uncover baseline change, use the Glasgow Coma Scale. If the
patient has already applied with an endotracheal tube and can't response verbally, use the abbreviation "T" score.
B. Diagnostic Evaluation for Acute Head Injury
The doctors are who responsible to the patient in the emergency department, they will order some examination trough
CT scan or MRI (possible for hemorrhage, cerebral edema, or shift of midline structure), EEG (may reveal seizure
activity), ICP monitoring (possible increased of ICP) and skull X-ray (may be fracture).
1. Assest neurologic and respiratory status to monitor for sign of increased ICP and respiratory distress
2. Monitor and record vital sign and intake and output, hemodynamic variables, ICP, cerebral perfusion
pressure, specific gravity, laboratory studies, and pulse oximetry to detect early sign of compromise.
3. Observe for sign of increasing ICP to avoid treatment delay and prevent neurologic compromise
4. Assess for CSF leak as evidenced by otorhea or rinorrhea. CSF leak could leave the patient at risk for infection
5. Assess for pain. Pain may cause anxiety and increase ICP
6. Check cough and gag reflex to prevent aspiration
7. Check for sign of diabetes insipidus (low urine specific gravity, high urine output) to maintain hydration
8. Administer I.V fluids to maintain hydration
9. Administer Oxygen to maintain position and patency of endotracheal tube if present, to maintain airway and
hyperventilate the patient and to lower ICP
10. Provide suctioning; if patient is able, assist with turning, coughing, and deep breating to prevent pooling of
secretions
11. Maintain postion, patency and low suction of NGT to prevent vomiting
12. Maintain seizure precautions to maintain patient safety
13. Administer medication as prescription to decrease ICP and pain
14. Allow a rest period between nursing activities to avoid increase in ICP
15. Encourage the patient to express feeling about changes in body image ot allay anxiety
16. Provide appropriate sensory input and stimuli with frequent reorientation to foster awarness of the
environtment
17. Provide means of communication, such as a communcation board to prevent anxiety
18. Provide eye, skin, and mouth care to prevent tissue damage
19. Turn the patient every 2 hours or maintain in a rotating bed if condition allows to prevent skin breakdown.