NCP Craniocerebral Trauma (Acute Rehabilitative Phase)

Craniocerebral trauma, also called head or brain injury (open or closed), includes skull fractures, brain concussion, cerebral contusion/laceration, and hemorrhage (subarachnoid, subdural, epidural, intracerebral, brainstem). Primary injury occurs from a direct or indirect blow to the head, causing acceleration/deceleration of the brain. Secondary brain injury results from diffuse intracerebral axonal injury, intracranial hypertension, hypoxemia, hypercapnia, or systemic hypotension. Cerebral concussion is the most common form of head injury.

Consequences of brain injury range from no apparent neurological disturbance to a persistent vegetative state or death. Therefore, every head injury must be considered potentially dangerous.


This plan of care focuses on acute care and acute inpatient rehabilitation. Brain injury care for those experiencing moderate to severe trauma progresses along a continuum of care, beginning with acute inpatient hospital care andinpatient rehabilitation to subacute and outpatient rehabilitation, as well as home- and community-based services.


Cerebrovascular accident (CVA)/stroke

Psychosocial aspects of care

Seizure disorders/epilepsy

Surgical intervention

Thrombophlebitis: deep vein thrombosis

Total nutritional support: parenteral/enteral feeding

Upper gastrointestinal/esophageal bleeding

Patient Assessment Database

Data depend on type, location, and severity of injury and may be complicated by additional injury to other vital organs.


May report: Weakness, fatigue, clumsiness, loss of balance

May exhibit: Altered consciousness, lethargy

Hemiparesis, quadriparesis

Unsteady gait (ataxia); balance problems

Orthopedic injuries (trauma)

Loss of muscle tone, muscle spasticity


May exhibit: Normal or altered BP (hypotension or hypertension)

Changes in heart rate (bradycardia, tachycardia alternating with bradycardia, other dysrhythmias)


May report: Behavior or personality changes (subtle to dramatic)

May exhibit: Anxiety, irritability, delirium, agitation, confusion, depression, impulsivity


May exhibit: Bowel/bladder incontinence or dysfunction


May report: Nausea/vomiting, changes in appetite

May exhibit: Vomiting (may be projectile)

Swallowing problems (coughing, drooling, dysphagia)


May report: Loss of consciousness, variable levels of awareness, amnesia surrounding trauma events

Vertigo, syncope, tinnitus, hearing loss

Tingling, numbness in extremity

Visual changes, e.g., decreased acuity, diplopia, photophobia, loss of part of visual field

Loss of/changes in senses of taste or smell

May exhibit: Alteration in consciousness from lethargy to coma

Mental status changes (orientation, alertness/responsiveness, attention, concentration,

problem solving, emotional affect/behavior, memory)

Pupillary changes (response to light, symmetry), deviation of eyes, inability to follow

Loss of senses, e.g., taste, smell, hearing

Facial asymmetry

Unequal, weak handgrip

Absent/weak deep tendon reflexes

Apraxia, hemiparesis, quadriparesis

Posturing (decorticate, decerebrate); seizure activity

Heightened sensitivity to touch and movement

Altered sensation to parts of body

Difficulty in understanding self/limbs in relation to environment (proprioception)


May report: Headache of variable intensity and location (usually persistent/long-lasting)

May exhibit: Facial grimacing, withdrawal response to painful stimuli, restlessness, moaning


May exhibit: Changes in breathing patterns (e.g., periods of apnea alternating with hyperventilation)

Noisy respirations, stridor, choking

Rhonchi, wheezes (possible aspiration)


May report: Recent trauma/accidental injuries

May exhibit: Fractures/dislocations

Impaired vision, visual field disturbances, abnormal eye movements

Skin: Head/facial lacerations, abrasions, discoloration, e.g., raccoon eyes. Battle’s sign around ears (trauma signs)

Drainage from ears/nose (CSF)

Impaired cognition

Range of motion (ROM) impairment, loss of muscle tone, general strength; paralysis

Fever, instability in internal regulation of body temperature


May exhibit: Expressive or receptive aphasia, unintelligible speech, repetitive speech, dysarthria, anomia

Difficulty dealing with noisy environment, interacting with more than one or two individuals at a time

Changes in role/family structure related to illness/condition


May report: Use of alcohol/other drugs

Discharge plan

DRG projected mean length of inpatient stay: 17.1 days (inclusive/multiple care setting)

May require assistance with self-care, ambulation, transportation, food preparation, shopping, treatments, medications, homemaker/maintenance tasks; change in physical layout of home or placement in living facility other than home

Refer to section at end of plan for postdischarge considerations.


CT scan (with/without contrast): Screening image of choice in acute brain injury. Identifies space-occupying lesions, hemorrhage, skull fractures, brain tissue shift.

MRI: Uses similar to those of CT scan but more sensitive than CT for detecting cerebral trauma, determining neurologic deficits not explained by CT, evaluating prolonged interval of disturbed consciousness, defining evidence of previous trauma superimposed on acute trauma.

Cerebral angiography: Demonstrates cerebral circulatory anomalies, e.g., brain tissue shifts secondary to edema, hemorrhage, trauma.

Serial EEG: May reveal presence or development of pathological waves. EEG is not generally indicated in the immediate period of emergency response, evaluation, and treatment. If the patient fails to improve, EEG may help in diagnostic evaluation for seizures, focal or diffuse encephalopathy.

X-rays: Detect changes in bony structure (fractures), shifts of midline structures (bleeding/edema), bone fragments.

Brainstem auditory evoked responses (BAER): Determines levels of cortical and brainstem function.

PET/SPECT tomography: Detects changes in metabolic activity in the brain and may be used for differentiation of head injuries. (These procedures are not in widespread clinical use, but are more often used for research.)

Audiometry, otology, and vestibular function tests: Diagnostic procedures that identify hearing loss, reasons for balance problems, and/or eighth cranial nerve dysfunction.

Lumbar puncture and CSF analysis: May be performed in patient with suspected or known increased intracranial pressure when CT or MRI is not diagnostic. Generally contraindicated in acute trauma.

ABGs: Determines presence of ventilation or oxygenation problems that may exacerbate/increase intracranial pressure.

Serum chemistry/electrolytes: May reveal imbalances that contribute to increased intracranial pressure (ICP)/changes in mentation.

Toxicology screen: Detects drugs that may be responsible for/potentiate loss of consciousness.

Serum anticonvulsant levels: May be done to ensure that therapeutic level is adequate to prevent seizure activity.


1. Maximize cerebral perfusion/function.

2. Prevent/minimize complications.

3. Promote optimal functioning/return to preinjury level.

4. Support coping process and family recovery.

5. Provide information about condition/prognosis, potential complications, treatment plan, and resources.


1. Cerebral function improved; neurological deficits resolving/stabilized.

2. Complications prevented or minimized.

3. Activities of daily living (ADLs) needs met by self or with assistance of other(s).

4. Family acknowledging reality of situation and involved in recovery program.

5. Condition/prognosis, complications, and treatment regimen understood and available resources identified.

6. Plan in place to meet needs after discharge.