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.
CARE SETTING
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.
RELATED CONCERNS
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.
ACTIVITY/REST
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
CIRCULATION
May exhibit: Normal or altered BP (hypotension or hypertension)
Changes in heart rate (bradycardia, tachycardia alternating with bradycardia, other dysrhythmias)
EGO INTEGRITY
May report: Behavior or personality changes (subtle to dramatic)
May exhibit: Anxiety, irritability, delirium, agitation, confusion, depression, impulsivity
ELIMINATION
May exhibit: Bowel/bladder incontinence or dysfunction
FOOD/FLUID
May report: Nausea/vomiting, changes in appetite
May exhibit: Vomiting (may be projectile)
Swallowing problems (coughing, drooling, dysphagia)
NEUROSENSORY
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)
PAIN/DISCOMFORT
May report: Headache of variable intensity and location (usually persistent/long-lasting)
May exhibit: Facial grimacing, withdrawal response to painful stimuli, restlessness, moaning
RESPIRATION
May exhibit: Changes in breathing patterns (e.g., periods of apnea alternating with hyperventilation)
Noisy respirations, stridor, choking
Rhonchi, wheezes (possible aspiration)
SAFETY
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
SOCIAL INTERACTION
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
TEACHING/LEARNING
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.
DIAGNOSTIC STUDIES
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.
NURSING PRIORITIES
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.
DISCHARGE GOALS
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.
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.
CARE SETTING
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.
RELATED CONCERNS
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.
ACTIVITY/REST
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
CIRCULATION
May exhibit: Normal or altered BP (hypotension or hypertension)
Changes in heart rate (bradycardia, tachycardia alternating with bradycardia, other dysrhythmias)
EGO INTEGRITY
May report: Behavior or personality changes (subtle to dramatic)
May exhibit: Anxiety, irritability, delirium, agitation, confusion, depression, impulsivity
ELIMINATION
May exhibit: Bowel/bladder incontinence or dysfunction
FOOD/FLUID
May report: Nausea/vomiting, changes in appetite
May exhibit: Vomiting (may be projectile)
Swallowing problems (coughing, drooling, dysphagia)
NEUROSENSORY
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)
PAIN/DISCOMFORT
May report: Headache of variable intensity and location (usually persistent/long-lasting)
May exhibit: Facial grimacing, withdrawal response to painful stimuli, restlessness, moaning
RESPIRATION
May exhibit: Changes in breathing patterns (e.g., periods of apnea alternating with hyperventilation)
Noisy respirations, stridor, choking
Rhonchi, wheezes (possible aspiration)
SAFETY
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
SOCIAL INTERACTION
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
TEACHING/LEARNING
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.
DIAGNOSTIC STUDIES
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.
NURSING PRIORITIES
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.
DISCHARGE GOALS
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.
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