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Nursing Care of Head Injury

Posted on April 20, 2010 | No Comments

Emergency Care

  • First consideration is to ensure a clear airway
  • Keep spine straight; patient is carefully turned to a lateral or semiprone position
  • Flexion or hypertension should be avoided in case there is a cervical fracture
  • Keep patient covered, quiet and undistrubed

General Care:

  • Establish airway
  • Prevent aspiration pneumonia
  • Check for cardiovascular complications
  • Serach for new evidence of spinal injuries. Do not allow the newly injured patient to move about even though he/she is conscious.
  • Observe the skull and scalp injuries. cover open head wound with the cleanest material avaialble at the scene
  • Prevent infection. Gove prophylactic dose for tetanus.
  • Observe for CSF leakage – otorrhea, rhinorrhea, Battle’s sign-tenderness and eccymosis or mastoid bone especially for basilar skull fracture
  • Obeserve for signs and symptoms of increased ICP; watch for nuclear rigidity.
  • Control restlessness and pain. Narcotics are contraindicated following head injury, and are not given if ICP is prevent.
  • Maintain fluid/electrolyte; acid-base balance and adequate nutrition. Record I & O.

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