Nursing Care of Head Injury
Posted on April 20, 2010 | No Comments on Nursing Care of Head Injury
- 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
- 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.