HomeNursingNursing CareplansNursing homes and plans HEAD INJURY

Nursing homes and plans HEAD INJURY

Nursing homes and plans HEAD INJURY

Head injuries aimed at a variety of trauma on the scalp, skull, or brain, including konkusio (most often), cerebral contusions or tears, fractures, and vascular injury (epidural and subdural hematoma). Types include linear skull fractures (more often in children), depression, compound (ties between rips the scalp and brain), and basic (including the base of the skull or skull base).
Complications of head injury may include increased intracranial pressure (ICP), epidural or subdural hemorrhage, and cerebral edema. Prognosis depends on the severity of injury and duration of coma.
Treatment includes giving IV fluids, anti-seizure, and steroids
Therefore, because no selamnya show signs of injury when there is, it would require strict monitoring at 24 to 48 hours after head trauma. Recording during a fall or an accident is an important part to dilakji and the threat of injury to the spinal.
Nerve supply

Keasadaran disorders in different periods
Headache (post-konkusiuo syndrome)
Reflex depression
General weakness


Decrease in respiration



Cerebral contusion
Contusion severity depends on the extent of brain injury, the amount of cerebral edema, and the amount of bleeding.
Nerve supply

Kemungjkinan loss of consciousness
Mild weakness and sensory motor
Post-traumatic seizures (sign up).

Skull fracture
Nerve supply

Changes in skull shape
Bleeding kojuntiva (berhubunganb with anterior fossa fracture)
Cerebrospinal fluid (CSF) rinorrhea
Periorbital bruising (raccoon eyes)
CSF otorrhea
Cranial nerve paralysis in C1, C7, and C8
Post-traumatic seizures (sign up)


Hipovolumia (associated with fractures above the sinus sagitalis or lateral).


Bruising on the basis of the neck (related to the fracture of the skull base and mastoid fracture above the bulge).

Epidural hematoma
The signs and symptoms of epidural hematoma occurred after the onset awake and conscious.
Nerve supply

A temporary loss of consciousness
Headache suddenly
Decreased level of consciousness (LOC)
Unilateral pupil dilation, dilatation pupl bilaterally (jikatidak decompression).
Decerebrate posturing (sign lanjut0


Respiratory Depression




Throw up

Acute subdural hematoma
Acute subdural hematoma usually occurs with common symptoms, although signs and symptoms of cerebral lacerations, contusions or hematomas inraserebral also can be noted.
Nerve supply

Loss of consciousness
Local Seizures
Unilateral pupillary dilatation
Drowsiness and confusion
Progressive decline in thinking.

Chronic subdural hematoma
Nerve supply

A progressive decline in the LOC (may occur several weeks or months as a result of a relatively minor injury).
Nuchal rigidity
Ipsilateral pupil dilation
Strain or bulging fontanel (in infants)
Increased head circumference size
Refkels hyperactive
Slight fever


Throw up

Eyes, ears, nose, and throat

Retinal hemorrhage.

Nursing Diagnosis
Ineffective breathing pattern (with the potential failure of breath) are associated with increased ICP
Expected results
Children will maintain adequate respiratory effort and gas exchange is characterized by breathing patterns based on their age, PaO2 80 to 100 mm Hg, PaCO2 of 25 to 30 mm Hg, and pink mucous membranes.
1. Keep the airway open with the child’s neck straight after servical vertebral fractures repaired. Do not do hyperextension of the neck.
2. Replace the oral airway
3. Anticipate needs endotrachea intubation if the child has increased dyspnea.
4. Elevate the head of the child on the bed 30 degrees after spinal cord injury repair.
5. pairs of nasogastric tube or orogastric tube.
6. Mucus suctioning only as directed; given oxygen before after suction.
7. Monitor the child’s breathing frequency, kledalaman, and the pattern of breath every hour until she was stable.
8. Monitor blood gas analysis (AGD) are likely to show an abnormal degree.
1. Aligning the head kembantu reduce upper airway obstruction. Hyperextension can press the trachea.
2. Through oral airway to help prevent airway obstruction in children with decreased LOC.
3. Intubation is required to provide mechanical ventilation to maintain adequate gas exchange.
4. Elevation of the head on the bed to help maximize the reduction diapragma, assist ventilation efforts.
5. Installation of the hose will reduce teknan in the stomach, which will reduce the vomiting and aspiration. In the state of the skull base fracture, only orogastric tube can be done because the risk of infection from an open pathway from the brain, especially if the child was increasing spending CSF through the nose
6. Suction reduced because it can increase ICP. (Note: suction through a nasal fracture of the skull base is contraindicated because it is risky opening track on the brain).
7. Abnormal breathing pattern can reduce the efficiency and the widespread influence of respiratory gas exchange.
8. PaO2 levels may be at 25 to 30 mm Hg cause terjadsinya vaskonstriksi at the bottom of cerebral blood volume, will reduce the increase in ICP. (Levels less than 20 mm Hg can cause severe vasoconstriction, increase the occurrence of lactic acidosis and as a result of brain ischemia).
Nursing Diagnosis
Impaired peripheral tissue perfusion associated with hypotension due to shock hipovolumik.
Expected results
Children will maintain adequate tissue perfusion is characterized by strong peripheral pulses, kestremitas warm, body temperature less than 100 º F (37.8 º C), capillary filling time of 3 to 5 seconds, the blood pressure in accordance with tiungkat age.
1. Monitor vital signs every hour, and check the warmth of the extremities, capillary refill speed, strong pulse, and pink nails.
2. monitor central venous pressure and systemic arterial pressure every hour if the child using invasive monitoring
3. Give blood products, colloid fluids, or IV fluids, as instructed.
1. Increased tenperatur rectal and skin temperature can indicate decreased systemic perfusion is poor, probably as signs hipovolumia. Fever may indicate epidural hematoma. Cold pressure increases oxygen consumption and produce peripheral vasoconstriction. Shock can cause hypotension, tachycardia followed by bradycardia, and increased respiratory frequency.
2. Hypotension occurred as a result of brain injury due to cerebral ischemia. Central venous pressure and systemic arterial pressure to reduce hypotension.
3. Fluids help to increase the volume of fluid circulation. Hypotonic fluid is usually not given because it can increase the addition of extracellular fluid. Hipovolumia as a result of bleeding.
Nursing Diagnosis
Risk reduction in fluid volume associated with nausea and vomiting.
Expected results
Children will maintain adequate hydration is characterized by moist mucous membranes, good skin turgor, and electrolyte levels sesduai age level.
1. monitor fluid intake and output every 2 to 8 hours, depending on the results of urine specific gravity at every 8 hours.
2. Weigh the child’s weight every day, and assess skin turgor and mucous membranes every 8 hours.
1. Increased urine concentration may indicate reduction in fluid.
2. weight loss, poor skin turgor and dry mucous membranes indicated a decrease of fluid.
Nursing Diagnosis
Risk of injury associated with LOC disruption due to head injury or increased ICP (or both).
Expected results
Anaka will not show any signs due to injury.
1. Assess the child’s circumstances neuroligs every hour for 8 hours first, then sesduai instructions below:
· Disorders LOC, such as reduced response to pain stimulus, impaired pupillary response, decreased reflexes, and seizures.
· Unilateral pupillary dilatation, did not react, or the pupil resides.
· Decrease aktiiftas motor.
2. Tandfa monitor vital signs of children every hour (until stabilized) there is a sign of tachycardia, bradycardia, hypotension, pulse pressure, decreased respiratory frequency.
3. Maintain cerebral perfusion pressure above 50 mm Hg memalui CSF fluid flow through the flow of intracranial pressure in order to reduce pressure.
4. Provide rest periods between nursing intervention or treatment.
5. Give IV lidocaine (xylocaine) or other analgesic, as instructed, before making interventions such as suctioning mucus kemanyaman disturbing.
6. Give diuretics, including mannitol (Osmitrol) and furosemide (Lasix), as directed. Monitor the balance of electrolytes, especially potassium.
7. Monitor the flow of fluid from hisdung and ears. Perform glucose by reagent strip of fluid flowing from the nose or ears.
1. LOC disorders may indicate increased ICP. Unilateral pupil dilation, the pupil who does not react, or settle an indication of emergency such as occurrence of anoksia brain. Inappropriate motor responses, such as decreased reflexes, decreased response to stimuli, or seizures, may indicate brain damage.
2. These signs can indicate Cushing’s syndrome (rare in children), as a result of using steroids as a treatment of cerebral edema.
3. Cerebral perfusion pressure, which measured blood alairan brain, must be maintained to prevent ischemia.
4. Adequate rest helps prevent the increase in ICP.
5. Giving analgesics prior to suctioning mucus or actions that cause discomfort will reduce siriko stimulation of children, will increase ICP.
6. This treatment helps reduce ICP by monitoring the volume of liquid in the chamber osmotic serebral.Diuretik such as mannitol, influential force fluid from the brain extracellular space into the bloodstream. Because of a rebound effect can occur can occur on average 6 hours after treatment was stopped. Nonosmotik diuretics such as furosemide sitemik blood flow through the bottom of renal activity, lowering the volume of cerebral fluid. Diuretics can cause electrolyte imbalance, particularly reduced levels of potassium, which can trigger arrhythmias.
7. CSF with a positive glucose test, which flows through the nose and ears.
Nursing Diagnosis
Decrease in cardiac output associated with bleeding.
Expected results
Children will maintain adequate cardiac output by heart rate ditadai appropriate age level, blood pressure, and hematocrit; pink mucous membranes, strong pulse, time poengisian capillary 3 to 5 seconds.
1. Monitor the child’s vital signs every hour until the first 8 hours, as instructed.
2. Review assessment every 8 hours Fisk associated with bleeding, such as interference with the shape of the skull, the expenditure of blood or external hematoma, bleeding from the ears, or changes in LOC. Report the signs immediately.
Children may experience tachycardia or hypotension, both of which are physiological responses to hemorrhage.
Physical findings of bleeding may be significant for the decrease in circulating volume.
Nursing Diagnosis
Risk of injury due to seizures.
Expected results
Children will not show any signs of injury characterized by maintaining the function akitifitas nerurologis despite having seizures (approximately 10% of children with cerebral contusion showed akitifitas seizures that began several hours or several years after injury.
1. Prevent the occurrence of seizures, including setting up equipment easily artificial airway and suctioning of mucus and pairs of side rails and bearings.
2. Give anticonvulsant medications as directed.
1. Therefore kerjang can cause the child to fall, suffered head trauma, anoksia, choking, and probably to die, prevention is needed to help prevent injury and risk of complications.
2. Treatment with anticonvulsants to help control the seizures.
Nursing Diagnosis
Pain associated with head trauma.
Expected results
Children will show marked decreases discomfort revealed reduced pain or no pain and maintain vital signs within limits according to age.
1. Assess the child’s complaints of pain, note the location of pain, duration, and severity. Juka review vital signs, note the increase in pulse rate, increase or decrease the frequency of breath and sweating. In order to reduce the pain robah child lying position, kuirangi stimulation, and provide pain medication.
2. less the amount of light, noise, and various other environmental stimuli in the child’s room.
1. Assessment of pain is needed, especially in children who are still easy to express ketidaknyamannya. Pain occurs due to increased ICP due to hypoventilation and Valsalva maneuvers. Increased frequency pulse, or sweating indicate discomfort.
2. Stimulus may interfere with children who have head trauma because stimulation would improve neurological irritability, a lowered pain tolerance. Stimulation may also increase ICP.
Nursing Diagnosis
Anxiety (children and parents) are associated with head trauma.
Expected results
Children and parents will show reduced anxiety is characterized by showing a decrease agitation and the question is appropriate in relation to disease and treatment.
1. Explain to the children and parents about the purpose of all nursing actions are performed and how the actions to be taken.
2. Allow parents to live with the child, depending on the circumstances of children.
1. Aspa know before handling procedures that will be done, and mnegapa, will help reduce anxiety
2. allow parents to provide emotional support to children, and will reduce the anxiety of children. It will also reduce the anxiety parents allowed to see and participate in child care.
Nursing Diagnosis
Risk of infection in connection with the injury.
Expected results
Children will exhibit no signs or symptoms of infection characterized by body temperature of less than 100 º F (37.8 º C), there is no liquid flowing from the wound, and the number of white blood cells based on their age.
1. examine the number and characteristics of the fluid that comes out of the child’s nose, mouth, or auditory canal.
2. monitor child’s temperature every 4 hours
3. Review the signs and symptoms of meningitis, ternasuk stiffness, easily aroused, fever, headache, vomiting, and convulsions.
4. wound dressing change and use sterilization techniques.
1. Assessing fluid flow can indicate leakage of CSF, which showed terbukannya flow from the brain. (Examination of cerebrospinal fluid by using reagent strips to detect the amount of glucose present in cerebrospinal fluid: reduced number of glucose indicated an infection) and the opening of the flow from the brain to an increased risk of infection in children.
2. hyperthermia can be a sign of infection
3. Cerebrospinal fluid that flows show an increase of meningitis as a result of the opening of the flow from the brain.
4. Sterile technique will help prevent the entry of bacteria into the open wounds, and reduce the risk of infection.
Nursing Diagnosis
Risk of damage to skin integrity related to physical immobility
Expected results
Child, indicating no signs of damage to the skin integirtas characterized by increased joint mobility and reduced skin damage and hurt caused by pressure.

do exercises passive range-of-motion (ROM) every 4 hours
Replace the pedestal board at the foot of a child or using rubber boots when not doing ROM exercises
Maintain proper body position, and change the position every 2 hours


Passive ROM exercises help maintain joint motion which will reduce the risk of skin damage.
Pedestal board will prevent footdrop and skin damage; high-top sneakers maintain joint angle as a board support
Using the tool handle and grip the leg and back PART normal prisoners will help prevent muscle tension that is sometimes caused by the position should not be. Change the position to help prevent skin damage.

Nursing Diagnosis
Lack of knowledge related to home care
Expected results
The parents will express his understanding of home care instructions and will demonstrate home care procedures.

Intruksikan parents about the nature and expected in children who suffered head injuries
Teach parents recognize the signs of possible komplkasi, including interference LOC (tinkat kesasdaran), changes in gait of children, fever, seizures, recurrent vomiting, and changes in conversation.
Teach parents about the purpose and use of drugs, including a description of treatment and possible drug reactions.
Teach parents about the prevention of seizures, including use traditional helmet, maintain the airway during the period of seizure, and the tidal barrier bed when the kids are in bed.
Emphasize the importance of children to do their own activities of daily living, doing activities that can provide stumulasi, and meet the needs of cleanliness.
Provide security-related information on the use of seat belts, the car seat belts and helmets.


Knowledge will help parents understand well the need for treatment and possible long-term effects of the injury.
Knowing how to recognize signs of possible complications will make the parent quickly contact a doctor if necessary.
Children must receive all drugs work effectively — guaranteed. Knowing about the likelihood of treatment response would help parents as soon as possible to ask for help from doctors when necessary.
Prevention will help prevent injury to the child during the seizure.
Children can lose its ability to perform daily activities and requires practice and constant encouragement.
Help convince parents and children how to follow the preventive security measures to reduce threats from various injuries.

Pedokumentasian check list
During his stay in hospital care, notes:
Objec child and assessments during home sakt.
Changes in the situation of children
Associated with laboratory tests and diagnostic examinations
Neurological Condition
Fluid intake and output
Response of children to treatment
Reaction oranhg children and parents to injury and stayed in hospital care.
Guidelines for teaching patients and families
Guidelines for home plans.