HEAD INJURY

  
 
I. Definition
 
Head injury is neurological damage caused by an object or bone fragment penetrating
or tearing a brain tissue by the influence of a force or energy transmitted to the brain
and finally the effect of acceleration and deceleration on the brain is limited to a rigid
compartment.  (Pris & Avilson, 1995: 115)      
 
II. Classification
1. Type:
a. Open head trauma
This trauma causes skull fracture and dura laceration.
Brain damage can occur when skull bones are damaged or the like
due to sharp objects. Linear fracture in the temporal area where the artery hits
The medium is in the path of the temporal bone, often causing bleeding
epidural. Base area fracture caused by trauma from the top or head
parts that hit the road or other objects.
 
b. Closed head trauma
 Cerebral communication or concussion
This is a form of minor head injury where there is fainting (less than
10 minutes).
 Cerebral contusions or brain bruising
Is a small bleeding or petechiae in the brain tissue as a result
rupture of capillaries along with tissue breakdown, rupture
nerves or brain causes odem of the brain and surrounding tissue to occur
increased ICP, herniation and brainstem compression. (Disturbance Askep
Persarafan, 1995: 49)
 
2. Based on the severity of the injury
a. Light
 GCS: 14-15
 Loss of consciousness or history less than 30 minutes.
 Not accompanied by skull fractures, cerebral contusions and hematoma.
b. Moderate
 GCS: 9 - 13
 There was loss of consciousness less than 30 minutes and more than 24 hours,
vomiting, amnesia, post trauma.
 Skull fractures do not occur.
 
c. Severe
 GCS: 3 - 8
  There was loss of consciousness in less than 30 minutes and 24 hours.
 Skull fracture, intra cranial hematum.
 
III. Etiology
a. Open head trauma
 Penetrating trauma such as sharp objects or gunfire
 Trauma due to a collision or accident
 
b. Closed head trauma
 Blunt trauma
 Impact trauma or accidents
 Fall down
 Dynamic mechanism  
 
IV. Signs and symptoms
 
a. Open head trauma
 Battla sign (blue behind ear above mastoid)
 Hemothympani (bleeding in the eardrum)
 Periorbital ecchymosis (black eyes without direct trauma)
 Rhinore
 Ottorhoe
 
b. Closed head trauma
 Komusio cerebri
  Fainting < 24 hours disoriented in front of eyes
   Cerebri Contusio
 Fainting> 10 minutes. Small bleeding occurs edema around the brain
 
c. Emergency Phase
 Bruises
 Blood from the ear
 Seizures
 
d. Minor injury
 Headache
  Nauseous vomit
  Vertigo
   Hearing disorders
 
e. The injury is moderate
 24 hours unconscious
 Abnormal flexion and extension
 Brain edema
  
V. Complications
A. Open head trauma: infection, meningitis, bleeding
B. Closed head trauma: intra cranial bleeding
C. Leakage of spinal cord fluid
D. Diabetes insipidus
E. Post traumatic seizures
F. Bleeding that often occurs:
1. Epidural hematum
2. Subdural hematum
3. Intra cranial bleeding
4. Sub arachnoid hemorrhage
 
VI. Prognosis
 
GCS on admission has a great prognostic value, patient score
3-4 has an 85% chance of dying or being vegetative.
 
VII. Pathophysiology
 
The brain can function properly when oxygen and glucose needs can be met. The brain
does not have oxygen reserves, so a lack of blood flow to the brain, even briefly, will
cause malfunctioning. Likewise, the need for oxygen as fuel for brain metabolism
should not be less than 20 mg% because it will cause a coma. The need for glucose is as
much as 25% of all the body's glucose needs, so that if the plasma glucose level drops to
70% there will be early symptoms of cerebral dysfunction.
 
When the brain experiences hypoxia , the body tries to meet its oxygen needs through
an anaerobic metabolic  process which can cause blood vessels to
dilate. In severe contusions or brain damage there will be accumulation of Lactic
Acid due to Anaerobic Metabolism . This will lead to Metabolic Acidosis .
 
Under normal circumstances Cerebral Blood Flow (CBF) is 50-60 ml / minute / 100 g
of brain tissue, which is 15% of the Cardiac Output . Head trauma causes changes in
heart stroke function. Atypical Myocardial Activity , Changes in Vascular
Pressure and Pulmonary Edema . Autonomous Changes in Ventricular Function are
changes in T and P waves, Dysrhythmias, Atrial and Ventricular Fibrillation ,
Tachycardia .
 
As a result of Brain Bleeding will affect Vascular Pressure , where a decrease
in Vascular Pressure causes the Arterial blood vessels to contract. The influence
of sympathetic and parasympathetic innervation on the arteries and arteries of
the brain is not so great.
Head injuries according to pathophysiology are divided into two:
 
1. Primary Head Injury
Direct impact on the dynamic mechanism ( Acceleration - Rotation Deceleration )
which causes disruption of the network.
On Head Injuries Primary may occur:
 Light concussion
 Bruised brain
 Lacerations
 
2. Secondary Head Injury
In Secondary Head Injury will occur:
 Systemic Hypotension
 Hypoxia
 Hypercapnea
 Brain Edema
 Respiratory Complications
 
Infection / complications in other organs
Bleeding is common
 
A. Epidural Hematoma
 
There is a collection of blood between the skull and the Duramater due to the
rupture of the blood vessels / branches of the Meningeal Media Artery found
in Duramater . These blood vessels cannot close on their own because this is very
dangerous. It can occur within a few hours to 1-2 days. The most frequent locations
are in the Temporalis and Parietal Lobes .
 
The symptoms that occur:
 Decreased Level of Consciousness
 Headache
 Throw up
 Hemiparesis
 Ipsilateral Pupil Dilatation
 Breathing in rapid then shallow irregular
 Decreased Pulse
 Increased Temperature
 
B. Subdural Hematoma
 
Collecting blood between Duramater and brain tissue , can
occur Acute  and Chronic . Occurs due to rupture of the vein / vein bridge which is
usually found between Duramater , bleeding slowly and slightly. Acute periods
 occur in 48 hours - 2 days or 2 weeks. Chronic can occur in 2 weeks or several
months.
 
Signs and Symptoms:
 Headache
 Confused
 Sleepy
 Withdraw
 Think slow
 Seizures
 Pupillary edema
 
C. Intra Cerebral Bleeding
In the form of bleeding in brain tissue due to rupture of arteries; Capillaries; Veins.
 
Signs and symptoms :
 Headache
 Loss of consciousness
 Respiratory Complications
 Contra Lateral Hemiplegia
 Pupil Dilation
 Changes in vital signs
 
D. Sub arachnoid hemorrhage
Bleeding in the Sub Arachnoid cavity due to tearing of blood vessels and the surface
of the brain, almost always occurs in severe head injuries.
 
Signs and symptoms :
 Headache
 Loss of consciousness
 Hemiparese
 Ipsilateral Pupil Dilatation
 Stiff Chuck
 
VIII. Management
1. Medical
a. Dexamethasone as an anti-edema treatment
b. Hyperventilation therapy treats vasodilatation
c. Administration of analgesics
d. Anti-edema treatment with hypotonic solution
e. Antibiotics contain a blood brain barrier
f. Food or drink (liquid) such as infusion
 
 2. Nursing
a. Cerebral contusion
 Patients with total bedrest so that all complaints are treated with symptomatic
such as analgesic administration.
 After complaints such as nausea and vomiting were gone, then the mobilization
of sitting in bed was started.
 Activities are adjusted to the body's abilities.
 If the patient goes home, tell control a week after going home.
b. Cerebral Komusio
 Complication prevention and treatment.
 Monitoring of awareness and vital functions such as RR, BP, Polse, 15 minutes
in the first 11 hours every 30 minutes thereafter.
 Overcoming respiratory problems such as the patient lying on his side.
 Sucking lenders, 02 and endofacial fitting.
 Administration of fluids and electrolytes such as glucose and NaCl (1500-2000)
 Feeding like sonde
 
IX. Assessment
 
client data collection objektif and subjectively in disorders of the neurologic system in
connection with a head injury depends on the shape, location, type of injury and
complications in other vital organs. The data that need to be found are as follows:
 
1. The identity of the client and family (person in charge)
Name, age, gender, religion, ethnicity, marital status, address, blood type, income,
client relationship with the person in charge
 
2. Medical history
 Level of consciousness / GCS (3-15)
 Convulsion
 Throw up
 Dyspnea / tachypnea
 Headache
 Symmetrical face / not
 Weak
 Head wound
 Paralize
 Accumulation of secretions in the airways
 The presence of liquor from the nose and ears
 Seizures
 
 Past medical history must be known, both related to the nervous system and other
systemic diseases. Likewise, a family history of diseases, especially those with
infectious diseases.
The medical history can be reviewed from the client or family as subjective
data. These data are very meaningful because they can affect the prognosis of the
client.
 
3. Physical examination
The neurological aspects studied were:
 Consciousness level, usually GCS <15
 Disorientation of people, place and time.
 There is a Positive Babinski Reflex
 Change in the value of the Vital Signs
 Stiff Chuck
 Hemiparese.
 Cranial nerves can be disturbed if the head injury extends to the brain stem due
to brain edema or brain hemorrhage , in this case it is necessary to study the
nerves I, II, III, V, VII, IX, XII.
 
4. Supporting investigation
 CT-Scan (with or without contrast), identifies the extent of
the lesion , determinants of ventricular bleeding and changes in brain
tissue . Note : To determine the presence of infarction / ischemia network,
dilakuka n at 24-72 hours after injury.              
 MRI : Used the same as a CT scan with or without radioactive contrast . 
 Cerebral Angiography : Shows Cerebral Circulation Anomalies , Such
As : Secondary Brain Tissue Changes to Udem , Bleeding and Trauma .
 EEG series : Can see the development of pathological wave movements
 X Ray : Detects changes in bone structure (fracture), changes in line structure
(Bleeding / Edema), Bone Fragments . 
 BAER : Correcting the limits of the function of the Cortex and Cerebellum 
 PET : Detects changes in Brain Metabolic activity . 
 CSF / Lumbar Function : Can be done if Sub Arachnoid hemorrhage is
suspected .
 ABGs : Detect the presence of ventilation or breathing problems (oxygenation)
if there is an increase in intra cranial pressure .
 Toxicology Screen : To find out the effect of the drug, which causes a decrease
in consciousness.
 
X. Management
Conservative:
 Bed rest total
 Administration of drugs
 Observation of vital signs ( G C S and Level of Consciousness )
 
XI. Priority of Care
1. Maximize Perfusion / Brain Function
2. Prevent complications
3. Optimal function setting / return to normal function
4. Support the client / family coping recovery process
5. Providing information about the disease process, prognosis of the treatment
plan and rehabilitation
 
XII. Aim
1. Improved brain function: Neurological deficits decrease / remain
2. Complications do not occur
3. Daily needs can be met alone or assisted by others
4. Families can accept reality and participate in care
5. The disease process, prognosis, treatment program can be understood by the
family as a source of information
 
 
XIII. Nursing diagnoses that may arise:
1. Ineffective breathing patterns due to depression in the respiratory centers in the
brain
2. Ineffective airway hygiene due to sputum buildup
3. Impaired brain tissue perfusion associated with brain edema

Several nursing diagnoses can be made for patients with

       

head injuries are :

 
1. Ineffective Breath Patterns Associated with Depression in the Breath Center in
the Brain
 
AIM
Maintain an effective breathing pattern through the Ventilator
 
EVALUATION CRITERIA
 There is no use of the breathing muscles
 Cyanosis and / or signs of Hypoxia were absent
 Blood Gas within Normal limits .
 
ACTION PLAN
 Count the patient's breaths in one minute, the patient's rapid exhalation can
cause Respiratory Alkalosis and slow breathing increases the Pa Co2 pressure
and causes Respiratory Acidosis .
 Check the tube installation, to provide adequate ventilation in giving Tidal
Volume .
  Observation of the ratio of inspiration and expiration . In the Expiration phase
it is usually 2x longer than Inspiration , but can be longer to compensate for air
trapping against gas exchange disturbances.
 Pay attention to patient humidity and temperature. Dehydration can dry out
pulmonary secretions / fluids so they become thick and increase the infection
rate.
 Check the ventilator interval every time (15 minutes). the obstruction can lead
to inadequate drainage volume and cause air distribution is inadequate.
 Keep an ambu bag close to the patient, helping to provide
adequate ventilation if there is interference with ventilation .
 
2. Ineffective airway hygiene due to sputum buildup
 
OBJECTIVE :
Maintain the airway and prevent Aspiration
 
EVELUATION CRITERIA
 Clean breath sound
 There is no secretion on the hose and an alarm is heard due to elevated engine
sound
 Cyanosis no
 
ACTION PLAN
 Assess closely (every 15 minutes) the smoothness of the
airway. Obstruction can be caused p e n gumpulan sputum, bleeding,
bronchospasm , the problem of the tube.
 Evaluate chest movements and chest auscultation (every 1
hour). Symmetrical movements and clean breath sounds indicate proper tube
placement and the absence of sputum buildup .
 Perform mucus suction in less than 15 seconds if there is a lot of
sputum. Suctioning of mucus is not always routine and time should be limited to
prevent hypoxia .
 Perform chest physiotherapy every 2 hours. Increases Ventilation for all parts
of the lung and provides a smooth flow and release of Sputum .
 
3. Impaired brain tissue perfusion associated with brain edema
 
AIM
Maintain and improve the level of awareness of motor functions.
 
RESULT CRITERIA
 Vital signs stable
 No increase in intra cranial pressure .
 
 ACTION PLAN
 Monitor and record neurological status using GCS
        
 Monitor vital signs every 30 minutes.
        
 Keep head up level 15- 30 degree and not pressing
        
 Avoid excessive coughing, vomiting, straining, maintain urine measurement
and avoid prolonged constipation         
 Observe seizures and protect the patient from injury due to seizures.
       
 Give oxygen according to the patient's condition
        
 Give drugs indicated correctly and correctly ( Collaboration ).
- Helps reduce Intra-cranial Pressure biologically / chemically such as Osmotic
Diuretics to draw water from brain cells so that it can reduce Brain
Udem         
- Steroids (Dexamethason) to reduce inflammation , reduce tissue edema .         
- Anti-seizure drugs to reduce seizures         
- Analgesics to reduce pain, negative effect of increased intra-cranial
pressure .         
- Antipyretics to reduce heat which can increase the use of Brain Oxygen .