MARKING KEY

HEAD INJURY

TOTAL MARKS 10%

7% FOR CORRECT LABELLING, 3% FOR GOOD DRAWING.

(a)Explain contusion giving four (4) specific features that

differentiate it from other head injuries (16%).
1. Contusion is a severe injury involving the brain structures which
become bruised with possible surface haemorrhage.
2. The patient is unconscious for a longer period of time than in other
minor brain shaking because of the bruising effect of the brain,
coupled with convulsions in some patients.
3. The blood pressure and temperature are altered as a result of direct
injury to the brain centres that regulate the functions of the heart,
lung and heat regulation.
4. There may or may not be bleeding from the external auditary canal
which may signify a basal skull fructure or laceration in the canal .
Otorrhoea (CSF) from the ears also indicates basal skull fructures
as is a source of meningitis.
5. Abnormal flexor and extensor posturing of extremities either
spontaneously or on stimulation may be present. There may be
hemiparesis and cranial nerve dysfunction depending on the part of
the brain affected.
Give 4% for each correct point to make 16.

(b)Describe in detail the management of Mr. Mumbi in the first 24

hours of his admission under the following headings. (64%).

(i) Medical/Surgical management (20%)

Objectives: (4%)
1. To maintain the clear airway
2. To reduce intracranial pressure
 3. To resolve the unconscious state
4. To prevent complications like brain abscess, meningitis etc 2%
for 2 objectives.

Investigations (5%)

1. Full physical assessment

2. Assessment of test of head injury (open or closed,
cardiovascular assessment.
3. Cranial x-ray
4. Computed tomography
5. Neurological assessment using glasgow coma scale.
6. blood for blood sugar.

Rescussitation:

(i). Reduce intracranial pressure and cerebral oedema by

intravenous administration of:-
1. Frusemide 50 mg IV in the infusion
2. Mannital 10 to 20% 500 ml
3. Dexamethazone 12 mg IV stat to reduce cerebral oedema
-3-

4. Hyperventilate using a ventilator and intubation

5. Nasogastric tube insertion
6. Catheterisation
7. If there is depressed bone, craniotory and bone elevation are
done
8. If closed injury with haematomas burr holes are done
9. If open injury -debridement of the lacerated outer tissue is
done.
10. If open injury, antibiotic, benzyl penicillin 2 mega. units 6
hrly for 5 days and gentamycin 80 mg 8 hrly for 5 days.
(ii) Nursing Care - 44%:

Objectives -(2%)
1. To maintain physiological functions
 2. To control or prevent intracranial pressure and cerebral
oedema.

25
MAINTAINING A PATIENT AIRWAY AND
VENTILATION. (4%)

- Establish a constant patient's airway with adequate respiratory

exchange.
- Prevent aspiration by proper positioning lateral position or
semi prone
- Tracheostomy can be performed
- Ventilator are applied to aid in ventilation
- Insert an airway
- endotracheal intubation are done to ensure patient air way.
- This is all done to prevent cerebral anoxia which causes most
deaths in head injury patients
- Suctioning be done to prevent choking
- To prevent hypoxia while suctioning the duration of suctioning
should be only 15 seconds.
- Assisted ventilation may be necessary to make sure the patient
is adequately exchanging air.
- Ensure maximum respiratory function by oxygen
administration. (Give 10%).
Minimisation of rise in intracranial pressure (3%).
- Maintain proper positioning.
1. Keep head of bed elevated for venous drainage
2. Maintain patient's head in neutral position
- No Pillows
- Prevent head from tilting to the side as there may be spinal
injuries.
- Advise to exahale a lot of air on position changing.
3. Turn the patient all in one place to prevent further injury.
Avoid severe hip flexion.
- COMFORT AND REST ( 2 % )
1. Limit suction to 15 seconds or less.
 2. Space nursing care activities to minimise duration of
increase in intracranial pressure.
3. Avoid conversations at the bedside as the patient is able to
hear.
- ELIMINATION ( 2 %)
- Decrease chance of valsava meneurers or feacal impaction.
-4-

1. Monitor frequency and consistency of patient's stools.

Administer stool softeners PRN.
2. Catheterise to prevent retention of urine or bed sore
formation.
3. If patient is awake, do not allow him to assist with position
changes.
4. Instruct him to exhale during changes in position.
TEMPERATURE REGULATION (1%)

 Maintain normothermia:
1. Administer antipyretic medication and provide external
cooling promptly.
VITAL SIGNS AND OTHER OBSERVATIONS (4%)
 P, TPR - Rate, Depth of respiration
 Pulse rate, heart sounds, blood pressure to monitor
functioning of vital organs.
 Observe colour of the skin, lips and finger nails for cyanosis
 Look for evidence of in continence and catheterise if not
done to protect skin .
 Ensure the patient is breathing deeply enough to oxygenate
his lungs and to eliminate CO
2.
 Check heart and blood pressure and look for evidence of
possible sources for bleeding.
 Be certain that cardiac output and blood volume are
sufficient to supply brains and kidneys metabolic
requirements for effective excretion.
 INTRAVENOUS INFUSION (2%)

 Start IV line with a large bore needle on all patients in

coma.
 When starting infusion with a large bore needle on all
patients in coma, collect blood samples for laboratory
investigations at the same time.

ASSESSMENT OF LEVEL OF CONSCIOUSNESS:

 Observe responses to skin stimuli using glasgow coma
scale.
1. Examine pupil sizes and reactivity to light for indications
of increased intracranial pressure.
2. Call his name and record and report response.
3. Try reaction to painful stimuli.
4. When pupils are delated and fixed alarm the doctor as it
is an indication that there is more damage to the brain
with a lot of cerebral oedema which requires emergency
management.
5. Vital signs - intracramial pressure Bp rises, pulse is slow,
respiration may be noisy and slow (chyne stokes).
6. Temperatures rises sometimes record and report findings.
7. Check limb rigidity.
-5-
- Speech
- Testless
- Causes can be pain, shock or a sign of improvement.
- Fill bladder- urine retention

INVESTIGATION SPECIMEN COLLECTION (1%)

INVESTIGATION SPECIMEN COLLECTION (1%)

Assist in collection of specimen such as:-

- Blood for blood sugar

- Hypoglycaemia further causes brain damage

GENERAL CARE (1%) Very vital, patient can not do it alone.

1. Bed bath daily
2. Oral toilet
3. Hair care
4. Nail care: All these are for body integrity.
5. Pressure area care - change of position by frequent turnings
- change soiled linen.

SAFETY AND PREVENTIVE MEASURES: (5%)

- Nurse in cot bed or bed with side rails to maintain safety
- Observe seizure precailtory for.
- Give adequate support when turning the patient
- Remove dentures to prevent asyphyxia.
- Any contact lenses, remove and store safety.
- Prevent injury during convulsions and control them with short
time e.g. padded side rails
- Keep nails short and clean
- Avoid over sedation in the unconscious patient it may mask the
condition
- Do not leave unconscious patient for along time alone.
- Prevent hypoxaemia by effective
- Avoid fluid over load.

EYE CARE (3%):

- Freqquent inspections of eyes with a flashlight, shielding an

open for partially open eye.
- Simple eye irrigations, and
- Instilling protective eye drops to prevent corneal ulceration
arising from drying, these can lead to keratitis, and blindness.
- A covered tray for eye care be prepared, care be given four
hourly.
- The eye may be irrigated with normal saline solution.
- If corneal reflex is absent, apply a protective shield.
 -6-

BODY MOVEMENT:

Observe the extremities of a patient for the presence of rhythmic

spontoneos movements indicative of a convulsive seisure. Once
this is detected, notify the doctor.

POSITIONING AND EXERCISES (3%):

- Position the patient properly at all times.

- Move the patient about periodically.
- Passively exercise him extremities to promote blood
circulation
- Combine, air ring on the bed, frequent turnings, exercises and
proper positioning in bed to prevent decubitus formation.

EAR AND NOSE CARE (3%):

- Nasal passages may be blocked by dried up mucus
- Gently swab the nose with an applicator maintained with water
or normal saline;
- Next used one with a lubricant
- Never suctions ears or nose of a patient with head injury.

MOUTH CARE (2%):

- Every 2 hours
- Provide oral hygiene
- Prevent excessive drying of the oral mucous membranes
- Oral care prevents other complications such as parotitis,
sordes, herpes simplex, aspirations and respiratory tract
infection. The latter 2 are the commonest causes of death in
unconscious patients. During mouth care of the unconscious
patient excess secretions should be removed with suctions to
prevent choking.
MAINTAINING NUTRITION AND FLUID BALANCE (2%)
- Unconscious patients can not swallow normally for fear of
aspirating.
- Tube feedings are the most desirable method of providing
prolonged giving nutritious fluids. Nourishment for
unconscious patients’ intravenous fluids must run slowly to
prevent further increased cerebral oedema and intracranial
pressure.

PSYCHOLOGICAL CARE AND HEALTH EDUCATION (2%)

- The family needs psychological support - It may be upset
because the patient can not communicate.
- Or they may be anxious about possible death of their relative
- Explain the condition to the family and the treatment and
nursing care
- Involve them in the care
- Inform the family to be careful in their discussion near the
patient as he/she is able to hear
- They should be allowed access to the patient.

Total =44%