AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
Instructor
Serial/Semester
Location
Start/Finish Time
Date
LESSON OBJECTIVE
Performance: To gain an understanding of head injuries.
Conditions:
The student will be presented a powerpoint presentation by the instructor and will have
all necessary references made available to him/her.
Standard:
1.
Given the five elements of the nursing care process and a patient with a head injury
by correctly responding to written, oral, and experiential assessment measures.
TEACHING POINTS
1. Identify the etiology, pathophysiology, sign
and symptoms, medical/surgical and nursing
management for the patient with
craniocerebral trauma
2.
3.
4.
5.
6.
7.
8
9.
10.
INSTRUCTIONAL STRATEGY
Interactive Lecture
Method:
Instructor
Media:
Classroom
Environment:
OTHER LESSON SPECIFICATIONS
Knowledge Lesson
Type of Lesson:
1/50
Ratio:
Resources:
.
End of Lesson Test: None
Minutes
Instructional Time: 81
Reference(s):
ISBN 0-323-01728-2
Adult Health Nursing, 4th Edition
01 Jan 2003
ISBN 0-7817-3553-X
Introductory Medical-Surgical Nursing, 8th Edition
01 Jan 2002
LESSON PLAN APPROVAL
Signature of Standards Officer
Date
AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
INTRODUCTION
Allocated Time:
Review:
5 Minutes
You have had previous anatomy and physiology lectures in your combat medic
training, this lecture will build upon prior instruction.
Objective:
To discuss/describe topics related to the nursing process.
Importance:
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
Fit:
Head injury causes death or serious disability in people of all age groups. It is
highly likely you will care for a head injury patient in a number of clinical
assignments.
Approach:
You will be presented the subject in lecture format and will be tested using a
written exam at a later date.
Control Statement:
If you have any questions during the lesson please feel free to ask.
BODY
1. Teaching Point: Identify the etiology, pathophysiology, sign and symptoms, medical/surgical and
nursing management for the patient with craniocerebral trauma
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Craniocerebral Trauma - Can be direct (head is directly injured) or indirect (tension, strain, or
shearing)
(1) Second most common cause of neurological injury
(2) Major cause of death between ages 1 and 35
(3) Craniocerebral trauma may result in injury to the scalp, skull, or brain tissue
(4) The amount of obvious damage may not reflect the extent of injury
(5) The effects of head injuries can include
(a) Cerebral edema
(b) Sensory and motor deficits
(c) Increased intracranial pressure (IICP)
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
b. Causes of head injury
(1) MVA’s
(2) Falls
(3) Sports
(4) Industrial accidents
(5) Assaults
c. Open head injuries result from skull fractures or penetrating wounds. The amount of injury with this
type of wound is determined by velocity, mass shape and direction of impact
(1) Types of skull fractures(a) Linear- incomplete break, typical line
(b) Comminuted- bone is shattered into two or more fragments or pieces
(c) Depressed- results from a blunt trauma to a flat bone- causing an indentation
(d) Compound- an open wound exists over the fracture site, often bone may be protruding through
the skin
(2) Fractures at the base of the skull are more serious because of their location near the medulla
d. Closed head injuries
(1) Laceration- lacerations of the scalp bleed profusely because of the large vascularity in the region.
Heavy bleeding is not always reflective of significant injury
(2) Concussion results from violent jarring of the brain
(a) Patient can experience brief loss of consciousness followed by confusion, headache, irritability,
dizzy spells,unsteady gait
(b) Severity is thought to correlate with the duration of the amnesia
(c) Complete recovery is usual
(d) No damage to cerebral tissue
(3) Contusion– the result of a serious blow to the head associated with damage to brain tissue and nerve
fibers
(a) More serious than concussion due to bruising and possible hemorrhage of superficial cerebral
tissue
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
(b) Bruising of the brain occurs at site of injury or on the opposite side
(c) Permanent damage may result
e. Hematoma- results from hemorrhage post-craniocerebral trauma
(1) Common site
(a) Epidural - result from arterial bleeding between the dura and skull
1) May be alert after initial unconsciousness; become increasingly lethargic before lapsing into
coma
2) Headache
3) Ipsilateral pupil changes
4) Contralateral hemiparesis
(b) Subdural- results from venous bleeding between the dura and subarachnoid layers - usually a
slower bleed but more discrete in presentation- classified as acute, subacute or chronic bleed
1) Progressive deterioration in level of consciousness (LOC)
2) Ipsalateral pupil changes
3) Decreased extraocular muscle movement
4) Contralateral muscle movement
5) Periodic episodes of memory lapse, confusion, drowsiness, and personality changes
(c) Intracerebral- bleeding into the brain tissue
1) Classic signs of IICP
2) 3rd most common cause of stroke
(2) Clots cause pressure on the brain surface and displace brain tissue
(3) Individuals at high risk for cerebral hematomas include these patients:
(a) Receiving anticoagulants
(b) Have an underlying bleeding disorder
1) Hemophilia
2) Thrombocytopenia
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
3) Leukemia
4) Aplastic Anemia
f. Nursing Assessment
(1) Signs and Symptoms vary depending on severity of injury and if any loss of consciousness due to
cerebral edema
(2) Determine how the injury happened and assess for the following:
(a) Signs of IICP
1) Decreasing or altered LOC
a) One of the earliest signs
b) May develop rapidly or slowly
2) Headache
3) Vomiting, possibly projectile
4) Papilledema (swelling of the optic disc from IICP being transmitted forward from the brain)
5) Change in Vital Signs
6) Unequal pupils or abnormal response to light
7) Posturing
a) Decorticate or Decerebrate
b) Spontaneous or in response to painful stimuli
(b) Nausea
(c) Abnormal sensation
(d) Bleeding/fluid from nose (rhinorrhea) or ears (otorrhea)
(e) Orientation
(f) Motor status
(g) Seizure activity
(h) Abnormal speech
(i) Signs of basilar skull fracture – late sign
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
1) Battle’s sign – periauricular ecchymosis - bruising near/of the mastoid process behind the ear
2) Raccoon eyes – periorbital ecchymosis – bruised area around the eyes
(j) Cushing’s Triad or Cushing’s Response - An important diagnostic sign of late-stage IICP
1) Increased Systolic Blood Pressure
2) Widening Pulse Pressure (difference between systolic and diastolic measurement)
3) Bradycardia
g. Diagnostic tests/Devices
(1) Detecting CSF in otorrhea and rhinorrhea drainage
(a) Wet a Dextrostick with fluid from nose or ears - observe for color change indicating presence of
glucose; Only used if no blood present as it may provide false positive test
(b) Halo sign – Collect droplets on white absorbent pad; creates a yellow ring that encircles a central
red area - indicative of leakage of CSF
(2) The Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI assist in
diagnosing:
(a) Skull fractures and/or embedded skull fragments (If the head injury is severe enough to cause a
skull fracture, then it is severe enough to get a CT Scan)
(b) Intracranial bleeding
(c) Shifts in brain tissue (i.e. space occupying brain tumor)
(d) Edema at the injury site
(e) Densities that indicate presence/location of hematoma
(3) Internal monitoring devices – to monitor and diagnose IICP
(a) Ventricular catheter
(b) Subarachnoid bolt or screw
(c) Epidural sensor
h. Medical/Surgical Management of Head Injury Patient
(1) Lifesaving measures
(2) Maintenance of body function until recovery
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
(3) Patent airway and adequate oxygenation
(a) Suctioning - Never suction through the nose because of the possibility of skull fracture
(b) Administration of oxygen; endotracheal (ET) intubation may be necessary
1) Controlling ventilations with an ET tube and ventilator, the PCO2 can be lowered, increasing
pH
2) The increase in pH will decrease vasodilation, decreasing intracranial pressure
(c) Arterial blood gases – monitoring of PCO2, PO2, pH, bicarbonate levels
(4) Simple skull fracture
(a) Bed rest
(b) Close observation for signs of IICP
(c) Scalp lacerations need to be cleaned, debrided and sutured
(5) Depressed skull fracture
(a) Requires surgery to:
1) Remove bone fragments
2) Control bleeding
3) Elevate the depressed fracture
4) Repair damaged tissue
(b) Antibiotics to control infection
(c) Medications to treat cerebral edema and IICP
(d) Anticonvulsants to treat or prevent seizures
(6) Scalp lacerations
(a) Cleaned, debrided, and sutured
(b) Heavy bleeding is not always reflective of significant injury
(7) Concussion
(a) Activity temporarily halted
(b) Tylenol for analgesia
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
(c) Observed for IICP and/or other complications
(8) Contusion
(a) Drug Therapy and mechanical ventilation as required
(b) CT and/or MRI
(9) Hematoma
(a) Rapid LOC change and sings of uncontrolled IICP indicate a surgical emergency
(b) Holes (aka burr holes) drilled in the skull to:
1) Relieve pressure
2) Remove a clot
3) Stop any bleeding
4) If unsuccessful, more invasive Intracranial surgery is performed.
(c) Intracranial surgery
1) Craniotomy
2) Craniectomy
3) Cranioplasty
(d) Complications associated with Intracranial surgery include:
1) Cerebral edema
2) Infection
3) Shock
4) Fluid and electrolyte imbalances
5) Venous thrombosis (especially arms and legs)
6) IICP
7) Seizures
8) Cerebrospinal Fluid (CSF) leakage
9) Stress ulcers
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
10) Hemorrhage
(10) Some subdural hematomas become walled off and absorbed by the body with no treatment
required
i. Medications administered
(1) Reduce cerebral edema & IICP
(a) Mannitol- Osmotic diuretic - for IICP, draw water from the edematous brain tissue
(b) Dexamethasone Corticosteroids- for IICP- anti-inflammatory, must monitor blood sugar levels
because the medication can affect carbohydrate metabolism and glucose utilization
(2) Anticonvulsants to treat or reduce seizures
(a) Phenytoin (Dilantin)
(b) Fosphenytoin (Cerebyx)
(3) Analgesics that do not depress respirations - opioid narcotics depress respiratory drive
(4) Antipyretics such as acetaminophen (Tylenol) are often prescribed because hyperthermia increases
brain metabolism and increases the risk of brain damage
j. Nursing Management
(1) Obtain history
(2) Perform neurologic exam to include:
(a) Vital Signs
(b) LOC
(c) Presence of absence of movement of extremities
(d) Pupil size, equality and reaction to light for evidence of IICP
(3) Examine head for bleeding, abrasions, and lacerations
(4) Observe for:
(a) Change in neurologic exam (evaluated at least hourly)
(b) Signs of IICP
(c) Respiratory distress or inability to oxygenate
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
(d) Changes in vital signs (taken every 15-30 minutes)
(5) Elevate head of bed to 30-45 degrees to promote venous return
(6) Place neck in neutral position to promote venous drainage
(7) Position patient to avoid IICP; hips, waist, head, neck
(8) Restrict fluid intake
(9) Implement measures to help the patient avoid Valsalva’s maneuver
(10) Ensure foley is in place
(11) Perform suctioning only as necessary and for no longer than 15 seconds
(12) Administer oxygen via cannula or mask to improve cerebral perfusion; endotracheal intubation
may be necessary
(13) Use a hypothermia blanket to control body temperature
k. Nursing diagnoses
(1) Potential for infection
(a) Check for signs of torn meninges
1) Blood or serous drainage from ears or nose
2) No attempt should be made to clean out the orifice
3) Patient should not cough, sneeze or blow nose - no valsalva maneuver
4) CSF will show a positive reaction for glucose on a Testape or Dextrostick
(2) Emotional support
(a) Impaired memory
(b) Impaired judgement
1) Patients with these symptoms require firm but gentle care.
2) Reorientation
a) Memory aids such as log books and written schedules may be helpful
3) Limit setting
(c) Restlessness
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
1) Assess bladder
2) Assess pain
(3) Breathing pattern ineffective(a) Maintain patent airway
(b) Administer oxygen
(4) Injury - risk for (a) Elevate HOB
(b) Maintain body position
(c) Check VS
(d) Anticipate needs
(5) Social interaction impaired(a) Support verbalization about feelings
(b) Involve patient in care
(c) Build trust, give full attention, recognize qualities to promote self-esteem
(6) Communication impaired(a) Speak slowly
(b) Ask questions
(c) Speech therapy
(7) Nutrition imbalance (a) Assess swallowing ability
(b) Position patient with HOB elevated
(c) Provide easy to swallow foods
(d) Provide IV, tube feeding, supplements
k. Nursing and Patient Education
(1) All meds must be taken regularly, without interruption, for as long as required
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
(2) Teach patient and family medication actions, side effects, dosage, and schedule
(3) Teach patient/family to observe for complications
(4) Residual effects may require rehabilitation
(5) Persons with head injury is more prone to injuries and problems related to brain damage
(6) Prognosis is unpredictable; recovery does not directly correlate to the amount of damage occurring
with injury
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Name the 4 types of skull fractures and identify which is more severe.
From mild to severe- Linear, Comminuted, Depressed, Compound.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
END OF LESSON TEST
Allocated Time:
Instructions:
Test Questions or
Performance
Expected:
Test Key:
0 Minutes
You will be tested on this subject at a later date.
You will be expected to review and study the material taught in this session in
order to pass the associated written test. If you have difficulty with the material
please see me so we can review together.
None.
CONCLUSION
Allocated Time:
Summary:
5 Minutes
Review and re-emphasize the difficult Teaching Points below.
1.
Identify the etiology, pathophysiology, sign and symptoms,
medical/surgical and nursing management for the patient with
craniocerebral trauma
2.
3.
4.
5.
6.
7.
8
9.
10.
Closing Statement:
11
Nurses work in various health care settings so it is important to gain an
AFAMS Master Lesson Plan (MLP)
Nursing Program
Head Injuries
understanding of this subject as it will apply to your clinical practice.
Re-motivating
Statement:
12
Head injury causes death or serious disability in people of all age groups. It is
highly likely you will care for a head injury patient in a number of clinical
assignments.