head injury

cranial nerve 3 (oculomotor)

moves eyelid, eyeballs and adjusts pupil and lens of eye

eye components of the GCS scale

spontaneously 4

open to command or speech 3

open to pain 2

no eye opening 1

verbal component of GCS scale

oriented 5

confused but answers questions 4

inappropriate responses 3

incomprehensible sounds 2

no response 1

motor response in the GCS scale

obeys commands 6

purposeful movement to stimulus 5

withdraws from pain 4

decorticate posture 3

decerebrate posture 2

no motor response 1

early signs of ICP

unilateral pupil change in size or reactivity

altered resp pattern

unilateral hemiparesis

vomiting, headache, seizure

5 monitoring types of ICP

epidural, intraparenchymal, subarachnoid, ventricular, subdural

cushings triad

thalamus, hypothalamus, pons and medulla

signs of cushings triad

increased systolic and decreased diastolic (wide range)

bradycardia

irregular respirations

compensatory mechanism of ICP (CSF)

displacement into spinal cord and venous system

decreased production of CSF

compensatory mechanism of ICP (blood volume)

vasoconstriction of cerebral vasculature

compensatory mechanism of brain volume in ICP

displacement of brain (herniation)

non-surgical interventions of ICP

mannitol - draws fluid from brain to bloodstream

hypertonic solution -draws water from cerebral tissue

nursing goal of ICP

maintain airway, ICP within normal range, monitor fluid and electrolytes, monitor LOC

nursing interventions to decrease ICP

reduce stimulation and raise HOB

signs of basal skull fracture

otorrhea and rhinorrhea, battle sign, bulging tympanic membrane, tinnitus, paralysis, raccoon eyes

complications of head injury

epidural hematoma

subdural hematoma

intraparenchymal hematoma

interventions of head injury

monitor for deterioration - frequent neuro vitals

maintain cerebral oxygen and perfusion

prevent hyperthermia