HEAD INJURY

NURSING
DIAGNOSIS

 Risk for delayed growth and development related

to late sequelae of head injury
HEAD TRAUMA

 Occur commonly in childhood, and most head injury in children is

minor and not associated with brain injury or long-term
consequences.

Children often receive head injuries when they are involve in

multiple-trauma injuries such as: motor vehicle accidents, fall from
swing sets, windows, or bunk beds.
 SIGNS &
SYMPTOMS

Some children may experience:

Minor personality changes

Memory deficits
Headache
Irritability
Blurry visions
 NURSING
INTERVENTIONS

 Children should always wear a helmet when riding a bicycle, skating or

skiing.
 Watch children closely while biking.
 Bicycling on the street requires good bike control and ability to follow
traffic rules.Young children should never be allowed to ride on the street.
 Use window gates and guards to protect children from falling out.
 Teach children how to cross the street safely by looking both ways for
cars.
SKULL FRACTURE
SKULL FRACTURE

A skull fracture is a crack in one of the bones of the skull.

Detecting skull fractures in children is important because

associated cerebral injury often occurs under the fracture.

Many fractures are simple linear types; most involve the parietal
bones.
In some children, instead of bone fracturing, the suture lines
separate. This occurs more commonly in the lambdoid suture line; a
coronal suture separation is rare and, if present, indicates severe
trauma.
If the base of the skull is fractured, a child usually exhibits ecchymosis
around the eyes of behind an ear.

Rhinorrhea or otorrhea (clear fluid draining from the nose or ear)

may be noticeable.

If a fracture is depressed (a bone fragment is pressing inward) or

compounded (bone is broken into pieces), surgery will be necessary
to remove or repair broken fragments and halt any bleeding that is
occurring from a blood vessel being cut by a bone fragment.
 NURSING
INTERVENTIONS

 If CSF is draining from the nose or ear, a child will be admitted to

the hospital for observation because this implies the force of the
blow was severe.

 Keep the child in semi-Fowler’s position so fluid drains out, not

inward, to reduce the possibility of introducing infection.

 Make certain children do not hold their nose or pack their nostril
with something to halt the drainage so the amount of escaping
can be judged.
 If the drainage is excoriating to the upper lip, coat the space with an
ointment such as petrolatum.

 Children may be prescribed a prophylactic antibiotic to reduce the

risk of meningitis.

 Maintain patent airway; assist with intubation and ventilatory

assistance is needed.

Elevate the head of the bed after feedings, and check residuals to
prevent aspiration.

Monitor respiratory rate, depth, and pattern of respirations.

CONCUSSION
 NURSING
DIAGNOSIS

 Risk for injury related to effects of concussion

 CONCUSSION

Concussion is the temporary and

immediate impairment of
neurological function caused by a
hard, jarring shock to the skull.
It may occur on the side of the head
that was struck (coup injury) or as the
brain recoils from the force of the blow
and strikes the opposite surface of the
skull (a contrecoup injury)
Children have at least a transient loss of consciousness at the time
of injury and may vomit and show irritability after regaining
consciousness.

They typically have no memory (amnesia) of the event that led up

to the injury or of the injury itself.
NURSING DIAGNOSIS &
INTERVENTIONS

 Risk for injury related to effects of concussion

 Assess child’s vital signs, level of consciousness and neurologic function initially and
then 30 minutes until discharge.

 Institute measures to calm the child. Encourage the parents to hold and reassure
him.

 Teach parents how contrecoup injuries occur and what symptoms they cause.

 Child needs continuing care such as being roused every 2 hours during night to
ensure he is conscious.
CONTUSION
 CONTUSION

A brain contusion occurs when

there is tearing or laceration of
brain tissue.

It is also known a bruising on the

brain.

The symptoms are the same as for

a concussion but more severe.
SIGNS & SYMPTOMS

In addition, symptoms related to the specific brain area that is

lacerated such as a focal seizure, eye deviation, or loss of speech
will occur.
Difficulty understanding speech.
Memory challenges.
Localized numbness or tingling.
Difficulty coordinating movements.
Difficulty speaking.
Problems with attention.
COMA
 NURSING
DIAGNOSIS

 Risk for ineffective airway clearance related to brain stem

pressure

 Risk for impaired skin integrity related to lack of mobility

Risk for imbalanced nutrition, less than body requirement,

related to inability to take in oral food or fluid.
 COMA

Coma (unconsciousness from which a child cannot be roused) or

stupor (grogginess from which a child can be roused) may occur in
children after severe head trauma. Because these are both
symptoms of underlying disorders, its important to obtain a
thorough history of the injury so treatment can be directed
specifically toward the cause.
 NURSING
INTERVENTION

 Risk for ineffective airway clearance related to brain

stem pressure

 Some children who are comatose require endotracheal intubation

or tracheotomy with mechanical ventilation to ensure an open
airway and adequate oxygenation.

An endotracheal tube maybe replaced with a tracheotomy after 3-

7 days to prevent necrosis of the pharynx from pressure of the
endotracheal tube.
 NURSING
INTERVENTION

Risk for impaired skin integrity related to lack of

mobility

 Bathe children who are comatose daily to stimulate skin circulation;

include the hair as part of the bath about every 3 days.

Change the child’s position at least every 2 hours to prevent pressure

ulcer formation or development of hydrostatic pneumonia from pooled
secretions in the lungs.

Keep the linen on the bed dry and free from wrinkles.
Use of sheepskin, an egg-carton foam, or an alternating-pressure or
water mattress can help to decrease skin pressure.

Perform thorough passive range-of-motion exercise to maintain

muscle tone and prevent contractures.
 NURSING
INTERVENTION

Risk for imbalanced nutrition, less than body requirement,

related to inability to take in oral food or fluid.

Children who are unconscious cannot be fed orally due to the risk
of aspiration into the lungs. Therefore, nutrition is maintained by
nasogastric (NG) or gastrostomy tube feedings, IV fluid
administration, or total parenteral nutrition (TPN).

Give mouth care at least twice daily with clear water and a padded
tongue blade.
 Coat lips with petrolatum or a commercial ointment to
prevent drying and cracking.

If a child’s eye tend to be dry, close them to prevent corneal

ulceration. Artificial tears (methylcellulose) may be prescribed to
keep eyes from drying until the child regains consciousness.
GLASGOW COMA
SCALE

Severe trauma: 3 – 8
Moderate trauma: 9 – 12
Slight trauma: 13 – 15
SCORING FOR GLASGOW COMA SCALE:

 Eye opening:

4 – child opens eyes spontaneously when you approach

3 – child opens eyes in response to speech (spoken or shouted)
2 – child opens eyes only in response to painful stimuli, such as
pressure in a nail bed.
1 – child does not open eyes in response to painful stimuli.
 Verbal response:

5 – child is oriented to time, place, and person (child above 4 years

old knows name, date, and where he or she is; infant appears to
recognize parents).
4 – child able to converse, although not oriented to time, place, or
person (does not know who or where he or she is; infant says words
but does not appear to differentiate parents from others).
3 – child speaks only in words or phrases that make little or no sense (“I
want frazzle no”; infant’s vocabulary is less than it is normally).
2 – child response with incomprehensible sounds, such as groans.
1 – child does not respond verbally at all.
 Motor response:

6 – child can obey a simple command such as “hand me a toy”

(infant smile or attunes)
5 – child moves an extremity to locate a painful stimulus applied to
the head or trunk and attempts to remove the source.
4 – child attempts to withdraw from the source of pain.
3 – child flexes arms at the elbows and wrists in response to painful
stimuli to the nail beds (decorticate rigidity)
2 – child extends arms (straightens the elbows) in response to
painful stimuli (cerebrate rigidity)
1 – child has no motor response to pain on any extremity.
NEUROLOGICAL
EXAMINATION
 Complete neurological examination – 20 minutes

 Full examination:

 Cerebral function
 Cranial nerve function
 Cerebellar function
 Motor function
 Sensory function
 Reflex function
CEREBRAL
FUNCTION
Both general and specific cerebral functions need to
be evaluated by assessing:

 Level of consciousness
 Orientation
 Intelligence
 Performance
 Mood
General behavior
Level of consciousness

Allow child to answer

Conversation questions without
prompting and listen
carefully to be certain the
answer is appropriate to
the question.
 Orientation

Person Time
Place
 Asking the child
Intellectual
questions on
performance
common topics
 Immediate Recent Remote
recall memory memory

Retain a concept Is a long term call

for a short time Covers a slightly
longer period of
time
Specific cerebral function:

Motor
Language
integration

Sensory
interpretation
Language Listen to the child’s ability
to articulate.
 Sensory
interpretation STEREOGNOSIS

• Ability of a child to
recognize an object by
touch

• Ask a child to close his or

her eyes and then place a
familiar object, such as key, a
penny, or a bottle cap, in her
hand and ask her to identify
it.
 Sensory GRAPHESTHESIA
interpretation

• Ability to recognize a shape that

has been traced on the skin.

• Ask a child to close his or her eyes;

trace first a circle and then a
square on the back of his or her
hand and then ask him or her
whether the shapes are the same
or different.
 Sensory
interpretation KINESTHESIA

• Is the ability to distinguish

movement.

• Have a child close her eyes and

extend her hands in front of her.

• Raise one of her fingers and ask her

whether it is up and down.
 • Complex motor
skill
Motor
Integration
Such as, folding a
piece of paper and
putting it into an
envelope.
CRANIAL NERVE
FUNCTION
 • Assess child’s ability to recognize
common odors such as peanuts, butter
or an orange while eyes are closed
OLFACTORY
• Newborn:
NERVE CN 1
• Turn towards mother’s breast
partly out of recognition of
the smell of breastmilk
 • Assess vision fields and
OPTIC NERVE visual acuity
CN 2
• Snellen eye chart
SNELLEN EYE CHART
PROCEDURE:

1) Hang the chart so the 20 ft line is at the child’s eye level.

2) Provide a good light

3) Measure a distance 20 ft from the chart.

4) Provide a 3x5 inches card to cover the eye not being tested.
5) If the child wear glasses, screen first with the glasses in place. Do not
screen the child first without glasses and then with them because this
forces the child to strain to read the chart.

6) To begin testing, tell the child to stand, keep both eyes open and cover
the left eye with the card ( the edge of the card should rest across the
child’s nose).

7) Begin at the 40 ft line of the chart, using a pointer, point to each

symbol on the line from left to right.
8) If passes the 40 ft line, have the child read the 30 and 20 ft lines or
the last line child can read.

9) Visual acuity is always stated as a fraction. 20/20

10) Test the eyes separately and then together.

11) Observe children for straining or squinting as they read the chart.
 • Assess pupillary size,
OCULOMOTOR equality, reaction to light,
NERVE CN 3 and ability to follow an
object in all directions.
• Newborn – able to focus on a moving object
-- Blink reflex

• Infant – see black & white objects better than colored objects.
- see objects at a distance of 19 cm (8-10 in)
 • Assess ability to discern light touch
to test sensory component

• Assess symmetry and strength of

bite to test motor component.
TRIGEMINAL
• Newborn:
NERVE CN 5
• quiet down at a soothing
touch
• cry at painful stimuli
• Show sucking and rooting
reflex
 • Assess motor strength by asking child
to close eyes while you attempt to
open them.

• Note symmetry of facial expressions

FACIAL NERVE
such as:
CN 7
- Smile
- Wrinkling forehead

• Assess taste by asking child to

identify salt or sugar
 • Assess hearing by the response
to a whispered word.
ACOUSTIC NERVE
CN 8
• Newborn:

• Recognize mother’s
voice
GLOSSOPHARYNGEAL • Gag reflex
NERVE CN 9
 • Ability to swallow
VAGUS NERVE
CN 10
• Gag reflex
 • Ask child to turn head to
the side; try to turn it to
center.
ACCESSORY
NERVE CN 11
• Ask the child to elevate
shoulders while you press
down on them.
 • Ask child to protrude
tongue
HYPOGLOSSAL
NERVE CN 12 • Ask child to press on
side of the cheek with
tongue
CEREBELLAR
FUNCTION
 Observe the child walk whether the
walk is natural

 Stand on one foot

 Tandem walk

 Finger-nose test
MOTOR FUNCTION
 Ask to squeeze fingers or hop, skip, or jump.

 Grasp with the hands and push against a surface

with the feet
SENSORY FUNCTION
 Have a child close him or her eyes and then ask the
child to point to the spot where you touch him or her
with an object

 Light touch – wisp of cotton

 Pain – safety pin

 Temperature - hot or cold water

 Vibration – touching the bony prominences (iliac crest,

elbows, knees) with vibrating tuning fork
REFLEX TESTING
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TRICEPS REFLEX
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REFLEX
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RESPONSE
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