Head Injury Nursing Diagnosis Care Plan: Comprehensive Guide for Effective Care

Traumatic brain injury (TBI), commonly referred to as head injury, is a significant health concern involving brain damage due to external mechanical force. This damage can lead to temporary or permanent impairments affecting sensory perception, cognitive functions, mobility, and behavior. Effective nursing care is crucial in managing TBI, and a well-structured nursing diagnosis care plan is paramount for optimal patient outcomes.

Overview of Traumatic Brain Injury

TBIs are frequently caused by falls, assaults, motor vehicle accidents, and any impact resulting in a blow to the head. The severity of a TBI can range from mild, such as a concussion, to moderate or severe, potentially leading to prolonged unresponsiveness, coma, or even death. Understanding the mechanisms of injury is essential for devising appropriate nursing strategies.

Brain damage from TBI is categorized into two phases: primary and secondary injuries.

Primary injuries occur at the moment of the initial impact, directly affecting the brain and skull. These include:

• Skull fractures: Breaks in the cranial bones.
• Intracranial hemorrhage: Bleeding within the skull.
• Cerebral contusions: Bruising of brain tissue.
• Concussions: Mild TBIs causing temporary neurological dysfunction.
• Penetrating injuries: Injuries from objects piercing the skull, like gunshot wounds or projectiles.

Secondary injuries develop in the hours and days following the initial trauma and can significantly worsen patient outcomes. These complications include:

• Increased intracranial pressure (ICP): Elevated pressure inside the skull.
• Cerebral edema: Swelling of the brain tissue.
• Hydrocephalus: Accumulation of cerebrospinal fluid in the brain.
• Brain herniation: Displacement of brain tissue due to increased pressure.
• Chronic traumatic encephalopathy (CTE): A degenerative brain disease caused by repeated head injuries.

Nursing Process for Head Injury Care

The nursing process is fundamental in managing patients with head injuries. The approach varies based on the severity of the TBI. For mild TBI, management primarily involves neurologic assessments and patient education concerning post-concussive symptoms like irritability, fatigue, headache, and sleep disturbances.

In moderate to severe TBI cases, the focus shifts to acute treatment aimed at maintaining cerebral perfusion and enhancing functional recovery by minimizing secondary brain injuries. Rehabilitation nurses play a vital role in supporting patients throughout their recovery, helping them overcome physical, emotional, and cognitive challenges.

Nursing Assessment for Head Injury

The initial step in nursing care is a comprehensive nursing assessment, gathering physical, psychosocial, emotional, and diagnostic data. This section details the subjective and objective data pertinent to traumatic brain injuries, which is critical for formulating an effective Head Injury Nursing Diagnosis Care Plan.

Review of Health History in Head Injury Patients

1. Assess for Visible Signs of Head Trauma:
Patients with TBI often present with external signs of trauma, such as lacerations, bleeding, and ecchymosis around the head. Nurses must immediately evaluate the patient’s level of consciousness and be vigilant for changes in pupil size, shape, and reactivity, or a decrease in the Glasgow Coma Scale (GCS) score, as these may necessitate urgent intervention.

2. Determine TBI Severity:
Recognizing the signs and symptoms associated with different severities of TBI is essential for appropriate management.

Signs and symptoms of mild TBI include:

• Headache: Often described as a persistent or throbbing pain in the head.
• Dizziness: Feelings of unsteadiness or vertigo.
• Drowsiness: Excessive sleepiness or difficulty staying awake.
• Blurred vision: Difficulty seeing clearly.
• Tinnitus: Ringing in the ears.
• Balance disturbances: Problems with coordination and equilibrium.
• Nausea and vomiting: Feelings of sickness and throwing up.
• Impaired cognitive and emotional state: Confusion, difficulty concentrating, mood changes.
• Possible loss of consciousness: Brief period of unresponsiveness.

Signs of moderate TBI encompass those of mild TBI, along with:

• Persistent headache: Headache that does not resolve easily.
• Seizures: Uncontrolled electrical disturbances in the brain.
• Fluid drainage from nose or ears: Cerebrospinal fluid (CSF) leak, indicating skull fracture.
• Confusion: Disorientation and difficulty thinking clearly.
• Unusual behavior: Inappropriate actions or emotional responses.
• Loss of consciousness lasting minutes to hours: Prolonged unresponsiveness.

Patients with severe TBI may exhibit:

• Hemiplegia: Paralysis of one side of the body.
• Flexor or extensor posturing: Abnormal body positioning indicating severe brain injury.
• Language deficits: Difficulty speaking or understanding language (aphasia).
• Behavioral and cognitive changes: Significant alterations in personality, memory, and thinking.
• Hemiparesis: Weakness on one side of the body.

3. Assess Symptoms in Children:
Children, especially infants and toddlers, may not articulate typical adult symptoms. Nurses should observe for:

• Changes in eating habits: Refusal to eat or poor feeding.
• Persistent crying: Inconsolable or high-pitched crying.
• Changes in sleep habits: Increased drowsiness or difficulty waking up.
• Seizures: Convulsions.
• Drowsiness: Unusual lethargy.
• Loss of interest in toys: Decreased engagement with surroundings.
• Inability to pay attention: Difficulty focusing or tracking objects.
• Loss of balance: Unsteady gait or frequent falls.

4. Identify the Cause of Injury:
Understanding the mechanism of injury is crucial. Falls and motor vehicle accidents are leading causes of TBIs. Even without visible injuries like bruising or wounds, patients with a history of falls or MVAs should be evaluated for head trauma.

5. Identify Risk Factors for TBI:
Certain populations are at higher risk for TBIs. These include:

• Children (under 4 years): Due to developing motor skills and larger head-to-body ratio.
• Young adults (15-24 years): Higher risk-taking behaviors.
• Older adults (over 60 years): Increased risk of falls.
• Male gender: Higher participation in risky activities.
• Athletes and extreme sports participants: Increased exposure to head impacts.
• Military personnel: Combat-related injuries.
• Abuse victims: Physical violence.
• Alcohol or substance use: Impaired judgment and coordination.
• History of previous TBI: Increased vulnerability to subsequent injuries.

6. Note Patient’s Environment and Occupation:
Certain occupations carry a higher TBI risk. Examples include:

• Military personnel: Combat and training.
• Construction workers: Falls and falling objects.
• Truck drivers (freight): Accidents.
• Building and dwelling service employees: Falls from heights.

7. Interview Witnesses:
Gathering information from witnesses is vital. Ask about the incident details and any first aid administered at the scene to guide prompt and accurate treatment.

8. Review Medications:
Assess the patient’s medication list, including OTC drugs, prescriptions, and supplements. Identify substances that may cause drowsiness, lightheadedness, increase fall risk, or elevate bleeding risk associated with head injuries.

Physical Assessment for Head Injury

1. Neurological Assessment:
Conduct a thorough neurological assessment, monitoring level of consciousness, orientation, behavior, motor function, speech, reflexes, and sensations. Utilize the GCS to quantify eye, verbal, and motor responses, aiding in TBI severity assessment.

2. Assessment of Physical Wounds:
Inspect and monitor wounds, lacerations, and contusions for bleeding, swelling, or embedded objects. Assess for injuries to the eyes, ears, and face. Clear drainage from ears or nose may indicate a cerebrospinal fluid (CSF) leak. Bruising behind the ear (Battle’s sign) or around the eyes (Raccoon eyes) are indicative of a basilar skull fracture. Palpate the scalp for depressions or open areas.

3. Monitor Vital Signs and General Status:
TBI can disrupt the circulatory system, leading to hypotension, hypertension, hyperthermia, or hypothermia. Closely monitor vital signs for abnormalities that could signal complications such as increased intracranial pressure or hemorrhage.

4. Brain Injury Screening:
Employ a Brain Injury Screening Tool (BIST) to evaluate symptoms and identify patients at risk for poor recovery who might need hospitalization or specialized care. Key questions include inquiries about loss of consciousness, vomiting, head or neck pain, light or sound sensitivity, dizziness, and cognitive difficulties.

Diagnostic Procedures for Head Injury

1. Laboratory Tests:
Glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase (UCH-L1) are serum biomarkers associated with brain injury extent. GFAP levels are particularly reliable up to seven days post-injury. These proteins are released from damaged neurons and astrocytes.

2. Coagulation Monitoring:
A complete blood count (CBC), including platelet count, and prothrombin time/international normalized ratio (PT/INR) may be ordered to assess clotting factors to manage bleeding risks.

3. Imaging Orders:
Computed tomography (CT) scans are crucial for rapidly detecting skull fractures, hemorrhages, hematomas, and brain swelling. Magnetic resonance imaging (MRI) is indicated if brainstem or vascular injuries are suspected.

4. Intracranial Pressure (ICP) Monitoring:
Monitor ICP, especially in severe TBI. Elevated ICP can exacerbate brain damage. A catheter inserted into the brain can track pressure and guide prompt treatment. ICP monitoring is often warranted for patients with abnormal head CT scans and/or a GCS score of 8 or less. ICP values exceeding 20-25 mmHg require intervention, and sustained levels over 40 mmHg indicate severe, life-threatening intracranial hypertension.

Nursing Interventions for Head Injury

Nursing interventions are crucial for patient recovery following a TBI. The following section outlines essential nursing interventions for patients with traumatic brain injuries, forming the basis of a head injury nursing diagnosis care plan.

1. Emergency Treatment:
Emergency care for moderate to severe TBI focuses on stabilizing blood pressure, ensuring adequate oxygenation and perfusion, and preventing further head and neck injuries.

2. Medication Administration:
Medications in the acute phase of TBI may include:

• Anticonvulsants: To prevent seizures.
• Coma-inducing drugs: To reduce brain metabolic demand and ICP in severe cases.
• Mannitol: An osmotic diuretic to reduce cerebral edema.

3. Encourage Rest:
For mild TBI, limiting physical and mental activity, known as “brain rest,” can be the primary treatment. This helps reduce symptom aggravation and promote healing.

4. Surgical Procedures:
Surgery might be necessary to prevent further brain damage and address specific injuries, including:

• Decompressive craniectomy: Removing a portion of the skull to allow brain swelling.
• Hematoma evacuation: Surgically removing blood clots.
• Skull fracture repair: Stabilizing and repairing skull fractures.
• Hemorrhage repair: Controlling bleeding within the brain.

5. Reduce Intracranial Pressure (ICP):
Techniques to lower ICP include:

• Head elevation: Positioning the head of the bed at a 30-45 degree angle (semi-Fowler’s position).
• Brief hyperventilation: To temporarily reduce CO2 levels and cause cerebral vasoconstriction.
• Hyperosmolar therapy: Using mannitol or hypertonic saline to draw fluid out of the brain tissue.
• Therapeutic cooling (hypothermia): To reduce brain metabolic rate and ICP.
• Barbiturate-induced coma: In severe cases to decrease brain activity and ICP.

6. Rehabilitation Referral:
For severe TBIs, rehabilitation is critical. Patients may need support from physical therapists, occupational therapists, speech-language therapists, physiatrists, and neuropsychologists to regain skills like walking, talking, eating, and performing daily activities. Rehabilitation nurses provide continuous inpatient care during this phase.

7. Coping and Support Mechanisms:
Recovery from severe TBI can be lengthy, often taking months or years. Patients may experience emotional distress related to relearning basic skills. Support groups can offer emotional outlets and understanding. Encourage patients to establish routines, use memory aids, and focus on one task at a time to prevent overwhelm.

8. Prevention of Future TBI:
Educate patients and families on measures to prevent future TBIs:

• Fall prevention strategies for older adults and children.
• Use of safety gear, such as helmets during risky activities.
• Consistent seatbelt use in vehicles.
• Avoiding risky behaviors, especially under the influence of alcohol or drugs.
• Safe firearm storage.
• Regular physical activity to improve balance and coordination.

Nursing Care Plans for Head Injury

Once nursing diagnoses are identified for TBI, nursing care plans prioritize assessments and interventions for both short-term and long-term care goals. Examples of nursing care plans relevant to head injury are detailed below, providing a framework for a comprehensive head injury nursing diagnosis care plan.

Acute Confusion Care Plan

Patients with mild to severe TBI may experience altered cognition, ranging from acute confusion to prolonged confusion with amnesia.

Nursing Diagnosis: Acute Confusion

Related to:

• Brain injury
• Neurologic trauma
• Decreased level of consciousness

As evidenced by:

• Cognitive dysfunction
• Misperception
• Agitation or restlessness

Expected Outcomes:

• Patient will maintain baseline level of consciousness and memory.
• Patient will respond appropriately to questions.

Nursing Assessments:

1. Assess Sensory Awareness: Crucial for patient safety, as parietal lobe injury can impair sensory perception and responses to stimuli.
2. Assess Orientation and Personality Changes: Upper cerebral functions are first affected by altered circulation or oxygenation, leading to motor, cognitive, perceptual, and personality changes.
3. Assess Cognitive Impairment Level: Determines appropriate rehabilitation strategies by understanding the extent of cognitive deficits.

Nursing Interventions:

1. Ensure Patient Safety: Provide a hazard-free environment due to impaired ability to follow directions.
2. Reorient Patient as Needed: Frequent reorientation helps patients with mild TBI who are disoriented or have short-term memory loss, fostering trust and cooperation.
3. Use Short and Simple Explanations: Improves understanding and retention of instructions, vital before and during care.
4. Eliminate Extraneous Noise: Reduces anxiety, confusion, and sensory overload.
5. Provide Structured Therapies and Activities: Promotes consistency, reassurance, and a sense of control, reducing anxiety and confusion.

Deficient Knowledge Care Plan

Many TBI patients face long-term physical and cognitive disabilities, necessitating comprehensive patient and family education to address misconceptions, adapt to changes, develop coping strategies, and ensure adherence to care plans.

Nursing Diagnosis: Deficient Knowledge

Related to:

• Cognitive dysfunction
• Inadequate access to resources
• Misinformation
• Neurobehavioral manifestations

As evidenced by:

• Inappropriate behavior
• Inaccurate statements about condition
• Inaccurate follow-through of instructions
• Development of complications

Expected Outcomes:

• Patient and/or family will demonstrate knowledge of condition, treatments, and prognosis through verbalization and adherence to follow-up.

Nursing Assessments:

1. Assess Cognitive Ability: Tailor teaching methods to patient’s cognitive status to ensure effective learning.
2. Assess Support System: Identify available support as severe TBI often requires extensive assistive care.

Nursing Interventions:

1. Encourage Participation in Treatment Regimen: Fosters control and improves adherence.
2. Encourage Therapy Participation: Maximize functional recovery through rehabilitation and continuous family support post-discharge.
3. Discuss Potential Behavioral, Mood, Personality Changes: Prepare family for these challenges post-TBI.
4. Emphasize Follow-up Care: Essential for optimal recovery and long-term management.
5. Instruct on Structured Home Routine: Provides stability and predictability beneficial for TBI patients.

Ineffective Breathing Pattern Care Plan

TBI can lead to respiratory distress and altered breathing patterns due to brainstem impairment.

Nursing Diagnosis: Ineffective Breathing Pattern

Related to:

• Brainstem impairment
• Altered level of consciousness
• Respiratory muscle weakness

As evidenced by:

• Bradypnea or Tachypnea
• Cyanosis
• Irregular breathing patterns
• Shallow respirations
• Hypoventilation or Hyperventilation
• Hypoxemia or Hypoxia
• Nasal flaring
• Accessory muscle use

Expected Outcomes:

• Patient will maintain arterial blood gases within acceptable range.
• Patient will not require mechanical ventilation if possible.

Nursing Assessments:

1. Assess Respiratory Rate, Rhythm, and Depth: Note irregularities like Cheyne-Stokes respirations, tachypnea, bradypnea, or shallow breathing.
2. Assess Blood Gas Values and Oxygen Saturation: Declines indicate ineffective breathing and respiratory complications.
3. Monitor for ARDS: Be alert for dyspnea, cyanosis, altered mental status, and rales, as ARDS is a severe complication post-TBI.

Nursing Interventions:

1. Position Patient at 30-45 Degrees: Elevate head to reduce ICP and promote lung expansion.
2. Administer Supplemental Oxygen: Essential to correct hypoxia and improve breathing patterns.
3. Assist with Ventilatory Support: Mechanical ventilation may be needed in severe cases to protect airways and ensure oxygenation.
4. Encourage Breathing Exercises and Ambulation: Improve cardiorespiratory fitness post-TBI.

Ineffective Cerebral Tissue Perfusion Care Plan

Patients with TBI are at risk for decreased cerebral tissue perfusion due to swelling, bleeding, or CSF leaks.

Nursing Diagnosis: Ineffective Tissue Perfusion (Cerebral)

Related to:

• Hemorrhage
• Skull fractures
• Cerebral edema
• Decreased systemic blood pressure
• Hypoxia

As evidenced by:

• Mental status changes
• Decreased LOC
• Pupillary changes
• Changes in motor response
• Difficulty swallowing or speaking

Expected Outcomes:

• Patient will maintain expected level of consciousness, motor, sensory, and cognitive function.
• Patient will demonstrate adequate cerebral perfusion with stable vital signs.

Nursing Assessments:

1. Obtain Accurate Patient History: Gather details about injury event from witnesses or first responders to guide treatment.
2. Frequent Neurological Status Monitoring: Changes indicate complications and need for urgent intervention.
3. Monitor Vital Signs: Detect hypotension, hypertension, and Cushing’s triad (late sign of increased ICP).
4. Evaluate Diagnostic Studies: CT scans and MRIs to identify injury extent and guide surgical needs.

Nursing Interventions:

1. Evaluate Pupillary Responses: Report changes in size, reactivity, and shape as indicators of ICP.
2. Monitor Bilateral Motor Responses: Detect deterioration in mobility and posture, indicating progressive brain injury.
3. Maintain Head and Neck in Midline: Prevent jugular vein compression and increased ICP.
4. Provide Rest Periods: Limit stimulation to prevent ICP increase.
5. Administer IV Fluids: Maintain perfusion with crystalloids or colloids, avoiding hypotonic and dextrose solutions.
6. Administer Supplemental Oxygen: Correct hypoxemia, which can increase ICP.
7. Administer Medications: Diuretics like mannitol to reduce brain swelling.
8. Prepare for Surgical Intervention: Craniotomy to relieve pressure, remove bone fragments, control bleeding, and evacuate hematomas.

Ineffective Thermoregulation Care Plan

Hyperthermia and hypothermia can occur post-TBI due to hypothalamic damage, inflammation, or infection.

Nursing Diagnosis: Ineffective Thermoregulation

Related to:

• Brain injury
• Inflammatory process
• Neurological impairment
• Secondary infection

As evidenced by:

• Increased or decreased body temperature
• Flushed or cool skin
• Hypertension
• Increased respiratory rate
• Tachycardia
• Seizures

Expected Outcomes:

• Patient will maintain body temperature within normal range.
• Patient will not experience complications like seizures due to thermoregulation issues.

Nursing Assessments:

1. Monitor Patient Temperature: Consistent monitoring detects complications and guides treatment.
2. Assess Causative Factors: Identify if fever is due to inflammation, hypothalamic damage, or infection.
3. Monitor for Complications: Fever increases risk of seizures and ICP, requiring close monitoring.

Nursing Interventions:

1. Administer Antipyretics: Acetaminophen to maintain normothermia and prevent further brain damage.
2. Prevent Overheating: Keep patient cool with loose clothing, cool cloths, and adjusting room temperature.
3. Adjust Room Temperature: Maintain a neutral environment to prevent temperature extremes.
4. Administer IV Fluids: Ensure hydration to replace fluid loss from hyperthermia and manage systemic demands. Isotonic fluids are preferred.