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Comment on this procedure
* Management and care of Acute Head Injury may be undertaken by all Registered Nurses unless in a critical area or patient ventilated or has haemodynamic monitoring, critical care certificate nurses and registered nurses under supervision of same only
* Vital signs, Glasgow Coma Scale and pupil observations Q1h (maximum) but may be as frequent as every 15 to 30 minutes.
* SBP maintained within 90-200mmHg.
* Core body temperature maintained 38%C.
* Intervention individualised depending on nature and/or severity of injury.
* Unconscious patients or those with impaired cough and/or gag reflex must have airway protection.
* Maximise O2 uptake and minimise CO2 retention.
* Disorientated, confused patients or those with impaired judgement must be protected from physical injury.
* Prevent increases in Intracranial pressure.
* Prevent increases in intrathoracic pressure.
* Unconscious and/or severe head injured patients to have IDC and naso/oropharyngeal tube.
* Cervical spine injury to be assumed until proven otherwise.
OUTCOMES:
* Limit primary injury.
* Prevent secondary injury.
* Maximise potential neurological recovery.
* Maintain homeostasis.
R : 13.1
PROCEDURES:
* Notify Physician immediately of significant change in vital signs, neurological observations, urine output or biochemistry.
* Place unconscious patients in "recovery" position with guedels in situ.
* Place ventilated patients in semi-recumbent position with head elevated 30%.
* Place head in midline position and avoid compression/kinking neck veins (may require support with sandbags/
rolled towel).
* Secure ETT as per policy.
* Suction ETT only when necessary.
* Remove excess oral secretions.
* Assess temperature with rectal tube or IDC sensor.
* Cool patients with temperature >38%C as per policy.
* Measure urine output Q1h.
* Minimise straining and/or movement.
* Maintain adequate sedation and give analgesia/sedatives/paralysing agents as prescribed.
* Notify Physician immediately if shivering/seizures/pain observed.
* Use spenco mattress and give Q2-4h pressure care for immobile patients.
* Use a hard cervical collar and log roll patients with suspected neck injury. Head must be supported by one staff member during procedure.
* Give supplemental O2 as prescribed.
NURSES ROLE:
* Observe/record response to treatment.
* Carry out prescribed treatment.
* Act as a liaison and/or keep family/significant others informed of patients progress.
REF: Civetta, Taylor et al, 1992 Critical Care, 2nd Edition, J.B. Lippincott Co, Philadelphia.
R : 13.2
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