HHC Health & Home Care Clinical Policy And

HHC HEALTH & HOME CARE Section: 14-22
Emergency: Head Injury __RN
PURPOSE:
To evaluate and monitor patient sustaining head injury
until EMS arrives. Prevent further injury and
complications.
CONSIDERATIONS:
1. It is necessary to observe the symptoms common
with head injuries, which are reportable to the
emergency medical caregivers. Clinical
manifestations indicative of a head injury are:
Unconsciousness
Headaches
Dizziness
Confusion or delirium
Respiratory irregularities
Symptoms of shock
Changes in body temperature
Pupillary abnormalities
Visual disturbances
Nausea and vomiting
Clear or blood-tinged fluid draining from nose
or ears
Bleeding from nose, ear canal, or mouth
Paralysis of muscles of extremities of side opposite
injury and paralysis of muscles on face on same
side of injury
Disturbance of speech
Convulsions, twitching of muscles
Pale or flushed face
Weak and rapid pulse
Loss of bowel and bladder control
2. If examination of scalp wound indicates cranial
fracture, do not cleanse because of the danger of
contamination of brain and increased bleeding.
EQUIPMENT:
Pillow or rolled blanket
Gauze dressing
Blood pressure cuff
Stethoscope
Gloves, if available
PROCEDURE:
1. Adhere to Universal Precautions.
2. Assess respiratory status. Open airway. Initiate
CPR if indicated (see policy 15-7 through 15-8).
3. Evaluate for hemorrhage.
4. Arrange for immediate medical attention (call 911).
5. Determine patient's baseline condition. Report to
physician.
a. Assess level of responsiveness, orientation.
b. Assess presence of headache, double vision,
nausea, or vomiting.
c. Check pupil size and reaction to light.
d. Monitor blood pressure, pulse, respirations.
e. Assess movement and strength of extremities.
f. Assess for other injuries and open wounds.
6. Obtain as much specific information about the injury
as possible from the patient or witness. Report to
physician or paramedics.
a. What caused the injury?
b. Force and direction of the blow?
c. Any loss of consciousness? How long?
d. Any bleeding from eyes, ears, nose, mouth?
e. Any paralysis or flaccidity of the extremities?
f. Any seizure activity?
7. Treatment.
a. Keep patient lying down. Treat for shock.
Immobilize neck. If necessary, open airway by
chin lift/jaw thrust. If vomiting occurs, log roll
patient to side while maintaining C-spine
traction. Never position patient so that head is
lower than rest of body.
b. Control hemorrhage.
c. Do not give fluids by mouth.
d. Do not give sedatives.
e. If scalp wound is present, apply a large
dressing over injury, and bandage it in place
with a full-head bandage.
f. Treat other injuries.
g. Maintain quiet restful environment, and continue
to evaluate patient for any changes in condition.
8. Discard soiled supplies in appropriate containers.
AFTER CARE:
1. Document in patient's record:
a. How injury occurred.
b. Description of wound.
c. Symptoms.
d. Treatment administered and patient's response.
2. Transfer recorded data to person assuming
medical responsibility for patient
3. Call nursing supervisor
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