Preventing Injury
Often, as the patient emerges from coma, a period of lethargy and stupor is followed by
a period of agitation. Each phase is variable and depends on the individual, the location
of the injury, the depth and duration of coma, and the patient's age. The patient
emerging from a coma may become increasingly agitated toward the end of the day.
Restlessness may be caused by hypoxia, fever, pain, or a full bladder. It may indicate
injury to the brain but may also be a sign that the patient is regaining consciousness.
(Some restlessness may be beneficial because the lungs and extremities are exercised.)
Agitation may also be due to discomfort from catheters, IV lines, restraints, and
repeated neurologic checks. Alternatives to restraints must be used whenever possible.
Strategies to prevent injury include the following:
The patient is assessed to ensure that oxygenation is adequate and the bladder is
not distended. Dressings and casts are checked for constriction.
Padded side rails are used or the patient's hands are wrapped in mitts to protect
the patient from self-injury and dislodging of tubes (Fig. 63-6). Restraints are
avoided, because straining against them can increase ICP or cause other injury.
Enclosed or floor-level specialty beds may be indicated.
Opioids are avoided as a means of controlling restlessness, because these
medications depress respiration, constrict the pupils, and alter responsiveness.
Environmental stimuli are reduced by keeping the room quiet, limiting visitors,
speaking calmly, and providing frequent orientation information (eg, explaining
where the patient is and what is being done).
Adequate lighting is provided to prevent visual hallucinations.
Efforts are made to minimize disruption of the patient's sleep/wake cycles.
The patient's skin is lubricated with oil or emollient lotion to prevent irritation
due to rubbing against the sheet.
If incontinence occurs, an external sheath catheter may be used on a male
patient. Because prolonged use of an indwelling catheter inevitably produces
infection, the patient may be placed on an intermittent catheterization schedule.Maintaining Body Temperature
An increase in body temperature in the patient with a head injury can be the result of
damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The
nurse monitors the patient's temperature every 2 to 4 hours. If the temperature
increases, efforts are made to identify the cause and to control it using acetaminophen
and cooling blankets to maintain normothermia (Bader & Littlejohns, 2004; Diringer,
2004). Cooling blankets should be used with caution so as not to induce shivering,
which increases ICP. If infection is suspected, potential sites of infection are cultured
and antibiotics are prescribed and administered.
Use of mild hypothermia to 34° to 35° C (94° to 96° F) has been tested in small
randomized controlled trials for at least 12 hours versus normothermia (control) in
patients with closed head injury (Alderson, Gadkary & Signorini, 2005). The clinical
trials with small samples showed improvement in patient outcomes but need to be
repeated in larger trials. Because hypothermia increases the risk of pneumonia and has
other side effects, this treatment is not currently recommended outside of controlled
clinical trials.
Maintaining Skin Integrity
Patients with traumatic head injury often require assistance in turning and positioning
because of immobility or unconsciousness. Prolonged pressure on the tissues decreases