difficulties in coping with changes in the patient's temperament, behavior, and
personality. Such changes are associated with disruption in family cohesion, loss of
leisure pursuits, and loss of work capacity, as well as social isolation of the caretaker.
The family may experience marital disruptions, anger, grief, guilt, and denial in
recurring cycles (Hsueh-Fen & Stuifbergen, 2004).
To promote effective coping, the nurse can ask the family how the patient is different
now, what has been lost, and what is most difficult about coping with this situation.
Helpful interventions include providing family members with accurate and honest
information and encouraging them to continue to set well-defined short-term goals.
Family counseling helps address the family members' overwhelming feelings of loss
and helplessness and gives them guidance for the management of inappropriate
behaviors. Support groups help the family members share problems, develop insight,
gain information, network, and gain assistance in maintaining realistic expectations and
hope.
The Brain Injury Association (see Resources) serves as a clearinghouse for information
and resources for patients with head injuries and their families, including specific
information on coma, rehabilitation, behavioral consequences of head injury, and
family issues. This organization can provide names of facilities and professionals who
work with patients with head injuries and can assist families in organizing local support
groups.
Many patients with severe head injury die of their injuries, and many of those who
survive experience long-term disabilities that prevent them from resuming their
previous roles and functions. During the most acute phase of injury, family members
need support and facts from the health care team.
Many patients with severe head injuries that result in brain death are young and
otherwise healthy and are therefore considered for organ donation. Family members of
patients with such injuries need support during this extremely stressful time and
assistance in making decisions to end life support and permit donation of organs. They
need to know that the patient who is brain dead and whose respiratory and
cardiovascular systems are maintained through life support is not going to survive and
that the severe head injury, not the removal of the patient's organs or the removal of life
support, is the cause of the patient's death. Bereavement counselors and members of the
organ procurement team are often very helpful to family members in making decisions
about organ donation and in helping them cope with stress.
Monitoring and Managing Potential Complications
Decreased Cerebral Perfusion Pressure
Maintenance of adequate CPP is important to prevent serious complications of head
injury due to decreased cerebral perfusion (Bader et al., 2003; Littlejohns et al., 2003).
Adequate CPP is greater than 70 mm Hg. Any decrease in this pressure can impair
cerebral perfusion and cause brain hypoxia and ischemia, leading to permanent
damage. Therapy (eg, elevation of the head of the bed and increased IV fluids) is
directed toward decreasing cerebral edema and increasing venous outflow from the
brain. Systemic hypotension, which causes vasoconstriction and a significant decrease
in CPP, is treated with increased IV fluids.
Cerebral Edema and Herniation
The patient with a head injury is at risk for additional complications such as increased
ICP and brain stem herniation. Cerebral edema is the most common cause of increased
ICP in the patient with a head injury, with the swelling peaking approximately 48 to 72