hours after injury. Bleeding also may increase the volume of contents within the rigid,
closed compartment of the skull, causing increased ICP and herniation of the brain
stem and resulting in irreversible brain anoxia and brain death (Arbour, 2004; Censullo
& Sebastian, 2004). Measures to control ICP are discussed in Chapter 61 and listed in
Chart 63-5.
Impaired Oxygenation and Ventilation
Impaired oxygen and ventilation may require mechanical ventilatory support. The
patient must be monitored for a patent airway, altered breathing patterns, and
hypoxemia and pneumonia. Interventions may include endotracheal intubation,
mechanical ventilation, and positive end-expiratory pressure. These topics are
discussed in further detail in Chapters 25 and 61.
Impaired Fluid, Electrolyte, and Nutritional Balance
Fluid, electrolyte, and nutritional imbalances are common in the patient with a head
injury. Common imbalances include hyponatremia, which is often associated with
SIADH (see Chapters 14 and 42), hypokalemia, and hyperglycemia (Hickey, 2003).
Modifications in fluid intake with tube feedings or IV fluids, including hypertonic
saline, may be necessary to treat these imbalances (Johnson & Criddle, 2004). Insulin
administration may be prescribed to treat hyperglycemia.
Undernutrition is also a common problem in response to the increased metabolic needs
associated with severe head injury. If the patient cannot eat, enteral feedings or
parenteral nutrition may be initiated within 48 hours after the injury to provide
adequate calories and nutrients (Bader et al., 2003). Nutritional support in the form of
early feeding after head injury is associated with better survival outcomes and
decreased disability (Yanagawa, Bunn, Roberts, et al., 2002).
Post-traumatic Seizures
Patients with head injury are at an increased risk for post-traumatic seizures. Post-
traumatic seizures are classified as immediate (within 24 hours after injury), early
(within 1 to 7 days after injury), or late (more than 7 days after injury) (Somjen, 2004).
Seizure prophylaxis is the practice of administering antiseizure medications to patients
with head injury to prevent seizures. It is important to prevent post-traumatic seizures,
especially in the immediate and early phase of recovery, because seizures may increase
ICP and decrease oxygenation. However, many antiseizure medications impair
cognitive performance and can prolong the duration of rehabilitation. Therefore, it is
important to weigh the overall benefit of these medications against their side effects.
Research evidence supports the use of prophylactic antiseizure agents to prevent
immediate and early seizures after head injury, but not for prevention of late seizures
(Somjen, 2004).
The nurse must assess the patient carefully for the development of post-traumatic
seizures. Risk factors that increase the likelihood of seizures are brain contusion with
subdural hematoma, skull fracture, loss of consciousness or amnesia of 1 day or more,
and age older than 65 years (Somjen, 2004). The nursing management of seizures is
addressed in Chapter 61.
Other complications after traumatic head injury include systemic infections
(pneumonia, urinary tract infection [UTI], septicemia), neurosurgical infections (wound
infection, osteomyelitis, meningitis, ventriculitis, brain abscess), and heterotrophic
ossification (painful bone overgrowth in weight-bearing joints).