Head Injury in Children
Comprehensive Nursing Management Notes
A comprehensive guide for nursing students on assessment, management, and care planning
Table of Contents
Introduction to Pediatric Head Injury
Definition & Significance
A pediatric head injury refers to any trauma to the scalp, skull, or brain in a child. Traumatic brain injury (TBI) specifically is a disruption to the normal function of the brain caused by a mechanical impact to the head.
Clinical Significance
Head injuries are one of the most common causes of disability and death in children. They require prompt assessment and management to prevent secondary injury and long-term complications.
Unique Considerations in Children
- Larger head-to-body ratio (higher center of gravity)
- Thinner skull bones with greater elasticity
- Unfused sutures in infants
- Developing brain with greater neuroplasticity
- Different injury patterns compared to adults
- Age-dependent clinical presentation
Primary Nursing Concerns
- Preventing secondary brain injury
- Maintaining cerebral perfusion
- Monitoring neurological status
- Managing increased intracranial pressure
- Preventing complications
- Supporting families through traumatic situation
Epidemiology & Classification
Epidemiology
Prevalence & Incidence
- Leading cause of mortality in children aged 1-18 years
- Over 500,000 emergency department visits annually in the US
- Approximately 60,000 hospitalizations per year
- More than 3,000 pediatric deaths annually from head trauma
- Males more prone to TBI across all pediatric age groups
Common Causes by Age Group
- Infants (0-12 months): Falls, non-accidental trauma (NAT)
- Toddlers (1-3 years): Falls, motor vehicle accidents
- Preschool (3-5 years): Falls, pedestrian accidents
- School-age (6-12 years): Sports injuries, bicycle accidents, motor vehicle accidents
- Adolescents (13-18 years): Sports injuries, motor vehicle accidents, assault
Non-Accidental Trauma (NAT) Alert
Always maintain a high index of suspicion for NAT (child abuse) in pediatric head injuries, especially when:
- History inconsistent with injury pattern
- Delay in seeking medical attention
- Multiple injuries in various stages of healing
- Retinal hemorrhages
- Bilateral subdural hematomas in young children
- Significant neurologic injury with minimal external trauma
Classification
A. Severity Classification (Glasgow Coma Scale)
| Severity | GCS Score | Clinical Features |
|---|---|---|
| Mild TBI | 14-15 | Brief or no loss of consciousness, temporary confusion, headache, dizziness |
| Moderate TBI | 9-13 | Loss of consciousness (minutes to hours), confusion lasting days to weeks, physical/cognitive impairments lasting months |
| Severe TBI | 3-8 | Prolonged unconsciousness (coma), significant neurological deficits, high risk of mortality |
B. Types of Head Injuries
Scalp Injuries
- Abrasions
- Lacerations
- Contusions (bruising)
- Hematomas (cephalohematoma, subgaleal hematoma)
Skull Fractures
- Linear (non-displaced)
- Depressed (bone fragment pushed inward)
- Basilar (base of skull)
- Compound (with overlying skin breach)
- “Ping-pong” fractures (infant skull indentation)
- Growing skull fractures (leptomeningeal cysts)
Brain Injuries – Focal
- Contusions (bruising of brain tissue)
- Lacerations (tears in brain tissue)
- Epidural hematoma (between skull and dura)
- Subdural hematoma (between dura and arachnoid)
- Subarachnoid hemorrhage (in subarachnoid space)
- Intraparenchymal hemorrhage (within brain tissue)
- Intraventricular hemorrhage (into ventricles)
Brain Injuries – Diffuse
- Concussion
- Diffuse axonal injury (DAI)
- Cerebral edema (swelling)
- Hypoxic-ischemic injury
- Second impact syndrome
Mnemonic: “SCALP” – Types of Pediatric Head Injuries
- S – Scalp injuries (lacerations, hematomas)
- C – Cranial fractures (linear, depressed, basilar)
- A – Axonal injuries (diffuse axonal injury, concussion)
- L – Localized hemorrhages (epidural, subdural)
- P – Parenchymal injuries (contusions, lacerations)
Pathophysiology
Understanding Brain Injury Mechanisms
Primary vs. Secondary Injury
Head trauma involves two distinct phases of injury:
Primary Injury
Direct mechanical damage that occurs at the moment of impact, including:
- Contusions and lacerations
- Skull fractures
- Vascular damage with hemorrhage
- Axonal shearing
Secondary Injury
Cascading cellular processes that evolve over hours to days following impact:
- Cerebral edema
- Increased intracranial pressure
- Ischemia/hypoxia
- Excitotoxicity (glutamate release)
- Inflammation
- Metabolic dysfunction
- Apoptosis (programmed cell death)
- Vasospasm
Cellular Mechanisms of Injury
- Mechanical Impact: Deformation of brain parenchyma and vascular structures relative to the skull
- Ionic Flux: Unregulated potassium efflux, sodium and calcium influx
- Neurotransmitter Release: Unrestricted glutamate release triggers voltage/ligand-gated ion channels
- ATP Depletion: Ionic pumps upregulated to restore homeostasis, depleting cellular energy reserves
- Impaired Metabolism: Lasting 7-10 days post-injury, with altered cerebral blood flow
- Neuronal Damage: Cytoskeletal damage, altered neurotransmission, axonal dysfunction
Critical Nursing Implication
During the impaired metabolic state (lasting 7-10 days), the brain is extremely vulnerable to secondary injury. This is when nursing vigilance is most critical to prevent complications that could worsen outcomes.
Age-Related Pathophysiological Considerations
| Age Group | Unique Factors | Implications |
|---|---|---|
| Infants |
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| Toddlers/Preschoolers |
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| School-Age/Adolescents |
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Mind Map: Pathophysiology of Pediatric TBI
Clinical Manifestations
Signs & Symptoms
The clinical presentation of pediatric head injury varies widely based on the type and severity of injury, age of the child, and time since injury. Understanding these manifestations is crucial for proper assessment and triage.
Mild TBI (GCS 14-15)
- Brief or no loss of consciousness
- Headache
- Dizziness, balance problems
- Nausea or vomiting (usually limited)
- Fatigue, drowsiness
- Irritability, mood changes
- Confusion, disorientation
- Memory or concentration problems
- Visual disturbances
- Sensitivity to light or noise
- Sleep disturbances
Moderate TBI (GCS 9-13)
- Loss of consciousness minutes to hours
- Persistent/worsening headache
- Repeated vomiting
- Seizures
- Pupillary changes (mild)
- Moderate confusion
- Focal neurological deficits
- Amnesia
- Lethargy
- Significant behavioral changes
- Weakness or numbness in extremities
- Unsteady gait, coordination problems
Severe TBI (GCS 3-8)
- Extended loss of consciousness/coma
- Severely altered mental status
- Significant pupillary abnormalities
- Decerebrate/decorticate posturing
- Sustained increased ICP signs
- Respiratory irregularities
- Cushing’s triad (↑BP, ↓HR, irregular breathing)
- Persistent vomiting
- Seizures
- Loss of brainstem reflexes
- Hemodynamic instability
- Signs of herniation
Age-Specific Manifestations
| Age Group | Unique Manifestations | Assessment Challenges |
|---|---|---|
| Infants (<1 year) |
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| Toddlers (1-3 years) |
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| School-Age (6-12 years) |
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| Adolescents (13-18 years) |
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Mnemonic: “HEADS UP” – Warning Signs Requiring Immediate Medical Attention
- H – Headache that worsens or won’t go away
- E – Extreme changes in behavior (agitation, lethargy)
- A – Altered consciousness, difficult to arouse
- D – Disorientation, confusion, or slurred speech
- S – Seizures
- U – Unequal pupils or unusual eye movements
- P – Persistent vomiting or worsening symptoms
Nursing Assessment
Systematic Assessment Approach
Key Principle
A systematic, age-appropriate assessment is essential for accurate triage and identification of life-threatening conditions in pediatric head injury. Always begin with the primary survey (ABCs) before conducting a detailed neurological assessment.
Primary Assessment (Initial Survey)
Airway, Breathing, Circulation (ABCs)
- Airway: Assess patency, presence of foreign bodies, ability to protect airway
- Breathing: Respiratory rate, effort, breath sounds, oxygen saturation
- Circulation: Heart rate, blood pressure, capillary refill, peripheral pulses
- Disability: Brief neurological check – level of consciousness, pupillary response, movement
- Exposure: Quick head-to-toe examination, maintaining temperature control
Critical Action Point
Stabilize ABCs before proceeding to detailed neurological assessment. Hypoxia and hypotension significantly worsen TBI outcomes.
Brief Focused Neurological Check
- Level of Consciousness: AVPU scale (Alert, Voice responsive, Pain responsive, Unresponsive)
- Pediatric Glasgow Coma Scale (PGCS): Modified for age-appropriate responses
- Pupillary Response: Size, symmetry, reactivity to light
- Motor Function: Spontaneous movement, posturing, response to stimuli
- Signs of Increased ICP: Bradycardia, hypertension, irregular breathing (Cushing’s triad)
In infants, check fontanelle status: bulging fontanelle suggests increased ICP
Secondary Assessment (Detailed Evaluation)
History Taking (SAMPLE)
- Signs and symptoms
- Allergies
- Medications
- Past medical history
- Last meal (time)
- Events leading to injury
Additional Critical History Elements:
- Mechanism of injury (force, direction, height of fall)
- Loss of consciousness (duration, if any)
- Behavior changes since injury
- Vomiting (frequency, timing)
- Seizure activity
- Prior head injuries
- Developmental history
- Immunization status (tetanus)
Physical Examination
- Head & Scalp: Inspect and palpate for contusions, lacerations, depressions, hematomas, CSF leakage
- Face: Symmetry, periorbital/retroauricular ecchymosis (raccoon eyes, Battle’s sign)
- Eyes: Pupil size/reactivity, extraocular movements, fundoscopic exam (if available)
- Ears: CSF otorrhea, hemotympanum
- Nose: CSF rhinorrhea, septal hematoma
- Spine: Tenderness, step-offs, swelling (cervical spine stabilization)
Neurological Examination:
- Cranial nerve assessment (age appropriate)
- Motor strength (symmetry, weakness)
- Sensory function
- Deep tendon reflexes
- Coordination (if developmentally appropriate)
- Gait (if ambulatory and safe)
Pediatric Glasgow Coma Scale (PGCS)
| Parameter | Infants (0-23 months) | Children (2-5 years) | Older Children (>5 years) | Score |
|---|---|---|---|---|
| Eye Opening | Spontaneously | Spontaneously | Spontaneously | 4 |
| To speech | To speech | To speech | 3 | |
| To pain | To pain | To pain | 2 | |
| No response | No response | No response | 1 | |
| Verbal Response | Coos, babbles | Appropriate words/phrases | Oriented, appropriate | 5 |
| Irritable cry, consolable | Inappropriate words | Confused, disoriented | 4 | |
| Inconsolable crying | Crying/screaming | Inappropriate words | 3 | |
| Moans, grunts | Moans, grunts | Incomprehensible sounds | 2 | |
| No response | No response | No response | 1 | |
| Motor Response | Normal spontaneous movements | Obeys commands | Obeys commands | 6 |
| Withdraws to touch | Localizes pain | Localizes pain | 5 | |
| Withdraws to pain | Withdraws to pain | Withdraws to pain | 4 | |
| Abnormal flexion (decorticate) | Abnormal flexion (decorticate) | Abnormal flexion (decorticate) | 3 | |
| Extension (decerebrate) | Extension (decerebrate) | Extension (decerebrate) | 2 | |
| No response | No response | No response | 1 | |
| Total Score (Sum of Best Eye, Verbal, and Motor Responses) | 3-15 | |||
Ongoing Neurological Assessment
Frequency of Assessment
- Severe TBI (GCS ≤8): Every 15-30 minutes
- Moderate TBI (GCS 9-13): Every 1-2 hours
- Mild TBI (GCS 14-15): Every 2-4 hours
- Increase frequency if deterioration noted
- After stabilization, gradually decrease frequency
Key Parameters to Monitor
- Level of consciousness (GCS)
- Pupillary size and reactivity
- Motor strength and symmetry
- Vital signs (especially HR, BP for Cushing’s response)
- Respiratory pattern
- Fontanelle status (in infants)
- Headache intensity (if able to communicate)
- Vomiting episodes
- Seizure activity
Warning Signs of Deterioration
Immediate Action Required
- Drop in GCS by ≥2 points
- Development of unequal pupils
- New onset of posturing
- Cushing’s triad (bradycardia, hypertension, irregular breathing)
- Fixed, dilated pupils
Concerning Changes
- Increasingly severe headache
- Repeated vomiting
- Progressive drowsiness
- New focal neurological deficits
- Seizure activity
- Bulging fontanelle (infants)
Monitor Closely
- Irritability that worsens
- Unusual drowsiness
- Confusion or disorientation
- Balance problems
- Worsening symptoms
- Significant behavior changes
Diagnostic Evaluation
Imaging and Diagnostic Studies
Common Imaging Studies
Non-Contrast CT Scan of the Head
The first-line imaging modality for acute head trauma evaluation.
- Purpose: Identify acute hemorrhage, fractures, mass effect, edema
- Advantages: Rapid, readily available, high sensitivity for acute bleeding
- Limitations: Radiation exposure, limited evaluation of diffuse axonal injury
- Nursing role: Prepare child/family, maintain immobilization, monitor during transport
Magnetic Resonance Imaging (MRI)
Second-line imaging, usually obtained after initial stabilization.
- Purpose: Better visualization of brain parenchyma, diffuse axonal injury, posterior fossa
- Advantages: No radiation, superior for subtle injuries, better for subacute/chronic injury
- Limitations: Time-consuming, requires complete stillness, not suitable for unstable patients
- Nursing role: Screen for metal objects, provide sedation if needed, monitor during procedure
Other Imaging Studies
- CT Angiography (CTA): Evaluates vascular injuries, dissections
- Skull X-rays: Limited use, may be used in settings without CT access
- Ultrasound: Limited use in infants with open fontanelles
- Cervical Spine Imaging: Required in significant head trauma to rule out associated injuries
Decision Guidelines for Imaging
PECARN Algorithm for Pediatric Head CT
The Pediatric Emergency Care Applied Research Network (PECARN) developed evidence-based guidelines to identify children at very low risk of clinically important traumatic brain injuries.
Children <2 Years of Age:
- CT Recommended: GCS ≤14, altered mental status, palpable skull fracture
- Observation vs. CT: Loss of consciousness ≥5 seconds, severe mechanism of injury, occipital/parietal/temporal scalp hematoma, not acting normally per parent
- Observation Recommended: None of the above factors present
Children ≥2 Years of Age:
- CT Recommended: GCS ≤14, altered mental status, signs of basilar skull fracture
- Observation vs. CT: Loss of consciousness, history of vomiting, severe headache, severe mechanism of injury
- Observation Recommended: None of the above factors present
Additional Diagnostic Studies
- Laboratory Studies:
- Complete blood count
- Coagulation studies
- Chemistry panel
- Blood type and screen/cross
- Toxicology screen (if altered mental status)
- Blood alcohol level (adolescents)
- Intracranial Pressure Monitoring: For severe TBI (GCS ≤8)
- Electroencephalogram (EEG): If seizures are suspected
- Ophthalmologic Examination: To detect retinal hemorrhages (especially important in suspected NAT)
Nursing Considerations for Diagnostics
- Explain procedures in age-appropriate language
- Prepare child and family for what to expect
- Ensure continuous monitoring during transport
- Maintain cervical spine precautions until cleared
- Have emergency equipment available during transport
- Document neurological status before and after procedures
Mind Map: Diagnostic Approach to Pediatric Head Injury
Nursing Management
Emergency Phase Management
Primary Goals
The emergency phase focuses on stabilizing the child, preventing secondary brain injury, and quickly identifying life-threatening conditions requiring immediate intervention.
Airway & Breathing Management
Nursing Interventions
- Maintain cervical spine immobilization during airway assessment
- Ensure patent airway; suction as needed (avoid stimulating gag reflex)
- Administer oxygen to maintain SpO₂ >94%
- Assist with rapid sequence intubation if GCS ≤8 or unable to protect airway
- Monitor end-tidal CO₂ if intubated (aim for 35-40 mmHg)
- Avoid prophylactic hyperventilation (PaCO₂ <30 mmHg) in first 48 hours
- Position head midline at 30° elevation (once hemodynamically stable)
- Ensure proper ETT securement if intubated
Circulation Management
Nursing Interventions
- Establish IV/IO access (preferably 2 lines for severe TBI)
- Administer isotonic crystalloids (normal saline) to maintain age-appropriate BP
- Avoid hypotonic solutions (increase cerebral edema)
- Monitor for signs of shock and treat promptly
- Hypotension significantly worsens TBI outcomes
- Aim for normotension (avoid hypertension which may increase ICP)
- Monitor for Cushing’s triad (bradycardia, hypertension, irregular breathing)
- Obtain blood samples for laboratory studies
Neurological Management
Nursing Interventions
- Perform frequent neurological assessments (GCS, pupils, motor response)
- Monitor for signs of increased ICP:
- Decreasing level of consciousness
- Pupillary changes (sluggish, unequal, dilated)
- Cushing’s triad
- Bulging fontanelle in infants
- Vomiting, especially projectile
- Posturing (decorticate or decerebrate)
- Administer medications as ordered:
- Osmotic agents (3% hypertonic saline or mannitol) for increased ICP
- Anticonvulsants if seizures present or for prophylaxis in severe TBI
- Sedation/analgesia as needed
- Prepare for emergency interventions:
- ICP monitoring device placement
- Possible emergency neurosurgery
Other Emergency Management
Nursing Interventions
- Maintain normothermia (hypothermia not recommended in pediatric TBI)
- Control any external bleeding with direct pressure
- Check blood glucose and correct hypoglycemia
- Prevent aspiration (NPO status until fully evaluated)
- Document all findings and interventions
- Prepare for transfer to higher level of care if needed
- Provide emotional support to family members
- Consider child protective services notification if NAT suspected
Mnemonic: “BRAIN SAVE” – Emergency Phase Priorities
- B – Breathing and oxygenation (maintain SpO₂ >94%)
- R – Restrict neck movement (C-spine precautions)
- A – Assess neurological status frequently
- I – ICP management (positioning, osmotic agents if needed)
- N – Normalize vital signs (prevent hypotension)
- S – Seizure prevention and management
- A – Avoid secondary injury (maintain cerebral perfusion)
- V – Vascular access (establish IV/IO lines)
- E – Expedite diagnostic imaging (prepare for CT)
Acute Care Phase Management
Primary Goals
The acute care phase focuses on preventing secondary injury, managing complications, and promoting recovery through comprehensive nursing interventions.
Intracranial Pressure Management
Nursing Interventions
- Monitor ICP if monitoring device in place (goal <20 mmHg)
- Calculate and maintain adequate cerebral perfusion pressure (CPP)
- CPP = MAP – ICP
- Minimum CPP goal: 40 mmHg for infants/young children, 50 mmHg for older children
- Position head of bed at 30° with head midline
- Ensure cervical collar is not too tight (can impede venous drainage)
- Implement ICP-reducing interventions as ordered:
- Osmotic therapy (3% hypertonic saline or mannitol)
- Sedation and analgesia
- Neuromuscular blockade if needed
- CSF drainage via external ventricular drain if present
- Barbiturate therapy for refractory ICP
- Minimize noxious stimuli and activities that increase ICP:
- Cluster care when possible
- Prevent pain, agitation, coughing, straining
- Maintain normal body temperature
Respiratory Management
Nursing Interventions
- Monitor ventilator settings and maintain PaCO₂ at 35-40 mmHg
- Verify proper ETT position and securement
- Perform oral care regularly while maintaining ETT stability
- Suction airway as needed (consider pre-oxygenation and sedation)
- Monitor for ventilator-associated pneumonia
- Implement ventilator bundle protocols
- Position to optimize ventilation without compromising ICP
Hemodynamic Management
Nursing Interventions
- Maintain euvolemia with isotonic fluids
- Monitor for dysautonomia (wide swings in BP, HR, temperature)
- Implement age-appropriate BP goals to maintain adequate CPP
- Administer vasoactive medications as ordered
- Monitor for signs of diabetes insipidus (polyuria, hypernatremia)
- Monitor for SIADH (hyponatremia, fluid retention)
- Maintain strict I/O measurements
- Monitor electrolytes closely and correct imbalances
Neurological Monitoring
Nursing Interventions
- Perform regular neurological assessments (GCS, pupillary response, motor function)
- Monitor for post-traumatic seizures and administer anticonvulsants as ordered
- Implement seizure precautions
- Document trends in neurological status
- Perform neurovascular checks of extremities
- Assist with serial imaging studies as ordered
- Monitor for signs of increasing ICP between assessments
Supportive Care
Nutrition & Metabolic Support
- Initiate enteral nutrition within 72 hours when possible
- Implement feeding protocols as tolerated
- Monitor blood glucose (maintain 80-180 mg/dL)
- Administer stress ulcer prophylaxis
- Monitor for signs of aspiration
- Adjust nutrition based on metabolic demands
Infection Prevention
- Maintain sterile technique for invasive lines/monitors
- Monitor for signs of infection
- Administer prophylactic antibiotics for open head injuries
- Implement hospital-specific infection prevention bundles
- Monitor temperature and intervene for fever
- Perform catheter/line care per protocol
Skin & Mobility
- Implement pressure injury prevention
- Perform range of motion exercises as tolerated
- Position carefully to avoid increasing ICP
- Maintain skin integrity with routine care
- Consider specialty beds for immobile patients
- Manage scalp wounds/surgical sites
Psychosocial Support
Child Support
- Provide age-appropriate explanations
- Minimize environmental stimuli in acute phase
- Establish consistent routines
- Provide comfort measures
- Allow for expression of emotions
- Use child life specialists when available
- Maintain day/night cycles
Family Support
- Provide regular updates on child’s condition
- Educate on equipment, alarms, procedures
- Encourage participation in care when appropriate
- Refer to support services (social work, chaplain)
- Support family coping mechanisms
- Prepare family for changes in appearance/behavior
- Connect with community resources
Monitoring for Complications
Early Complications (Days 1-3)
- Increasing ICP/cerebral edema (peaks at 72 hours)
- Herniation syndromes
- Early post-traumatic seizures
- CSF leaks (rhinorrhea, otorrhea)
- Expanding hematomas
- Electrolyte imbalances
- Coagulopathy
- Hypoxic-ischemic injury
Later Complications (Days 4+)
- Ventilator-associated pneumonia
- Catheter-associated UTI
- Endocrine dysfunction (SIADH, diabetes insipidus)
- Deep vein thrombosis
- Late post-traumatic seizures
- Hydrocephalus
- Dysautonomia/Autonomic storming
- Pressure injuries
Rehabilitation Phase Management
Primary Goals
The rehabilitation phase focuses on maximizing functional recovery, preventing secondary complications, supporting reintegration, and addressing the long-term needs of the child and family.
Physical Rehabilitation
Nursing Interventions
- Collaborate with physical therapy on mobility plan
- Progress mobilization as tolerated:
- Range of motion exercises
- Assisted sitting and standing
- Ambulation with assistance
- Balance and coordination activities
- Implement bowel and bladder programs
- Monitor for spasticity and implement positioning protocols
- Administer medications for tone management as ordered
- Encourage age-appropriate self-care activities
- Monitor for pain during rehabilitation activities
- Document functional progress and setbacks
Cognitive Rehabilitation
Nursing Interventions
- Collaborate with speech and occupational therapy
- Implement cognitive rehabilitation strategies:
- Memory aids and techniques
- Attention training activities
- Problem-solving exercises
- Environmental modifications for cognitive deficits
- Establish consistent daily routines
- Use clear, concrete communication
- Provide cognitive rest periods to prevent fatigue
- Monitor for frustration and provide emotional support
- Adapt activities based on cognitive abilities
- Support educational re-entry planning
Behavioral Management
Nursing Interventions
- Monitor for common post-TBI behavioral issues:
- Irritability and aggression
- Impulsivity
- Emotional lability
- Disinhibition
- Apathy
- Implement consistent behavior management strategies
- Create a structured, predictable environment
- Use positive reinforcement techniques
- Administer medications for behavior management as ordered
- Teach family appropriate behavioral intervention techniques
- Document behavioral patterns and effective interventions
Family Education and Support
Nursing Interventions
- Provide comprehensive education on:
- Expected recovery trajectory
- Home care requirements
- Medication management
- Signs of complications
- Safety precautions and prevention of re-injury
- Community resources
- Involve family in therapy sessions for skill carryover
- Provide emotional support for family members
- Connect with support groups and peer networks
- Assist with transitional planning for home and school
- Conduct home evaluations for needed modifications
- Coordinate follow-up appointments
Discharge Planning and Community Reintegration
Home Preparation
- Assess home environment for safety
- Recommend necessary home modifications
- Arrange for durable medical equipment
- Train family in transfers and positioning
- Establish medication management plan
- Create emergency response plans
School Reintegration
- Collaborate on Individualized Education Plan (IEP)
- Provide school staff education
- Recommend appropriate accommodations
- Plan for gradual return to school
- Include cognitive rest periods
- Monitor for academic challenges
- Advocate for needed services
Long-term Follow-up
- Schedule follow-up appointments
- Coordinate with outpatient therapies
- Monitor for late-emerging issues
- Document developmental milestones
- Support transition to adult services if needed
- Adjust plan as child grows and develops
- Review safety plans periodically
Nursing Care Plan: Sample for Rehabilitation Phase
| Nursing Diagnosis | Goals/Outcomes | Nursing Interventions | Evaluation |
|---|---|---|---|
| Risk for Ineffective Cerebral Tissue Perfusion related to increased intracranial pressure |
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| Impaired Physical Mobility related to neurological injury |
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| Disturbed Thought Processes related to brain injury |
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| Risk for Interrupted Family Processes related to child’s injury and care needs |
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Mind Map: Comprehensive Nursing Management of Pediatric Head Injury
Complications & Prevention
Potential Complications
Early Complications
Neurological Complications
- Cerebral Edema: Peaks 72 hours post-injury, can lead to increased ICP and herniation
- Herniation Syndromes: Life-threatening condition requiring immediate intervention
- Early Post-traumatic Seizures: Occur within 7 days of injury, more common in children than adults
- CSF Leaks: Rhinorrhea or otorrhea indicating dural tear, risk for meningitis
- Expanding Hematomas: May require surgical evacuation
Systemic Complications
- Hypoxia: Secondary to respiratory depression, aspiration, or pulmonary contusions
- Hypotension: Due to blood loss, neurogenic shock, or other injuries
- Electrolyte Imbalances: Hypo/hypernatremia, hypocalcemia
- Coagulopathy: TBI-associated coagulation disorders
- Stress-induced Hyperglycemia: Can worsen neurological outcomes
Late Complications
Neurological Complications
- Late Post-traumatic Seizures: Occur >7 days after injury, may become chronic epilepsy
- Post-traumatic Hydrocephalus: Impaired CSF absorption, may require shunting
- Growing Skull Fracture: Leptomeningeal cyst formation, more common in children <3 years
- Post-concussion Syndrome: Persistent symptoms including headache, dizziness, cognitive issues
- Dysautonomia/Autonomic Storming: Episodic hypertension, tachycardia, hyperthermia, posturing
Functional Complications
- Cognitive Impairments: Memory, attention, executive function, processing speed deficits
- Behavioral Changes: Emotional lability, impulsivity, aggression, apathy
- Motor Deficits: Weakness, spasticity, coordination problems, ataxia
- Communication Disorders: Speech and language problems
- Academic Difficulties: Learning problems, difficulty returning to school
- Psychological Issues: Anxiety, depression, PTSD
- Sleep Disturbances: Insomnia, hypersomnia, altered sleep patterns
Signs of Herniation Syndromes (Nursing Emergency)
Clinical Manifestations
- Decreased level of consciousness (often rapid deterioration)
- Pupillary changes (unilateral or bilateral dilation)
- Cushing’s triad (bradycardia, hypertension, irregular breathing)
- Decorticate or decerebrate posturing
- Loss of brainstem reflexes
- Respiratory pattern changes (Cheyne-Stokes, ataxic, apneustic)
Emergency Nursing Interventions
- Notify provider immediately
- Elevate head of bed to 30° with head midline
- Ensure adequate oxygenation and ventilation
- Administer osmotic agents as ordered (mannitol or hypertonic saline)
- Prepare for possible hyperventilation (temporary measure only)
- Prepare for possible emergency surgery
- Continuous monitoring of vital signs and neurological status
Hospital-Acquired Complications
Infectious Complications
- Ventilator-associated pneumonia
- Catheter-associated urinary tract infections
- Central line-associated bloodstream infections
- Surgical site infections
- Meningitis (especially with CSF leaks or invasive procedures)
- Ventriculitis (with ICP monitors/EVDs)
Immobility Complications
- Pressure injuries
- Deep vein thrombosis
- Contractures
- Muscle atrophy
- Osteopenia
- Constipation
Other Complications
- Stress ulcers
- Malnutrition
- Medication side effects
- Iatrogenic anemia (from blood draws)
- ICU delirium
- Hospital-acquired weakness
Prevention Strategies
Primary Prevention (Preventing Initial Injury)
Infant & Toddler Safety
- Falls Prevention:
- Use safety gates at top and bottom of stairs
- Secure furniture that could tip over
- Use window guards and stops
- Avoid infant walkers
- Always use changing table safety straps
- Never leave infants unattended on elevated surfaces
-