Head Injury & Basilar Skull Fracture: Nursing Case Study

Basilar Skull Fracture: Assessment and Initial Interventions

A basilar skull fracture is a linear skull fracture that extends over the base of the frontal and temporal lobes. This type of fracture can cause damage to nerve pathways, cranial nerves, or vital centers. The patient's vital signs and neurologic status must be monitored frequently.

Question 1: Which assessment technique allows the nurse to assess for Battle's sign?

The correct answer is to observe the area behind the patient's ears. Battle's sign refers to ecchymosis (bruising) behind the ears and is a common manifestation of a basilar skull fracture. Assessing pupillary response to light is an important part of the neurologic exam but does not demonstrate Battle's sign. Periorbital ecchymosis — known as "raccoon eyes" — is a separate but equally common manifestation. Testing the patient's ability to follow directions is also part of the neurologic assessment but does not demonstrate Battle's sign.

Other manifestations of a basilar skull fracture include tinnitus, facial paralysis, hearing difficulty, epistaxis, and cerebrospinal fluid (CSF) leakage from the nose or ears (rhinorrhea).

Question 2: What methods can the nurse use to determine if the drainage is CSF?

The correct answer is to observe for a "halo" around a spot of drainage. When a drop of drainage is placed on a white dressing, CSF will separate from blood and form a halo ring around the blood spot. The nurse may also assess the appearance of the drainage and use a dextrostick to check for glucose, since CSF — unlike normal nasal drainage — contains glucose. However, if CSF is mixed with blood, the glucose test may yield a false positive, because blood also contains glucose. Measuring specific gravity or quantity of the drainage will not confirm whether it is CSF.

Question 3: Which nursing intervention should be initiated to prevent increased ICP?

The correct intervention is to administer a prescribed stool softener as needed (PRN). Activities such as performing a Valsalva maneuver, coughing, and vomiting increase ICP and must be prevented. The head of the bed should be elevated approximately 30 degrees, and neck flexion and extension should be avoided. Applying a hyperthermia blanket is contraindicated, because increased body temperature raises cerebral blood flow. Restraints should not be used, since straining against them can also increase ICP — clients with head injuries are frequently sedated with agents such as propofol (Diprivan) to prevent restlessness. Packing the nares would prevent CSF from draining and could further increase ICP; a sterile drip pad should be used instead.

Question 4: Which medication is best for treating the patient's headache?

The correct choice is acetaminophen (Tylenol). Tylenol is a non-opioid analgesic and will not cause CNS depression. Opioids — including morphine sulfate, oxycodone/aspirin (Percodan), and hydrocodone/acetaminophen (Lortab) — should be avoided following head trauma because they can cause CNS depression and mask symptoms of increasing ICP. If a non-opioid analgesic does not relieve pain, a hydrocodone product may be considered, since CNS depression is less likely with these than with other opioids; however, acetaminophen remains the best first-line choice.

Glasgow Coma Scale and Neurologic Monitoring

After the patient is medicated and reports headache relief, the nurse continues to monitor vital signs and assesses neurologic status using the Glasgow Coma Scale (GCS). Approximately one hour later, the patient's GCS rating drops from 13 to 10.

Question 5: What does this change indicate?

This indicates diminished neurologic status. The GCS numerical rating ranges from 3 to 15, with 15 representing the best possible rating and 3 indicating a poor prognosis with high mortality. Any decrease of two or more points is considered significant and requires immediate notification of the physician. A comatose state typically corresponds to a score of 7 or less, and clients with scores greater than 8 generally have a good prognosis for recovery.

Question 6: What are the three components measured by the GCS?

The GCS measures verbal response, motor response, and eye opening. These responses range from spontaneous and fully oriented reactions to responses only to noxious stimuli, down to no response at all. The motor response component includes observation for abnormal decorticate (flexor) and decerebrate (extensor) posturing. Seizure activity, muscle strength, posturing, gag reflex, blink reflex, Babinski reflex, pupillary response, visual field, and eye movement are all important neurologic parameters, but they are not the components measured by the GCS.

Increased intracranial pressure (ICP) is the leading cause of death from head trauma among individuals who survive the initial injury and reach the hospital.

Increased Intracranial Pressure: Pharmacologic Management

Question 7: What is the most important indicator of increasing ICP?

The single most significant indicator is a change in level of consciousness (LOC). Fixed, dilated pupils and pupillary changes are indicators of increased ICP, but they are not typically the first or most important sign. Hypertension, bradycardia, and widening pulse pressure are significant but late indicators. Altered respiratory patterns such as Cheyne-Stokes respiration may also indicate increasing ICP but are not the primary indicator.

Priority nursing diagnoses for a client with increased ICP include decreased intracranial adaptive capacity, ineffective tissue perfusion (cerebral), disturbed sensory perception (tactile), and risk for injury. The physician prescribes the following: normal saline 0.9% at 30 mL/hour; 15% Mannitol (Osmitrol) IVPB every 12 hours; furosemide (Lasix) 40 mg IVP following Mannitol; dexamethasone (Decadron) 4 mg IVP every 6 hours; and phenytoin (Dilantin) 100 mg IVP every 8 hours.

Question 8: Which medication should not be mixed with any other medication or IV solution other than normal saline?

The answer is phenytoin (Dilantin). Dilantin may be used after head injury to prevent seizure activity. A precipitate forms when Dilantin is mixed with other medications or solutions, so it must be administered alone, and the IV tubing must be flushed with normal saline before and after administration. Mannitol is an osmotic diuretic; furosemide is a loop diuretic and antihypertensive agent; and dexamethasone is a glucocorticoid — none of these carries the same incompatibility restriction as phenytoin.

Question 9: Which nursing intervention should be included when administering Mannitol?

The nurse should use IV tubing with a filter. Mannitol is a hypertonic solution used to reduce intracranial pressure and is often given alongside a diuretic such as furosemide. It should be administered undiluted, but a filter must be used to prevent any particulates from entering the IV line. Monitoring serum glucose is important when administering corticosteroids such as dexamethasone, but not Mannitol. Mannitol does not need to be cross-checked against a blood type, nor does it require administration through a central line.

Question 10: Why is the normal saline administered using an electronic controller and a buretrol?

This method is chosen to reduce the risk of fluid overload. The client with increased ICP requires very careful IV fluid management, because fluid volume overload would further increase ICP. Using an electronic controller and buretrol ensures precise delivery. This method does not prevent thrombophlebitis, anaphylactic shock, or infiltration.