Nursing Care Plan for Skull Fractures

Pathophysiology

Fractures of the skull include the cranium, face, and base of the skull.  These fractures can be superficial or penetrate deeper into the cranial cavity. They put the patient at risk for cranial nerve damage, cerebral edema, meningitis, and bleeding on the brain. All of these things can lead to increased ICP, herniation, and brain death.

Etiology

Fractures of the skull require a massive force of trauma to the face or head. This is seen commonly in assaults, motor vehicle collisions, or falls

Desired Outcome

Prevent long-term neurological damage, protect airway, and preserve the patient’s functional ability.

Skull Fractures Nursing Care Plan

Subjective Data:

  • Pain
  • Reported trauma

Objective Data:

  • Unstable midface
  • Racoon eyes
  • Battle’s sign
  • Obvious deformity or ecchymosis
  • Misaligned jaw
  • Bleeding from ears/nose

Nursing Interventions and Rationales

  1. Monitor airway and respiratory status

  2. Swelling in face or in brain can cause compromised airway or breathing. Cranial nerve damage may also impair swallowing.

  3. Assess drainage for CSF, avoid nose blowing

  4. Halo’s sign (yellow ring around blood spot on gauze) indicates a CSF leak from nose/ears or through a fracture. Nose blowing can cause a CSF leak or bleed.

  5. Assess cranial nerve function

  6. Facial fractures and basilar skull fractures carry a high risk of cranial nerve damage, including sensation to the face and ability to swallow.

  7. Assess LOC and ICP/CPP with frequent neuro checks.

    CPP = MAP – ICP (monitor hemodynamics)

  8. Neurological changes related to increasing ICP may be subtle or may occur rapidly. Frequent detailed neuro checks allow changes to be recognized quickly so that interventions can be initiated.

  9. Perform interventions to minimize ICP:

    • Maintain HOB 30-45°
    • Decrease stimuli
    • Avoid valsalva maneuvers
    • Maintain HOB 30-45°
      • HOB < 30 = increased blood flow to brain → Increased ICP
      • HOB > 45 = increased intrathoracic pressure → decreased venous outflow from brain → increased ICP
    • Decrease stimuli
      • Agitation or stress can cause increased ICP
    • Avoid valsalva maneuvers
      • Coughing or bearing down can cause increased ICP

  10. Assess swallow prior to giving anything by mouth – involve Speech Therapy as appropriate

  11. Due to muscle weakness, patients may experience difficulty swallowing. It may be appropriate to have ST assess for appropriate interventions to prevent aspiration.

  12. Administer analgesics as ordered

  13. Severe pain can cause increased ICP, among other complications. Give pain medications as ordered and as needed.


References

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