Question

The nurse is reviewing the orders of a client with a severe head injury due to a fall. Which order would the nurse question? A. Prepare for insertion of an ICP monitor B. Start D5W IV at \(200 \mathrm{~mL} /\) hour C. Maintain head of bed \(25^{\circ}-30^{\circ}\) elevation D. Keep the head in neutral alignment

Short answer

Answer: B. Start D5W IV at \(200 \mathrm{~mL} /\) hour

Step-by-step solution

Understanding the treatment options

First, let's understand each of the treatment options and their implications to a patient with a severe head injury: A. Prepare for insertion of an ICP monitor: Inserting an Intra-cranial Pressure (ICP) monitor is crucial to assess the patient's brain pressure and prevent complications. B. Start D5W IV at \(200 \mathrm{~mL} /\) hour: D5W refers to 5% dextrose solution in water. The rate of infusion mentioned here is \(200 \mathrm{~mL} /\) hour. This solution provides hydration, calories, and prevents hypoglycemia. C. Maintain head of bed \(25^{\circ}-30^{\circ}\) elevation: Elevating the head of the bed helps to reduce intracranial pressure by promoting venous drainage. D. Keep the head in neutral alignment: This also helps to prevent increased intracranial pressure. Now that we understand the implications of each treatment option, we can identify the one that the nurse should question.

Identifying the questionable order

As we analyze the options, we recall that maintaining the proper osmotic balance is crucial in patients with head injuries. D5W is a hypotonic solution and can exacerbate cerebral edema, which could be dangerous for a patient with a severe head injury. Therefore, the nurse should question the order related to D5W IV solution: Answer: B. Start D5W IV at \(200 \mathrm{~mL} /\) hour

Key concepts

Intracranial Pressure Monitoring

Intracranial pressure (ICP) monitoring is an essential procedure in the management of patients with severe head trauma. It involves the use of specialized devices to measure the pressure within the skull, which encloses the brain and cerebrospinal fluid. This is critical because after a traumatic injury, swelling or bleeding can increase this pressure, potentially leading to further brain damage or even death.

Monitoring ICP helps healthcare professionals make informed decisions about the treatment. It guides interventions like medication adjustments, the need for surgery, or other procedures to relieve pressure. Higher intracranial pressure is often managed with maneuvers such as elevating the head, hyperventilation to reduce carbon dioxide levels (which can decrease ICP), and using medications like mannitol or hypertonic saline to draw fluid out of the brain tissue.

It's not only about the ICP numbers; healthcare providers also consider the patient's overall clinical condition, including neurological signs and other vital signs, while interpreting the readings. Therefore, preparing for the insertion of an ICP monitor, as suggested in option A, is a standard and critical step in the management of severe head injury cases.

Head Injury Treatment

Proper treatment of a head injury is paramount to preventing secondary damage and promoting recovery. Following the initial assessment and resuscitation, a multi-faceted approach is used, incorporating medication, surgery, and supportive care.

Key components of head injury treatment include maintaining adequate cerebral perfusion, preventing secondary brain injury, and minimizing cerebral edema. Strategies such as keeping the head in neutral alignment, per option D, support these goals by ensuring optimal blood flow and reducing the risk of elevated ICP. Similarly, elevating the head of the bed between 25 to 30 degrees, stated in option C, reduces ICP by enhancing venous return from the brain.

Other treatment considerations involve the evaluation for surgery to address issues like hematomas or contusions, the use of medications to control seizures or reduce ICP, and close monitoring for complications. Each patient's treatment plan is highly individualized, depending on the severity and location of the injury, and pre-existing medical conditions.

IV Fluids in Head Trauma

The administration of IV fluids in patients with head trauma is a delicate balance. It is essential for maintaining hydration and cerebral perfusion, but the choice of fluid is critical. Hypertonic solutions, such as normal saline, are generally preferred as they help to maintain the osmotic gradient between the blood and the brain tissues.

Option B mentions the use of D5W IV at 200 mL/hour, which is a hypotonic solution. This type of fluid can potentially aggravate brain swelling, known as cerebral edema, because it can shift fluid into the intracellular space, including brain cells. This is the reason the nurse should question the order for D5W for a patient with severe head injury.

Instead, isotonic or hypertonic solutions are often recommended to prevent the worsening of cerebral edema. These fluids help maintain the proper electrolyte balance and avoid the risk of exacerbating cerebral edema, which is critical in the acute management of head injuries.