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Example Care Plan_Skull Fractures (Cheat Sheet)
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Today we are diving into skull fractures. The patho behind skull fractures. Skull fractures, or any fracture that includes the cranium, the face, or the base of the skull. These fractures are dangerous because they can be superficial, but they can also penetrate pretty deep into the cranial cavity. Some of the nursing considerations that we want to think about is we want to assess for CSF or cerebral spinal fluid. We want to assess drainage. We also want to do frequent neuro tracks and we want to assess for the battle signs or raccoon eyes. The battle sign is just the bruising over the mastoid process. And then the raccoon eyes, is the darkening around your eyes. We also want to assess for, and manage the pain. One of the desired outcomes is that we want to prevent long-term neurological damage.
This is affecting the skull, which is protecting your brain. We just want to protect from any long-term damage. And then we want to protect the airway and preserve the patient's functional abilities. So with any fracture, but especially a skull fracture, when someone tells you that there is a reported trauma, car accident, or anything like that, you want to think about skull fractures. If they complain of pain, you also want to immediately go there. Some of the things that we're going to see is, that we're going to see an unstable mid-face, raccoon eyes, and battle’s sign. We're going to also see any type of just obvious deformity. We'll see some ecchymosis and then we will also see a misaligned jaw. And that's just from the impact of the trauma that caused the fracture. We may see bleeding from the nose or the ears, and then we will also possibly see clear drainage from the ears or the nose.
That's the cerebral spinal fluid. We're going to be very mindful of that. Some nursing interventions that you want to think of. Number one, remember ABC. We want to monitor that airway and that respiratory status because swelling can occur in the face. It can cause a compromised airway, and we do not want that cranial nerve damage to also impair swallowing. So the patients are also at risk for aspiration. So we want to assess CSF fluid. So CSF cerebral, spinal fluid, the way that we do that is by looking for what we call a halo sign and pretty much a halo sign is you take a piece of gauze, put it under the clear drainage that's coming from the nose and it'll create like a ring or a halo around of blood. And so if you see that nine times out of 10, it is a cerebral spinal fluid.
You want to make sure that you tell the patient not to blow their nose, because that can exacerbate the injury. Like I said, frequent neuro checks. We want to do neuro checks one to two hours or more. The reason why is because they can have changes in their level of consciousness. We also want to do an ICP intracranial pressure or cerebral perfusion pressure, with those neuro checks and those would be ordered by the provider. Finally, we want to make sure that we minimize ICP. We want to keep that intracranial pressure low. So the way we do that, keep the head of the bed up 30 to 45 degrees. So head of the bed 35 degrees, I mean, 30 to 45 degrees. That's going to keep the drainage down. We also want to decrease stimuli. We don't want the patient agitated, and we want to avoid that bearing down. That again, it's just going to keep that pressure away from the head and decrease the incidence of draining the CSF.
Quick overview on the key points, fractures of the skull are a no-no they're bad. Okay. Some of the things that the patient's going to report is pain. They're going to report the actual trauma. Uh, we are going to be looking for objective data as nurses. And we're going to look for the raccoon eyes, which is the darkness around the eyes, the battle sign, which is the mastoid process here. And if we have any type of bleeding or drainage from the nose or the ears, CSF drain is very important. CSF drainage. That's the clear liquid from the nose or ears. In addition to the halo sign, you can also test it for glucose. If it tests positive for glucose, then that means it is CSF and not mucus. The risk for infection is something else we want to be considerate of. If the is testing for CSF, also minimize the ICP, head of the bed up, decrease the stimuli, avoid the solver maneuvers. We love you guys; go out and be your best self today. And, as always, happy nursing.
This is affecting the skull, which is protecting your brain. We just want to protect from any long-term damage. And then we want to protect the airway and preserve the patient's functional abilities. So with any fracture, but especially a skull fracture, when someone tells you that there is a reported trauma, car accident, or anything like that, you want to think about skull fractures. If they complain of pain, you also want to immediately go there. Some of the things that we're going to see is, that we're going to see an unstable mid-face, raccoon eyes, and battle’s sign. We're going to also see any type of just obvious deformity. We'll see some ecchymosis and then we will also see a misaligned jaw. And that's just from the impact of the trauma that caused the fracture. We may see bleeding from the nose or the ears, and then we will also possibly see clear drainage from the ears or the nose.
That's the cerebral spinal fluid. We're going to be very mindful of that. Some nursing interventions that you want to think of. Number one, remember ABC. We want to monitor that airway and that respiratory status because swelling can occur in the face. It can cause a compromised airway, and we do not want that cranial nerve damage to also impair swallowing. So the patients are also at risk for aspiration. So we want to assess CSF fluid. So CSF cerebral, spinal fluid, the way that we do that is by looking for what we call a halo sign and pretty much a halo sign is you take a piece of gauze, put it under the clear drainage that's coming from the nose and it'll create like a ring or a halo around of blood. And so if you see that nine times out of 10, it is a cerebral spinal fluid.
You want to make sure that you tell the patient not to blow their nose, because that can exacerbate the injury. Like I said, frequent neuro checks. We want to do neuro checks one to two hours or more. The reason why is because they can have changes in their level of consciousness. We also want to do an ICP intracranial pressure or cerebral perfusion pressure, with those neuro checks and those would be ordered by the provider. Finally, we want to make sure that we minimize ICP. We want to keep that intracranial pressure low. So the way we do that, keep the head of the bed up 30 to 45 degrees. So head of the bed 35 degrees, I mean, 30 to 45 degrees. That's going to keep the drainage down. We also want to decrease stimuli. We don't want the patient agitated, and we want to avoid that bearing down. That again, it's just going to keep that pressure away from the head and decrease the incidence of draining the CSF.
Quick overview on the key points, fractures of the skull are a no-no they're bad. Okay. Some of the things that the patient's going to report is pain. They're going to report the actual trauma. Uh, we are going to be looking for objective data as nurses. And we're going to look for the raccoon eyes, which is the darkness around the eyes, the battle sign, which is the mastoid process here. And if we have any type of bleeding or drainage from the nose or the ears, CSF drain is very important. CSF drainage. That's the clear liquid from the nose or ears. In addition to the halo sign, you can also test it for glucose. If it tests positive for glucose, then that means it is CSF and not mucus. The risk for infection is something else we want to be considerate of. If the is testing for CSF, also minimize the ICP, head of the bed up, decrease the stimuli, avoid the solver maneuvers. We love you guys; go out and be your best self today. And, as always, happy nursing.
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