Nurse Practitioner

CLINICAL PROTOCOL
Head injury

Potential signs /symptoms of specific head trauma:

# Base of skull:
Otorrhoea / rhinorrhoea
Haemotympanum or bloody drainage from ear
Raccoon eyes: bilateral peri orbital bruising in the absence of facial trauma
Battle sign: mastoid bruising (late sign)

Depressed skull fracture:

S/S dependant on extent of damage
Injury may result in cerebral oedema, decreased level of consciousness, unilateral
pupil dilation (on side of injury), weakness on opposite side of in jury
Fitting

Extradural haematoma:
Brief LOC followed by a lucid period.
Severe vomiting and headache
Rapid physical deterioration with decreasing level of consciousness
Pupil dilation on side of haematoma
Weakness on opposite side

Subdural haematoma:
Altered level of consciousness, headache, personality changes
Dilated pupil on side of haematoma
Weakness on opposite side

Concussion (may be retrospective diagnosis):

Transient LOC, some memory loss
Nausea, vomiting, dizziness and headache

CLINICAL PRACTICE GUIDELINE

Scope
Initial Assessment and Interventions
History of injury Circumstances surrounding the
injury.
Current medications (note any
recent change in meds).
Any LOC
Physical Check for ongoing danger.
examination Assess ABC and conscious level.
Reassure and stay with the pt. (if
1st person on site).
Assess vital signs (T, P, R, BP, O2
saturation, GCS).
Check for obvious injury:
Outcomes
Outcomes
Identify patients not suitable for
NP CP exit CP and refer to
current GP.
Determine most appropriate
treatment option for the Pt.
Identify patients not suitable for
NP CP exit CP and refer to
current GP.
 Nurse Practitioner

CLINICAL PROTOCOL
Head injury

abrasions, lacerations, contusions

or fractures.
Pain assessment Assess pain with appropriate pain scale. Determine need for analgesia and
most appropriate type.
Investigations Outcomes
Pathology Not generally required
Imaging Consider need for x-ray if a fracture is Identify patients not suitable for
suspected. NP CP exit CP and refer to
Consider CT scans if pt. has risk factors, current GP.
or has a suspected head injury.
Patient Education / Follow-up Outcomes
Follow up If required after 24 hours.
appointment
Referral to allied Consider need for referral to: Ongoing care and prevention of
health providers Continence specialist future falls and injuries
Physiotherapist
Podiatrist
OT
Pharmacist (HMMR)
Patient/carer Verbal/written instructions from Pt. /carer understands their
Education NP/GP diagnosis, treatment plan and
reason for follow up if required.
Medication Verbal/written instructions from Ensure patient/carer understands
instructions NP/GP problem, treatment and follow up

Certificates Absence from work certificates Ensure appropriate

Certificate of attendance documentation completed
Letter Copy of notes to GP / Specialist or Ensure continuity of care and
acute care facility referral to health care team
GP hospital admission
Interpretation of results and management decisions Outcome
Minor head injury Review as above Identify patients not suitable for
No LOC Analgesia as required NP CP exit CP and refer to
Refer for path/imaging if required current GP.
Application of dressings if required
Vital signs for 24 hours incl GCS
hourly neuro obs for min 4
hours. Notify GP of any changes in
vital signs.
Reassessment of falls risk status
by RACF if appropriate
Semi-conscious on Vital signs and neuro obs 15 Identify patients not suitable for
examination, Hx of minutely for 4 hours, then NP CP exit CP and refer to
LOC hourly for 4 hours. Refer to GP if current GP.
any change in observations.
 Nurse Practitioner

CLINICAL PROTOCOL
Head injury

O2 at 8-12L/min
Nil by mouth
+/- IV access
Refer for path/imaging if required.
Reassessment of falls risk status
by RACF if appropriate.

Serious GCS Identify patients not suitable for

injury/unconscious Ensure clear airway, neck NP CP exit CP and refer to
on examination protection current GP.
+/- oropharyngeal airway
O2 12L/min
Establish IV access
Vital signs and neuro obs 15
minutely
Nil by mouth
Prepare for transport to ED

Goals of Treatment
Relief of symptoms
Prevention of recurrence
Prevention of complications

Evaluative strategies
Unexpected Review Patient Notes. Full audit clinical
representation events.
NP Clinical NP Clinical Practice/Medical Report Audit
Practice
Key Terms
NP Nurse Practitioner CP Clinical Protocol
GP General Practitioner
S4 Schedule of the drug administration
act

References
1. Australian Medicines handbook (2011). Australian Medicines Handbook Pty Ltd, SA;
2011
2. RACGP (2008). Guidelines for mild traumatic brain injury following closed head
injury. Accessed 20 Dec 2011 at:
http://www.maa.nsw.gov.au/default.aspx?MenuID=148
3. Department of Health Western Australia (2005). Remote Area Nursing Emergency
Guidelines. Accessed 20 Dec 2011 at: www.ocno.health.wa.gov.au
 Nurse Practitioner

CLINICAL PROTOCOL
Head injury

Authorship, Endorsement and acknowledgement

This CP was originally written by: Reviewed and authorised by:
Carol Jones
Nurse Practitioner Dr. Frank Reedman Jones
Murray Medical Centre Mandurah MBBCh, DCH, DRCOG, FRACGP, FACRRM
Murray Medical Centre: Primary Care
Physician

Dr. Eileen Bristol

MBChB,MRCGP,DRCOG,FRACGP
Murray Medical Centre: Primary Care
Physician

Carol Jones
RN, RM, PGradDipNursePractitioner, NP
Nurse Practitioner

Date Written: December 2011 Review Date: December 2013