Head injury / suspected traumatic brain injury following fall from height (12 feet), with risk of intracranial hemorrhage.

• ABCDE and cervical-spine protection
• GCS or pediatric GCS, pupils, consciousness
• Seizures, repeated vomiting, irritability, abnormal drowsiness
• Scalp hematoma, signs of skull fracture, bleeding from nose/ear
• Limb movement and other injuries

1. Stabilize ABCDE with cervical-spine protection
   • Maintain manual in-line cervical stabilization and spinal precautions.
   • Ensure a patent airway while protecting the neck.
   • Give oxygen as prescribed, monitor SpO₂ and respiratory effort.
   • Assess circulation: pulse, skin color, capillary refill, BP, and signs of shock. Establish IV access and give prescribed isotonic fluids or blood products if needed.
   • Expose fully to look for bleeding or associated injuries, while preventing hypothermia.
2. Prevent hypoxia and hypotension
   • These can worsen brain injury.
   • Keep the child adequately oxygenated and perfused.
   • Monitor continuously: SpO₂, HR, RR, BP, temperature, and cardiac rhythm if indicated.
   • Avoid unnecessary stimulation, prolonged suctioning, or delays in escalation.
3. Frequent neurological assessment
   • Record baseline and repeat pediatric GCS/AVPU, behavior, response to parents, pupil size and reactivity, limb movement, and vital signs.
   • In an 18-month-old, watch for irritability, poor consolability, reduced interaction, lethargy, poor feeding, or “not acting normally.”
   • Escalate immediately for falling GCS, increasing drowsiness, unequal/fixed pupils, new weakness, abnormal posturing, repeated vomiting, seizure, apnea, bradycardia, hypertension, or irregular respirations.
4. Identify raised intracranial-pressure warning signs
   • Maintain the head and neck in neutral alignment. Do not flex, rotate, or obstruct venous drainage.
   • Elevate the head of bed only if ordered and compatible with spinal precautions and hemodynamic stability.
   • Minimize crying, pain, fever, agitation, and excessive handling.
   • Prepare for urgent CT, neurosurgical review, or PICU transfer if neurological status deteriorates.
5. Control seizures and provide safety
   • Maintain seizure precautions: padded cot, suction and oxygen available, IV access maintained.
   • If a seizure occurs, time it, protect the child from injury, position safely with spinal precautions, maintain airway, and administer prescribed anticonvulsant therapy.
   • Document seizure features and postictal status.
6. Keep NPO and prepare for urgent investigations
   • Keep NPO until surgical/anesthetic risk is assessed.
   • Assist with ordered CT head and cervical-spine imaging.
   • Obtain ordered blood tests, including CBC, blood grouping/crossmatch, glucose, and coagulation studies.
   • Do not delay emergency stabilization for imaging.
7. Observe for associated trauma and safeguarding concerns
   • Assess scalp swelling or wounds, skull-fracture signs, bleeding from ear/nose, bruising, abdominal injury, fractures, and pain.
   • Measure and document all findings precisely.
   • Because the child is preverbal and the mechanism is severe, document the history carefully and follow local child-protection policy if the history or injuries are inconsistent.
8. Support and inform the parents
   • Explain the need for close observation and possible imaging in simple language.
   • Encourage parents to report behavior that is unusual for their child.
   • Provide emotional support without allowing feeding or unnecessary movement.

Risk for decreased cerebral tissue perfusion related to traumatic head injury and possible increased intracranial pressure.

Pediatric Head-Injury Nursing Care Plan

Focused assessment

• Mechanism and time of fall, loss of consciousness, vomiting, seizure, and behavior since injury
• Pediatric GCS or AVPU, activity/interaction, consolability, response to caregiver
• Pupils: size, equality, reaction to light
• Limb movement, tone, weakness/asymmetry, abnormal posturing
• HR, RR, BP, temperature, SpO₂, capillary refill
• Scalp hematoma, wounds, signs of skull/base-of-skull fracture, bruises, other injuries
• Cervical tenderness or inability to move normally
• Intake/output, blood glucose if ordered
• Parent’s report of the child’s normal baseline behavior

1. Ineffective cerebral tissue perfusion / risk of increased intracranial pressure

• Child maintains or returns to baseline neurological status.
• Pediatric GCS/AVPU does not decline.
• Pupils remain equal and reactive, with symmetrical limb movement.
• No signs of worsening raised intracranial pressure.

• No decrease in neurological score.
• Child remains alert or returns to developmental baseline.
• Pupils equal/reactive and no new focal neurological signs.
• No repeated vomiting, seizure, or signs of raised ICP.

2. Risk for ineffective airway clearance and impaired gas exchange

• Airway remains patent.
• SpO₂ and respiratory pattern remain within ordered age-appropriate targets.
• No aspiration, apnea, cyanosis, or respiratory distress.

• Patent airway and no aspiration.
• Stable oxygen saturation and respiratory pattern.
• No cyanosis, apnea, or increasing work of breathing.

3. Risk for decreased cardiac output / ineffective tissue perfusion

• Hemodynamic status remains stable for age.
• Peripheral perfusion is adequate.
• Urine output is maintained as ordered.
• No signs of shock.

• Stable circulation and improving/normal capillary refill.
• No evidence of shock or ongoing bleeding.
• Urine output adequate for age and condition.

4. Risk for injury related to seizures, altered consciousness, and possible cervical-spine trauma

• Child remains free from further injury.
• Seizures, if they occur, are identified and managed promptly.
• Cervical spine remains protected until cleared.

• No falls, aspiration, or cervical-spine compromise.
• Any seizure is managed promptly and fully documented.
• Child remains protected during all movement and procedures.

5. Acute pain and anxiety of child/parents

• Pain is recognized using an age-appropriate scale and reduced after treatment.
• Child is more consolable and rests between assessments.
• Parents express understanding of monitoring and danger signs.

• FLACC/pain score reduced.
• Child is calmer or consolable.
• Parents understand why the child is monitored and when to call for help.

Immediate escalation criteria

• Any decrease in GCS/AVPU or inability to rouse normally
• Unequal, dilated, or non-reactive pupils
• New asymmetry of movement, weakness, or posturing
• Repeated/persistent vomiting, seizure, apnea, or irregular breathing
• Agitation or behavior that is markedly abnormal for the child
• Bradycardia, hypertension, hypotension, worsening oxygenation, or signs of shock
• Suspected CSF leak, palpable skull fracture, or new focal neurological deficit