Medical Surgical Head Injury #1
The nurse is performing an assessment on a client with an intracranial hematoma. Which assessment finding is most important?
- Increased muscular pain, especially during sleep.
This answer is not correct because muscular pain at night is not a sign of intracranial hematoma. Symptoms of intracranial bleeding include worsening headache, drowsiness, confusion, paralysis on the opposite side of the body from the head injury, unequal pupils, and drowsiness.
- Cogwheel rigidity.
This answer is not correct because cogwheel rigidity is found in clients with Parkinson’s disease. It is characterized by muscular rigidity in which passive movements of the limbs elicit ratchet-like start-and-stop movements through range-of-motion of joints. Symptoms of intracranial bleeding include worsening headache, drowsiness, confusion, paralysis on the opposite side of the body from the head injury, unequal pupils, and drowsiness.
- Tingling to extremities and inability to ambulate.
This answer is not correct because although this is an assessment finding of intracranial hemorrhage, it is not the most important finding. Tingling to extremities and paralysis is caused by decreased perfusion to brain tissue.
- Hamstring and spinal pain leading to resistance when the hip and knee is flexed then extended.
This answer is correct because it indicates a positive Kernig’s sign. This is caused by increasing intracranial pressure or swelling of the meninges. A client with a positive Kernig’s sign should have a CT scan and lumbar puncture to determine if the client has meningeal inflammation due to an infection or an intracranial hemorrhage.
An intracranial hematoma is when an injury causes a collection of blood in the skull or within the brain. Assessing for Kernig’s sign involves extending the thigh and knee after flexing them to right angles, causing resistance and pain in the hamstring and indicates irritation of the meninges.
Hamstring pain and resistance when the hip and knee are flexed then extended is an example of positive Kernig’s sign and may occur with intracranial hematomas. In Kernig’s, the client is supine and when the examiner passively straightens the leg at the knee (after flexion to 90 degrees), the client may experience pain along the spine which prevents or limits passive extension of the knee. It is important to note that pain alone is not a positive Kernig’s sign, but pain leading to resistance or contracture is a positive sign. The pain associated with intracranial bleeding is not isolated to nighttime only. If present, it may indicate increased pressure and may be severe and persistent.
Test Taking Tip
A positive Kernig’s sign is important to report so that treatment can be initiated. Take special time to know all the “signs” taught in nursing school. Those signs point to something that is wrong, which needs an intervention to follow.