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Traumatic brain injury (TBI) is a serious form of head injury that causes damage to the brain resulting from an external mechanical force. This condition can result in temporary and permanent impairment in sensory perception, cognition, mobility, or psychosocial function.

Major causes of TBI include falls, assault, motor vehicular accidents, and injuries causing a blow to the head. This condition may be categorized as mild to moderate causing a brief change in consciousness (see concussion) or severe causing prolonged unresponsiveness, coma, or death.

Damages occurring due to TBI are often described as primary or secondary. Primary injury is associated with the direct effects of trauma on the skull and brain at initial impact. Secondary injury refers to the complications arising hours to days later from dysfunction and pathophysiological changes of the brain tissue like infection, increased intracranial pressure, and hypoxemia.

Patients with TBI often exhibit external signs of head trauma like lacerations, bleeding, and ecchymosis. The patient's level of consciousness may be affected and changes in pupil shape, size, and reactivity or a decrease in the Glasgow coma scale (GCS) require immediate intervention. Changes in the patient's vital signs can indicate increased ICP.

The signs and symptoms of mild TBI include headache, dizziness, drowsiness, balance disturbance, nausea and vomiting, and impaired cognitive and emotional state. Patients with severe TBI can display hemiplegia, flexor or extensor posturing, language deficits, behavioral and cognitive changes, and hemiparesis.

Computed tomography (CT) scan is often ordered to rapidly identify areas of developing hematomas that require immediate intervention. Additionally, magnetic resonance imaging (MRI) is indicated if brain stem and vascular injury are suspected.

The Nursing Process

Management of TBI varies depending on the severity of the injury. The management of patients with mild TBI includes neurologic assessment as well as patient education about post-concussive symptoms like irritability, fatigue, headache, and sleep disturbances. While in most cases, the symptoms of mild TBI will resolve, an evaluation by a specialist may be needed for persistent symptoms.

The management of moderate to severe TBI is focused more on the optimization of functional recovery through minimizing secondary brain injury.

Nursing responsibilities in the treatment of patients with TBI will not only involve patient education and meticulous physical and neurologic assessment and monitoring but also interventions that will support cerebral perfusion and prevent ischemia.

Ineffective Cerebral Tissue Perfusion

Patients with TBI are susceptible to a decrease in cerebral tissue perfusion. As a result of brain injury, there may be swelling, bleeding, or CSF leaking affecting perfusion. Increased ICP occurs when the brain is not able to accommodate further volume changes, resulting in decreased cerebral perfusion, brain tissue ischemia, and edema. If cerebral edema is left untreated, the brainstem will herniate downward causing irreversible brain damage and death.

Nursing Diagnosis: Ineffective Tissue Perfusion

Hemorrhage

Skull fractures

Cerebral edema (localized or generalized response to injury)

Decreased systemic blood pressure

Hypoxia

As evidenced by:

Mental status changes

Decreased LOC

Pupillary changes

Changes in motor response

Difficulty swallowing or speaking

Expected Outcomes:

The patient will maintain an expected level of consciousness, motor response, sensory function, and cognition.

The patient will display adequate perfusion as evidenced by stable vital signs and hemodynamics.

Ineffective Cerebral Tissue Perfusion Assessment
3. Assess and monitor vital signs.
The mechanism of autoregulation is impaired following TBI. Severe TBI causes impairment in the function of the cerebral vasculature to modify systemic pressure to ensure sufficient blood flow to the brain. Blood pressure and pulse must be monitored frequently as the patient can exhibit hypotension or hypertension. Cushing's triad (irregular respirations, widened pulse pressure, and bradycardia), a classic but late sign of increased ICP, indicates imminent brainstem herniation.
Ineffective Cerebral Tissue Perfusion Interventions

Acute Confusion Care Plan

Patients suffering from mild TBI may experience altered cognition, including acute confusion, decreased memory, and impaired reasoning ability. Additionally, severe TBI can cause prolonged confusion with amnesia.

Nursing Diagnosis: Acute Confusion

Brain injury

Neurologic trauma

Decreased level of consciousness

As evidenced by:

Cognitive dysfunction

Misperception

Agitation or restlessness

Expected Outcomes:
1. Assess sensory awareness.
4. Eliminate extraneous noise as necessary.
This can help reduce the patient's anxiety, confusion, and exaggerated emotional responses associated with sensory overload. Assessment of sensory awareness is crucial to patient safety. Injury to the parietal lobe can cause loss of sensory perception and prevent appropriate responses to environmental stimuli.

The patient will maintain a baseline level of consciousness and will not experience decreased memory.

The patient will be able to respond appropriately to questions.

Acute Confusion Assessment

Acute Confusion Interventions

Deficient Knowledge Care Plan

Many patients suffering from TBI exhibit various long-term physical and cognitive disabilities. Patient and family education is important to clarify misconceptions, implement new behaviors to adapt to the resulting changes, develop coping strategies, and ensure adherence to the plan of care.

Nursing Diagnosis: Deficient Knowledge

Cognitive dysfunction

Inadequate access to resources

Inadequate awareness of resources

Inadequate knowledge of resources

Misinformation

Neurobehavioral manifestations

As evidenced by:

Inappropriate behavior

Inaccurate statements about topics related to the condition

Inaccurate follow-through of instructions

Development of further complications

Expected Outcomes:

The patient and/or family will demonstrate knowledge about the condition, treatments, and prognosis as evidenced by verbalization of teaching instructions and adherence with follow-up activities.

Deficient Knowledge Assessment

Deficient Knowledge Interventions

References and Sources

1. Lewis's Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, PhD, FAADN, CNE. 2020. Elsevier, Inc.

2. Lizzo JM, Waseem M, Tatikonda G. Brain Trauma (Nursing) [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568686/

3. Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.

4. Nakase-Richardson, R., Yablon, S. A., & Sherer, M. (2007). Prospective comparison of acute confusion severity with duration of post-traumatic amnesia in predicting employment outcome after traumatic brain injury. Journal of neurology, neurosurgery, and psychiatry, 78(8), 872-876. https://doi.org/10.1136/jnnp.2006.104190

5. Shaikh F, Waseem M, Boling AM. Head Trauma (Nursing) [Updated 2021 Nov 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568699/

6. Traumatic Brain Injury. Cleveland Clinic. © 2022 Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/8874-traumatic-brain-injury

7. Traumatic Brain Injury. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System. Copyright © 2022. https://www.hopkinsmedicine.org/health/conditions-and-diseases/traumatic-brain-injury

8. Traumatic Brain Injury & Concussion. Centers for Disease Control and Prevention. March 21, 2022. https://www.cdc.gov/traumaticbraininjury/index.html

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Traumatic Brain Injury (TBI) Nursing Diagnosis & Care Plan

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Traumatic brain injury (TBI) is a serious form of head injury that causes damage to the brain resulting from an external mechanical force. This condition can result in temporary and permanent...

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Contents: Pathophysiology
Head injury involves trauma to the skull leading to temporary or permanent brain damage. There are several different types of traumatic brain injuries (TBIs):

Reference: Saunders comprehensive review for the NCLEX-RN examination

Causes
The Mayoclinic includes the following events causing the most traumatic brain injuries, with falls being the most common accident.

Falls (from a ladder or down the stairs)

Vehicle-related collisions (cars, bicycles)

Violence (shootings, domestic violence)

Sports injuries (football, boxing, etc.)

Combat injuries (military)

Signs and Symptoms

Symptoms of Increased intracranial pressure (ICP)

Decreased level of consciousness (LOC)

Restlessness

Changes in behavior

Irritability

Confusion

Headache

Nausea and projectile vomiting

Pupillary changes

Changes in vital signs: (Cushing's triad)

Severe hypotension

Widened pulse pressure

Bradycardia

Seizures

Ataxia

Abnormal posturing

Decerebrate (extension)

Decorticate (flexion)

Cerebrospinal fluid leakage from the nose or ears

Secondary Injuries from TBI

Increased intracranial pressure

Hypotension

Hypoxia

Hemorrhage

Hydrocephalus

Brain herniation

Diagnosis

Arterial blood gas - to determine oxygen-carrying capacity

CBC - to identify hemodynamic stability and infection

CT scan - to identify scope of injury such as identifying subdural or epidural hematoma, and to rule out fractures

MRI - provides a more specific picture about brain tissue changes

Electroencephalogram (EEG) - to detect seizure activity
Treatment

Non- surgical

targeted temperature treatment: cooling the body down to a temperature of 32 to 34 degrees Fahrenheit to protect the brain

drug therapy

Surgical

Craniotomy

decompressive craniectomy

Nursing Diagnosis for Head Injury:

Nursing Care Plans for Head Injury

Expected Outcome: The patient will have an optimal cerebral tissue perfusion as evidenced by stable ICP and LOC

Avoid any activities and symptoms that increase ICP.

Position changes (keep head straight)
Endotracheal suctioning
Coughing, vomiting
Bending at the waist
Valsalva maneuvers
Pain
Fever
Shivering

These factors can increase cerebrospinal fluid and, therefore, intracranial pressure. Elevation of the head of the bed and maintaining a neutral alignment help reduce venous pressure and thus decrease ICP. Limiting suctioning and hyperoxygenation before suctioning helps keep ICP at bay. Treating pain, fever and shivering helps lower ICP as well.

Administer medication as ordered to decrease ICP.

Hyperosmotic agents (Mannitol)
Steroids
Barbiturates
Antipyretics
Muscle relaxants
Anticonvulsants

Medications such as Mannitol are used to draw fluid from interstitial spaces into the intravascular space reducing cerebral edema. Steroids help reduce brain swelling. Barbiturates are used to reduce brain metabolism and blood pressure. Antipyretics lower body temperature, which lowers metabolism, which lowers cerebral blood flow - decreasing ICP. Muscle relaxants prevent shivering. Seizures might increase metabolic demands and cerebral blood flow, increasing ICP. Anticonvulsants are administered to avoid seizure activity.

Risk for Seizures

Expected Outcome: The patient will remain free from seizure activity and injury thereof.
Risk factors:

Intracranial Bleeding

Contusion

Hyponatremia

Open and closed brain injuries

Hypoxia

Note characteristics during the seizure:

Onset
Duration
Type of seizure
Behavior at the onset, during, and after the seizure.

Documenting these characteristics can help to identify the type of seizure and allows for more specific treatment options.

Maintain seizure precautions.

Reduce environmental stimuli
Pad side rails
Place the bed in the lowest position
Have suction set up and ready if needed
Provide head protection

These implementations reduce the risk of injury during a seizure.

Assist the patient during the seizure.

Turn the patient's head to the side
Suction if necessary
Administer oxygen

These measures protect the patient's airway during and after the seizure.

Administer anticonvulsants as ordered and check therapeutic levels regularly.

Phenytoin (Dilantin) can only be mixed with NS. Its therapeutic level is 10 to 20 mcg/mL. Close monitoring for medication toxicity is essential. Signs include but are not limited to nausea, vomiting, restlessness, drowsiness, and visual changes.

Acute Confusion r/t increased intracranial pressure

Expected Outcome: The patient will demonstrate a stable cognitive status as evidenced by intact LOC.

Reorient the patient to person, time, place, and situation frequently.

Memory might be affected that requires frequent repetition of the same information. Informing the patient about their situation might reduce anxiety levels and bring their cognitive status back to baseline.

If possible, have the family communicate with the patient via facetime.

Seeing familiar faces and recognizing familiar voices might stimulate memory and helps with reorientation.

Deficient Knowledge r/t lack of experience with head injury

Expected Outcome: The patient will demonstrate knowledge about the disease process, treatment, and prognosis as evidenced by verbalizing correct information and posing appropriate and relevant questions.

Prepare the patient and family for possible need for physical, occupational, speech therapy, and ongoing home support.

Rehabilitation can be a long process that goes beyond the hospital stay. Patients and families need to be aware of all members of the healthcare team. The roles of significant others might turn into primary caregiver roles after the patient is discharged. Families need help to adjust to their new roles and situation.

More Care Plans: Risk for Falls Nursing Diagnosis & Care Plan Activity Intolerance Nursing Diagnosis & Care Plan Ineffective Airway Clearance Nursing Diagnosis & Care Plan Ineffective Breathing Pattern Nursing Diagnosis & Care Plan Ineffective Coping Impaired Gas Exchange Nursing Diagnosis & Care Plan Risk for Infection Nursing Diagnosis & Care Plan Risk for Bleeding Nursing Diagnosis & Care Plan

References:

Traumatic brain injury - Symptoms and causes. (2021). Retrieved from https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557

Deglin, J., Vallerand, A., & Sanoski, C. (2014). Davis's Drug Guide for Nurses (14th ed.) (14th ed.). FA Davis Company.

Blair, M., Ignatavicius, D., Rebar, C., Winkelman, C., & Workman, M. Medical-surgical nursing (8th ed.). Elsevier.

Silvestri, L. (2014). Saunders comprehensive review for the NCLEX-RN examination (6th ed.). St. Louis, Mo.: Elsevier/Saunders.

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Head Injury Nursing Diagnosis & Care Plan

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Contents: Pathophysiology Head injury involves trauma to the skull leading to temporary or permanent brain damage. There are several different types of traumatic brain injuries (TBIs): Causes The Mayoclinic includes the following events causing the most traumatic brain injuries, with falls being the most common accident.

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Prevention | Causes of Brain Injury | Stroke Rehabilitation | Traumatic Brain Injury (TBI)

What is an ABI or Acquired Brain Injury?

An acquired brain injury is an injury to the brain that is not hereditary, congenital or degenerative, and one that has occurred after birth.

In other words, it's something that happens, either from an unforeseen event or a medical cause.

The effects of an acquired brain injury can be severe and life-altering. The brain controls every part of human life: physical, intellectual, behavioral, social and emotional. When the brain is damaged, some part of a person's life is adversely affected.

A common form of acquired brain injury is traumatic brain injury, a sudden incident that damages the brain. These injuries are preventable in some cases with safety measures or lifestyle adjustments. Other acquired brain injuries occur from medical causes or disease processes. Either way, acquired brain injuries happen outside of our control. No one is to blame.

Common causes of acquired brain injury include:

External forces applied to the head and or neck (traumatic brain injury)

Anoxic/hypoxic injury (cardiac arrest, carbon monoxide poisoning, airway obstruction, hemorrhage, and drowning)

Intracranial surgery

Infectious diseases

Seizure disorders

Toxic exposure (substance abuse, ingestion of lead and inhalation of volatile agents)

Aneurysms

Medical causes like stroke (vascular obstruction)

Acquired Brain Injury Effects

Once a person has survived the acquired brain injury, there may be changes that affect many areas of an individual's life. Some are immediately apparent, such as weakness on one side of the body or difficulty speaking. Some are more subtle.

These changes are typically grouped in three major categories: physical, cognitive/thinking, and emotional/behavioral differences.

Some physical changes may include:

Muscle coordination problems

Full or partial paralysis

Changes in senses: hearing, sight, smell, etc.

Dizziness

Headache

Some cognitive/thinking changes may include:

Difficulty communicating

Memory problems

Poor judgment

Difficulty learning new things

Some emotional/behavioral changes may include:

Depression

Irritability/frustration

Difficulty with social skills

Inability to recognize changes in themselves

Recovery Timing

The number one question after an acquired brain injury is when will I be myself again?

The second question is, how long will it take?

You can expect the most rapid recovery from acquired brain injury in the first 18 months to two years following the injury; however, recovery can be a life-long process.

The type of injury, the severity of injury, the age of the person injured, as well as many other factors, affect the degree of improvement.

Family and other support persons play a major role in helping an individual resume productive and meaningful activity. An acquired brain injury often requires a major life adjustment around the person's new circumstances, and making that adjustment is a critical factor in recovery and rehabilitation.

Regaining Function and Prognosis

In the hospital, the goal is to medically stabilize the patient. After the hospital, the next phase is long term recovery.

The goal in treating an acquired brain injury is to focus on the cognitive, physical, emotional, or behavioral impairments that have caused changes in functioning.

Brain injury is a very complex phenomenon with dramatically varied effects and these greatly influence the results of rehab. No two persons are alike or can expect the same outcome or type of difficulties. The many unknowns make it difficult to predict the results of rehab ahead of time. What we do know is that not doing rehab will tend to affect long term recovery.

Rehabilitation versus returning home can make a dramatic difference in what capabilities are recovered and level of functioning as an individual returns to their life.

Acquired Brain Injury Treatment and Rehabilitation

At Pate Rehabilitation, we know treating acquired brain injuries demands a personalized, evidence-based and multidisciplinary approach guided by the patient's needs and goals.

Creating a therapeutic environment that matches the patient's tolerance for distraction and need for structure results in a much higher likelihood of the patient being able to return to home, work and community.

We have found that treating patients in isolation away from others in a quiet environment usually means that the patient will have much more difficulty returning to the community where there is little to no structure and constant distractions.

Scientific literature says that a combination of individual therapies and therapies provided with other people around is proven effective for brain injury rehabilitation.

At Pate, evidence-based techniques form the foundation from which to build individualized, functional activities. We strive to provide therapies that are meaningful and represent "real life " situations for the patients served.

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Acquired Brain Injury Treatment and Rehabilitation

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Acquired brain injury treatment affects millions of Americans. Learn about ABIs, causes, prevention and how we provide evidence-based treatment.

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Traumatic brain injury (TBI) is an injury to the brain caused by an external force. Common causes include falls, car accidents, assault or being struck by objects such as might occur during sport. TBI is classified according to its severity: mild, moderate or severe. From a medical perspective this judgment is based on what's known as the Glasgow Coma Scale (GCS), which assesses motor, verbal and eye-opening responses. The scale runs from 3 to 15, where 3 is assigned to someone who is dead or comatose and 15 is normal. Someone with a mild TBI generally has a GCS of 13-15.

In the absence of clinical assessment, TBI is considered moderate-to-severe if there is a loss of consciousness that is longer than 30 minutes and amnesia - memory loss - lasts for more than 24 hours. It's mild if those conditions are not met. Concussion is classified as a mild TBI (mTBI).

Signs and symptoms of traumatic brain injury (TBI)

Common symptoms of mild TBI are headaches, dizziness and fatigue, sleep disturbances, memory or concentration problems, and blurred vision. But a person may not display all of these at all times.

For severe TBI, symptoms can include slurred speech, profound confusion, seizures, persistant headaches, or loss of consciousness.

Prominent TBIs

The tragic outcomes of a spate of one-punch attacks - so-called 'coward punches' - in recent years has drawn considerable attention and resulted in harsher sentencing laws for perpetrators. Many researchers in the TBI field argue the tough laws are justified because even when a single punch isn't lethal, or doesn't have any apparent immediate effects, the head trauma can lead to irreversible consequences years or decades later.

Recent highly publicised cases of severe TBI have included Formula One driver Jules Bianchi, who died as the result of head injuries received when the car he was driving crashed during the 2015 Japanese Grand Prix. Retired Formula One driver Michael Schumacher continues to receive intensive treatment for severe head injuries that he suffered during a skiing accident in France, in 2013. In both of these cases, a severe TBI resulted in an immediate and prolonged loss of consciousness.

However, a loss of consciousness isn't always necessary for the consequences of TBI to be catastrophic. In 2009, British actress Natasha Richardson knocked her head while skiing. Thinking she was fine, she declined medical care on multiple occasions before later experiencing headaches that prompted her to go to hospital. Richardson subsequently died due to an epidural haematoma, a build-up of blood between the skull and the membrane that surrounds the brain. Haematomas are considered secondary injuries, meaning that the damage done to the brain doesn't coincide directly with the blow to the head.

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Traumatic brain injury (TBI) is an injury to the brain caused by an external force.

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Recognising you are a special person after brain injury

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Recognising you are a special person after brain injury

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#ThanksToYou: Recognising your special person after brain injury