A concussion, a mild form of traumatic brain injury (TBI), is characterized by a temporary disruption of brain function. This often results from a blow or jolt to the head or body, causing the brain to move rapidly within the skull. This movement can lead to a cascade of effects that impair neurological function, impacting memory, consciousness, and coordination. For nurses, understanding the nuances of concussion and formulating accurate nursing diagnoses is crucial for effective patient care and recovery.
Understanding Concussion: Causes, Symptoms, and Nursing Role
Concussions are frequently caused by falls, especially among young children and older adults. Athletes, particularly those in high-impact sports like football, soccer, and hockey, face an elevated risk. Motor vehicle accidents, physical altercations, and combat situations are also significant causes.
Symptoms of a concussion can be varied and may include headaches, dizziness, mood changes, cognitive difficulties, visual disturbances, and altered sleep patterns. These symptoms usually manifest immediately after the injury but can sometimes be delayed, appearing days or even weeks later. While most individuals recover within a few days to weeks, the role of nursing care is vital in assessment, monitoring, and facilitating optimal recovery. Nurses are integral in neurological assessments, coordinating care, providing emotional support, advocating for patients, and delivering essential prevention education.
To provide effective nursing care, a systematic approach is necessary, starting with a thorough nursing assessment.
Nursing Assessment for Concussion
The nursing assessment is the cornerstone of care for patients with concussions. It involves gathering comprehensive data – physical, psychosocial, emotional, and diagnostic – to inform nursing diagnoses and subsequent interventions.
Review of Health History: Subjective Data
Obtaining a detailed health history is crucial in assessing a patient with a suspected concussion. This involves exploring subjective symptoms reported by the patient or their caregivers.
1. General Symptom Assessment: It’s important to understand the breadth of symptoms a patient may be experiencing. Common concussion symptoms include:
- Tinnitus (ringing in the ears)
- Headache
- Nausea and vomiting
- Confusion
- Dizziness
- Amnesia (inability to recall events before or after the injury)
- Clumsiness and motor incoordination
- Loss of consciousness
- Delayed response to questions
- Taste and smell disorders
- Personality changes
2. Onset and Timing of Symptoms: Documenting the time of injury and when symptoms began is critical. Delayed symptom onset or worsening neurological status post-injury can signal a more severe brain injury requiring immediate medical attention. Be alert for red-flag symptoms such as severe headaches, seizures, loss of consciousness, focal neurological deficits, and deteriorating mental status.
3. Pediatric Considerations: In children, recognizing concussion can be more challenging. Observe for non-verbal cues and symptoms such as:
- Easy fatigability
- Excessive crying
- Decreased interest in play or favorite toys
- Seizures
- Vomiting
- Unsteady gait
- Irritability
- Behavioral changes
4. Mechanism of Injury: Identifying how the injury occurred provides valuable context. Common mechanisms include falls, sports-related injuries, motor vehicle accidents, and assaults.
5. Persistent Vomiting: Inquire about persistent vomiting, as it can be indicative of severe brain injury and increased intracranial pressure (ICP), especially when coupled with worsening headaches, disorientation, and altered mentation.
6. History of Concussions: A history of previous concussions, particularly multiple, severe, or those with prolonged symptoms, increases the risk of prolonged recovery and post-concussive syndrome. Inquire about symptoms like persistent headache, sound sensitivity, dizziness, and memory impairment.
7. Abuse Indicators: Especially in pediatric cases, consider the possibility of physical abuse as a cause of head injury. Infants are particularly vulnerable due to neck weakness. Mechanisms of abusive head trauma include striking the head, slamming against surfaces, or violent shaking.
8. Medication Review: Review the patient’s medication list. Certain medications, such as anticoagulants, can increase bleeding risk, while narcotics can alter mental status. In older adults, medications with anticholinergic effects, benzodiazepines, corticosteroids, H2 antagonists, sedative-hypnotics, and tricyclic antidepressants can also cloud mentation and affect neurological assessments.
9. Mood Disorders and Substance Abuse History: Explore the patient’s history of mood disorders and substance use. Concussions can have both direct and indirect links to alcohol and cannabis use and can manifest as depression or panic disorder. Long-term psychological effects can influence substance use and mood regulation.
10. Lifestyle, Occupation, and Recreation: Assess lifestyle factors that increase concussion risk. Children and older adults are at higher risk of falls. Athletes in contact sports and individuals with physically demanding occupations also have elevated risks.
Physical Assessment: Objective Data
The physical assessment provides objective data to complement the health history.
1. ABCs and Cervical Spine Precautions: Prioritize assessment of Airway, Breathing, and Circulation (ABCs). In unconscious or mentally compromised patients, assume cervical spine injury until cleared by imaging. Maintain neck neutrality or apply a cervical collar during ABC assessment.
2. Mental Status and Neurological Exam: Conduct a detailed neurological examination in a quiet environment to ensure accuracy. Patients with mild TBI may exhibit confusion, delayed responses, emotional lability, headache, dizziness, visual disturbances, and amnesia. A comprehensive neurological exam should include:
- Glasgow Coma Scale (GCS): Assess level of consciousness based on eye-opening, verbal response, and motor response. Scores range from 13-15 for minor, 9-12 for moderate, and 3-8 for severe brain injury.
- Mental Status: Evaluate orientation to person, place, and time.
- Cranial Nerve Assessment: Assess function of all twelve cranial nerves.
- Ocular Examination: Assess visual fields, extraocular movements, and pupillary reflexes.
- Motor Exam: Evaluate muscle strength, tone, and range of motion.
- Sensory Exam: Test perception of pain, temperature, vibration, and position.
- Gait Assessment: Observe the patient’s ability to walk and maintain balance.
- Deep Tendon Reflexes: Assess reflexes in upper and lower extremities.
3. General Physical Examination: Perform a thorough physical exam to identify associated injuries:
- General Appearance: Observe skin color, alertness, and overall presentation.
- Head and Neck Palpation: Palpate for tenderness, including facial bones.
- Temporomandibular Joint (TMJ): Assess for TMJ pain or malocclusion while the patient opens and closes their jaw.
- Ears and Nose: Observe for rhinorrhea or otorrhea, which may indicate a skull fracture.
- Extremity Assessment: Evaluate upper and lower extremity strength, sensation, and reflexes.
- Gait, Coordination, and Balance: Assess these functions comprehensively.
4. Standardized Concussion Assessment Tools: Utilize standardized tools, especially in pre-hospital settings, to aid in concussion diagnosis.
- Sport Concussion Assessment Tool 5 (SCAT5): The most widely used tool for athletes.
- Child SCAT-5: Adapted for pediatric assessment in children aged 5-12.
Diagnostic Procedures
Diagnostic imaging plays a role in ruling out more serious conditions.
1. Imaging Scans: Anticipate imaging to exclude injuries that mimic concussion symptoms.
- Computed Tomography (CT) Scan: The preferred initial imaging for rapid assessment, particularly to rule out neurosurgical emergencies like intracranial hemorrhage or skull fractures.
- Magnetic Resonance Imaging (MRI): Considered if symptoms persist beyond a week to identify subtle brain changes and complications.
Common Nursing Diagnoses for Concussion
Based on the assessment data, several nursing diagnoses may be appropriate for patients with concussions. These diagnoses guide the development of individualized care plans.
Acute Confusion
Concussion can lead to cerebral bleeding or swelling, resulting in acute confusion.
Nursing Diagnosis: Acute Confusion
Related Factors:
- Significant blow to the head
- Brain injury
- Potential intracranial bleeding
As Evidenced By:
- Fluctuations in psychomotor activity
- Misperceptions
- Memory impairment
- Restlessness or agitation
- Fluctuating level of consciousness
- Visual or auditory hallucinations
- Disrupted sleep-wake cycle
Expected Outcomes:
- Patient will regain baseline alertness and orientation.
- Patient will demonstrate neurological assessment findings within normal limits.
- Patient will exhibit appropriate motor skills and reflexes.
Nursing Assessment for Acute Confusion:
- Frequent Level of Consciousness (LOC) Assessment: Changes in LOC can indicate increased intracranial pressure.
- Behavior and Cognition Monitoring: Assess behavior and cognitive function continuously to detect delirium, a common complication post-head injury. Baseline mental status is crucial for comparison.
- Review Imaging Results: Advocate for CT or MRI if symptoms worsen (severe headache, seizures, vomiting) to rule out serious intracranial pathology.
Nursing Interventions for Acute Confusion:
- Frequent Reorientation: Reorient the patient to person, time, situation, and place regularly. Memory deficits are common in concussion, and reorientation reduces anxiety and improves awareness.
- Promote Rest and Reduce Stimuli: Encourage rest in a quiet, dimly lit environment. Minimize cognitive exertion by limiting activities like reading or screen time.
- Ensure Safety: Implement safety measures, including frequent supervision, keeping essential items within reach, and using bed alarms to prevent falls.
- Family Support: Encourage family presence. Familiar faces and voices aid in reorientation and reduce anxiety. If discharged, family members should monitor symptoms and ensure proper recovery.
Impaired Memory
Concussion frequently affects memory due to damage to brain structures involved in memory processing.
Nursing Diagnosis: Impaired Memory
Related Factors:
- Brain trauma or injury
- Cerebral hypoxia
- Neurological impairment
As Evidenced By:
- Difficulty recalling events and information
- Difficulty remembering names, objects, and words
- Difficulty recalling events leading up to the injury
- Persistent forgetfulness
- Difficulty learning new information or skills
Expected Outcomes:
- Patient will demonstrate memory-enhancing techniques.
- Patient will report improved memory function.
Nursing Assessment for Impaired Memory:
- Cognitive and Memory Assessment: Obtain baseline and ongoing assessments of cognitive function and working memory using tools like the Acute Concussion Evaluation (ACE).
- Severity of Injury Assessment: Correlate the severity of injury with memory impairment. Gather details about the injury mechanism and events leading up to it.
- Sleep Quality and Patterns: Assess sleep quality, as insomnia can exacerbate memory problems and may be a consequence of post-traumatic anxiety.
Nursing Interventions for Impaired Memory:
- Environmental Reorientation: Reorient the patient to their environment to reduce anxiety. Use calm, reassuring communication.
- External Cueing Strategies: Teach and encourage the use of external memory aids like alarms, calendars, written lists, and pill organizers to improve autonomy and schedule management.
- Brain Rest and Quiet Environment: Emphasize physical and cognitive rest for the first 24-48 hours post-concussion. Provide a quiet, dimly lit room and limit screen time.
- Neuropsychology Referral: Recommend neuropsychological evaluation for comprehensive assessment of cognitive deficits and to guide rehabilitation strategies.
Impaired Physical Mobility
Concussion can impact balance and coordination, leading to impaired physical mobility.
Nursing Diagnosis: Impaired Physical Mobility
Related Factors:
- Neurological impairment
As Evidenced By:
- Weakness
- Reports of pain or discomfort during movement
- Impaired coordination
- Loss of balance
- Dizziness
- Impaired reflexes
Expected Outcomes:
- Patient will safely participate in desired physical activities.
- Patient will demonstrate improved balance, coordination, and reflexes.
- Patient will perform Activities of Daily Living (ADLs) with minimal assistance.
Nursing Assessment for Impaired Physical Mobility:
- Activity Ability and Tolerance: Assess the patient’s ability to engage in activities and their tolerance level. Consult physical and occupational therapy as needed.
- Need for Assistive Equipment: Evaluate the need for mobility aids like walkers, canes, or wheelchairs.
- Neurological Assessments: Perform regular neurological checks, including assessment of pupils, coordination, sensation, reflexes, and gait.
Nursing Interventions for Impaired Physical Mobility:
- Provide Assistive Equipment: Provide walkers or other devices as needed to support balance and mobility temporarily.
- Allow Self-Paced Activities: Encourage the patient to perform tasks at their own pace. Avoid over-assistance to promote recovery.
- Progressive Activity Encouragement: Encourage a gradual increase in activity level as tolerated to improve activity tolerance.
- Therapy Referral: Refer to physical and occupational therapy for specialized interventions to enhance balance and coordination.
Nausea
Nausea is a common symptom post-concussion, possibly due to cranial nerve disruption or increased ICP.
Nursing Diagnosis: Nausea
Related Factors:
- Brain trauma or injury
- Anxiety
- Fear
- Noxious environmental stimuli
- Increased intracranial pressure (ICP)
As Evidenced By:
- Food aversion
- Increased salivation
- Increased swallowing
- Gagging sensation
- Sour taste
Expected Outcomes:
- Patient will report relief from nausea.
- Patient will demonstrate effective nausea-reducing interventions.
Nursing Assessment for Nausea:
- Nausea and Vomiting Assessment: Assess onset, duration, timing, frequency, volume (if vomiting), aggravating factors, and history. Differentiate between acute and persistent nausea.
- Dehydration and Electrolyte Imbalance Assessment: Monitor for signs of dehydration (hypotension, tachycardia, decreased urine output, dry mucous membranes) and electrolyte imbalances.
- Nausea Triggers: Identify potential triggers like vestibular disturbances, visual changes, and cerebral blood flow alterations.
Nursing Interventions for Nausea:
- Avoid Nausea-Inducing Foods: Advise avoiding large meals, spicy, fatty, and salty foods.
- Administer Antiemetics: Administer prescribed antiemetics like metoclopramide, ondansetron, or prochlorperazine to block neurotransmitter receptors involved in nausea.
- Provide Emesis Basin and Call Light: Ensure easy access to an emesis basin and call light for safety and convenience if vomiting occurs.
- Non-Pharmacologic Nausea Management: Teach non-pharmacological techniques like deep breathing, acupressure, music therapy, and distraction.
- Promote Slow Position Changes: Instruct the patient to change positions slowly to minimize dizziness and nausea, especially if vestibular system involvement is suspected.
Risk for Injury
Patients with concussions are at increased risk for subsequent injuries due to cognitive and physical impairments.
Nursing Diagnosis: Risk for Injury
Related Factors:
- Impaired psychomotor performance
- Changes in cognitive function
- High-risk activities (sports, etc.)
- Brain injury
- Young age
As Evidenced By:
A risk diagnosis is not evidenced by signs and symptoms; interventions focus on prevention.
Expected Outcomes:
- Patient will demonstrate injury prevention behaviors.
- Patient will remain free from injuries.
- Patient will modify their environment to enhance safety.
Nursing Assessment for Risk for Injury:
- Cognitive Awareness Assessment: Assess for confusion or disorientation, which increases fall risk.
- Mobility and Fall Risk Assessment: Evaluate mobility and use tools like the Morse Fall Scale (MFS) to quantify fall risk.
- Home Environment Assessment: Assess the home environment for hazards like throw rugs, clutter, poor lighting, and stairs.
Nursing Interventions for Risk for Injury:
- Sports Safety Education: Emphasize the use of protective gear in sports, such as helmets and padding.
- Child Safety Education: Educate parents on car seat safety, seatbelt use, and home safety measures like stair gates.
- Prevent Second Injuries: Advise gradual return to activity and emphasize the dangers of returning to sports before full symptom resolution to prevent second-impact syndrome.
- Promote Strength and Balance Training: Encourage strength and balance exercises, especially for older adults, to prevent falls.
Nursing Interventions for Concussion Management: A Summary
Beyond diagnosis-specific interventions, general nursing interventions are essential for managing concussion. These include:
- Removal from Injury Site: Immediately remove the patient from hazardous environments to prevent further injury.
- Continuous Observation: Monitor patients closely, especially those with severe injuries, for worsening symptoms or complications, potentially requiring hospital admission.
- Rest Promotion: Encourage physical and cognitive rest in a quiet, dimly lit room to facilitate brain recovery.
- Activity Limitation: Advise against strenuous physical and mentally demanding activities initially.
- Gradual Return to Routine: Guide a gradual return to normal activities as symptoms improve, with healthcare provider clearance for sports or strenuous activities.
- Pain Management: Manage headaches with over-the-counter analgesics like acetaminophen or ibuprofen, avoiding narcotics.
- Blood Glucose and Hydration Maintenance: Promote small, frequent meals and adequate hydration to maintain stable blood glucose and hydration, addressing symptoms that can mimic or worsen concussion.
- Dietary Recommendations: Collaborate with dietitians for balanced diets rich in fruits, vegetables, and protein, potentially recommending supplements like resveratrol, turmeric, fish oils, and green tea extract.
- Medication Caution: Advise patients to consult providers before taking medications that could affect mood, sleep, or cognition.
- Concussion Prevention Education: Educate on protective gear, fall prevention, seatbelt use, and childproofing homes.
- Complication Monitoring and Intervention: Act promptly if complications like post-concussion syndrome, second-impact syndrome, or CTE are suspected. Address anxiety, depression, memory issues, and dementia risk.
Conclusion
Accurate nursing diagnoses are fundamental to providing comprehensive care for patients with concussions. By conducting thorough assessments and understanding the common nursing diagnoses associated with concussion – Acute Confusion, Impaired Memory, Impaired Physical Mobility, Nausea, and Risk for Injury – nurses play a critical role in promoting patient safety, facilitating recovery, and providing essential education to prevent future injuries. By prioritizing these nursing interventions, healthcare professionals can significantly improve outcomes and quality of life for individuals recovering from concussions.
