A concussion is a type of mild traumatic brain injury (TBI) that temporarily affects brain function. It is usually caused by a blow or jolt to the head or the upper body that causes the brain to move rapidly back and forth and bounce around in the skull. This irregular movement and subsequent injury can disrupt brain function and affect memory, consciousness, and motor coordination.
In this article:
- Causes & Symptoms
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Memory
- Impaired Physical Mobility
- Nausea
- Risk for Injury
Causes & Symptoms
Concussions are most often caused by falls. Athletes, especially in contact sports like football, hockey, rugby, or soccer, are at an increased risk for concussions. Other causes include motor vehicle accidents, war combat, and physical altercations.
Common symptoms of concussions include alterations in mood, cognitive function, headache, dizziness, visual changes, and changes to sleep patterns. Symptoms usually occur immediately but may not appear for days or weeks. Most patients recover in 48-72 hours and are headache-free within 2-4 weeks.
Nursing Process
Nurses have multiple responsibilities in the treatment and recovery of patients with concussions, which include assessment of neurological functioning, coordination and communication of care, emotional support, patient advocacy, and prevention education.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to a concussion.
Review of Health History
1. Assess the patient’s general symptoms.
Symptoms usually occur immediately but may not appear for days or weeks. Symptoms of a concussion include:
- Ringing in the ears
- Headache
- Nausea and vomiting
- Confusion
- Dizziness
- Inability to recall events before or after a hit or fall
- Clumsy movement
- Loss of consciousness
- Delayed response to questions
- Disorders of taste and smell
- Personality changes
2. Note the time of injury and symptom onset.
A delayed onset of symptoms or any deterioration in neurologic status following the initial injury and assessment may indicate a more severe head injury. Symptoms including severe headaches, seizures, loss of consciousness, focal neurologic changes, and deteriorating mental status are all concerning signs that warrant immediate follow-up.
3. Investigate head trauma in children.
Head trauma is common among young children. Recognizing significant injury may be more difficult due to their inability to verbalize their feelings. Signs and symptoms to monitor in children are:
- Tiring easily
- Excessive crying
- Lack of interest in playing or favorite toys
- Seizures
- Vomiting
- Unsteadiness
- Irritability
- Behavior changes
4. Identify the mechanism of injury.
Concussions are most often caused by falls. Other causes include athletes who participate in contact sports, motor vehicle accidents, war combat, and physical altercations.
5. Inquire about persistent vomiting.
Persistent vomiting could indicate a severe brain injury and increased intracranial pressure. Additional indicators include a worsening headache, disorientation, and change in mentation.
6. Assess for a history of concussions.
Ask the patient about the incidence of concussions in the past. Patients with a history of prior concussions, especially more than one, or those that were severe or had persistent symptoms, are at an increased risk for prolonged recovery time. Persistent neurologic symptoms indicating postconcussive syndrome include:
- Headache
- Decreased tolerance to sound
- Dizziness
- Memory impairment
7. Note for signs of physical abuse, especially in children with head injuries.
Infants are particularly at risk, due to their poor neck strength. Physical abuse can potentially cause traumatic brain injury (TBI) by:
- Striking someone in the head with an object
- Slamming someone’s head against a wall
- Dragging someone down stairs or onto the ground
- Aggressively shaking a person
8. Review the patient’s medication list.
Certain medications can increase bleeding risk while narcotics can cloud the patient’s mentation. In geriatric patients, medications known to cause altered mentation, which could adversely affect mental status testing for a concussion, include anticholinergics, benzodiazepines, corticosteroids, H2 Receptor antagonists, sedative-hypnotics, and tricyclic antidepressants.
9. Assess for a history of mood disorders and substance abuse.
There are notable direct and indirect consequences of a history of concussions related to alcohol and cannabis usage. It can manifest as depression and panic disorder. A concussion may have long-term psychological effects and influence substance use and mood.
10. Ask the patient about their lifestyle, occupation, and recreational activities.
Children and older adults are at a higher risk for falls. In addition, athletes by profession or those who participate in contact sports have an increased risk of a concussion.
Physical Assessment
1. Assess the ABCs.
The first assessment should concentrate on the airway, breathing, and circulation. The care team must assume that all patients who are unconscious or mentally incapacitated have had a cervical spine injury until they are cleared by diagnostic imaging (CT scan, MRI). While assessing the ABCs, ensure the neck is maintained in a neutral position or a cervical collar is applied.
2. Assess mental status and perform a detailed neurologic exam.
The examination should occur in a quiet location, such as a private room in an emergency department or the locker room at a sporting event, for the most accurate assessment. Patients suffering from a mild TBI may experience confusion, a delayed response to questions, changes in emotional state, headache, dizziness, visual disturbances, and amnesia. A detailed neurologic exam will include:
- Glasgow Coma Scale (GCS)
- 15-point scale assessing the level of awareness of a patient with potentially impaired consciousness in these three areas:
- Eye-opening
- Verbal response
- Motor response
- Minor brain injury 13-15 points, moderate brain injury 9-12 points, severe brain injury 3-8 points
- 15-point scale assessing the level of awareness of a patient with potentially impaired consciousness in these three areas:
- Mental status: orientation to person, place, and time
- Cranial nerve assessment
- Eyes: visual fields, extraocular movements, and pupillary reflexes
- Motor exam: muscle strength and tone, range of motion
- Sensory exam: patient’s perception of pain, temperature, vibration, and position
- Gait assessment: ability to walk unassisted while maintaining balance
- Deep tendon reflexes
3. Perform a physical assessment.
Complete a thorough physical examination to assess for injuries such as fractures, bruising, or swelling.
- Assess the overall general appearance such as skin color and alertness.
- Palpate the head and neck for tenderness, including facial bones.
- Palpate the jaw while opening and closing for temporomandibular joint (TMJ) pain or malocclusion.
- Ears and nose: observe for persistent rhinorrhea or otorrhea, which could indicate a skull fracture.
- Evaluate upper and lower extremity strength, sensation, and reflexes.
- Assess gait, coordination, and balance.
4. Use a standardized tool.
Several standardized diagnostic tools can be used in the pre-hospital setting to help determine whether a concussion is present following a head injury. These include:
- Sport Concussion Assessment Tool 5 (SCAT5): most common tool for assessing athletes
- Child SCAT-5: for pediatric assessment ages 5-12
Diagnostic Procedures
1. Assist the patient with an imaging scan.
Anticipate imaging procedures to rule out other injuries that can resemble the signs or symptoms of a concussion.
- A Computerized tomography (CT) scan is the radiographic study of choice for prompt assessment to rule out neurosurgical emergencies.
- Magnetic resonance imaging (MRI) is considered if symptoms are present for more than a week to identify changes in the brain and examine complications.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a concussion.
1. Remove the patient from the site where they were injured if it is unsafe.
Promptly move the patient to an area of safety to begin assessment and treatment. For example, immediately withdrawing an athlete from competition or removing a pedestrian from a roadway.
2. Continuously observe the patient after the concussion.
Hospital admission may be necessary for severe head injury to monitor the patient. This is to ensure that signs and symptoms are not worsening and complications are not developing.
3. Encourage rest in a quiet, dimly lit room.
Rest is the best approach to help the brain recover following a concussion. This includes activity limitations that require thinking, recalling, and mental concentration, such as reading or using a computer.
4. Limit physical activities.
Advise the patient to refrain from strenuous physical activities that exacerbate symptoms or increase the risk of another concussion. This includes sports or any intense movement. Absolute rest is usually unnecessary, and the patient may participate in gentle activities like walking.
5. Encourage the patient to resume their normal routine gradually.
Encourage the patient to gradually increase their time at work or school, completing more assignments or other thinking-intensive activities. Patients can resume their routine as their symptoms improve.
Note: Playing sports or resuming strenuous activities again too soon puts the patient in danger of another concussion or brain injury. Emphasize that returning to those activities will require the healthcare provider’s clearance.
6. Alleviate any pain.
Preventatively medicating for pain is not advisable following a concussion. For managing headaches as they arise, over the counter medications such as acetaminophen or ibuprofen may be used. Avoid narcotics that may cloud the patient’s mental status.
7. Maintain blood glucose levels within normal limits.
If the patient is dealing with nausea or decreased appetite, promote eating small meals throughout the day and aim for 64 ounces of water in small, frequent sips. Low blood sugar and dehydration can mimic or exacerbate concussion symptoms.
8. Collaborate with a dietitian.
Recommend a balanced diet low in processed foods and saturated fats. Diets should be high in fruits, vegetables, and protein. Supplements that may be beneficial to add to the diet include:
- Resveratrol
- Turmeric
- Fish oils
- Green tea extract
9. Emphasize caution with medications.
Advise the patient not to take drugs that could affect their mood, sleep schedule, or cognitive abilities without provider approval.
10. Educate the patient on the importance of preventing another concussion.
Include the following strategies in the plan of care:
- Use protective gear during contact sports
- Implement fall prevention strategies
- Always utilize seat belts
- Apply window guards and block off stairways for children
11. Intervene when potential complications are identified.
Complications may develop after a concussion. Act immediately once symptoms of the following complications have been observed:
- Post-concussion headaches: persistent headaches that may last up to 1 week after concussion
- Post-concussion vertigo: persistent dizziness lasting months after concussion
- Post-concussion syndrome (PCS): persistent symptoms that extend for weeks to months after the initial injury; the most frequently observed concussion complication.
- Second-impact syndrome: one of the most fatal concussion complications. In second-impact syndrome (SIS), the brain swells severely and quickly after a second head injury occurs before the original concussion fully heals.
- Chronic traumatic encephalopathy (CTE): Tau protein deposition and recurrent head trauma cause slow, progressive neurodegeneration
- Anxiety and depression
- Memory and concentration issues
- Dementia
Nursing Care Plans
Once the nurse identifies nursing diagnoses for concussion, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for concussion.
Acute Confusion
Concussions may lead to bleeding in or around the brain, causing symptoms such as prolonged drowsiness and confusion.
Nursing Diagnosis: Acute Confusion
Related to:
- Significant blow to the head
- Brain injury
- Possible bleeding in the brain
As evidenced by:
- Fluctuation in psychomotor activity
- Misperceptions
- Impaired memory
- Restlessness or agitation
- Fluctuation in the level of consciousness
- Visual or auditory hallucinations
- Erratic sleep-wake cycle
Expected outcomes:
- Patient will regain alertness with orientation within normal limits.
- Patient will demonstrate a neurological assessment within normal limits.
- Patient will demonstrate appropriate motor skills and reflexes.
Assessment:
1. Assess the patient’s level of consciousness frequently.
A change in mental status may be indicative of an increase in cerebral pressure.
2. Assess the patient’s behavior and cognition continually.
Almost half of the patients with head injuries may develop delirium, which invokes acute changes in mental status. Knowledge of the patient’s baseline mental status is key in assessing delirium.
3. Review imaging results.
Imaging may not always be necessary, but if symptoms worsen into severe headaches, seizures, or vomiting, advocate for a CT scan or MRI.
Interventions:
1. Reorient the patient to person, time, situation, and place frequently.
In concussions, memory might be affected, requiring frequent repetition of important information. Informing the patient about their situation may reduce anxiety levels and improve their awareness.
2. Allow for rest and reduce stimuli.
The most important intervention after a concussion is rest. Complete darkness and quiet aren’t necessary, but brain rest is encouraged.
3. Promote safety.
When in a confused state, safety is vital. Ensure frequent supervision, keep items within reach, and the bed alarm on.
4. Encourage family support.
Seeing familiar faces and recognizing familiar voices stimulate memory and help with reorientation. If the patient is cleared for discharge, a family member may need to stay with them to monitor for symptoms and ensure they are recovering.
Impaired Memory
A concussion is a traumatic brain injury that affects brain function and may cause memory loss. Memory loss occurs due to damage to the limbic system, which is the brain structure that plays a vital role in memory and emotion.
Nursing Diagnosis: Impaired Memory
Related to:
- Brain trauma or injury
- Cerebral hypoxia
- Neurological impairment
As evidenced by:
- Difficulty recalling events and information
- Difficulty recalling familiar names, objects, and words
- Difficulty recalling events leading up to injury
- Persistent forgetfulness
- Difficulty acquiring new information
- Difficulty acquiring a new skill
Expected outcomes:
- Patient will demonstrate techniques that can help with memory loss.
- Patient will be able to report improved memory.
Assessment:
1. Assess the patient’s overall cognitive function and memory.
Obtain baseline and ongoing assessments of the patient’s cognitive function and working memory. Screening tools such as the Acute Concussion Evaluation (ACE) can be used for initial evaluation. Determining and monitoring the patient’s cognitive function and memory can evaluate the effectiveness of the current treatment regimen and identify developing complications.
2. Assess the severity of trauma or injury.
The severity of the injury or trauma can significantly affect memory impairment in patients with concussion. Gather as much information as possible about the events leading up to the injury and the specific mechanism of injury to assist in the evaluation process.
3. Assess the patient’s current sleep quality and patterns.
Insomnia may contribute to memory problems and may be a result of the anxiety following a traumatic event. Increased cortisol levels (stress hormone) may cause poor sleep quality.
Interventions:
1. Reorient the patient to their environment.
Reorientation helps decrease the anxiety levels of patients with concussion and memory problems. Utilize calm conversation, taking special care not to provide details that may upset them unnecessarily.
2. Encourage the patient to use external cueing strategies.
External cues can help remind patients to perform certain activities or attend to appointments or other obligations at specific times. Some of these strategies include smart alarm watches, phone alarms, calendars, written lists, and pill organizers. These assist the patient in remaining in control of their environment and schedule and help them re-establish autonomy.
3. Encourage brain rest and provide a quiet environment.
Physical and cognitive rest should be encouraged for the first 24-48 hours after a concussion. Provide a dimly lit, quiet room and limit the use of screens. Once patients are symptom-free at rest, resting for more than two days has been shown to delay recovery time.
4. Refer the patient to a neuropsychologist for follow-up.
Evaluation by a neuropsychologist can supplement the initial evaluation by emergency providers. Neuropsychological testing will provide information on multiple aspects of the brain that may be affected by the concussion and what issues those may cause for the patient.
Impaired Physical Mobility
Mobility, including coordination and balance, can be affected following a concussion.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Neurological impairment
As evidenced by:
- Weakness
- Reports of pain or discomfort in movement
- Impaired coordination
- Loss of balance
- Dizziness
- Impaired reflexes
Expected outcomes:
- Patient will safely participate in desired physical activities.
- Patient will display improvement in balance, coordination, and reflexes.
- Patient will perform ADLs with the least amount of assistance.
Assessment:
1. Assess the patient’s ability and tolerance to engage in activities.
This will help provide baseline data which will aid in determining a proper direction for treatment. Physical and occupational therapy may be consulted.
2. Assess the patient’s need for special equipment.
Mechanical lifts, canes, wheelchairs, and assistive devices may be required when performing tasks.
3. Perform neurological assessments.
The nurse should perform neuro checks as ordered and assess the pupils, coordination, sensations, reflexes, gait, and more for improvement or changes.
Interventions:
1. Provide equipment as needed.
Concussion symptoms usually aren’t severe or permanent, but the patient may need a walker or equipment temporarily to support balance and weakness.
2. Allow the patient to perform tasks at their own pace.
Excessive assistance may slow their physical recovery. Take your time with the patient and encourage independent activity as allowed.
3. Encourage progressive activity as tolerated.
A gradual increase in the patient’s movement will help increase their tolerance to activity. As symptoms improve, the patient should resume light exercise.
4. Refer to therapy as required.
Specialized therapies such as physiotherapy and occupational therapy will provide treatment to safely improve their balance and coordination.
Nausea
Nausea may be a symptom following a concussion due to cranial nerve disruption. Patients presenting with persistent nausea are more likely to suffer from post-concussion syndrome.
Nursing Diagnosis: Nausea
Related to:
- 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 state relief of nausea.
- Patient will demonstrate interventions that can help decrease nausea and vomiting.
Assessment:
1. Assess for nausea and vomiting.
This assessment includes onset, duration, timing, volume of emesis (if any), frequency or pattern, associated or aggravating factors, and past medical and social history. Patients can experience short-term nausea after a mild traumatic brain injury. Persistent or situational nausea may also occur after recovering from an initial concussion.
2. Assess for any signs of dehydration and electrolyte imbalances.
Monitor for low blood pressure, increased heart rate, decreased urine output, dry mucous membranes, dry skin, increased body temperature, thirst, weakness, and altered mental status. Nausea may be accompanied by vomiting or decreased fluid intake. Prolonged nausea and vomiting can lead to dehydration along with other electrolyte imbalances.
3. Assess other triggers that can aggravate nausea.
Chronic or recurring nausea may occur after a concussion. It may be aggravated by other causes, such as alterations in the vestibular (inner ear) area, visual disturbances, and changes in cerebral blood flow and pressure.
Interventions:
1. Encourage the patient to avoid nausea-inducing foods.
Large meals, salty, spicy, and fatty foods can further aggravate nausea and cause stomach upset and bloating.
2. Administer antiemetics as ordered.
Antiemetics helps reduce nausea and vomiting by blocking specific receptors that respond to neurotransmitters like histamine, serotonin, and dopamine. Common antiemetics for post-concussion nausea management include:
- Metoclopramide
- Ondansetron
- Prochlorperazine
3. Ensure the patient has an emesis basin and call light at the bedside.
If vomiting occurs, a nearby emesis basin and call light will help contain the waste and allow the patient to call for help. This will also improve the patient’s safety, as they will not have to get out of bed, minimizing fall risk.
4. Teach the patient non-pharmacologic methods to manage nausea.
Techniques such as deep breathing, acupressure, music therapy, and distraction may assist the patient in managing nausea.
5. Instruct the patient to shift positions slowly and gently.
Nausea may be accompanied by dizziness if the concussion has affected the patient’s vestibular system or vision. Instruct the patient to move slowly and gently, as erratic movements can exacerbate the patient’s nausea and dizziness.
Risk for Injury
Patients who perform contact or high-risk sports are at an increased risk for a concussion. Children are also at increased risk for head injuries. After sustaining a concussion, preventing further injury is a priority.
Nursing Diagnosis: Risk for Injury
Related to:
- Impaired psychomotor performance
- Changes in cognitive function
- High-risk activities
- Brain injury
- Young age
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will demonstrate behaviors to help in avoiding injury.
- Patient will remain free of injuries.
- Patient will modify their environment as indicated to enhance safety.
Assessment:
1. Assess for changes in cognitive awareness.
Confusion or disorientation puts the patient at risk for falls or injuries.
2. Assess the patient’s ability to ambulate and identify the risk for falls.
Alterations in mobility increase the risk of falls. The Morse Fall Scale (MFS) is a simple fall risk assessment tool commonly used among healthcare facilities. It uses a point scale system that assesses six variables. An MFS score of 0-24 means no risk, 25-50 indicates low risk, and >51 is a high risk for falls.
3. Check on the home environment to identify the presence of safety risks.
Patients experiencing impaired mobility and deficits are at risk for injury from common hazards. Throw rugs, clutter, dim lighting, and stairs may increase the risk.
Interventions:
1. Encourage safety with sports.
Safety equipment such as helmets, headgear, and padding should always be worn correctly.
2. Educate parents on child safety.
Remind parents always to ensure their kids are strapped into car seats correctly and using their seat belts. In homes with stairs, use safety gaits to prevent falls.
3. Prevent second injuries.
Encourage the patient to return to activities slowly. A return to sports before symptoms have resolved and a second concussion may result in life-threatening brain swelling.
4. Promote strength training.
Older adults at risk for falls will benefit from strength and balance training to prevent falls and head injuries.
References
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