Concussion Nursing Care Plans Diagnosis and Interventions
Concussion NCLEX Review and Nursing Care Plans
A concussion is a traumatic brain injury which causes a disturbance in brain function.
The effects can include headaches, difficulty in concentration, problems with memory, balance and coordination, and loss of consciousness in some cases.
Most of its complications are brief and temporary and most people are able to recover fully after the injury.
It is usually caused by accidents such as falls, which is the most common and a blow to the head.
Jarring which is often caused by violently shaking of the head can also result in a concussion.
People who engage in contact sports such as football or soccer can also be at risk.
Close monitoring of symptoms is very important during the first hours post injury.
Although it only temporarily affects brain function, it can also cause prolonged drowsiness and confusion indicating bleeding within the brain which can be fatal.
Signs and Symptoms of Concussion
•Headache, or feeling of pressure in the head
•Ringing in the ears
•Temporary loss of consciousness
•Amnesia surrounding the traumatic event
•Dizziness or lightheadedness
Causes of Concussion
Our brain has a gelatin-like consistency and is protected by cerebrospinal fluid, which acts as a cushion from bumps and jolts.
A concussion can result from any direct or indirect injury to the skull brought about by a violent blow to the head causing the brain to forcefully slide within the walls of skull.
It can also be caused by any sudden movement resulting in acceleration or deceleration of the head brought about by accidents such as falls, vehicular crash, accidents from sports activities and being violently shaken.
Complications of Concussion
Some people may experience the following complications after a brain injury:
- Post-traumatic headaches. Concussion-related headaches that can last up to 7 days
- Post-traumatic vertigo –a sense of spinning or dizziness that can lasts for days, weeks or months
- Post-concussion syndrome-15% to 20% of people may have headaches, dizziness and problems in cognition that persists beyond three weeks. If it lasts for more than three months, it is defined as post-concussion syndrome
- Cumulative effects of multiple brain injuries- There is no evidence as of the moment which concludes that repeated injuries can lead to cumulative effects. An ongoing research regarding sub-concussive injury is still in the works.
- Second impact syndrome –On rare occasion, one can experience rapid and fatal swelling of the brain after suffering a second concussion just before the symptoms of a previous concussion have subsided.
For sports-related brain injury, it’s important that athletes refrain from going back if they still have signs and symptoms of concussion
Diagnosis of Concussion
- Physical Exam- the doctor will review the medical history and conduct the following tests:
- Neurological Examination
- Cognitive Testing
- Imaging: tests may be required for people with signs and symptoms to check for bleeding and swelling; cranial computerized tomography (CT Scan)- standard test for adults; Magnetic resonance imaging (MRI)
An overnight hospitalization after a concussion may be necessary for further evaluation.
Treatment of Concussion
- Rest. Treatment for concussion focuses on getting adequate physical and mental rest to aid in recovery and healing of the brain. Relative rest is needed for the first 48 hours after injury. This means steering clear of physical activities that may aggravate symptoms is required. It includes staying away from activities that exerts physical effort such as lifting heavy objects, sports or any vigorous movements. Activities that overstimulate the brain including those that requires immense amount of concentration like playing video games, doing schoolwork, reading, texting or using of a computer should also be avoided. However, avoiding all kinds of stimuli (e.g. lying in a dark room is not recommended).
- Pain relief. For those who are experiencing headaches, which can happen a few days or weeks after a concussion, an analgesic or pain reliever may be taken as prescribed by the doctor. Paracetamol may be given but void administering ibuprofen as this increased the risk for bleeding.
- Therapy. Different therapies that can help rehabilitate vision, cognitive and balance problems may be recommended by the physician. Once symptoms have improved, the doctor may allow the patient to resume to the daily routine gradually. Light physical activity for the first few days like light jogging may be recommended.
Nursing Diagnosis Concussion
Nursing Care Plan for Concussion 1
Nursing Diagnosis: Acute Pain related to traumatic brain injury secondary to concussion, as evidenced by pain score of 10 out of 10, guarding sign on the head, restlessness, and irritability
Desired Outcome: The patient will report a pain score of 0 out of 10.
|Nursing Interventions for Concussion||Rationales|
|Assess the patient’s vital signs. Ask the patient to rate the pain from 0 to 10, and describe the pain he/she is experiencing.||To create a baseline set of observations for the patient. The 10-point pain scale is a globally recognized pain rating tool that is both accurate and effective.|
|Administer analgesics/ pain medications as prescribed.||To provide pain relief to the patient.|
|Ask the patient to re-rate his/her acute pain 30 minutes to an hour after administering the analgesic.||To assess the effectiveness of treatment.|
|Provide more analgesics at recommended/prescribed intervals.||To promote pain relief and patient comfort without the risk of overdose.|
|Reposition the patient in his/her comfortable/preferred position. Encourage pursed lip breathing and deep breathing exercises.||To promote optimal patient comfort and reduce anxiety/ restlessness.|
|Refer the patient to a pain specialist as required.||To enable to patient to receive more information and specialized care in pain management if needed.|
Nursing Care Plan for Concussion 2
Nursing Diagnosis: Activity intolerance related to traumatic brain injury secondary to concussion, as evidenced by pain score of 8 out of 10, fatigue, disinterest in ADLs due to headache, verbalization of tiredness and generalized weakness
Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.
|Nursing Interventions for Concussion||Rationales|
|Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.||To create a baseline of activity levels and mental status related to acute pain, fatigue and activity intolerance.|
|Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with 60-90 minutes of undisturbed rest.||To gradually increase the patient’s tolerance to physical activity. To prevent triggering of acute pain by allowing the patient to pace activity versus rest.|
|Administer analgesics as prescribed prior to exercise/ physical activity. Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.||To provide pain relief before an exercise session. To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.|
|Refer the patient to physiotherapy / occupational therapy team as required.||To provide a more specialized care for the patient in terms of helping him/ her build confidence in increasing daily physical activity after the brain trauma.|
Nursing Care Plan for Concussion 3
Nursing Diagnosis: Risk for Decreased Intracranial Adaptive Capacity related to injury with cerebral edema secondary to concussion as evidenced by increased intracranial pressure of more than 10 mmHg
Desired Outcome: The patient will be able to maintain optimal tissue perfusion as evidenced by stable intracranial pressure of less than 10 mmHg and no decrease of 2 or more scores in the Glasgow coma scale (GCS score) level of consciousness.
|Nursing Interventions for Concussion||Rationale|
|Assess the patient’s GCS score, including pupil size and reaction.||The Glasgow coma scale is an assessment tool that focuses on three aspects namely: |
a. Eye response;
b. verbal response; and
c. motor response.
GCS scores range from as low as 3 (coma) to as high as 15 (normal).
Assessing the patient using the GCS is an effective tool for determining the neurologic status.
Drops in GCS levels would mean cerebral ischemia and therefore would increase the patient’s intracranial pressure.
|Take note for the occurrence of rhinorrhea, otorrhea, Battle’s sign (bruising at the back of the ear, over the mastoid) and raccoon eyes (bruising around the eye’s orbits).||These clinical manifestations would indicate serious injury to the skull and would mean for immediate surgical and medical intervention.|
|Take note of deviations in the patient’s protective reflexes like coughing, swallowing, and gagging||Loss of the protective reflexes may mean issues in the brain due to cerebral edema and therefore would contribute to patient aspiration.|
|Monitor intracranial pressure (ICP) utilizing a corneal catheter device. Ensure that levels are below 10 mm Hg||Increase in the patient’s ICP (above 10 mmHg) would cause injury to the brain stem through either compression or herniation. Since the respiratory center in the brain is located at the brain stem, any deviations in this part would cause apnea and cardiac arrest to the patient.|
|Maintain the head of the bed elevated to at least 30 degrees, ensuring that the patient’s head is kept in neutral position.||Keeping the patient’s head elevated and maintained in a neutral position will decrease ICP through promotion of venous return.|
|Limit nursing and medical interventions to the patient.||Any stimuli may precipitate a rise in the patient’s ICP.|
|Provide a calm and safe environment. Reorient the patient during episodes of confusion.||Reducing unnecessary stimuli and providing psychological support and assurance to the patient helps in reducing anxiety, therefore may help in normalizing ICP.|
|Avoid activities and/or conditions that may cause elevations in ICP such as: |
Sudden position changes
Uncontrolled pain or fever
|Certain activities (such as coughing) and conditions (such as pain) increase the patient’s cerebrospinal fluid, consequently elevating ICP.|
|Administer medication therapy as indicated and as ordered such as: Steroids|
|Compliance with medication regimen would help in reducing ICP through: |
1. Reduction of swelling (steroids);
2. Lowering of cerebral blood flow by decrease in metabolism as a result of low core temperature (antipyretics);
3. Reduction of fluid in the interstitial spaces, thereby lowering cerebral edema (hyperosmotic agents); and
4. Prevention of seizure that may exacerbate brain metabolic demand and blood flow.
Nursing Care Plan for Concussion 4
Nursing Diagnosis: Risk for Seizures related to intracranial bleeding secondary to concussions as evidenced by decrease in level of consciousness and involuntary hyperactivity or hypoactivity of the muscles of the body.
Desired Outcome: The patient will be free from the occurrence or recurrence of seizures and remain free from injury due to seizure activity.
|Nursing Interventions for Concussion||Rationale|
|Observe the patient for occurrence of seizure. Take note of contributing factors for its occurrence and the characteristics of seizure activity such as: |
Time of occurrence
Body part/s involved
Length of seizure activity
State of the patient after seizure (post-seizure)Patients with non traumatic, non penetrating head injury (around 5%), experience seizures. Accurate and timely documentation of seizure will help in its management.
|Monitor for clinical manifestations of airway compromise (usually by obstruction).||Usually during seizure episodes, the patient cannot consciously control muscle movement. This condition thereby allows for the tongue to relax and fall to the back of the mouth, causing hypoxia by obstruction.|
|Enact seizure precautions such as: |
Maintaining side rails up
Padding up of the bed
Lowering of the height of the bed if possible. Reduction of stimuli (i.e., environmental)
Head protection if possible
Supplemental oxygen and suction set-up available a bedside
|Enabling seizure precautions promotes patient safety. It helps in preventing injury to the patient and healthcare team on episodes of uncontrolled body movement during seizures.|
|During seizure episodes, ensure for patency of the patient’s airway. Avoid putting anything in the patient’s mouth while on active seizure.||Inserting objects to open the airway, during an active seizure episode, will only cause soft tissue injury to the patient’s mouth, even breaking their teeth. Furthermore, it may cause aspiration causing additional harm to the patient|
|After seizure activity, ensure that the patient is turned to his side, provide supplemental oxygen, and suction secretions as needed.||Turning the patient to his side helps in maintaining airway patency. Providing supplemental oxygen ensures adequacy of oxygen levels, preventing hypoxia. Suctioning secretions as necessary ensures patency of airway and prevention of aspiration.|
|Provide anticonvulsants as ordered. Make sure to check regularly for the therapeutic levels with the administered treatment.||Drug therapy of choice differs for every seizure subtype, some of which will require combination therapy and regular dose adjustments. Anticonvulsants acts by raising the seizure threshold through the following avenues: Nerve cell membrane stabilization Reduction of neuron excitability Direct therapeutic effect on the limbic system, hypothalamus and thalamus.|
|Investigate and explore with the patient different stimuli that may cause seizure episodes.||Alcohol, certain drugs, environmental stimuli (e.g., flashing lights, loss of sleep, etc.) increases brain activity and would cause occurrences of seizures.|
|Observe the occurrence of status epilepticus.||Status epilepticus is a medical emergency characterized by tonic-clonic (rhythmical jerking) seizure episodes occurring in rapid succession. If left untreated, it may lead to metabolic acidosis, hyperthermia, hypoglycemia, arrhythmias, hypoxia, increased ICP, airway obstruction, and respiratory arrest. Immediate intervention is warranted to prevent irreversible damage, even death.|
Nursing Care Plan for Concussion 5
Nursing Diagnosis: Disturbed Sensory Perception related to neurologic and biochemical alterations secondary to concussion as evidenced by inappropriate responses and disorientation to person, place and time.
Desired Outcome: The patient will be able to maintain role performance through learning ways to address hallucinations and demonstrate techniques in reorienting to reality.
|Nursing Interventions for Concussion||Rationale|
|Acknowledge to the client that the voices are real. However, explain that you do not hear the voices.||Validating with the patient that the voices are not part of the healthcare provider’s reality will enforce doubt on the validity of the hallucination.|
|Monitor for increasing episodes of fear, anxiety, or agitation.||This may precipitate hallucinations that can be disturbing for the patient, thereby causing harm either directed to self or others.|
|Explore the hallucinations with the patient.||Exploring the hallucinations will give the patient a sense of control, thus will help him in addressing them.|
|Assist the patient in recognizing instances where the hallucinations are most prevalent.||Addressing and identifying these situations will help the nurse and the patient the times where hallucinations induce the most anxiety to the patient.|
|If the hallucinations suggest harm, either directed to self or others, Ensure to activate Safety precautions as necessary by: Notifying other members of the team (doctors, hospital staff, etc.)If in the hospital, initiate suicide or violence precaution protocols Patients with hallucinations often act out the commands for self-harm or violence to others. Early detection and intervention ensures safety and will save lives.|
|Stay with the patient during episodes of hallucinations. Instruct the patient to tell the “voices” to go away in a matter-of-fact approach as needed.||The patient can learn to control and push away hallucinations as they come with repeated instructions. This ensures for the patient to regain a sense of control and reorientation to reality.|
|Provide a calm and safe environment with little stimuli as much as possible.||Minimizing external sources of stressful stimuli decreases anxiety levels that may trigger hallucinations.|
|Intervene by using one-on one sessions, seclusion of the patient or administration of as needed medications as necessary.||Intervening before an impending escalation of anxiety levels ensures controlling the patient’s hallucinations as much as possible.|
|Ensure that conversation topics are basic and based on reality. Discuss and open topics to the patient one at a time.||The patient’s thought processes and perception are compromised. Focusing on simple and reality-based topics help the patient to stay focused.|
|Coordinate with the patient on what activities help in controlling anxiety and distracting from the hallucinations. Practice diversional skills with the patient.||Having the patient take an active role in his care will ensure compliance with his treatment regimen. Practicing diversion techniques assist in relieving stressful experiences of the patient.|
|Let the patient participate in reality-based activities such as writing, drawing simple art, listening to music, etc.||Averting the patient’s focus and energies to acceptable activities may decrease incidences that the patient will act on the hallucinations. It can also assist as a distraction to the voices.|
Other Nursing Diagnosis for Concussion
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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