In rare cases, a secondary injury caused by cerebral hypoxia and ischemia can lead to cerebral edema and increased intracranial pressure (ICP). Some patients develop a postconcussion syndrome (postinjury sequelae after a mild head injury). Symptoms may be experienced for several weeks and, in unusual circumstances, may last up to 1 year. In rare situations, patients who experience multiple concussions may suffer long-term brain damage. Complications of cerebral concussion include seizures or persistent vomiting. In rare instances, a concussion may lead to intracranial hemorrhage (subdural, parenchymal, or epidural).
The most widely accepted theory for concussion is that acceleration-deceleration forces cause the injury. Sudden and rapid acceleration of the head from a position of rest makes the head move in several directions. The brain, protected by cerebrospinal fluid (CSF) and cushioned by various brain attachments, moves more slowly than the skull. The lag between skull movement and brain movement causes stretching of veins connecting the subdural space (the space beneath the dura mater of the brain) to the surface of the brain, resulting in minor disruptions of the brain structures. Common causes of concussion are a fall, a motor vehicle crash, a sports-related injury, and a punch to the head.
Nursing care plan physical assessment and examination
If the patient cannot report a history, speak to the life squad, a witness, or a significant other to obtain a history. Determine if the patient became unconscious immediately and for how long—a few seconds, minutes, or an hour—at the time of the trauma. Find out if the patient experienced momentary loss of reflexes, arrest of respirations, and possible retrograde or antegrade amnesia. Elicit a history of headache, drowsiness, confusion, dizziness, irritability, giddiness, visual disturbances (seeing stars), and gait disturbances. Mild cerebral concussions can cause headaches, dizziness, memory loss, momentary confusion, residual memory impairment, and retrograde amnesia; there is no loss of consciousness. Classic cerebral concussions cause a loss of consciousness lasting less than 24 hours; the patient usually experiences confusion, disorientation, and amnesia upon regaining consciousness. A postconcussive syndrome that may occur weeks and even months after injury may lead to headache, fatigue, inattention, dizziness, vertigo, and memory deficits.
First evaluate the patient’s airway, breathing, and circulation (ABCs). After stabilizing the patient’s ABCs, perform a neurological assessment, paying special attention to early signs of ICP: decreased level of consciousness, decreased strength and motion of extremities, reduced visual acuity, headache, and pupillary changes.
Check carefully for scalp lacerations. Check the patient’s nose (rhinorrhea) and ears (otorrhea) for CSF leak, which is a sign of a basilar skull fracture (a linear fracture at the base of the brain). Be sure to evaluate the patient’s pupillary light reflexes. An altered reflex may result from increasing cerebral edema, which may indicate a life-threatening increase in ICP. Pupil size is normally 1.5 to 6.0 mm. Several signs to look for include ipsilateral miosis (Horner’s syndrome), in which one pupil is smaller than the other with a drooping eyelid; bilateral miosis, in which both pupils are pinpoint in size; ipsilateral mydriasis (Hutchinson’s pupil), in which one of the pupils is much larger than the other and is unreactive to light; bilateral midposition, in which both pupils are 4 to 5 mm and remain dilated and nonreactive to light; bilateral mydriasis, in which both pupils are larger than 6 mm and are nonreactive to light. Check the patient’s vital signs, level of consciousness, and pupil size every 15 minutes for 4 hours. If the patient’s condition worsens, he or she should be admitted for hospitalization. Continue neurological assessment throughout the patient’s hospital stay to detect subtle signs of deterioration. Observe the patient to ensure that no other focal lesion, such as a subdural hematoma, has been overlooked.
The patient with a concussion has an unexpected, sudden illness. Assess the patient’s ability to cope with the potential loss of memory and temporary neurological dysfunction. In addition, assess the patient’s degree of anxiety about the illness and potential complications. Determine the significant other’s response to the injury. Expect parents of children who are injured to be anxious, fearful, and sometimes guilt-ridden.
Nursing care plan primary nursing diagnosis: Altered thought process related to cerebral tissue injury and swelling.
Nursing care plan intervention and treatment
Patients with mild head injury often are examined in the emergency department and discharged home. Generally, a family member is instructed to evaluate the patient routinely and to bring the patient back to the hospital if any further neurological symptoms appear. Parents are often told to wake a child every hour for 24 hours to make sure that the patient does not have worsening neurological signs and symptoms. Treatment generally consists of bedrest with the head of the bed elevated at least 30 degrees, observation, and pain relief.
Generally, patients are not admitted to the hospital for a cerebral concussion. Make sure that before the patient goes home from the emergency department, the significant others are aware of all medications and possible complications that can occur after a minor head injury. Teach the patient and significant other(s) to recognize signs and symptoms of complications, including increased drowsiness, headache, irritability, or visual disturbances that indicate the need for reevaluation at the hospital. Teach the patient that occasional vomiting after sustaining a cerebral concussion is normal. The patient should not go home alone, because ensuing complications are apt to include decreased awareness and confusion. If the patient is admitted to the hospital, institute seizure precautions if necessary. Ensure that the patient rests by creating a calm, peaceful atmosphere and a quiet environment. Limit visitors to the immediate family or partner, and encourage the patient to rest for 24 hours without television or loud music.
Nursing care plan discharge and home health care guidelines
Explain that a responsible caregiver should continue to observe the patient at home for developing complications. Instruct the caregiver to awaken the patient every 1 to 2 hours throughout the night to assess her or his condition. Explain that the caregiver should check the patient’s orientation to place and person by asking “Where are you? Who are you? Who am I?” Teach the patient and caregiver to return to the hospital if the patient experiences persistent or worsening headache, blurred vision, personality changes, abnormal eye movements, a staggering gait, twitching, or constant vomiting. Teach the patient to recognize the symptoms of postconcussion syndrome, which may last for several weeks and include headache, dizziness, vertigo, anxiety, and fatigue.
When the patient is a child, teach the parent(s) that it is a common pattern for children to experience lethargy and somnolence a few hours after a concussion, even if they have manifested no ill effects at the time of the trauma. Such responses do not necessarily indicate serious injury. If the symptoms persist or worsen, explain that the parent(s) should notify the healthcare provider immediately.