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Traumatic Brain Injury Nursing Guide

TBI General Overview 

Traumatic brain injury (TBI) occurs when an external force damages the brain, leading to temporary or permanent neurological dysfunction. TBI can range from mild (concussion) to severe, potentially resulting in long-term disability or death.  

Nurses help with the acute management and rehabilitation of TBI patients, including monitoring neurological status, preventing secondary injuries, and educating patients and caregivers about recovery and long-term care. 

TBI etiology and epidemiology 

Etiology: 

TBI can result from any trauma that disrupts brain function. Common causes include: 

  • Falls: The leading cause of TBI, particularly among children and older adults. 
  • Motor vehicle accidents: Another major cause, especially in young adults. 
  • Sports injuries: Contact sports, such as football and boxing, carry a high risk for TBI. 
  • Assaults: Physical violence, including gunshot wounds and blunt trauma, can cause significant brain injuries. 
  • Blast injuries: Common in military personnel, often leading to complex, multi-system trauma. 

Types of TBI: 

  • Mild TBI (concussion): Temporary neurological dysfunction, often with no visible brain damage on imaging. 
  • Moderate TBI: Loss of consciousness lasting from minutes to hours, with possible lasting cognitive and physical effects. 
  • Severe TBI: Extended loss of consciousness or coma, often with significant brain damage, requiring long-term care. 

Epidemiology: 

  • TBI affects approximately 69 million people globally each year. 
  • It is a leading cause of death and disability in young adults, especially men. 
  • Older adults (65+) are also at high risk, particularly due to falls. 

TBI ICD-10 code 

The ICD-10 codes for traumatic brain injury are: 

  • S06.9X9 — Unspecified intracranial injury with loss of consciousness of unspecified duration  
  • S06.0X9 — Concussion with loss of consciousness of unspecified duration  

TBI diagnosis 

Diagnosis of TBI begins with a thorough history of the injury and clinical assessment, followed by diagnostic imaging. 

Clinical assessment: 

  • Glasgow Coma Scale (GCS): Used to assess the level of consciousness in TBI patients. Scores range from 3 (deep coma) to 15 (normal consciousness). 
    • Mild TBI: GCS 13–15 
    • Moderate TBI: GCS 9–12 
    • Severe TBI: GCS ≤8 
  • Neurological examination: Evaluation of mental status, pupil size and reactivity, cranial nerves, motor function, and sensory function. 

Diagnostic tests: 

  • CT scan: The gold standard for identifying acute brain injuries such as hemorrhage, skull fractures, and cerebral edemaswelling. 
  • MRI: Used to detect more subtle injuries, such as diffuse axonal injury or small hemorrhages, often seen in mild to moderate TBI. 
  • Blood tests: Biomarkers like S100B and glial fibrillary acidic protein (GFAP) are being explored for TBI detection. 

TBI management 

The management of TBI focuses on preventing secondary brain injury, managing symptoms, and promoting long-term recovery. 

Acute management: 

  • Airway, breathing, circulation (ABCs): Ensure airway patency, adequate oxygenation, and blood pressure control. 
  • Intracranial pressure (ICP) monitoring: In moderate to severe cases, monitor ICP to prevent brain herniation and further damage. 
  • Surgery: Hematomas or significant brain swelling may require neurosurgical intervention (e.g., craniotomy) to relieve pressure. 
  • Sedation and pain control: Proper pain management and sedation help reduce metabolic demands on the injured brain. 

Long-term management: 

  • Rehabilitation: Physical, occupational, and speech therapy play a key role in recovering function. 
  • Cognitive therapy: Addresses memory, attention, and problem-solving deficits. 
  • Medications: Antiepileptic drugs to prevent post-traumatic seizures, as well as medications for mood disorders or spasticity. 

TBI nursing care plan 

Nursing considerations 

Nurses are critical in managing patients with TBI, providing continuous neurological assessments, preventing complications, and educating patients and families. Collaboration with multidisciplinary teams is key in both acute care and rehabilitation settings. 

Assessment 

  • Neurological status: Regularly monitor (using the GCS) assessing for any changes in consciousness, pupil response, and motor function. 
  • Vital signs: Continuously monitor heart rate, oxygen saturation, and blood pressure to detect signs of increased intracranial pressure (Cushing’s triad: bradycardia, hypertension, irregular breathing). 
  • Cognitive and behavioral status: Assess memory, orientation, mood, and agitation. 
  • Pain and sedation levels: Monitor for pain and ensure adequate sedation when appropriate to reduce intracranial pressure. 

Nursing diagnosis/risk for 

  • Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure as evidenced by altered level of consciousness and changes in pupil response. 
  • Risk for injury related to impaired motor function and cognitive deficits. 
  • Impaired memory related to brain injury as evidenced by difficulty recalling recent events. 
  • Risk for infection related to invasive monitoring (e.g., ICP monitors) or surgical interventions (e.g., craniotomy). 

TBI interventions 

  • Monitor intracranial pressure (ICP). Use ICP monitoring devices if indicated and manage ICP elevation through positioning (head of bed at 30 degrees), minimizing stimulation, and administering medications such as mannitol or hypertonic saline. 
  • Frequent neurological checks. Assess GCS, pupillary response, and motor function frequently in patients with a significant TBI. 
  • Administer medications. Administer osmotic diuretics (e.g., mannitol), sedatives, and antiepileptic drugs as prescribed. 
  • Ensure proper oxygenation. Maintain adequate oxygen levels to prevent hypoxia and secondary brain injury. 
  • Educate families. Provide information about the patient’s condition, potential long-term effects, and the recovery process. 

Expected outcomes 

  • The patient’s intracranial pressure remains within normal limits (5-15 mmHg). 
  • The patient shows improvement or stabilization in neurological function as evidenced by GCS and physical exams. 
  • The patient and family demonstrate understanding of the injury, treatment, and long-term rehabilitation needs. 
  • The patient avoids secondary complications during the acute recovery period. 

Individual/caregiver education 

  • Signs of complications: Teach patients and caregivers how to recognize signs of increased intracranial pressure, such as severe headaches, vomiting, or altered consciousness, and the importance of seeking immediate medical attention. 
  • Rehabilitation: Emphasize the importance of continuing physical, occupational, and speech therapy to regain lost functions. 
  • Cognitive recovery: Explain that cognitive improvements can take time and may require ongoing therapy and support. 

FAQs

Traumatic Brain Injuries: An Overview

The goal of this course is to provide continuing education to nursing professionals in the acute care setting about traumatic brain injuries (TBIs).

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Additional Information

Course Contributor

Ann M. Dietrich, MD, FAAP, FACEP, Professor of Pediatrics and Emergency Medicine for the University of South Carolina School of Medicine Greenville, has over 30 years of experience in pediatric emergency medicine. Throughout her career, Dietrich has helped educate medical students, residents, fellows, and junior attendings, including as an educator at Ohio State University and the American College of Emergency Physicians. She also collaborated on several research projects, including one on concussions and one on improving mental healthcare for children. Dietrich helped develop guidelines on the impact of concussions on children and worked with trauma surgeons to enhance care for pediatric trauma patients.

Resources 

References 

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