Traumatic Brain Injuries: Classification, Assessment, and Care

Serious patient in hospital gown looking at x-ray image of her traumatic brain injury

A head-on collision at the 50-yard line. An unexpected fall. An exploding grenade.

These all-too-real situations could result in traumatic brain injuries, or TBIs. According to data from the Centers for Disease Control, between 3.2 million and 5.3 million Americans are living with a TBI-related disability that interferes with their daily life.

Nurses, in particular, are in a unique position when it comes to TBI care. Not only are they tasked with providing early assessment and interventions (and preventing secondary injury); they’re also responsible for preparing patients and families for the transition from acute care to outpatient therapies.

What is a traumatic brain injury (TBI)?

In an article from the Archives of Physical Medicine and Rehabilitation, researchers Menon, Schwab, Wright, and Maas define a traumatic brain injury (TBI) as “an alteration in brain function or other evidence of brain pathology, caused by an external force,” like injuries sustained in a car crash, fall, or sporting event. Other common causes of traumatic brain injuries include physical abuse or use of firearms.

Given its nonreversible and chronic health effects, TBIs are increasingly recognized as a disease and often accompany other forms of trauma—a condition known as polytrauma.

On average, males are more likely to experience TBIs resulting from sports injuries, traffic accidents, intentional self-harm, and assault, whereas females tend to have higher rates of injury from falls. Sadly, TBIs in children are often associated with abuse.

To learn more about traumatic brain injuries and nursing, enroll in the following CE courses: Traumatic Brain Injury, 3rd Edition and Traumatic Brain Injury: Occupational Therapy Interventions.

Classifying traumatic brain injuries

Effective care for patients who have undergone TBIs starts with the critical question: How did this injury happen? Over the years, experts have proposed several classification systems to help tell the proper story behind a TBI.

By scale

First developed in 1973, the Glasgow Coma Scale (GCS) measures a patient’s motor, verbal, and eye-opening responses and quantifies the results, placing them on a scale from mild to severe injury.

By cause

Traumatic brain injuries can also be classified according to the cause of damage:

  • Blunt trauma: An external force has impact with the head, causing injury to the internal structures of the skull or brain tissue. A boxer punched in the temple might experience a blunt trauma TBI as the external blow’s force bounces her brain against the inside of her skull.
  • Blast trauma: The shock wave of an explosive device can direct objects into the cranium and may also affect the ear canals. Military personnel in proximity to a bomb or other concussive weapon may experience a TBI from blast trauma.
  • Penetrating trauma: An object penetrates the brain tissue and typically must be removed. Patients with penetrating injuries are more likely to experience infections, cerebrospinal fluid (CSF) leaks, aneurysms in distal blood vessels, or epilepsy.

A one-two hit

TBIs are complex and multifaceted injuries, with damage extending from the moment of injury well into the future.

In a primary brain injury, the effects occur rapidly and are associated with bleeding and tearing forces, often caused by the rapid acceleration and deceleration of the head. Rotational forces, usually caused by boxing or lateral force injuries, may cause the brain to shift side-to-side in the skull. This causes injury to lower structures, like the brainstem, lateral brain tissue, and blood vessels.

In a secondary brain injury, consequences and complications are revealed over the days, weeks, or months after the event. However, these secondary injuries are not inevitable. Preventing these kinds of injuries is the highest priority for healthcare providers during the acute phase of the patient’s recovery.

What to look for

Symptoms of TBI vary and are affected by both the part of the brain damaged and how it was damaged. A nurse’s sharp eye and careful monitoring is critical at this stage and in the transmission of patient information—there may be many instances (whether caused by post-traumatic amnesia, intoxication, seizure, PTSD, or similar conditions) when a patient may not remember the details of what caused their TBI.

  • Initial physical symptoms may include brief or extensive loss of consciousness, seizures, pupil changes, clear fluids draining from the nose or ears (otorrhea or rhinorrhea), fatigue, dizziness, nausea, blurred vision, or tinnitus.
  • Cognitive and emotional processes may also be affected. Patient symptoms may include: confusion, difficulty concentrating, increased slowness in processing information, agitation, sadness, or uncontrollable anger.

Immediate, short-term, and long-term care

After the initial injury, a patient’s care proceeds in stages.

First comes the immediate assessment, usually performed by emergency personnel at the scene, which focuses on the ABCs of trauma care: airway management, breathing stabilization, and circulation stabilization. Only when the patient is stable will the emergency personnel investigate the scene for the cause of injury, amount of blood lost, etc., to inform healthcare providers.

Once at the hospital, healthcare providers must determine the severity of the TBI and whether acute interventions are needed for intracranial bleeding or intracranial pressure (ICP) management.

Nursing therapies after admission are designed to prevent secondary brain injury and complications, with emphasis on behavioral management, positioning, early mobility, environmental and fever management, and regulation of ICP.

In intensive and acute care settings, nurses may begin range-of-motion exercises to the patient’s extremities, employ positioning to prevent pressure injuries, promote deep breathing and ventilation, and initiate family or caregiver training.

Maximal independence

A traumatic brain injury can (and often does) have life-long consequences. The complications of a TBI vary widely and can include seizures, chronic headaches, depression, stroke, Parkinson’s disease, and pain. Other long-term complications—like Alzheimer’s disease, mood and behavior disorders, and post-traumatic dementia—are also possible.

A healthcare provider’s goal isn’t to improve the patient’s abilities beyond his or her preinjury level; it’s to return the patient to his or her environment in the best possible physical condition with the best possible neurologic outcome: maximal independence.

This article is based on the 3-hour Nursing CE course, “Traumatic Brain Injury, 3rd Edition,” written by Esther Bay, PhD, ACNS, BSN.

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