Question

Randy Adams is a 38-year-old male patient of Dr. Joseph Reynolds who was admitted yesterday morning for 24-hour observation for mild concussion following a motor vehicle accident. Randy lost consciousness during the accident and was very confused when he arrived in the ER after EMS transport. He is an Iraq war veteran and he seemed to think after the accident that this all happened in Iraq. Dr. Reynolds is concerned that Randy has some residual problems from a couple of explosive incidents that occurred while he was in Iraq. The physician is unsure whether Randy's current symptoms are from the car accident or from prior injuries so he has referred him for consultations to both a neurologist and to a behavioral health specialist.

Based on the above please discuss the following.

1. Pathophysiology of concussive injuries and treatment

2. Neurological assessment tools used in your current practice setting (if not presently working, please describe one used during prior employment or schooling)

3. Current best practices associated with post-traumatic stress disorder (PTSD)

4. Nursing interventions you would include in this patient's plan of care

Answer 1

1.Concussion, also known as mild traumatic brain injury (mTBI) is typically defined as a head injury with a temporary loss of brain function.Common causes include motor vehicle collisions, falls, sports injuries, and bicycle accidents. Pathology of a concussion seems to start with the disruption of the cell membrane of nerve cells which in turn leads in a migration of potassium from within the cell into the extracellular space and release of glutamate which potentiates further potassium shift. This resulting in depolarization and suppression of nerve activity. In an effort to restore ion balance, the sodium-potassium ion pumps increase activity, which results in excessive ATP (adenosine triphosphate) consumption and glucose utilization. Lactate accumulates but, paradoxically, cerebral blood flow decreases, which leads to a proposed "energy crisis." After this increase in glucose metabolism, there is a subsequent lower metabolic state which may persist for up to 4 weeks after injury. A completely separate pathway involves a large amount of calcium accumulating in cells, which may impair oxidative metabolism and begin further biochemical pathways that result in cell death.

Signs and symptoms:

• Headache or a feeling of pressure in the head
• Temporary loss of consciousness
• Confusion or feeling as if in a fog
• Amnesia surrounding the traumatic event
• Dizziness or "seeing stars"
• Ringing in the ears
• Nausea
• Vomiting
• Slurred speech
• Delayed response to questions
• Appearing dazed
• Fatigue

You may have some symptoms of concussions immediately. Others may be delayed for hours or days after injury, such as:

• Concentration and memory complaints
• Irritability and other personality changes
• Sensitivity to light and noise
• Sleep disturbances
• Psychological adjustment problems and depression
• Disorders of taste and smell

Short-term effects

Postconcussive syndrome:

• The main symptom of postconcussive syndrome is persistent headache for one to two weeks, lasting up to months after the injury.
• Sometimes people with postconcussive syndrome will have dizziness, difficulty concentrating, difficulty sleeping, or problems doing certain types of activities such as reading.
• Nausea and vomiting may occur.
• Affected individuals may also experience other subtle cognitive or emotional problems.
• Affected individuals can develop at least one symptom of postconcussive syndrome within the first month following injury, and some have at least three symptoms by three months post-injury.
• Postconcussive syndrome is more common after a serious concussion than after a mild one.
• Symptoms usually are relieved with mild pain relievers such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil).
• Postconcussive syndrome usually goes away on its own with time. Some people may have symptoms that do not go away, even after months. In this situation, contact a doctor. Sometimes tests (such as an MRI or cognitive function testing) or consultations with a neurologist can better assess this problem.

Long-term effects

• Concussions are known to be cumulative. That is, each time you have a concussion it is easier to get another concussion in the future.
• Repeated concussions can lead to long-term memory loss, psychiatric disorders, brain damage, and other neurologic problems.
• If a person has had a number of concussions, the doctor likely will advise the person to avoid the activities that may put them at risk for future head injuries and to discontinue contact sports. Professional athletes are particularly prone to the effects of cumulative concussions.

Treatment:

It is according to the severity,in open injury and internal bleeding some times surgical intervention is needed.

Rest and reduced physical activity is main advice

Medications may be prescribed to treat sleep problems and depression.Analgesics such as ibuprofen can be taken for headache, but paracetamol (acetaminophen) is preferred to minimize the risk of intracranial hemorrhage.

2.Neurological assessment:

A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired. This typically includes a physical examination assessing of mental status, cranial nerves, motor and sensory function, pupillary response, reflexes, the cerebellum, and vital signs. in which and a review of the patient's medical history,but not deeper investigation such as neuroimaging (Neuroimaging or brain imaging is the use of various techniques to either directly or indirectly image the structure, function/pharmacology of the nervous system)through Computed axial tomography,Diffuse optical imaging,Event-related optical signal,Magnetic resonance imaging,Functional magnetic resonance imaging,Magnetoencephalography,Positron emission tomography,Single-photon emission computed tomography,Cranial ultrasound.

3.Current best practices associated with post-traumatic stress disorder (PTSD)

Psychotherapy and medications are main treatment for PSTD.

The trauma-focused psychotherapies with the strongest evidence are:

• Prolonged Exposure (PE)
  Teaches you how to gain control by facing your negative feelings. It involves talking about your trauma with a provider and doing some of the things you have avoided since the trauma.
• Cognitive Processing Therapy (CPT)
  Teaches you to reframe negative thoughts about the trauma. It involves talking with your provider about your negative thoughts and doing short writing assignments.
• Eye-Movement Desensitization and Reprocessing (EMDR)
  Helps you process and make sense of your trauma. It involves calling the trauma to mind while paying attention to a back-and-forth movement or sound (like a finger waving side to side, a light, or a tone).

• Brief Eclectic Psychotherapy (BEP)
  A therapy in which you practice relaxation skills, recall details of the traumatic memory, reframe negative thoughts about the trauma, write a letter about the traumatic event, and hold a farewell ritual to leave trauma in the past.
• Narrative Exposure Therapy (NET)
  Developed for people who have experienced trauma from ongoing war, conflict, and organized violence. You talk through stressful life events in order (from birth to the present day) and put them together into a story.
• Written Narrative Exposure
  Involves writing about the trauma during sessions. Your provider gives instructions on the writing assignment, allows you to complete the writing alone, and then returns at the end of the session to briefly discuss any reactions to the writing assignment.
• Specific cognitive behavioral therapies (CBTs) for PTSD
  Include a limited number of psychotherapies shown to work for PTSD where the provider helps you learn how to change unhelpful behaviors or thoughts.

other types of psychotherapy are:

• Stress Inoculation Training (SIT)
  A cognitive-behavioral therapy that teaches skills and techniques to manage stress and reduce anxiety.
• Present-Centered Therapy (PCT)
  Focuses on current life problems that are related to PTSD.
• Interpersonal Psychotherapy (IPT)
  Focuses on the impact of trauma on interpersonal relationships.

Medications are:

There are four antidepressant medications that are recommended for PTSD:

• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Fluoxetine (Prozac)
• Venlafaxine (Effexor).

4.Nursing interventions:

• Assessment of patient by physical examination, assessing of mental status, cranial nerves, motor and sensory function, pupillary response, reflexes, the cerebellum, and vital signs.
• orient patient to time,place and person.
• ensure availability of all basic care
• Most patients with PTSD report sleep disturbances, leaving them tired the next day, a treatment plan should focus on helping the patient regain their restorative sleep.
• Cognitive therapy,Teach patients who suffer from PTSD that they are having a natural response to unnatural events. This will help prevent patients from stigmatizing themselves because they are having difficulty coping with their emotions.