Case Study- Cerebral Contusion

LYCEUM NORTHWESTERN UNIVERSITY COLLEGE OF NURSING

A CASE STUDY ON CEREBRAL CONTUSION R/O IC BLEEDING

Surgical Ward- Group 4 Job David Parado Dianne Perez Catherine Pimentel Juliezen Poblacio Marifel Quimson Rizza Rocacorba Jan Deo Santos Kareen Pearl Solis Kevin Jake Tagaban Juliet Torio Allen May Valdez Zandro Villanueva Victor Francis Vinluan Ms. Desiree Bauzon Clinical Instructor

TABLE OF CONTENTS

Page Number I.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . 3

II.

Objectives A. General Objectives . . . . . . . . . . . . . . . . . . 4 B. Specific Objectives . . . . . . . . . . . . . . . . . . 4

III.

Anatomy and Physiology . . . . . . . . . . . . . . . 5

IV.

Patient’s Profile . . . . . . . . . . . . . . . . . . . . . . 6

V.

History . . . . . . . . . . . . . . . . . . . . . . . . . . .

VI.

Course of Confinement . . . . . . . . . . . . . . . . . 8

VII.

Laboratory Results . . . . . . . . . . . . . . . . . . . . 9

VIII.

Comprehensive Drug Study . . . . . . . . . . . . . . 12

IX.

Assessment . . . . . . . . . . . . . . . . . . . . . . . . . 14

X.

Pathophysiology . . . . . . . . . . . . . . . . . . . . .

XI.

Nursing Care Plan . . . . . . . . . . . . . . . . . . .

XII.

Medical Management . . . . . . . . . . . . . . . . .

XIII.

Nursing Management . . . . . . . . . . . . . . . . .

XIV.

Discharge Planning . . . . . . . . . . . . . . . . .

I.

Introduction

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17 19 22 22 23

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Cerebral Contusions are scattered areas of bleeding on the surface of the brain, most commonly along the under surface and poles of the frontal and temporal lobes. They occur when the brain strikes a ridge on the skull or a fold in the dura mater, the brain’s tough outer covering. A Cerebral Contusion can occur directly beneath the site of impact when the brain rebounds against the skull from the force of a blow or when the force of a blow drives the brain against the opposite side of the skull or when the head is hurled forward and stopped abruptly. The brain continues moving and slaps against the skull and then rebounds which may result to bruises. These bruises may occur without other types of bleeding or they may occur with acute subdural or epidural hematomas. Most patients with Cerebral contusions have had a serious head injury. The signs and symptoms of a contusion include sever headache, dizziness, increased of one pupil or sudden weakness in an arm or leg. The person may seem restless, agitated or irritable. Often, the person has memory loss or seems forgetful. These symptoms may last for several hours to weeks, depending on the seriousness of the injury. Cerebral edema, or swelling typically develops around the contusion within 48 to 72 hours after injury. Any period of loss of consciousness or amnesia of the head injury should be evaluated by a health-care professional. As the brain tissue swells, the person may feel increasingly drowsy or confused. If the person is difficult to awaken, medical attention should be sought immediately. This could be a sign of more severe injury. As with other types of Intracranial Pressure hemorrhages, cerebral contusions are most rapidly and accurately diagnosed using Computed Tomography (CT) brain Scans. If pressure on the brain increases significantly or if the hemorrhages from a sizeable blood clot in the brain (an intracerebral hematoma), a craniotomy to open a section of the skull may be required to surgically remove the cerebral contusion. Recovery after the brain injury varies widely. Treatment outcomes vary according to size and location of the Cerebral contusion. Other predictors include age, the initial Glasgow coma score and the presence of other types of Brain injuries.

II. Objectives General: To gain knowledge and attitude in the care of a patient with

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cerebral contusion

Specific: To gain more knowledge To review the anatomy and physiology of the brain and circulatory systems To provide an individualized plan of care for the patient To understand the physiologic processes associated with the condition

III. Anatomy and Physiology The Brain The brain, when fully developed, is a large organ which fills the cranial cavity. Early in its development the brain becomes divided into three parts known as the forebrain, the midbrain and the hindbrain. The forebrain is the largest part and is called the cerebrum; it is divided into the right and left hemispheres by a deep longitudinal fissure. The separation is complete t the front and back but in the center, the hemispheres are joined by a broad band of nerve fibres called the corpus callosum. The outer layer of the cerebrum is called the cerebral cortex and is composed of grey matter (cell bodies) thrown into numerous folds or convolutions called gyri, separated by fissures called sulci. This enables the surface area of the brain, and therefore the number of cell bodies, to be increased greatly. The general pattern of the gyri and sulci is the same in all humans; three main sulci divide each hemisphere into four lobes, each named after the skull bone under which it lies. The central sulcus runs downwards and forwards from the top of the hemisphere to a point just above the lateral sulcus; the lateral sulcus runs backwards from the lower part of the front of the brain and the parieto-occipital sulcus runs downwards and forwards for a short way from the upper posterior part of the hemisphere. The lobes of the hemispheres are the frontal lobe, lying in front of the central sulcus and above the lateral sulcus; the parietal lobe lying between the central sulcus and the parieto-occipital sulcus and above the line of the lateral sulcus; the occipital lobe, which forms the back of the hemisphere and the temporal lobe lying below the lateral sulcus and extending back to the occipital lobe. The area lying immediately in front of the central sulcus between is known as the pre-central gyrus and is the motor area from which arise many of the motor fibres of the central nervous system. Immediately behind the central sulcus lies the sensory area, called the post-central gyrus, in the cells of which several kinds of sensation are interpreted. Longitudinal section of a hemisphere shows grey matter (cell bodies) on the outside and white matter (nerve fibres) forming the interior. The nerve fibres connect one part of the brain with the other parts and with the spinal cord, but within the white matter groups of nerve cells can be seen forming areas of grey matter. These areas of grey matter are called cerebral nuclei.

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The main function of these areas is coordination of movement and posture of the body: disorders affecting these areas cause jerky movements and unsteadiness. The cavities within the brain are called ventricles. There are two lateral ventricles, a central third ventricle and a fourth ventricle between the cerebellum and the pons. All are filled with cerebrospinal fluid. The midbrain lies between the forebrain and the hindbrain. It is about 2 cm in length and consists of two stalk-like bands of white matter called the cerebral peduncles, which convey impulses passing to and from the brain and spinal cord, and four small prominences called the quadrigeminal bodies, which are concerned with sight and hearing reflexes. The pineal body lies between the two upper quadrigeminal bodies. The hindbrain has three parts:

1. The pons, which lies between the midbrain above and the medulla oblongata below. It contains fibres which carry impulses upwards and downwards and some which communicate with the cerebellum.

2. The medulla oblongata lies between the pons above and the spinal cord below. It contains the cardiac and respiratory centres which are also known as the vital centres and which control the heart and respiration.

3. The cerebellum projects backwards beneath the occipital lobes of the

cerebrum. It is connected to the midbrain, the pons and the medulla oblongata by three bands of fibres called the superior, middle and inferior cerebellar peduncles respectively. The cerebellum is responsible for the coordination of muscular activity, control of muscle tone and maintenance of posture. It is continuously receiving sensory impulses concerning the degree of stretch in muscles, the position of joints and information from the cerebral cortex. It sends information to the thalamus and the cerebral cortex. The midbrain, the pons and the medulla have many functions in common and together re often known as the brain stem. This area also contains the nuclei from which originate the cranial nerves.

IV. Biographical Data Name: C. D Age: 54 years old Sex: Female

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Civil Status: Single Religion: Roman Catholic Address: Carael, Dagupan City, Pangasinan Chief Complaint: Multiple Bruises and Abrasions Admitting Diagnosis: Cerebral Contusion r/o IC Bleeding Date Admitted: October 24, 2009 Time: 09:20 AM Admitting Physician: Dr. Maria Camilla Rosario

V. A.

History History of Present Illness

This is the case of ., a female client from Carael, Dagupan City who was admitted at Region 1 Medical Center last October 24, 2009 around 9 o’clock in the morning with chief complain of multiple injury with diagnosis of Cerebral Contusion r/t Intracranial bleeding. The present condition started prior to admission when she was accidentally hit by a car. She was rushed to the institution for proper medical treatment and was assessed to have sustained a cerebral wound, abrasion and hematoma on the right eye. There were episodes of vomiting of custard-like substance, a short state of loss of consciousness and other sensory and neural deficits like ptosis, hemiparesis and slurred speech which did not last for long. During Mrs. F. S’s stay in the institution her blood pressure was constantly high, with an on and of fever, thready pulse and a respiration rate within normal range. She also has abrasions and wounds in different parts of the body specifically on arms and legs which were cleaned and dressed. Further more, the patient had a wound on the left side of her forehead, it was cleaned, sutured and dressed upon admission. The patient was given the following meds: Dexamethasone Captopril Chloramphenicol Penicillin G Sodium Work- ups were done to detect other abnormalities that the client might have sustained from the accident. A CT- Scan was ordered, along

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with a CXR, a CBC typing, Urinalysis and a Fecalysis by her attending physician. B.

Past Medical History

The patient’s present history of illness is her first admission to the institution but she have had consultations before for her diabetes wherein he was prescribed of a maintenance medication which was “Euglocon”. The patient does not regularly take her medication because she claims that she does not need it for she doesn’t feel anything wrong with herself. She also has a history of hypertension with BP ranging from 140/90- 160/100 which she tries to treat with herbal meds and concucsions such as using garlic. During the clients childhood years she suffered from asthma which she still has until the present. She recalls that she have had only few childhood illnesses like mumps, flu, colds, cough and chickenpox. The client cannot recall if she had completed her immunizations and aside from her diabetes and hypertension the client have no other diseases an according to her, she can still perform household chores just as long as she doesn’t feel any symptoms of elevated BP and she doesn’t feel fatigue. C.

Socio- cultural

The client is living with her oldest daughter, together with her son-in-law and three grandchildren in a semi- bungalow house. She takes care of her grandchildren and does all of the household chores including laundry and the like while her daughter and son-in-law manages a small buy and sell store. She depends on her daughter in times of financial needs and during her stay in the hospital, her other four children helps in paying for her hospital charges. The patient is a Dagupeña, she was born and raised in Dagupan. She is an active member of Jehovah’s Witness and believes that blood transfusion is a mortal sin because blood is a sacred and it should not be drank, eaten nor transfused or used for any other purposes. The patient used to smoked tobacco but stopped after she have joined Jehovah’s Witness. D.

Heredofamilial History

The patient had a family history of hypertension. The patient’s father passed away more than 20 years ago due to a stroke as a complication of hypertension. The patient also had history of

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heredofamilial disease like bronchial asthma and DM which she acquired or inherited from her mother’s side. The patient’s mother had passed away after her husband’s death due to old age. The patient has 5 children aged 52, 45, 42, 39, 38 respectively. All of them are apparently well which with no illnesses/diseases at the time of interview.

VI. Course of Confinement This case of Patient X, 54 years old, female who was admitted on October 24, 2009 at Region 1 Medical Center with the chief complain of multiple bruises and abrasions of arms and, forearms and forehead. The following diagnostic test were done: Hematology test which revealed elevated and decreased results---- White blood cell which revealed elevated results, Neutrophils which revealed elevated results, Lymhocytes which revealed decreased results, Red blood cells which revealed decreased results, Hemoglobin which revealed decreased results and Hematocrit which revealed decreased result, T Cage which revealed no definite fracture, dislocation, lytic nor blastic lesion is demonstrated and bones and joints are intact, CT Scan which revealed on the First CT Scan--- there is a 27 x 23 x 19mm (CC x AP x Tr), acute hemorrhage extravasations in the Right basal ganglia with minimal surrounding edema. The ensuing mass effect compresses the Right lateral ventricle. In addition, there is a subarachnoid hemorrhagic accumulation predominantly in the left temporal lobe along the Slyvian Cisterm and adjacent sulci There is no localized tumor or dystrophic calcification. The rest of the ventricles are enlarged, the midline structure are undisplaced. The corpus callosum, centrum semi ovale, thalani, brainstem, cerebellum, cranial base and calvarium show no findings of note. The Second CT scan revealed there is no reduction in the attention with unchanged size of the right Basal Ganglionichemorrhage. The Subarachnoid hemorrhage in the Left Slyvian cistern has diminished in size and density. The rest of the findings have remained the same. The following medications were ordered: Pen G Na 5M “u” IV q 8 hours, Chlaramphenicol 500 mg IV q 8 hours, Dexamethasone 8 mg IV q 8 hours, Ranitidine iv Q 8 HOURS, Captopril 25 mg SL now then q 30 minutes 3 doses. The patient received D5LR 15-16 gtts/min and replaced with the same Intravenous fluid. The following Nursing diagnosis were identified: Acute pain r/t trauma, ineffective cerebral tissue perfusion r/t hematoma on frontal lobe

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The following Nursing interventions were done: Continuous monitoring of Vital signs especially the Blood pressure, meticulous skin care, health teaching (advising the patient to eat foods rich in protein and Vitamin C), Glasgow coma assessment is done to determine the consciousness of the patient and encouraged verbalization of her feelings and concerns.

VIII. Laboratory Results A. CBC Typing - Identifies the total number of blood cells (leukocytes, erythrocytes and platelets) as well as the hemoglobin, hematocrit and RBC indices. Because cellular morphology is particularly important in most Hematologic disorders. In this test, a drop of blood is spread on the glass slide, stained and examined under a microscope. The shape and size of the erythrocytes and platelets, as well as the actual appearance of Leukocytes, provide useful information in identifying hemotologic conditions. Result

White Blood Cell

Neutrophils

12. 59

85.0

Normal Value

5.00-10.00

50.00-70.00

Significance High. Acute Infection *The WBC is an indicator of Immune function of the body. Elevation is seen during the ongoing infection of inflammation. High. Stress and Acute Infection * Neutrophils are recruited to the site of injury within the minutes following trauma and are the hallmark at acute inflammation Low. Chronic Infection; Viral Infection * A lymphocyte count 9

Lymphocytes

9.3

Red blood cell

4. 04

Hemoglobin

118

20.00-44.00

4.20-5.40

is usually a pary of a peripheral complete blood cell count and is expressed as percentage of lymphocytes to total white blood cells counted. Low. Anemia * Erythrocytes also play a part in the body’s immune system: when lysed by pathogens such as bacteria, their hemoglobin release free radicals that break down the pathogen’s cell wall and membrane, killing it. Low. Chronic Blood loss

125-160 * This is used to evaluate the hemoglobin content of erythrocytes. Low. Hemorhage; hemorrhage

Hematocrit

35.6

37.0-47.0 *This test is useful in the diagnosis of anemia.

B. CT Scan -provides cross-sectional images of soft tissue and visualizes the area of volume changes to an extremity and the compartment where changes takes place. CT Scan has a high degree of sensitivity for detecting lesions. Results: First CT Scan: There is a 27 x 23 x 19mm (CC x AP x Tr), acute hemorrhage extravasations in the Right basal ganglia with minimal surrounding edema. The ensuing mass effect compresses the Right

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lateral ventricle. In addition, there is a subarachnoid hemorrhagic accumulation predominantly in the left temporal lobe along the Slyvian Cisterm and adjacent sulci There is no localized tumor or dystrophic calcification. The rest of the ventricles are enlarged, the midline structure are undisplaced. The corpus callosum, centrum semi ovale, thalani, brainstem, cerebellum, cranial base and calvarium show no findings of note. Second CT: scan revealed there is no reduction in the attention with unchanged size of the right Basal Ganglionic-hemorrhage. The Subarachnoid hemorrhage in the Left Slyvian cistern has diminished in size and density. The rest of the findings have remained the same. Impression: Acute Right basal Ganglionic hemorrhage with minimal mass effect as described. Acute subarachnoid hemorrhage predominantly in the Left temporal region, as described. C. T Cage - which revealed no definite fracture, dislocation, lytic nor blastic lesion is demonstrated and bones and joints are intact.

VIII. Comprehensive Drug Study A. DEXAMETHASONE Brand name: Decadron, Deronil, Dexone, Hexadrol Drug Classification: Steroid Mechanism of action: Decreases the inflammation, mainly by stabilizing leukocyte lysosomal membranes. Also suppresses the immune response, stimulates bone marrow and influences protein, fat and carbohydrate metabolism. Indications • Cerebral Edema • Inflammatory Conditions • Shock

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Adverse Reaction CNS: Psychotic Behavior, Euphoria CV: Congestive hart failure, Hypertension, Edema Skin: Delayed wound healing, various skin eruptions Other: Muscle weakness, susceptibility to infections. Nursing Considerations • Gradually reduce drug dosage after long term therapy. Tell patient not to discontinue drug abruptly or without doctor’s consent. • Monitor patient’s weight, blood pressure and serum electrolytes. • Watch for depression or psychotic episodes, especially in highdose therapy. • Inspect patient’s skin for petechiae • Not used for alternate day therapy B. CAPTOPRIL Brand Name: Capoten Drug Classification: ACE inhibitors Mechanism of Action: By inhibiting Angiotensin- converting enzyme, prevents pulmonary conversion of Angiotensin I to Angiotensin II Indications • Hypertension • Congestive heart Failure Adverse Reactions Blood: Leukopenia, Agranulocytosis CNS: Fainting CV: Tachycardia, Congestive heart failure Skin: Pruritis Other: Angioedema on the face and Extremities Nursing Consideration • Monitor Patient’s Blood Pressure and Pulse rate frequently • Perform WBC and differential counts before starting treatment every 2weeks for the first 3 months of therapy and periodically thereafter • Advice patient to report any sign of infection • Should be taken 1 hour before meal since food in the G.I tract may reduce absorption. C. CHLORAMPHENICOL Brand name: Chloromycetin, Mychel Drug Classification: Antibiotic

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Mechanism of Action: Inhibits bacterial protein synthesis by binding to the 50S subunit of the ribosome. Indications • Severe infections caused by sensitive salmonella species • Various sensitive gram- negative organisms causing meningitis Adverse Reactions CNS: Headache, confusion, mild depression, delirium, GI: Nausea, vomiting Other: Infections by nonsusceptible organisms, hypersensitivity reaction Nursing Considerations • Culture and Sensitivity test may be done before first dose and p.r.n • Monitor CBC, platelets, serum iron and reticulocytes before and every 2 days during therapy. Stop drug immediately if anemia, leukopenia develops • Instruct patient to report adverse reactions to the doctor, especially nausea and vomiting and confusion. • Give IV slowly over 1minute •Monitor for evidence of super infection by nonsusceptible organisms D. PENICILLIN G Na Brand Name: Crystapen Drug Classification: Anti infective Mechanism of Action: Bactericidal against microorganisms by inhibiting cell-wall synthesis during active multiplication. Bacteria resist penicillin by producing penicillinases-enzyme that converts penicillin to inactivate penicillin acid. Adverse Reactions CNS: Convulsion Local: Vein irritation Others: Hypersensitivity (edema), overgrowth of nonsusceptible organisms. Nursing Considerations • Obtain cultures for sensitivity tests before first dose. Unnecessary to wait for test results before beginning therapy. • Before giving penicillin, ask patient if she had any allergic reactions to this drug. • If patient has High blood level of this dug, she may have convulsions. Be prepared by keeping side rails up on bed. • Give IV intermittently to prevent vein irritation. Change site every 48 hours.

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• Give penicillin at least 1 hour before bacteriostatic antibiotics. • With prolonged therapy bacterial or fungal super infections may occur especially patient’s who are elderly, debilitated or who have low resistance. E. Ranitidine Hydrochloride Brand Name: Zantac Drug Classification: Anti ulcer Mechanism of Action: Competi Adverse Reactions CNS: Convulsion Local: Vein irritation Others: Hypersensitivity (edema), overgrowth of nonsusceptible organisms. Nursing Considerations • Assess patient for abdominal pain. Note the presence of blood in the emesis, stool, or gastric aspirate. • Ranitidine may be added to total parenteral nutrition solutions • Don’t confuse Ranitidine with Ramantidine; Don’t confuse Zantac with Xanax or Zyrtec.

IX. Assessment I P P A Neurologic

*

al

Skin

*

Head

*

*

Result >responsive >conscious >oriented in date and place >with GCS of 15 >positive abrasions in both arms >sagging skin >positive bruises in left arm >pale colored skin >positive freckles >positive suture at the back of the head >negative

Significanc e

Indication

Normal

Abnormal

Indicates tissue trauma

Normal

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Eyes

*

Ears

*

Nose

*

Mouth

Neck

*

*

dandruff >head is symmetrical >coordinated extra ocular movement >shiny white and moist >pinkish conjunctiva >negative hearing disorder >negative tinnitus >negative nasal discharges >negative sinusitis >negative stomatitis >positive halitosis >22 teeth noted >moist >positive taste with good swallowing reflex >negative vein distention >negative goiter

Normal

Normal

Normal Normal Normal

Normal

Normal Normal

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I Upper Extremitie s

*

Chest

*

Breast

Abdomen

Genitourinar y

Lower Extremitie s

*

*

*

*

P P A

*

*

*

*

*

*

*

Result

Significanc e Abnormal

Indication

>positive bruises in both extremities >unclean nails >negative fracture Normal noted >negative mass Normal noted >negative abnormal breath sound >with 72 beats per minute >negative mass noted >brown colored nipple >negative inversion of nipple >negative abdominal distention >negative gastroenteritis >negative abrasions >negative swelling >negative dysuria >negative hematuria >negative pain on suprapubic >negative burning sensation when urinating >positive abrasion >positive bruises in both extremities >unclean nails >negative fracture noted

Normal

Normal Normal

Normal Normal Normal Normal Normal Normal Normal Normal

Abnormal Abnormal

Indicates tissue trauma Indicates tissue trauma

Normal

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X. Pathophysiology

Vehicular Accident

Direct and Indirect Head Trauma

Brain strikes the skull

Cortical injury occurs adjacent to the floor of the anterior/posterior cranial fossa, the sphenoid wing, the petrous ridge, the convexity of the skull, and the falx or tentorium

Vascular Injury

Parenchymal bruises on the surfaces of the brain

Multiple shearing injury

Edematous lesions

Multiple microhemorrhages

Multifocal hemorrhagic contusion

Tearing and bleeding of arteries

Acute traumatic damage to the brain

Blood extend bidirectionally to white matter, subdural and subarachnoid spaces

Brain herniation

Tissue injury

Neuronal Injury

Subdural Hematoma

Burst lobe Vascular response Mortality

Decreased blood circulation

Edema

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Decreased oxygenation

Ischemia

Increased Intracranial Pressure

Change in Vital signs

rising blood pressure or widening pulse pressure between systole and diastole pulse changesbradycardia to tachycardia as intracranial pressure rises

Headache

Crushing of Brain Tissue

Change in level of responsiveness lethargy, slowing of speech, quietness to restlessness, orientation to confusion, stupor, increasing drowsiness, coma and progressive deterioration

constant/increasing intensity aggravated by movement

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XII. Medical Management Assessment and diagnosis of the extent of the injury are accomplished by the initial physical and neurological examinations. CT and MRI are the primary neuroimaging diagnostic tools & are useful in evaluating the brain structure. Positron Emission Tomography (PET) is available in some trauma centers; this method of scanning examines brain function rather than structure. Any patient with head injury is pressured to have cervical spine injury until proven otherwise. The patient is transported from the scene of the injury on a board with the head & neck maintain in alignment with the body. All therapy is directed toward preserving brain homeostasis & preventing secondary brain injury, which is injury to the brain that occurs after the original traumatic event. If increase ICP, it is managed by maintaining adequate oxygenation, elevating the head of the bead & maintaining normal blood volume. Devices to monitor ICP or drain CSF can be inserted during surgery or at the bedside using aseptic technique. In managing intracranial bleeding, allow the brain to recover from the initial insult to prevent or minimize the risk for rebleeding and to prevent or beat complications. Primarily supportive and consists of bed rest with sedation to prevent agitation & stress, management of vasospasm & surgical medical treatment to prevent rebleeding.

XIII. Nursing Management The following are the nursing diagnosis:  

Hyperthermia r/t disturbance in the Hypothalamus Ineffective cerebral tissue perfusion r/t space occupying lesion

The following interventions are done during the patient’s stay in the hospital: • Continuous monitoring of Vital Signs of the patient especially the blood pressure and body temperature • Meticulous skin care • Advising the patient to eat foods rich in protein and Vitamin C. • Glasgow Coma Scale to determine the patient’s consciousness • As part of the therapeutic communication, encourage the patient and watcher to verbalize their feelings and concerns.

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XIV. Discharge Planning Nursing Considerations:  A neurologist should be consulted if the patient is believed at risk for complications  Special care is taken in the positioning of the head of the patient to avoid flexion of the neck which might impair circulation to the brain  Emotional supports are required to keep the person comfortable and calm  During convalescence the nurse maybe called on to assist the patient in developing self help capabilities  On Diet as Tolerated  The treatment for a contusion is usually to watch the patient closely for any change in level of consciousness Further Outpatient Care: • Glasgow coma scale level should be determined • It is important to keep in mind that recovery from a traumatic brain injury can be slow • It is best to ask the health-care providers if any change have occurred • Enough rest and nutrition should be needed for outpatient care Patient Education:  Patients should be instructed to avoid opening their mouths widely to prevent recurrent dislocation  Application of cold may limit the development of a contusion  Elevate the head of the bed to promote venous drainage and to lower increase intracranial pressure  Watch the person closely for any change in level of consciousness  If the headaches persists or becomes severe, it is best to seek medical attention

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