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Introduction   

When hearing the phrase TBI recovery, what comes to mind? If you’re a nurse, you’ve heard about traumatic brain injuries (TBI) at some point in your nursing studies and career. Maybe even before nursing school, conversations about caregiving, taking care of someone after a major accident, or the like existed every so often.

Presently, patients seek guidance and information on various health topics from nurses, including family and caregiver education for their loved ones after a TBI. The information in this course will serve as a valuable resource for nurses of all specialties, education levels, and backgrounds to learn more about family and caregiver education in TBI recovery.

Defining Traumatic Brain Injury (TBI)

Traumatic brain injury (TBI) is a type of head injury with a wide range of causes, clinical presentations, and lifelong complications. TBIs can range from strikes to the head to cranial impalement with a foreign object to internal bleeding from a blood clot. Because of the wide range of TBIs, clinical management options, post-TBI recovery options, and quality of life paths are all significantly variable depending on the severity of the TBI.

TBIs can often be life-altering with very little ease of returning to a life before a TBI. With adequate medication, treatment, therapy, and intervention, many people who have experienced TBI can lead a possibly more normal life. However, it is important to note that life in TBI recovery and post-TBI is going to be a new normal for the person who experienced a TBI, for their loved ones, for their families, and possible caregivers (1,2,3).

TBIs affect over one million people in the United States, with adolescents and elders being the most likely to experience a TBI. Men also experience TBI at higher rates than women. Athletes and those in the military also experience higher rates of TBI than the general population. In most TBIs, the frontal and temporal areas of the brain are often affected. It is important to note that moderate to severe TBIs are a leading cause of disability in the United States and remain a serious, severe concern for caregivers nationwide (1,2).

What If TBIs Are Left Untreated?

If TBI is left untreated, severe health complications can arise, such as developmental malformation, chronic headaches, nerve damage, stroke, organ damage, impaired oxygenation, impaired blood perfusion, and death. Given the importance of the brain as the body’s powerhouse, timely, medically accurate, and evidence-based care for TBIs is essential. After the assessment and management of a TBI, chronic TBI recovery care is essential for the patient to function and attempt to live a normal life after a TBI (1,2,3).

What Causes TBI?

TBIs are typically caused by physical strikes to the head, such as physical contact in sports, physical altercations, motor vehicle accidents, explosions, weapons, or falls. It is important to note that not all TBIs are caused by extreme situations, such as being stabbed in the head. Concussions, repeated head injuries, and chronic exposure to weapons have also been linked to TBIs. TBIs occur because sudden force, trauma, or stress to the brain can cause fractures to the skull, blood flow changes, oxygenation changes, movements of the brain itself in the skull, and more (1,2).

What Are TBI Risk Factors?

Risk factors for TBI include anyone who has a brain! Anyone is at risk for a TBI, but athletes, those in the military, and anyone else who is more involved with physical contact are at risk for TBI. People who are at increased fall risk, those with mobility issues, those taking certain medications that impair movement or judgment, and people with access to firearms are also at increased risk of TBI (1,2).

What Are the Most Common Types of TBI?

The most common types of TBI are concussion, hematoma, contusion, hemorrhage, and diffuse axonal injury (DAI).

First, concussions are a direct hit to the head without any visible bleeding or external visible damage. Concussions can cause a temporary loss of consciousness or altered mental status but typically do not require in-patient hospitalization or extensive TBI recovery. However, concussions were originally seen as mild head injuries that left no permanent damage to the body. More studies are showing that repeat concussions, especially among athletes in a short period, can lead to chronic brain damage, making TBI recovery for people experiencing concussions a lifelong journey (2).

Hematomas are when there are pockets of bleeding from cranial arteries or a fracture in the skull that causes an area in the cranium to swell with blood. Hematomas are acute and need emergency intervention to prevent death. People who experience cranial hematomas often need extensive TBI recovery.

Intracranial hemorrhage, or bleeding within the brain, occurs when there is sudden trauma to the brain that results in capillaries in the brain being broken and spilling blood into various parts of the brain. Strokes and blunt force trauma can lead to hemorrhages. Like hematomas, people who experience intracranial hemorrhages need acute emergency intervention to prevent death. People who experience intracranial hemorrhages often need extensive TBI recovery (2).

In addition, DAIs are the result of the neurons in the brain being stretched, sheared, twisted, or torn, often as a result of multiple concussions. Because DAIs are often a result of brain tissue not functioning healthily, DAIs are often recognized on autopsies or in far later stages of care, which makes early intervention and TBI recovery for people with DAIs extremely complex.

Because of the varied clinical presentations, acuity, and complications of various TBIs, family and caregiver education in TBI recovery can vary significantly and often requires coordination with several healthcare professionals (1,2,3).

Defining TBI Recovery Paths

There are several options for TBI recovery, including surgery, bone transplant, medications, blood transfusions, physical therapy, speech therapy, cognitive behavioral therapy, occupational therapy, and more. TBI recovery options can vary depending on the severity of TBI, patient’s location, patient preference, cost, and more (1,2,3).

How and Where Are TBI Recovery Methods Used?

TBI recovery methods are used in a variety of clinical settings, such as hospitals, outpatient clinical settings, nursing homes, hospice facilities, palliative care centers, public health departments, correctional facilities, residential addresses, and more (1,2,3).

What Are the Clinical Criteria for Prescribing TBI Recovery Measures?

Clinical criteria for prescribing TBI recovery measures truly depend on the TBI, patient health, patient prognosis, cost, insurance, health care access, and more. Because of the wide range of TBIs and medication options, clinical criteria for TBI recovery truly depend on the cause of TBI and patient prognosis (1,2,3).

What Is the Average Cost for TBI Recovery?

The cost of TBI recovery medications can significantly vary depending on the type of medication, insurance, dosage, administration route, frequency, and other factors. Cost is among a leading reason why many patients cannot maintain their medication regime (4). If cost is a concern for your patient, consider reaching out to your local pharmacies or patient care teams to find cost-effective solutions for your patients.

In addition, many TBI recovery patients will require medical intervention outside of medication, such as physical therapy, so the cost for that is also something to consider as well (1,2,3).

Common TBI Recovery Medications

The healthcare provider’s professional discretion and the patient’s condition should guide therapy. Consider reviewing a patient’s medication history, clinical presentation, and health history before prescribing TBI recovery medications. Consider consulting with a neurologist, TBI specialist, therapists, and other relevant clinical staff regarding TBI recovery medication options.

Pain medication options, such as non-steroidal anti-inflammatory drugs (NSAIDs) or opioids, are possible options for TBI recovery patients. Dosages, frequencies, types of these medications, and administration routes can vary significantly depending on the severity of the TBI, patient health, and caregiver’s ability to administer these medications.

It is also important to note that, depending on the type of TBI someone has experienced, pain sensation and perception can be altered, so from a nurse’s point of view, pain assessment is critical. In addition, it is also important to listen to the patients and their caregivers regarding pain management (1,2,3).

TBI recovery patients may also be prescribed selective serotonin reuptake inhibitors (SSRIs), such as sertraline, to help with possible mood changes and hormonal shifts. Some TBI recovery patients might also be prescribed antipsychotic medications, such as quetiapine, or anticonvulsant medications, such as valproic acid. Because of the wide clinical presentation in TBI recovery patients, some TBI recovery patients might not require any mood-altering medications.

Some TBI recovery patients might have to adjust their medication dosages, frequencies, and administration routes of these types of medications more often than others. Like pain management, it is also important to note that, depending on the type of TBI someone has experienced, mood expression can be altered, so from a nurse’s point of view, mood assessment is critical. In addition, it is also important to listen to the patients and their caregivers regarding mood changes and overall mood progression on these medications (1,2,3).

TBI Recovery Medications Side Effects

Every medication has the possibility of side effects, and medications for TBI recovery are no exception. Depending on the complications from the TBI, patients themselves might not be able to perceive possible side effects similar to their caregivers or healthcare professionals. As a result, it is important to educate caregivers on possible side effects of all medications to be administered and to monitor for any critical symptoms.

For instance, a patient recovering from TBI might be prescribed opioids, which have common side effects of respiratory depression and constipation. Depending on the extent of someone’s TBI, they may or may not have normal bowel functions fully intact, which could further be influenced negatively by opioid use (1,2,3).

Other medications, such as antipsychotics and antidepressants, can also have their own set of possible side effects. Because of several medication options, dosages, frequencies, administration routes, and more regarding medications for TBI recovery, consistent education and review of medication side effects are essential (1,2,3).

In general, it is important to monitor patient side effects to determine if the risks outweigh the benefits and to adjust the medication regime as needed.

TBI Recovery Medication Alternatives

Given the nature of TBI recovery, medications are rarely, if ever, enough to manage immediate or long-term recovery outcomes. TBI recovery medication alternatives often include changes to diet, changes to sleep, outpatient vital signs monitoring, various therapy options, and more.

Patients can try lifestyle modifications, such as stress reduction techniques, smoking cessation, alcohol cessation, and acupuncture, but these methods are often in conjunction with medication therapies. Because of the wide range of TBI recovery medications and adjacent recovery options, appropriate family and caregiver education is essential before patient discharge (1,2,3).

How Would Family and Caregivers Be Involved in Medication Administration?

Because there are several routes and several medication options for TBI recovery, medication education, including medication administration education, is essential for all family and caregivers involved in the care of a TBI-recovering patient. TBI recovery patients can have a wide variety of care professionals, such as home health aides, family members, therapists, nurses, surgeons, and more, so making sure everyone is aware of each medication’s administration route is essential.

It is important to provide culturally appropriate, evidence-based, and realistic education on medication administration for everyone involved in TBI recovery care for that patient. Family and caregivers should be aware of the general side effects of all medications administered and aware of red flags to report on (1,2,3).

Physical Therapy

Physical therapy (PT) is the treatment or management of a condition that involves the physical movements of body parts to restore their function and mobility to the best of their capabilities. PT is done by licensed physical therapists in PT offices. PT can be done a few times a week to a few times a month depending on the severity of the patient’s needs. In general, PT for patients in TBI recovery can vary significantly depending on the type of TBI sustained, patient’s finances, patient preference, health care access, and more (1,2,3).

Cost for TBI recovery PT can significantly vary as well depending on types of insurance, types of PT required, and locations of PT practices. Some physical therapists can work directly in a TBI-recovering patient’s home, but that will depend on the extent of PT needed and physical therapist availability. It is important to note that PT is not guaranteed to return function of speech as it was before the TBI, as PT can help improve bodily functions.

Overall health outcomes are not guaranteed by PT alone. If a patient recovering from TBI needs PT, discussing transportation, cost, and feasibility is also something to consider when talking to caregivers and family members (1,2,3).

Speech Therapy

Speech therapy (ST) is the treatment or management of a condition that involves speech recognition and oral movements to restore their function and mobility to the best of their capabilities. ST is done by licensed speech therapists in ST offices. ST can be done a few times a week to a few times a month depending on the severity of the patient’s needs. In general, ST for patients in TBI recovery can vary significantly depending on the type of TBI sustained, the patient’s finances, patient preference, health care access, and more (1,2,3).

Cost for TBI recovery ST can significantly vary as well depending on types of insurance, types of ST required, and locations of ST offices. It is important to note that ST is not guaranteed to return the function of speech as it was prior to the TBI, as ST can help improve speech function. Overall health outcomes are not guaranteed by ST alone. If a patient recovering from TBI needs PT, discussing transportation, cost, and feasibility is also something to consider when talking to caregivers and family members (1,2,3).

Psychotherapy

Psychotherapy is the treatment or management of mental health conditions and mental health state. Psychotherapy, also commonly known as mental health therapy, can be done by licensed mental health professionals, such as licensed mental health counselors, psychiatrists, mental health nurse practitioners, social workers, and more.

Psychotherapy can be done virtually or in person. Psychotherapy can be done weekly, monthly, or as needed depending on the severity of the patient’s needs. In general, psychotherapy for patients in TBI recovery can vary significantly depending on the type of TBI sustained, patient’s finances, patient preference, health care access, and more (1,2,3).

Cost for TBI recovery psychotherapy can significantly vary as well depending on types of insurance, types of psychotherapy, and mental health evaluations required. It is important to note that psychotherapy is not guaranteed to treat or cure mental health conditions. If a patient recovering from TBI needs psychotherapy, discussing transportation, cost, telehealth needs, and feasibility is also something to consider when talking to caregivers and family members (1,2,3).

Nursing Considerations

Nurses remain the most trusted profession for a reason, and nurses are often pillars of patient care in several healthcare settings. Patients turn to nurses for guidance, education, and support.

While there is no specific guideline for the nurses’ role in providing family and caregiver education for patients recovering from a TBI, here are some suggestions to provide quality care for TBI patients and their caregivers.

1. Take a detailed health history of the patient with TBI. Oftentimes, vital signs and history taking can be complex with a patient recovering from TBI, especially in more complex TBI recovery cases. Encourage their caregivers to be involved in the vital signs and history-taking process to learn about noticing any abnormalities or medical concerns that warrant medical attention. As nurses, we are aware that neurological injuries can lead to rapid fluctuations in vital signs, such as blood pressure and heart rate, but someone without medical knowledge might not be aware of this. If a patient is complaining of symptoms that could be related to their TBI, such as chest pain, trouble breathing, or headaches, inquire more about that complaint. Ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a patient’s complaint is not being taken seriously by other healthcare professionals, advocate for that patient to the best of your abilities.
2. Review medication history at every encounter. Oftentimes, in busy clinical settings, reviewing health records can be overwhelming, especially for patients recovering from TBI. Millions of people take medications for various reasons, and people’s medication histories can look similar over time. Ask each patient about how they are feeling on the medication, if their symptoms are improving, and if there are any changes to the medication history. Ask the caregivers if they are aware of the medications this patient is taking, the dosage, the frequency, and the purpose of these medications. Also, ask the caregivers if they have noticed any changes in the patient’s recovery process while on these medications, as medications can often change during TBI recovery.
3. Be willing to answer questions about TBI recovery and medication options. Many people do not know about medication side effects, risk factors to be aware of, and lifestyle changes that can influence TBI recovery. Be willing to be honest with yourself about your comfort level discussing topics and providing education on various TBI recovery medications, various TBI therapy recovery options, and various steps involved in comprehensive TBI recovery.
4. Communicate the care plan to other staff involved for continuity of care. For several patients, especially patients with complex TBI recovery, care often involves a team of nurses, specialists, pharmacies, surgeons, caregivers, and more. Ensure that patients’ records are up to date for ease in record sharing and continuity of care.
5. Stay up to date on continuing education related to medications and TBI recovery, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other healthcare professionals and educate your patients with the latest information. You can learn more about the latest research on TBI recovery by following updates from evidence-based organizations, such as the National Institutes of Health (NIH). You can also share any evidence-based information with caregivers.

How can nurses identify if someone is struggling with their TBI recovery?

Unfortunately, it is not possible to look at someone with the naked eye and determine if they are struggling with their TBI recovery, as recovery can look different in every patient case. While some people might have notable TBI recovery complications, such as trouble breathing or sharp headaches, the most common for many people in TBI recovery varies widely. In addition, nurses can answer questions and concerns regarding the TBI recovery process for both patients and their caregivers.

Nurses can also provide information on TBI recovery timelines, therapy options, medication options, and more. Nurses can provide quality care by completing health history, listening to patient’s concerns, addressing caregiver’s concerns, and offering medication and lifestyle management.

What should families and caregivers know about TBI recovery?

Patients should know that anyone has the possibility of experiencing TBI. That said, recovery after a TBI can range significantly depending on the extent of the TBI, a patient’s health before a TBI, finances, access to care, and caregiver availability. Patients and caregivers should be aware that if they notice any changes in their vision, experience any headaches or feel like something is a concern, they should seek medical care. Nurses should also teach patients and caregivers to advocate for their health to avoid untreated or undetected TBI recovery complications and unwanted side effects of TBI recovery medication.

Here are important tips for patient education in the inpatient or outpatient setting.

• Tell the health care provider of any existing medical conditions or concerns (need to identify risk factors)
• Tell the health care provider of any existing lifestyle concerns, such as alcohol use, other drug use, sleeping habits, diet, stress levels, or menstrual cycle changes (need to identify lifestyle factors that can influence TBI recovery medication use and therapy interventions)
• Tell the health care provider if you have any changes to your body, such as pain with urination, pain with movement, or increased fatigue (potential systemic TBI complication symptoms)
• Tell the nurse or health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life
• Keep track of your health, medication use, and health concerns via an app, diary, or journal (self-monitoring for any changes)
• Tell the health care provider right away if you are having thoughts of hurting yourself or others (possible increased risk of suicidality with TBI complications)
• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options or surgeries
• Tell the health care provider if you notice any changes while taking medications or on other treatments to manage TBI recovery (potential worsening or improving health situation)
• Track your blood pressure and heart rate with an at-home blood pressure cuff, keep track of your readings, and report any changes to your health care provider (self-monitoring for any changes)

Research Findings

There is extensive publicly available literature on TBI recovery options and TBI recovery education for caregivers via the National Institutes of Health (NIH) and other evidence-based journals. If a patient is interested in participating in clinical trial research, they can seek more information on clinical trials from local universities and healthcare organizations.

Conclusion

TBI recovery is a complex process for people with a history of TBIs and their caregivers. It is often a lifetime process that involves several medical interventions, surgeries, appointments, therapies, medications, and people. Oftentimes, clinical presentation and symptom management for TBI recovery can vary widely. Education and awareness of different medication options and different clinical presentations of TBI can influence the lives of many people healthily.

Case Study #1

Sam is a 36-year-old woman working as a teacher. She fell in the parking lot and hit her head when it was raining. She was transported to the emergency room, where exams showed she suffered a concussion. Sam leaves the emergency room with her husband, and she follows up with her primary care a few weeks later. At the primary care doctor, Sam says she’s been having some headaches and trouble sleeping for the past two weeks. Sam said she’d never felt this way before falling a few weeks ago. You look over at her vital signs, and you see that her blood pressure for today is 150/110. You look at her previous blood pressure readings, and you see that they have been in the 100s-110s/70s-80s in her prior visits. Her heart rate is 120 bpm.

Case Study #1 Continued

After talking with Sam, you decide to refer her back to the emergency room, as her symptoms have not been improving after the fall, and you are concerned about lingering complications. Sam goes to the emergency room with her husband, and the emergency room triage suspects that she is having a possible subdural hematoma. She is admitted to the hospital for observation, and further examination confirms the hematoma. Sam would like to know what her management options for this are, and she states her headache is getting worse with pain at 9/10.

Case Study #1 Continued

After a few days in the hospital being monitored and discussing with specialists, Sam decides to complete the subdural hematoma treatment. After a week of inpatient observation and recovery from her craniotomy, she is recovering from her procedure well and reports less pain. Sam wants to know if she can return to being a teacher and how she can get back to her life before this fall. She is planning to travel in a few weeks and wants to know if that is possible. Presently, Sam can use the bathroom by herself and move with assistance, but she is still having trouble processing all of what has happened in the past week and with the recent surgery. Sam’s husband also wants to know how he can help Sam because he has never taken care of anyone with head trauma, and Sam usually manages the medical appointments and medications in the marriage.

Case Study #2

Bob is a 76-year-old retired man working on his roof one day. While he is working on the roof, Bob trips on the ladder, causing him to fall from the roof to the front yard in a few seconds. He screams for his wife who calls emergency services. Upon admission to the emergency room, Bob is bleeding from the back of his head and is having trouble responding to some of the questions the nurses are asking.

The nurses ask Bob’s wife about his health history, in which she states that he has high blood pressure, diabetes, and migraines. She explains that he takes “a bunch of pills every day,” but she does not remember the names of his medications off the top of her head. She also states that his blood pressure was a bit high at the doctor’s office a few weeks ago, but his blood sugar has been OK the past few weeks. You look over at his vital signs, and you see that his blood pressure for today is 180/110. His heart rate is 130 bpm, his blood glucose is 140, and he is still conscious.

Case Study #2 Continued

After talking with Bob’s wife, the hospital care team decides to do some imaging and bloodwork to determine Bob’s state. The team suspects that he has external bleeding from the skull and is working on determining if there is any internal damage and other bodily concerns as well. Bob is still speaking a bit still, and he reports his pain is 9/10. He is still conscious but reports feeling very tired and having trouble seeing.

After a few hours of admission to the hospital, examination showed that Bob suffered from an external head injury with a possible occipital lobe fracture. Bob and his wife agree to surgical intervention to help with the fracture, but Bob’s wife is very concerned and starts crying.

Case Study #2 Continued

After a few days from the hospital admittance, Bob is recovering from his occipital fracture surgery. His surgery was reported to have no complications, and his wife and children are in the patient room with Bob. His vitals are stable, he is taking medications for his hypertension and migraines, and he has no other damage from the fall on other parts of his body.

You go in to review his health, and you notice that Bob is having trouble speaking. Bob is also having trouble remembering his name, and he states his head is starting to hurt a lot. Upon examination, you suspect a surgical complication and possible hemorrhage. You are concerned and call an emergency code in the hospital. The rapid response team does an exam, and further examination and imaging show that Bob is now suffering from an ICH. Bob is concerned he is going to die, and his wife and child are crying nonstop.

Case Study #2 Continued

After managing the ICH, Bob is recovering in the post-surgical unit. The surgeon discussed that Bob is going to have a social worker assigned to him shortly since he will need extensive care in his TBI recovery. Bob will most likely have trouble speaking, moving parts of his body, and going to the bathroom for several months, possibly for the rest of his lifetime.

Bob’s wife and child are deeply concerned, as they are on a limited income from Bob’s retirement. Bob’s wife and child are not familiar with medical terms or procedures and do not understand why a social worker is involved. Bob’s wife asks if Bob will die soon and if she needs to contact a lawyer. Bob’s child asks if he needs to take more time off of work to help with taking care of him in the hospital. Bob is unable to communicate his needs presently.

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