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statpearls_NBK430685\nurse-article-30545_15	Brain Trauma (Archived) (Nursing) -- Evaluation -- Clinical Decision Rules	Perhaps the most widely known and best-studied rule is the Canadian head CT rule. The Canadian head CT rule has inclusion and exclusion criteria. Patients to whom this rule applies are those with GCS 13-15 with loss of consciousness, amnesia to the head injury event, or witnessed disorientation. Patients who are less than 16 years old, are on blood-thinning medications or have a seizure after the injury get excluded from this decision rule. The Canadian head CT rule puts forth the following high-risk criteria: GCS under 15 at 2 hours post-injury, suspected open or depressed skull fracture, any signs of basilar skull fracture (hemotympanum, raccoon eyes, Battle sign, CSF otorrhea or rhinorrhea, 2 or more episodes of emesis, and age 65 years or older. Medium risk criteria include retrograde amnesia to the event of 30 minutes or greater, or a dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from a motor vehicle, or fall from more than 3 feet or over five stairs). If the patient is a candidate for the application of the rule and has no high or medium risk criteria, CT is not recommended. The sensitivity of this rule is 83 to 100% for all traumatic intracranial findings and 100% for findings requiring neurosurgical intervention. If either of the medium-risk criteria is positive, CT should be considered, and if any of the high-risk criteria are positive, the decision rule cannot rule out the need for imaging.	Brain Trauma (Archived) (Nursing) -- Evaluation -- Clinical Decision Rules. Perhaps the most widely known and best-studied rule is the Canadian head CT rule. The Canadian head CT rule has inclusion and exclusion criteria. Patients to whom this rule applies are those with GCS 13-15 with loss of consciousness, amnesia to the head injury event, or witnessed disorientation. Patients who are less than 16 years old, are on blood-thinning medications or have a seizure after the injury get excluded from this decision rule. The Canadian head CT rule puts forth the following high-risk criteria: GCS under 15 at 2 hours post-injury, suspected open or depressed skull fracture, any signs of basilar skull fracture (hemotympanum, raccoon eyes, Battle sign, CSF otorrhea or rhinorrhea, 2 or more episodes of emesis, and age 65 years or older. Medium risk criteria include retrograde amnesia to the event of 30 minutes or greater, or a dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from a motor vehicle, or fall from more than 3 feet or over five stairs). If the patient is a candidate for the application of the rule and has no high or medium risk criteria, CT is not recommended. The sensitivity of this rule is 83 to 100% for all traumatic intracranial findings and 100% for findings requiring neurosurgical intervention. If either of the medium-risk criteria is positive, CT should be considered, and if any of the high-risk criteria are positive, the decision rule cannot rule out the need for imaging.
statpearls_NBK430685\nurse-article-30545_16	Brain Trauma (Archived) (Nursing) -- Evaluation -- Clinical Decision Rules	Other decision rules to determine whether to recommend initial head CT include New Orleans Rule and Nexus II Rule.	Brain Trauma (Archived) (Nursing) -- Evaluation -- Clinical Decision Rules. Other decision rules to determine whether to recommend initial head CT include New Orleans Rule and Nexus II Rule.
statpearls_NBK430685\nurse-article-30545_17	Brain Trauma (Archived) (Nursing) -- Evaluation -- Clinical Decision Rules	The New Orleans Rule has more stringent inclusion criteria, requiring age greater than 18 and GCS of 15 in patients with blunt head trauma occurring within 24 hours, causing loss of consciousness, amnesia, or disorientation. Head CT is a recommendation in any patient with headache, vomiting, age greater than 60, drug or alcohol intoxication, persistent anterograde amnesia, visible trauma above the clavicles, or seizures.	Brain Trauma (Archived) (Nursing) -- Evaluation -- Clinical Decision Rules. The New Orleans Rule has more stringent inclusion criteria, requiring age greater than 18 and GCS of 15 in patients with blunt head trauma occurring within 24 hours, causing loss of consciousness, amnesia, or disorientation. Head CT is a recommendation in any patient with headache, vomiting, age greater than 60, drug or alcohol intoxication, persistent anterograde amnesia, visible trauma above the clavicles, or seizures.
statpearls_NBK430685\nurse-article-30545_18	Brain Trauma (Archived) (Nursing) -- Evaluation -- Clinical Decision Rules	Nexus II Rule recommends CT in any of the following: patients greater 65 years or older, evidence of skull fracture, scalp hematoma, neurologic deficit, altered level of alertness, abnormal behavior, coagulopathy, recurrent or forceful vomiting.	Brain Trauma (Archived) (Nursing) -- Evaluation -- Clinical Decision Rules. Nexus II Rule recommends CT in any of the following: patients greater 65 years or older, evidence of skull fracture, scalp hematoma, neurologic deficit, altered level of alertness, abnormal behavior, coagulopathy, recurrent or forceful vomiting.
statpearls_NBK430685\nurse-article-30545_19	Brain Trauma (Archived) (Nursing) -- Evaluation -- Clinical Decision Rules	In pediatric patients, the best decision tool to determine the recommendation of the CT scan is PECARN, which is based on a large-scale clinical trial of the same name and has had external validation repeatedly. This decision tool divides patients into two initial groups based on age. Those less than 2 years old are further stratified using one algorithm, and those 2 years old or older are further stratified using another algorithm. Children less than 2 years old who have GCS less than 15, altered mental status, or a palpable of a skull fracture should undergo CT. If a child less than 2 has a loss of consciousness longer than 5 seconds, non-frontal hematoma, severe mechanism of injury, or not acting normally per parents should undergo CT or undergo observation; this decision should be made using shared decision making with parents. If meeting none of the above criteria, the child may be safely discharged. In children 2 years or older, AMS, GCS under 15, or signs of basilar skull fracture should precipitate CT imaging. Children 2 years or older who have a loss of consciousness for longer than 5 seconds, recurrent vomiting, severe headache, or high mechanism of injury should either be observed or undergo CT imaging. If none of these symptoms are present, children may be safely discharged. [7]	Brain Trauma (Archived) (Nursing) -- Evaluation -- Clinical Decision Rules. In pediatric patients, the best decision tool to determine the recommendation of the CT scan is PECARN, which is based on a large-scale clinical trial of the same name and has had external validation repeatedly. This decision tool divides patients into two initial groups based on age. Those less than 2 years old are further stratified using one algorithm, and those 2 years old or older are further stratified using another algorithm. Children less than 2 years old who have GCS less than 15, altered mental status, or a palpable of a skull fracture should undergo CT. If a child less than 2 has a loss of consciousness longer than 5 seconds, non-frontal hematoma, severe mechanism of injury, or not acting normally per parents should undergo CT or undergo observation; this decision should be made using shared decision making with parents. If meeting none of the above criteria, the child may be safely discharged. In children 2 years or older, AMS, GCS under 15, or signs of basilar skull fracture should precipitate CT imaging. Children 2 years or older who have a loss of consciousness for longer than 5 seconds, recurrent vomiting, severe headache, or high mechanism of injury should either be observed or undergo CT imaging. If none of these symptoms are present, children may be safely discharged. [7]
statpearls_NBK430685\nurse-article-30545_20	Brain Trauma (Archived) (Nursing) -- Evaluation -- Rancho Los Amigos Scale	This scale is used to describe the behaviors, cognition, and emotional responses in patients who are emerging from a coma. Level I: No Response: Total Assistance - no response to stimuli Level II: Generalized Response: Total Assistance - inconsistent and non-purposeful responses Level III: Localized Response: Total Assistance - inconsistent response Level IV: Confused/Agitated: Maximal Assistance - bizarre, non-purposeful behavior, agitation Level V: Confused, Inappropriate Non-Agitated: Maximal Assistance - response to simple commands, non-purposeful, and random response to complex commands. Level VI: Confused, Appropriate: Moderate Assistance - follows simple commands, able to understand familiar tasks, but not new tasks Level VII: Automatic, Appropriate: Minimal Assistance for Daily Living Skills - Able to perform daily routine and understands familiar settings. Aware of diagnosis, but not impairments.	Brain Trauma (Archived) (Nursing) -- Evaluation -- Rancho Los Amigos Scale. This scale is used to describe the behaviors, cognition, and emotional responses in patients who are emerging from a coma. Level I: No Response: Total Assistance - no response to stimuli Level II: Generalized Response: Total Assistance - inconsistent and non-purposeful responses Level III: Localized Response: Total Assistance - inconsistent response Level IV: Confused/Agitated: Maximal Assistance - bizarre, non-purposeful behavior, agitation Level V: Confused, Inappropriate Non-Agitated: Maximal Assistance - response to simple commands, non-purposeful, and random response to complex commands. Level VI: Confused, Appropriate: Moderate Assistance - follows simple commands, able to understand familiar tasks, but not new tasks Level VII: Automatic, Appropriate: Minimal Assistance for Daily Living Skills - Able to perform daily routine and understands familiar settings. Aware of diagnosis, but not impairments.
statpearls_NBK430685\nurse-article-30545_21	Brain Trauma (Archived) (Nursing) -- Evaluation -- Rancho Los Amigos Scale	Level VIII: Purposeful, Appropriate: Stand By Assistance - Consistently oriented to person, place, and time and some awareness of impairments and how to compensate. They can carry out familiar tasks independently but might be depressed and/or irritable Level IX: Purposeful, Appropriate: Stand By Assistance on Request - Able to complete different tasks, aware of impairments, able to think about consequences with assistance	Brain Trauma (Archived) (Nursing) -- Evaluation -- Rancho Los Amigos Scale. Level VIII: Purposeful, Appropriate: Stand By Assistance - Consistently oriented to person, place, and time and some awareness of impairments and how to compensate. They can carry out familiar tasks independently but might be depressed and/or irritable Level IX: Purposeful, Appropriate: Stand By Assistance on Request - Able to complete different tasks, aware of impairments, able to think about consequences with assistance
statpearls_NBK430685\nurse-article-30545_22	Brain Trauma (Archived) (Nursing) -- Evaluation -- Rancho Los Amigos Scale	Level X: Purposeful, Appropriate: Modified Independent - Able to multitask in many different environments. May create tools for memory retention and anticipate obstacles which may result from impairments [8]	Brain Trauma (Archived) (Nursing) -- Evaluation -- Rancho Los Amigos Scale. Level X: Purposeful, Appropriate: Modified Independent - Able to multitask in many different environments. May create tools for memory retention and anticipate obstacles which may result from impairments [8]
statpearls_NBK430685\nurse-article-30545_23	Brain Trauma (Archived) (Nursing) -- Medical Management	Treatment depends on the severity of brain trauma.	Brain Trauma (Archived) (Nursing) -- Medical Management. Treatment depends on the severity of brain trauma.
statpearls_NBK430685\nurse-article-30545_24	Brain Trauma (Archived) (Nursing) -- Medical Management -- If no hemorrhage is present on CT or the patient meets criteria that CT is not indicated:	If the patient has a GCS of 15 and no focal neurologic deficits, the patient has a mild TBI and may be safely discharged. Post-concussive symptoms are possible and should be discussed with the patient. As previously discussed, some symptoms include headaches, mood changes, difficulty concentrating, or nausea. The patient may exhibit no symptoms and have a full recovery, or they may have symptoms that last for days to weeks. Some patients, especially those with a history of recurrent TBIs, may exhibit life-long symptoms. The patient should be cautioned to return for persistent nausea or vomiting, changes in mental status, seizures, weakness, numbness, severe headache, drainage from the ears or nose, or visual changes. If the patient had GCS of less than 15 or has any concerning exam findings, the patient may require further evaluation. Remember, it is possible to have medical reasons, including ischemic stroke, carotid or aortic dissection, or metabolic etiologies, which can lead to accidental traumatic injuries. The patient may require further laboratory studies or imaging. CT angiography or MRI may be a consideration if a non-contrast CT is non-diagnostic	Brain Trauma (Archived) (Nursing) -- Medical Management -- If no hemorrhage is present on CT or the patient meets criteria that CT is not indicated:. If the patient has a GCS of 15 and no focal neurologic deficits, the patient has a mild TBI and may be safely discharged. Post-concussive symptoms are possible and should be discussed with the patient. As previously discussed, some symptoms include headaches, mood changes, difficulty concentrating, or nausea. The patient may exhibit no symptoms and have a full recovery, or they may have symptoms that last for days to weeks. Some patients, especially those with a history of recurrent TBIs, may exhibit life-long symptoms. The patient should be cautioned to return for persistent nausea or vomiting, changes in mental status, seizures, weakness, numbness, severe headache, drainage from the ears or nose, or visual changes. If the patient had GCS of less than 15 or has any concerning exam findings, the patient may require further evaluation. Remember, it is possible to have medical reasons, including ischemic stroke, carotid or aortic dissection, or metabolic etiologies, which can lead to accidental traumatic injuries. The patient may require further laboratory studies or imaging. CT angiography or MRI may be a consideration if a non-contrast CT is non-diagnostic
statpearls_NBK430685\nurse-article-30545_25	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:	Airway Maintain SpO2 of at least 92% In patients with GCS under 8, intubation should be a strong consideration, as it is unlikely that they will be able to maintain their airway. Intubation:	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:. Airway Maintain SpO2 of at least 92% In patients with GCS under 8, intubation should be a strong consideration, as it is unlikely that they will be able to maintain their airway. Intubation:
statpearls_NBK430685\nurse-article-30545_26	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:	Patients should be pre-oxygenated as the risk of hypoxia outweighs the risk of hyperoxia. Historically lidocaine has been used for pre-treatment to blunt sympathetic response to airway manipulation during laryngoscopy, but studies have shown no definitive benefit. Etomidate allows hemodynamic stability and is a commonly used first-line agent for induction, though it has a reported risk of adrenal insufficiency. Propofol may be useful in lowering blood pressure, and thus the intracranial pressure in hypertensive patients. It may also have anti-epileptic effects. Ketamine has a theoretical risk of increasing intracranial pressure, though more recent studies have been equivocal on this. It may be useful in hypotensive patients to increase MAP and CPP. Paralytic agents such as rocuronium, vecuronium, or succinylcholine may be considered; however, these agents will limit the ability to perform a neurologic exam after administration. Breathing	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:. Patients should be pre-oxygenated as the risk of hypoxia outweighs the risk of hyperoxia. Historically lidocaine has been used for pre-treatment to blunt sympathetic response to airway manipulation during laryngoscopy, but studies have shown no definitive benefit. Etomidate allows hemodynamic stability and is a commonly used first-line agent for induction, though it has a reported risk of adrenal insufficiency. Propofol may be useful in lowering blood pressure, and thus the intracranial pressure in hypertensive patients. It may also have anti-epileptic effects. Ketamine has a theoretical risk of increasing intracranial pressure, though more recent studies have been equivocal on this. It may be useful in hypotensive patients to increase MAP and CPP. Paralytic agents such as rocuronium, vecuronium, or succinylcholine may be considered; however, these agents will limit the ability to perform a neurologic exam after administration. Breathing
statpearls_NBK430685\nurse-article-30545_27	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:	Hyperventilation is somewhat controversial. It may be transiently helpful in patients with increased intracranial pressure as hypocapnia may induce cerebral vasoconstriction and transiently decrease the expansion of hemorrhage; however, this is a temporizing measure to definitive management. Prolonged hypocapnia may cause cerebral ischemia. Targeting low-normal pCO2 of approximately 35 is reasonable. [9] Circulation	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:. Hyperventilation is somewhat controversial. It may be transiently helpful in patients with increased intracranial pressure as hypocapnia may induce cerebral vasoconstriction and transiently decrease the expansion of hemorrhage; however, this is a temporizing measure to definitive management. Prolonged hypocapnia may cause cerebral ischemia. Targeting low-normal pCO2 of approximately 35 is reasonable. [9] Circulation
statpearls_NBK430685\nurse-article-30545_28	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:	Maintain normotension with target SBP greater than 90 and less than 140 Initiate fluid resuscitation with normal saline with the goal of euvolemia. If the patient has hypotension that is refractory to fluid resuscitation, vasopressor support should be initiated. Phenylephrine may be the best choice for neurogenic shock as it has pure vasoconstriction effects, and studies have shown that it increases cerebral perfusion pressure (CPP) without increasing intracranial pressure (ICP). In patients who are bradycardic due to Cushing's reflex, norepinephrine may be a better choice. Packed red blood cells should be transfused for a goal of Hb over 10 mg/dL in severe TBI. Coagulopathy should be corrected. Increased intracranial pressure	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:. Maintain normotension with target SBP greater than 90 and less than 140 Initiate fluid resuscitation with normal saline with the goal of euvolemia. If the patient has hypotension that is refractory to fluid resuscitation, vasopressor support should be initiated. Phenylephrine may be the best choice for neurogenic shock as it has pure vasoconstriction effects, and studies have shown that it increases cerebral perfusion pressure (CPP) without increasing intracranial pressure (ICP). In patients who are bradycardic due to Cushing's reflex, norepinephrine may be a better choice. Packed red blood cells should be transfused for a goal of Hb over 10 mg/dL in severe TBI. Coagulopathy should be corrected. Increased intracranial pressure
statpearls_NBK430685\nurse-article-30545_29	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:	Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) - intracranial pressure (ICP) Elevation of the head of the bed to 30 degrees or reverse Trendelenburg positioning can lower ICP Hyperosmolar therapy via mannitol using bolus of 1 g/kg and/or hypertonic saline (dosing depends on the concentration available and vascular access) may be given to reduce ICP Seizures Patients with severe TBI, including GCS less than 10, cortical contusion, depressed skull fractures, subdural, epidural, subarachnoid, or intracerebral hemorrhage, penetrating head injury are at risk for seizures. Seizure activity that is apparent clinically or on EEG should be managed with benzodiazepines and anti-epileptic drugs (AEDs). Propofol may be optimal for post-intubation sedation. AED prophylaxis should be considered in severe TBI patients. Phenytoin or fosphenytoin are first-line, levetiracetam is an alternative that may have fewer side effects. Prophylaxis should be for 7 days.	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:. Cerebral perfusion pressure (CPP) = mean arterial pressure (MAP) - intracranial pressure (ICP) Elevation of the head of the bed to 30 degrees or reverse Trendelenburg positioning can lower ICP Hyperosmolar therapy via mannitol using bolus of 1 g/kg and/or hypertonic saline (dosing depends on the concentration available and vascular access) may be given to reduce ICP Seizures Patients with severe TBI, including GCS less than 10, cortical contusion, depressed skull fractures, subdural, epidural, subarachnoid, or intracerebral hemorrhage, penetrating head injury are at risk for seizures. Seizure activity that is apparent clinically or on EEG should be managed with benzodiazepines and anti-epileptic drugs (AEDs). Propofol may be optimal for post-intubation sedation. AED prophylaxis should be considered in severe TBI patients. Phenytoin or fosphenytoin are first-line, levetiracetam is an alternative that may have fewer side effects. Prophylaxis should be for 7 days.
statpearls_NBK430685\nurse-article-30545_30	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:	Neurosurgery consultation is necessary for patients with intracranial hemorrhage. While some patients may be monitored clinically and have repeat imaging studies to visualize if there is expansion, definitive management may be required. A Burr hole may help to evacuate a hematoma in an emergent setting with herniation. Patients may require a decompressive craniectomy. Patients may require close monitoring of intracranial pressure via an extraventricular drain (goal 10 to 15). [10] A multi-factorial approach is crucial to the long-term management of patients who have experienced brain trauma. Rehabilitation	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:. Neurosurgery consultation is necessary for patients with intracranial hemorrhage. While some patients may be monitored clinically and have repeat imaging studies to visualize if there is expansion, definitive management may be required. A Burr hole may help to evacuate a hematoma in an emergent setting with herniation. Patients may require a decompressive craniectomy. Patients may require close monitoring of intracranial pressure via an extraventricular drain (goal 10 to 15). [10] A multi-factorial approach is crucial to the long-term management of patients who have experienced brain trauma. Rehabilitation
statpearls_NBK430685\nurse-article-30545_31	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:	Many patients who have experienced brain trauma benefit from early initiation of rehabilitation services. Physical therapy, occupational therapy, and speech therapy are all considerations. After the initial stabilization, patients may benefit from care in an acute rehabilitation service or hospital, which allows the patient to undergo more intensive therapy. Patients will often need to continue therapy as an outpatient and may require new assistive devices or modifications to their homes or vehicles. Goal-directed treatment focuses on maximizing functional capacity is pursued during rehabilitation. Psychological impacts	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:. Many patients who have experienced brain trauma benefit from early initiation of rehabilitation services. Physical therapy, occupational therapy, and speech therapy are all considerations. After the initial stabilization, patients may benefit from care in an acute rehabilitation service or hospital, which allows the patient to undergo more intensive therapy. Patients will often need to continue therapy as an outpatient and may require new assistive devices or modifications to their homes or vehicles. Goal-directed treatment focuses on maximizing functional capacity is pursued during rehabilitation. Psychological impacts
statpearls_NBK430685\nurse-article-30545_32	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:	In addition to cognitive dysfunction and residual neurologic deficits, patients who have experienced brain trauma have increased rates of psychological disorders, including mood disorders, post-traumatic stress disorder, and schizophrenia. Psychotherapy or medications directed toward treating comorbid disorders can improve mental health and decrease the risk of suicide. Patients also benefit from having a network of support in their close friends and family as well as in the community as a whole. Case management or social workers can assist in providing outpatient resources in the community. [10] [11]	Brain Trauma (Archived) (Nursing) -- Medical Management -- If hemorrhage is present on CT:. In addition to cognitive dysfunction and residual neurologic deficits, patients who have experienced brain trauma have increased rates of psychological disorders, including mood disorders, post-traumatic stress disorder, and schizophrenia. Psychotherapy or medications directed toward treating comorbid disorders can improve mental health and decrease the risk of suicide. Patients also benefit from having a network of support in their close friends and family as well as in the community as a whole. Case management or social workers can assist in providing outpatient resources in the community. [10] [11]
statpearls_NBK430685\nurse-article-30545_33	Brain Trauma (Archived) (Nursing) -- Nursing Management	Assess vital signs Assess neurological status Check for elevation in ICP, look at pupillary response and size Manage pain Check cough and gag reflex Administer IV fluids Monitor ins and outs Administer oxygen if saturations less than 90% Provide suctioning Maintain Semi fowler position Maintain seizure precautions Provide prophylaxis against DVT and pressure sores Keep the patient in a quiet room with minimal traffic Provide sensory input and stimuli Educate patient and family about head trauma Turn the patient every few hours to prevent pressure ulcers	Brain Trauma (Archived) (Nursing) -- Nursing Management. Assess vital signs Assess neurological status Check for elevation in ICP, look at pupillary response and size Manage pain Check cough and gag reflex Administer IV fluids Monitor ins and outs Administer oxygen if saturations less than 90% Provide suctioning Maintain Semi fowler position Maintain seizure precautions Provide prophylaxis against DVT and pressure sores Keep the patient in a quiet room with minimal traffic Provide sensory input and stimuli Educate patient and family about head trauma Turn the patient every few hours to prevent pressure ulcers
statpearls_NBK430685\nurse-article-30545_34	Brain Trauma (Archived) (Nursing) -- Outcome Identification	Prognosis is highly variable in patients who have experienced brain trauma, but there are factors used to predict prognosis early in the course. Depth and duration of coma, post-traumatic amnesia, age, results of imaging studies (particularly CT), and intracranial pressure all contribute to the estimated prognosis. However, individual patients may always have better or worse outcomes depending on co-morbidities and unknown contributing factors. Low GCS, age greater than 60 or less than 2, and longer post-traumatic amnesia are all associated with worse outcomes.	Brain Trauma (Archived) (Nursing) -- Outcome Identification. Prognosis is highly variable in patients who have experienced brain trauma, but there are factors used to predict prognosis early in the course. Depth and duration of coma, post-traumatic amnesia, age, results of imaging studies (particularly CT), and intracranial pressure all contribute to the estimated prognosis. However, individual patients may always have better or worse outcomes depending on co-morbidities and unknown contributing factors. Low GCS, age greater than 60 or less than 2, and longer post-traumatic amnesia are all associated with worse outcomes.
statpearls_NBK430685\nurse-article-30545_35	Brain Trauma (Archived) (Nursing) -- Outcome Identification	Some patients will recover well and regain full functionality after brain trauma, particularly those who have experienced a mild traumatic brain injury. Patients who have experienced more severe traumatic brain injury may go on to have life-long deficits and significant disability. The most severe patients may die or persist in a vegetative state. [12]	Brain Trauma (Archived) (Nursing) -- Outcome Identification. Some patients will recover well and regain full functionality after brain trauma, particularly those who have experienced a mild traumatic brain injury. Patients who have experienced more severe traumatic brain injury may go on to have life-long deficits and significant disability. The most severe patients may die or persist in a vegetative state. [12]
statpearls_NBK430685\nurse-article-30545_36	Brain Trauma (Archived) (Nursing) -- Coordination of Care	An interprofessional team is crucial to successful treatment and rehabilitation of patients who have experienced brain trauma. A case manager or social worker can assist in providing information regarding resources, coordinating appointments, assisting with discharge planning, and working with insurance so that the patient may receive the care they need. Occupational therapists help in improving functional status and focus on activities of daily living, which may suffer severe limitations due to traumatic brain injuries; they may recommend alterations to the home to improve functional capacity. Physical therapists may recover strength, endurance, and coordination; they may also recommend the use of assistive devices and provide training on how to use them. Speech-language pathologists may evaluate and treat communication and swallowing difficulties. The nursing staff is vital at every stage, from providing intensive monitoring and potentially total care in an acute setting to educating patients in the longer term. A physiatrist may oversee the rehabilitation team and determine if a patient is appropriate for intensive rehabilitation programs. A primary care provider is key in long-term follow-up and coordinating care in patients with brain trauma. A neurologist is a physician who diagnoses and treats conditions of the nervous system, which include brain trauma and post-concussive syndrome. A neurosurgeon is a physician who determines the need for surgical intervention and performs such interventions as indicated. A neuropsychologist can perform more extensive cognitive testing and aid in assessing the patient's ability to manage their financial, legal, and medical decisions. If any pharmaceutical therapy plays a role in management, a pharmacist must be on the case to evaluate dosing, drug interactions, and counsel regarding adverse effect potential.	Brain Trauma (Archived) (Nursing) -- Coordination of Care. An interprofessional team is crucial to successful treatment and rehabilitation of patients who have experienced brain trauma. A case manager or social worker can assist in providing information regarding resources, coordinating appointments, assisting with discharge planning, and working with insurance so that the patient may receive the care they need. Occupational therapists help in improving functional status and focus on activities of daily living, which may suffer severe limitations due to traumatic brain injuries; they may recommend alterations to the home to improve functional capacity. Physical therapists may recover strength, endurance, and coordination; they may also recommend the use of assistive devices and provide training on how to use them. Speech-language pathologists may evaluate and treat communication and swallowing difficulties. The nursing staff is vital at every stage, from providing intensive monitoring and potentially total care in an acute setting to educating patients in the longer term. A physiatrist may oversee the rehabilitation team and determine if a patient is appropriate for intensive rehabilitation programs. A primary care provider is key in long-term follow-up and coordinating care in patients with brain trauma. A neurologist is a physician who diagnoses and treats conditions of the nervous system, which include brain trauma and post-concussive syndrome. A neurosurgeon is a physician who determines the need for surgical intervention and performs such interventions as indicated. A neuropsychologist can perform more extensive cognitive testing and aid in assessing the patient's ability to manage their financial, legal, and medical decisions. If any pharmaceutical therapy plays a role in management, a pharmacist must be on the case to evaluate dosing, drug interactions, and counsel regarding adverse effect potential.
statpearls_NBK430685\nurse-article-30545_37	Brain Trauma (Archived) (Nursing) -- Coordination of Care	A coordinated interprofessional team effort is absolutely essential in the diagnosis and management of brain trauma injuries, and only through this approach can patient outcomes achieve their optimal results. [Level V]	Brain Trauma (Archived) (Nursing) -- Coordination of Care. A coordinated interprofessional team effort is absolutely essential in the diagnosis and management of brain trauma injuries, and only through this approach can patient outcomes achieve their optimal results. [Level V]
statpearls_NBK430685\nurse-article-30545_38	Brain Trauma (Archived) (Nursing) -- Health Teaching and Health Promotion	Prevention is critical regarding brain trauma. Motor vehicle collisions, the most common cause of brain trauma, are not always preventable. However, some measures can be done to decrease risk, including wearing a seatbelt, not driving under the influence of drugs or alcohol, and using appropriate booster seats for children based on age. Bicyclists and motorcyclists should be encouraged to wear a helmet. There is active research on recurrent traumatic brain injuries in sports. In a patient who has already experienced brain trauma, it is important to not return to activities until he or she has improved. Recurrent brain trauma may put patients at risk of lifelong symptoms, and there may be cumulative and permanent effects.	Brain Trauma (Archived) (Nursing) -- Health Teaching and Health Promotion. Prevention is critical regarding brain trauma. Motor vehicle collisions, the most common cause of brain trauma, are not always preventable. However, some measures can be done to decrease risk, including wearing a seatbelt, not driving under the influence of drugs or alcohol, and using appropriate booster seats for children based on age. Bicyclists and motorcyclists should be encouraged to wear a helmet. There is active research on recurrent traumatic brain injuries in sports. In a patient who has already experienced brain trauma, it is important to not return to activities until he or she has improved. Recurrent brain trauma may put patients at risk of lifelong symptoms, and there may be cumulative and permanent effects.
statpearls_NBK430685\nurse-article-30545_39	Brain Trauma (Archived) (Nursing) -- Health Teaching and Health Promotion	In patients who have already experienced an injury, post-trauma recovery is a challenging process of physical, mental, and emotional recovery. Neurologic and psychiatric complications are common. Suicide prevention in patients who have experienced brain trauma is also essential, and patients should always be encouraged to seek help.	Brain Trauma (Archived) (Nursing) -- Health Teaching and Health Promotion. In patients who have already experienced an injury, post-trauma recovery is a challenging process of physical, mental, and emotional recovery. Neurologic and psychiatric complications are common. Suicide prevention in patients who have experienced brain trauma is also essential, and patients should always be encouraged to seek help.
statpearls_NBK430685\nurse-article-30545_40	Brain Trauma (Archived) (Nursing) -- Review Questions	Access free multiple choice questions on this topic. Comment on this article.	Brain Trauma (Archived) (Nursing) -- Review Questions. Access free multiple choice questions on this topic. Comment on this article.
statpearls_NBK430685\nurse-article-30554_0	Travelers Diarrhea (Nursing) -- Learning Outcome	List the causes of traveler's diarrhea Describe the presentation of traveler's diarrhea Summarize the treatment of traveler's diarrhea Recall the nursing role in the management of traveler's diarrhea	Travelers Diarrhea (Nursing) -- Learning Outcome. List the causes of traveler's diarrhea Describe the presentation of traveler's diarrhea Summarize the treatment of traveler's diarrhea Recall the nursing role in the management of traveler's diarrhea
statpearls_NBK430685\nurse-article-30554_1	Travelers Diarrhea (Nursing) -- Introduction	Travelers’ diarrhea is a common ailment in persons traveling to resource-limited destinations overseas. Estimates indicate that it affects nearly 40% to 60% of travelers depending on the place they travel, and it is the most common travel-associated condition. Bacterial, viral, and parasitic infections can cause symptoms, though bacterial sources represent the most frequent etiology. While travelers’ diarrhea is typically a benign self-resolving condition, it can lead to dehydration and, in severe cases, significant complications. [1] [2] [3]	Travelers Diarrhea (Nursing) -- Introduction. Travelers’ diarrhea is a common ailment in persons traveling to resource-limited destinations overseas. Estimates indicate that it affects nearly 40% to 60% of travelers depending on the place they travel, and it is the most common travel-associated condition. Bacterial, viral, and parasitic infections can cause symptoms, though bacterial sources represent the most frequent etiology. While travelers’ diarrhea is typically a benign self-resolving condition, it can lead to dehydration and, in severe cases, significant complications. [1] [2] [3]
statpearls_NBK430685\nurse-article-30554_2	Travelers Diarrhea (Nursing) -- Nursing Diagnosis	Inadequate fluid balance Pain Anxiety Inadequate nutrition Fatigue Ineffective control of bowel movements Fluid volume deficit Risk for decreased cardiac output Activity intolerance	Travelers Diarrhea (Nursing) -- Nursing Diagnosis. Inadequate fluid balance Pain Anxiety Inadequate nutrition Fatigue Ineffective control of bowel movements Fluid volume deficit Risk for decreased cardiac output Activity intolerance
statpearls_NBK430685\nurse-article-30554_3	Travelers Diarrhea (Nursing) -- Causes	The most common bacterial cause is enterotoxigenic Escherichia coli (ETEC), with estimates that the bacteria is responsible for nearly 30% of cases. Other common bacterial causes of travelers' diarrhea include Campylobacter jejuni , Shigella , and Salmonella species. Norovirus is the most common viral cause, while rotavirus is another source of infection. Giardia intestinalis is the most common parasitic source, while Cryptosporidium and Entamoeba histolytica can also cause travelers' diarrhea. The most common cause of travelers' diarrhea varies by region. In mild cases of Travelers' diarrhea, infectious bacteria are not identified. [4] [5] [6]	Travelers Diarrhea (Nursing) -- Causes. The most common bacterial cause is enterotoxigenic Escherichia coli (ETEC), with estimates that the bacteria is responsible for nearly 30% of cases. Other common bacterial causes of travelers' diarrhea include Campylobacter jejuni , Shigella , and Salmonella species. Norovirus is the most common viral cause, while rotavirus is another source of infection. Giardia intestinalis is the most common parasitic source, while Cryptosporidium and Entamoeba histolytica can also cause travelers' diarrhea. The most common cause of travelers' diarrhea varies by region. In mild cases of Travelers' diarrhea, infectious bacteria are not identified. [4] [5] [6]
statpearls_NBK430685\nurse-article-30554_4	Travelers Diarrhea (Nursing) -- Risk Factors	Estimates place the incidence of travelers’ diarrhea at 30% to 60% of travelers to resource-limited destinations. Incidence and causal agents vary by location, with the highest frequency reported in sub-Saharan Africa. Other locations with a high rate include Latin America, the Middle East, and South Asia. Risk factors are typically related to poor hygiene in resource-limited areas. These include poor hygienic practices in food handling and preparation, lack of refrigeration due to inadequate electrical supply, and poor food storage practices. Additional modifiable risk factors include proton pump inhibitor (PPI) use, recent antibiotic use, and unsafe sexual practices. Risk factors for severe complications are pregnancy, young or old age, travelers with underlying chronic gastrointestinal diseases, or people who are immunocompromised. [7] [8]	Travelers Diarrhea (Nursing) -- Risk Factors. Estimates place the incidence of travelers’ diarrhea at 30% to 60% of travelers to resource-limited destinations. Incidence and causal agents vary by location, with the highest frequency reported in sub-Saharan Africa. Other locations with a high rate include Latin America, the Middle East, and South Asia. Risk factors are typically related to poor hygiene in resource-limited areas. These include poor hygienic practices in food handling and preparation, lack of refrigeration due to inadequate electrical supply, and poor food storage practices. Additional modifiable risk factors include proton pump inhibitor (PPI) use, recent antibiotic use, and unsafe sexual practices. Risk factors for severe complications are pregnancy, young or old age, travelers with underlying chronic gastrointestinal diseases, or people who are immunocompromised. [7] [8]
statpearls_NBK430685\nurse-article-30554_5	Travelers Diarrhea (Nursing) -- Assessment	The onset of symptoms will typically occur one to two weeks after arrival in a resource-limited destination, though travelers can develop symptoms throughout their stay or shortly after arrival. Diagnostic criteria for Travelers' diarrhea are three or more loose stools in 24 hours or a two-fold increase from baseline bowel habits. Diarrhea often occurs precipitously and is accompanied by abdominal cramping, fever, nausea, or vomiting. The patients' review of systems should include blood in their stool, fever, chills, or any associated symptoms. A thorough travel history should be obtained, including timeline and itinerary, diet and water consumption at their destination, illnesses in other travelers, and possible sexual exposures.	Travelers Diarrhea (Nursing) -- Assessment. The onset of symptoms will typically occur one to two weeks after arrival in a resource-limited destination, though travelers can develop symptoms throughout their stay or shortly after arrival. Diagnostic criteria for Travelers' diarrhea are three or more loose stools in 24 hours or a two-fold increase from baseline bowel habits. Diarrhea often occurs precipitously and is accompanied by abdominal cramping, fever, nausea, or vomiting. The patients' review of systems should include blood in their stool, fever, chills, or any associated symptoms. A thorough travel history should be obtained, including timeline and itinerary, diet and water consumption at their destination, illnesses in other travelers, and possible sexual exposures.
statpearls_NBK430685\nurse-article-30554_6	Travelers Diarrhea (Nursing) -- Assessment	In most self-limited cases, a physical examination will show mild diffuse abdominal tender to palpation. Providers should assess for dehydration through skin turgor and capillary refill. In more severe cases, patients may have severe abdominal pain, high fever, and evidence of hypovolemia (tachycardia, hypotension).	Travelers Diarrhea (Nursing) -- Assessment. In most self-limited cases, a physical examination will show mild diffuse abdominal tender to palpation. Providers should assess for dehydration through skin turgor and capillary refill. In more severe cases, patients may have severe abdominal pain, high fever, and evidence of hypovolemia (tachycardia, hypotension).
statpearls_NBK430685\nurse-article-30554_7	Travelers Diarrhea (Nursing) -- Evaluation	Laboratory investigation is typically not required in most cases. However, stool studies are indicated for patients with high fever, hematochezia, or tenesmus. Typical stool studies include stool culture, fecal leukocytes, and lactoferrin. The stool should be assessed for ova and parasites in patients with longer duration of symptoms. New multiplex polymerase chain reaction (PCR) screens are becoming available and provide a quick analysis of multiple stool pathogens. These screens, however, are expensive, are not widely available, and may not change the clinical management of patients. [4]	Travelers Diarrhea (Nursing) -- Evaluation. Laboratory investigation is typically not required in most cases. However, stool studies are indicated for patients with high fever, hematochezia, or tenesmus. Typical stool studies include stool culture, fecal leukocytes, and lactoferrin. The stool should be assessed for ova and parasites in patients with longer duration of symptoms. New multiplex polymerase chain reaction (PCR) screens are becoming available and provide a quick analysis of multiple stool pathogens. These screens, however, are expensive, are not widely available, and may not change the clinical management of patients. [4]
statpearls_NBK430685\nurse-article-30554_8	Travelers Diarrhea (Nursing) -- Evaluation	Radiological studies are not required in most cases. Kidneys, ureters, and bladder studies can be obtained to assess for acute intra-abdominal pathology or look for evidence of perforation in severe cases. An abdominal computerized tomography (CT) can also be used as a diagnostic tool for intraabdominal pathology in severe cases.	Travelers Diarrhea (Nursing) -- Evaluation. Radiological studies are not required in most cases. Kidneys, ureters, and bladder studies can be obtained to assess for acute intra-abdominal pathology or look for evidence of perforation in severe cases. An abdominal computerized tomography (CT) can also be used as a diagnostic tool for intraabdominal pathology in severe cases.
statpearls_NBK430685\nurse-article-30554_9	Travelers Diarrhea (Nursing) -- Medical Management	Travelers' should receive education concerning risk reduction before travel. Learning objectives include avoiding tap water and ice, frequent hand washing, avoiding leafy vegetables or unpeeled fruit, and avoiding street food. Bismuth subsalicylate (two tabs four times a day) can be used for prophylaxis and can reduce the incidence of travelers' diarrhea by almost half. However, children and pregnant women should avoid Bismuth due to salicylate side effects. In short high-stakes travel, it may be reasonable to start antibiotics as prophylaxis. This is not advisable for longer-term travel. Rifaximin is a commonly used chemoprophylaxis due to its minimal systemic absorption and minimal side effects. [9] [10] [11] [10]	Travelers Diarrhea (Nursing) -- Medical Management. Travelers' should receive education concerning risk reduction before travel. Learning objectives include avoiding tap water and ice, frequent hand washing, avoiding leafy vegetables or unpeeled fruit, and avoiding street food. Bismuth subsalicylate (two tabs four times a day) can be used for prophylaxis and can reduce the incidence of travelers' diarrhea by almost half. However, children and pregnant women should avoid Bismuth due to salicylate side effects. In short high-stakes travel, it may be reasonable to start antibiotics as prophylaxis. This is not advisable for longer-term travel. Rifaximin is a commonly used chemoprophylaxis due to its minimal systemic absorption and minimal side effects. [9] [10] [11] [10]
statpearls_NBK430685\nurse-article-30554_10	Travelers Diarrhea (Nursing) -- Medical Management	The foundation of diarrhea management is fluid repletion. In mild cases, travelers should focus on increasing fluid intake. Water is usually sufficient exclusively. However, sports drinks, Pedialyte, and other electrolyte fluids can be substituted. Travelers' should avoid milk and juice, as this can worsen diarrhea. In more severe cases, oral rehydration salt tablets can rehydrate a depleted individual. In cases of severe dehydration, intravenous fluids are advised.	Travelers Diarrhea (Nursing) -- Medical Management. The foundation of diarrhea management is fluid repletion. In mild cases, travelers should focus on increasing fluid intake. Water is usually sufficient exclusively. However, sports drinks, Pedialyte, and other electrolyte fluids can be substituted. Travelers' should avoid milk and juice, as this can worsen diarrhea. In more severe cases, oral rehydration salt tablets can rehydrate a depleted individual. In cases of severe dehydration, intravenous fluids are advised.
statpearls_NBK430685\nurse-article-30554_11	Travelers Diarrhea (Nursing) -- Medical Management	Treatment is supportive in mild-moderate cases. In patients without signs of inflammatory diarrhea, loperamide can be used for symptomatic relief. The typical dose for adults is 4 mg initially with 2 mg after each subsequent loose stool, not to exceed 16 mg total in a day.	Travelers Diarrhea (Nursing) -- Medical Management. Treatment is supportive in mild-moderate cases. In patients without signs of inflammatory diarrhea, loperamide can be used for symptomatic relief. The typical dose for adults is 4 mg initially with 2 mg after each subsequent loose stool, not to exceed 16 mg total in a day.
statpearls_NBK430685\nurse-article-30554_12	Travelers Diarrhea (Nursing) -- Medical Management	Also, travelers can be prescribed antibiotics to take as needed at the onset of symptoms. Ciprofloxacin is commonly used for treatment, though there are concerns with resistance with Campylobacter species. For this reason, fluoroquinolones are not the drug class of choice for travelers to Asia. Azithromycin is preferred, especially for pregnant travelers and children. A standard regimen is 500 mg daily for three days, though evidence suggests that a single dose of 1000 mg may be slightly more effective. Parents can be given azithromycin powder with instructions to mix with water when needed. Rifaximin is a minimally absorbed antibiotic that is also available and is safe for older children and pregnant travelers.	Travelers Diarrhea (Nursing) -- Medical Management. Also, travelers can be prescribed antibiotics to take as needed at the onset of symptoms. Ciprofloxacin is commonly used for treatment, though there are concerns with resistance with Campylobacter species. For this reason, fluoroquinolones are not the drug class of choice for travelers to Asia. Azithromycin is preferred, especially for pregnant travelers and children. A standard regimen is 500 mg daily for three days, though evidence suggests that a single dose of 1000 mg may be slightly more effective. Parents can be given azithromycin powder with instructions to mix with water when needed. Rifaximin is a minimally absorbed antibiotic that is also available and is safe for older children and pregnant travelers.
statpearls_NBK430685\nurse-article-30554_13	Travelers Diarrhea (Nursing) -- Nursing Management	Obtain a travel history of diarrhea and abdominal discomfort Determine how many episodes of diarrhea patient is having Assess vital signs Assess orthostasis and degree of dehydration Manage nausea Send stools for culture Encourage oral fluid intake Encourage patient to avoid spicy, fatty and high carbohydrate foods Avoid medications that slow down bowel movements Administer loperamide when ordered Teach patient proper handwashing Educate patient on washing foods and the use of clean water Educate patient on traveler's diarrhea When traveling, tell the patient to drink bottled water	Travelers Diarrhea (Nursing) -- Nursing Management. Obtain a travel history of diarrhea and abdominal discomfort Determine how many episodes of diarrhea patient is having Assess vital signs Assess orthostasis and degree of dehydration Manage nausea Send stools for culture Encourage oral fluid intake Encourage patient to avoid spicy, fatty and high carbohydrate foods Avoid medications that slow down bowel movements Administer loperamide when ordered Teach patient proper handwashing Educate patient on washing foods and the use of clean water Educate patient on traveler's diarrhea When traveling, tell the patient to drink bottled water