Appraisal of the Nursing Care and Management of a Patient with Traumatic Brain Injury (TBI)

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Introduction

Traumatic Brain Injury (TBI) presents a pressing global health issue, necessitating a nuanced understanding of its multifaceted impact on individuals and society. The purpose of this paper is to systematically evaluate nursing care and management of a patient with traumatic brain injury (TBI), which globally affects around 69 million individuals annually with considerable variations determined by socioeconomic and demographic considerations (Dewan et al., 2018). In the UK, TBI is responsible for one million four hundred thousand yearly emergency department presentations and thus is an important concern for nursing practice (NICE, 2023). The aim of this study is to explore three interrelated aspects: the epidemiological background of risk and prevalence, the evidence-based management of a key complication – that is raised ICP – and the nurse’s role in promoting interprofessional collaboration. Both very much in line with the learning outcomes of the module as primarily critical evaluations and justifications of care strategies, this appraisal attempts to close the gap between the level of practice described as mere description and that requiring Level 7 advanced analytical skills, at which level nurses should be able to synthesize bioscientific evidence with contextual insights (Maas et al., 2022). The intention of this writing, therefore, is to provide a comprehensive model for managing TBI using acute care and long-term rehabilitation efforts to improve patient outcomes. The logic is based on literature such as Silverberg et al. (2019), which show the long-term sequelae of TBI, but there is a well-justified caveat against overreliance on current evidence bases, which the outcomes are assumed to show interpretation variability.

Epidemiology

A most profound global health catastrophe is represented by Traumatic Brain Injury (TBI) with the very broad incidence and varied etiologies that create a complex picture in epidemiology. Around 69 million new cases are estimated to occur each year worldwide, as per a comprehensive systematic review by Dewan et al. (2018) on the subject that included data from 57 countries. Nonetheless, the true number would be far greater as the actual surveillance is inconsistent, the definitions of TBI severity are heterogeneous, and many LMICs underreport incidents primarily due to poor diagnostic and reporting infrastructure. Data from HICs such as the United Kingdom reports an incidence of around 106 per 100,000 population, which dramatically contrasts with rates that are recorded between 150-170 per 100,000 in LMICs, where road traffic accidents happen to be the leading cause (Iaccarino et al., 2021). TBI leads to about 1.4 million visits to the emergency department in the UK per year, with 10-15% falling into the category of moderate to severe, largely involving young males (15-29 years) from high-energy mechanisms like sports injuries and motor vehicle collisions, and older adults more than 65 years via falls (NICE, 2023). These patterns show a demographic divide that mirrors behaviourally risky conduct in youth and physical vulnerability in the elderly, warranting nursing strategies tailored to these distinct groups.

The critical appraisal of these epidemiological sources gives rise to significant methodological challenges, thereby rendering them neither reliable nor comparable. Dewan et al.’s (2018) global evaluation, while more credible, pools together information from studies that differ widely in their methodologies, from hospital records to surveys of the general population, leading invariably to varied definitions and recording of TBI severity. Mild TBIs, seldom treated outside the hospital, are often excluded, resulting in an underestimation of prevalence figures. Similarly, NICE (2023) guidelines provide an excellent national view derived from UK hospital data. Still, it does not capture the milder cases managed in primary care or community settings, likely underestimating the actual burden by up to 20-30% by some community-based studies (Maas et al., 2022). These limitations arise because the mediation of reporting on injury cases is predicated on indirect access to healthcare services rather than the injury incidence itself. Such critiques leave these statistics somewhat provisional; therefore, nurses should understand them cautiously and campaign for better surveillance systems that capture the whole spectrum of TBI cases.

Age can be the ultimate determinant of the incidence and outcome of TBI, in combination with other factors, such as physiological and behavioral. For instance, the group of young adults (15-29 years) has a predisposition to high-energy mechanisms such as road traffic accidents and contact sports, which are generally associated with risk-taking behaviors often fueled by peer dynamics or specific occupational exposure (Hume et al., 2022). Older adults above 65 years are more susceptible to falls, and the incidence of these falls increases with age, as it may be impacted by frailty, multimorbidity, and polypharmacy that interfere with balance and reaction time (Fu et al., 2017). In the UK, more than 50% of TBIs are attributable to falls among this age group, and this picture remains the same globally with aging populations (NICE, 2023). Reviewing the evidence, Fu et al.’s (2017) community-based study in Canada provides a good deal of information on fall-related TBI among older persons with prospects in the form of large databases to determine predictors such as osteoporosis and gait instability. One minus here, however, concerns the nature of the setting, as Canada has some differences in healthcare access and environmental factors relative to the UK. Thus, further local validation is needed. Such age-related patterns warrant nursing intervention, whereby practices education about safety adoption would form part of the young adult programs, while fall assessment interventions for older people would involve home safety assessment and balance training.

Increased intake of alcohol increases the tendency of a person towards TBI, as many studies have found alcohol involved in 30-50% of such cases, and impaired judgment, slower reaction times, and higher susceptibility to accidents, which all belong to factors related to alcohol, increase the risk (Weil et al., 2018). Binge drinking is common in young men and, among older adults, alcohol and medication may interact to further promote falls into this risk factor. Reviews by Weil et al. (2018) integrate both mechanistic data from human and animal studies and indicate that acute alcohol intoxications can decrease cerebral metabolism, and in some instances neuroprotective effects may be afforded. This benefit, however, is countered by empirical evidence hounding diagnostic delays and worsened prognoses resulting from coagulopathy. Methodological differences—defining intoxication by different thresholds—introduce further inconsistencies: some studies use bias-prone self-reports, while others apply blood alcohol levels with varying cutoff points. Such differences underscore the imperatives of differentiated nursing strategies-that is, context-specific screening for alcohol use for emergency settings and provision of brief interventions to help prevent further cases.

SES makes the most substantial contributions to precursors of vulnerability, and the more disadvantaged SES groups are likely to experience increased tortuosity through access to unsafe environments, occupational hazards, and barriers toward rehabilitation (Venturini et al., 2024). UK citizens living in deprived areas are three times more likely to have sustained a TBI than counterparts in such areas. Factors associated with this disparity include inadequate housing, limited access to preventive healthcare, and increased incidence of alcohol-related injuries (Crozes et al., 2024). This is seen worldwide, but most particularly in low- and middle-income countries, where poverty is often related to increased dangers for road network accidents, due to poor infrastructure and lack of safety regulations (Iaccarino et al., 2021). The systematic review by Venturini et al. (2024) shows SES as a predictor of poor outcomes from diverse datasets. But still, causal inference is limited due to its sole reliance on observational studies, which may be confounded by pre-existing health conditions. Nursing practice, as an implication, would advocate a more equitable allocation of resources such as community-based rehabilitation programs, thereby creating room for addressing the differences and reducing the societal burden of TBI.

The gesturing and scope technique enables a deeper exploration of falls in older adults by moving beyond the physical injury to aspects such as psychological health and social roles, as the senior population continues to age. It has been noted that such falls not only inflict direct head trauma; they also serve to trigger a cascade of injuries that lead to reduced mobility, loss of independence, and an increased dependence on caregivers (Mattingly and Roth, 2022). Therefore, an elderly patient may shift from independent living to needing constant support, engendering isolation and depression so as not to facilitate recovery because of a reduced neuroplasticity (Hume et al., 2022). It shows how falls come together with age-related vulnerabilities like sarcopenia and cognitive decline, making it worth the effort to target nursing interventions toward physiotherapy and environmental modifications. TBI, from a societal level, currently carries UK costs estimated at £15 billion annually, which relates to healthcare expenditures, rehabilitation, and decreased productivity (Crozes et al., 2024). However, such a figure varies in accordance with methodology, hospital-focused estimates versus societal perspectives that include indirect costs like criminal justice involvement, where 60% of offenders report TBI histories, six times the general population rate (Haarbauer-Krupa et al., 2021).

The relationship between TBI and crime remains disputed, some attributing impulsivity and aggression to brain injury effects, while others suggest that existing vulnerabilities such as social poverty are the primary causes (Haarbauer-Krupa et al., 2021). Methodological constraints, including a generally short follow-up period and sampling bias through prison populations, make causality a fuzzy area. Still, the link with chronic conditions such as dementia — most often in older adults, but serious nonetheless — points to a long-term public health problem (Silverberg et al., 2019). That association needs to be critically evaluated not just in terms of the purely medical, but instead viewed within a biopsychosocial framework; this defines the areas where nursing advocacy is needed for promoting rehabilitation instead of punishment. Societally, these determinants reveal inequities: LMICs are faced with this burden chiefly because of poor prevention, while UK disparities in rehabilitation access will still perpetuate cycles of disability, making healthcare systems even worse off in the context of an ageing population (Maas et al., 2022).

Overall, the epidemiological profile of TBI is dependent on demographic, behavioral, and socioeconomic determinants with incidence and outcome being significantly driven by factors such as age, alcohol consumption, and SES-related issues. Although national and UK data provide a valid starting point for generalizing its magnitude, the validity is reduced due to inconsistencies in methodologies, for example, underreporting and various definitions, leading to a call for nurses to interpret statistics and advocate for better surveillance critically. The focus on falls in the elderly is an excellent example that calls for the targeting of interventions to address both individual harms like lost independence and societal burdens such as economic strain. Henceforth, nursing practice should engage in addressing these broader determinants of TBI through policy development, community outreach, and fair distribution of care.

Evidence-Based Nursing Assessment and Care Management

Nursing care has a great challenge coming from Traumatic Brain Injury (TBI), especially when dealing with its secondary complications such as raised intracranial pressure (ICP), which can lead to cerebral herniation and death due to the deprivation of cerebral perfusion pressure (CPP) as well as oxygen delivery (Rakhit et al., 2020). Nursing care can only be promoted effectively in terms of evidence-based assessment and management techniques. Even then, these two aspects require a blending of bioscientific knowledge and critical evaluation tailored to the context of the patient. Thus, this discussion will center on identification tools and management interventions, that is, the Glasgow Coma Scale (GCS) and the Full Outline of Unresponsiveness (FOUR) score for assessment; head-of-bed elevation, mannitol, and hypertonic saline for ICP therapy, evaluating their strengths, limitations, and justification within the TBI context.

The neurological examination is arguably one of the first steps in identifying raised ICP. The Glasgow Coma Scale (GCS) is perhaps the most widely recognized instrument in measuring eye, verbal, and motor responses on a scale of 3 to 15. Fast and standard approach for triage and prognostication (van Dijck et al., 2018). The fact that it has become incorporated into guidelines such as NICE (2023) enhances its potential application for interdisciplinary communication. However, on critical appraisal, it reveals limitations: the issue of inter-rater reliability being significant, especially in cases where patients are sedated or intubated, appears to be hollow from findings in the systematic review of Reith et al. (2017) in which all of these clinical studies were found to disagree because of subjective interpretation. The FOUR score, on the other hand, accommodates brainstem reflexes and respiratory patterns thus allowing for a more comprehensive assessment in an intensive care environment and could potentially enhance reliability for the comatose patient (Nunes Dos Santos and Stayt, 2025). The evidence supporting this tool, however, is somewhat limited, and most of its validation has been done in a few select populations: this limits its generalizability in comparison to the GCS that is accepted internationally. It must be justified that using the GCS, as a primary tool, is best; its advantages of being simple and offering prognostic value overweight the stated disadvantages when combined with FOUR in more complex situations, to ensure that patients receive a holistic assessment that caters to their acute needs, for instance by managing the airway in TBI patients, while not delaying unnecessary diagnosis.

A raised ICP can be therapeutically managed through an intervention that would indicate the physiological effects caused by the ICP. For instance, elevation of the head of bed at 30 degrees works as a non-pharmacological strategy so that venous drainage increases and the ICP can be reduced by gravity-mediated reduction of cerebral blood volume (Godoy et al., 2017). Recommended by NICE (2023), this intervention is very simple, highly economical, and immediately applicable, hence it’s first-line for resource-poor contexts. Biologic optimization of cerebral hemodynamics reduces secondary injury as shown by physiological studies; however, it could result in decreased CPP in the hypotensive patient, wherein continued monitoring is critically required to prevent ischemia, rarely in TBI patients with unstable vitals. This is an offer of strength in being non-invasive: however, the evidence base from observational studies in small patient samples does not constitute the stringent nature of randomized trials, implying very cautious application.

Mannitol, given pharmacologically, acts as an osmotic diuretic to rapidly reduce ICP by removal of fluid from brain tissue into the blood so as to create an osmotic gradient that decreases brain edema (Figueiredo et al., 2024). So rapid is its onset, as observed from randomized trials, that it has become the most preferred of acute interventions in emergencies presenting with sudden ICP spikes endangering herniation. However, its galaxy of dangers, including those of hypovolemia or renal toxicity, especially in volume-depleted TBIs, necessitate careful patient selection and monitoring, as critiqued in guidelines from Abdelmalik et al. (2019) pointing out that older studies tended to favor mannitol. In contrast, hypertonic saline maintains intravascular volume while causing shrinkage of edema and is thus a safer option in cases of hypotension (Figueiredo et al., 2024). Its superiority was confirmed in a meta-analysis by Thapa et al. (2021) as far as safeguarding CPP is concerned; however, caution was advised in management of electrolyte imbalances such as hypernatremia. Among the two options, mannitol is the faster agent suitable for euvolemic patients. At the same time, the hypertonic saline volume-sparing effect addresses frequent hypovolemia associated with TBI better, justifying a context-specific choice—mannitol for initial control, saline for sustainable management—based on hemodynamic stability.

From these assessment and management strategies, one can utilize the technique of gesturing and scope to focus on the broader aspect of how increased ICP influences patient independence, a significant outcome in the management of TBI. Increased ICP, if left uncontrolled, can lead to a long period of unconsciousness, motor deficits, and impaired cognition, and can severely limit a patient’s ability to perform daily activities. The example of an elderly TBI patient with chronic increases of ICP can illustrate the changes in the patient’s life. This patient may shift from independent living to requiring constant caregiving and further create rift in the personal relationships because family dynamics will now turn into dependency. Such a development will ultimately bring loss of autonomy, which can kindle mental health problems like depression or anxiety aggravated by social isolation due to mobility challenges suffered by the dependent individual. These findings are in agreement with those of Hume et al. (2022) concerning reduced neuroplasticity due to aging. Work performance is also affected, since severe TBI survivors have unemployment rates of 60% in the long run (Maas et al., 2022). This phenomenon also points out the making of the cascading impacts of pierce disabilities in ICP. In other words, effective management of ICP involves more than just ensuring a physiological equation; it also requires a determination in the quality of life, thus endorsing nursing efforts geared at optimizing the precision of assessment and intervention. Individualized care plans are necessary because even measures such as hypertonic saline and head elevation, aimed at preventing such outcomes, are not always practical.

The evaluation further validates these choices within the TBI-ICP setting. GCS, with all its imperfections, is the best initial tool available, being well-accepted universally and being easily learnt, while FOUR enhances the accuracy in questionable severe cases, where a timely escalation to advanced care is warranted (Reith et al., 2017; Nunes Dos Santos and Stayt, 2025). Just as head elevation is a practical first step due to its non-invasive nature, it warrants some monitoring; nevertheless, it has to be said that some available data on efficacy is not that strong on its own (Godoy et al., 2017). While mannitol fits well for acute ICP rises because of its rapid action, the side effects make hypertonic saline a better choice for those patients who are not so stable. This would be particularly true regarding the extras of volume status, which are closely tied to the hemodynamic challenges associated with TBI (Figueiredo et al., 2024; Thapa et al., 2021). These choices indicate balanced considerations of effectiveness, safety, and practicality, oriented to the acute nature of ICP changes, who may die with any delay or mismanagement concerning TBI.

Interprofessional collaboration involves nurses working with neurosurgeons and intensivists to monitor ICP trends and modify interventions (Matney et al., 2022). Because of their continual contact with patients, nurses have the opportunity to obtain changes early. However, Palusac et al. (2022) state that barriers such as staffing shortages can obstruct timely engagement. Digital tools for communication are dependent on electronic records in well-resourced settings; in contrast, inequitable access can undermine the effectiveness of such an approach, an aspect that emphasizes the nurses’ role in advocating for systematic support directed at sustaining evidence-based care. Thus, in conclusion, evidence-based nursing assessment and management of raised ICP due to TBI require critical synthesis of the tools and strategies involved on the grounds of their strengths and weaknesses in a given context. GCS and FOUR provide an excellent evaluation tool. At the same time, head elevation, mannitol, and hypertonic saline furnish tiered options for management, with their implementation honed based on the specifics of the patient. When narrowed to autonomy, much larger stakes can be invoked, thereby promoting a holistic strategy that interrelates physiologic control with psychosocial support, wherein nurses play a pivotal role in leveraging outcomes in the presence of clinical and systemic challenges.

Conclusion

This assessment has comprehensively evaluated how nursing care and management of Traumatic Brain Injury (TBI) have been addressed concerning epidemiology, raised intracranial pressure (ICP) management, and interprofessional collaboration, hence indicating the pressing need for an integrated evidence-based approach to this complex condition. Globally, approximately 69 million cases of TBIs occur annually, as revealed by epidemiological insights. In contrast, the UK sees 1.4 million emergency department attendances due to age-related risks, including falls in older adults and high-energy incidents in young people. Although these numbers are still very preliminary due to the underreporting and methodological inconsistencies, they signify the need for better-designed surveillance and focused preventive measures, for example, fall prevention programs, to reduce both the personal and societal burdens, including an economic cost of over £15 billion per year in the UK. The appropriate employment of Glasgow Coma Scale (GCS) and Full Outline of Unresponsiveness (FOUR) score in the management of raised ICP, alongside interventions like hypertonic saline and head elevation, reflects a context-specific balance of efficacy and safety. At the same time, evidence gaps call for process refinement. Narrowing to the impact on independence highlights the cascading effects on mental health and relationships, reinforcing the need for holistic care. Interprofessional collaboration, led by nurses, enhances outcomes but faces barriers like staffing shortages, emphasizing the need for systemic support. This synthesis aligns with a biopsychosocial model, advocating for acute interventions paired with long-term rehabilitation to address inequities and chronic sequelae like dementia. For nursing practice, this demands moving beyond descriptive application to critically appraise evidence, tailoring strategies to diverse contexts, and advocating for resource allocation. Future efforts should prioritize standardized data collection, advanced assessment tools, and multidisciplinary training to reduce TBI’s multifaceted impact, positioning nurses as central integrators in this evolving healthcare landscape.

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‌Talbot, K.J., Krüger, E. and Pillay, B.S. (2023). Experiences of acquired brain injury one-month post-discharge from acute hospitalization. African Journal of Disability, 12. doi: https://doi.org/10.4102/ajod.v12i0.1037

‌Brain Trauma Foundation Guidelines Summary: BTF Management of Severe TBI (4 th Edition) Shyam Murali, MD @smuramed Original document: Guidelines for the Management of Severe Traumatic Brain Injury (4 th Edition). (n.d.).Available at: https://criticalcarenow.com/wp-content/uploads/2020/11/BTF-Guidelines-for-TBI-Management.pdf.

Blackwood, T.J. (2024). Psychiatric Mental Health Nursing Made Easy: Beginner’s Guide to Mental Health Nursing. Jstone Publishing.

Avramović, P., Rietdijk, R., Attard, M., Kenny, B., Power, E. and Togher, L. (2022). Cognitive and behavioural digital health interventions for people with traumatic brain injury and their caregivers: a systematic review. Journal of Neurotrauma, 40(3-4). doi: https://doi.org/10.1089/neu.2021.0473

‌Palusak, C., Shook, B., Davies, S.C. and Lundine, J.P. (2022). A scoping review to inform care coordination strategies for youth with traumatic brain injuries: Care coordination personnel. International Journal of Care Coordination, p.205343452110706. doi: https://doi.org/10.1177/20534345211070647