Concussion: Why Nurses Need to Understand This Hidden Injury

Ann Worley


Pediatr Nurs. 2019;45(5):235-243. 

In This Article

Management and Treatment

Management at Home After Discharge

Because signs and symptoms are key indicators of progression of healing, symptom monitoring is essential to manage the child's period of return to their routine activities When a child is initially discharged to home, the provider should emphasize the key to recovery is relative rest in the first 2 to 3 days – physical, mental, and emotional. Complete bed rest, however, is not necessary (AAN, 2013; McCrory et al., 2017). The new Pediatric mTBI Guideline advises that inactivity beyond this period may actually worsen self-reported symptoms (CDC, 2018). Contrary to outdated practice, there is no need to wake the child up every few hours during the night to check on the child if he/she sustained an uncomplicated concussion; in fact, sleep is essential to the healing process, and the child should be allowed to take frequent naps during the day as needed (Children's Health, 2018). The new guideline emphasizes the benefits of early noncontact aerobic activity in this initial recovery period (Lumba-Brown et al., 2018).

The importance of social supports available to the child should also be assessed, and nurses can assist persons who are significant social contacts in the child's life to provide emotional reassurance, positive affirmation, and problem-solving interventions to optimize recovery (Sarmiento et al., 2018).

Return to Academics

The proposed recommendation for return to school or academics is the ability to concentrate for a minimum of 30 minutes (Gioia, 2016), although the child does not need to be symptom-free to return to school (Caine et al., 2014). After the child's medical clearance, all school personnel should be made aware of the injury, and academic modifications, such as reduction of homework, exemptions from standardized tests, and extra time to complete assignments, may be required. Returning to academics should be incremental, and if symptoms return with increased mental exertion, efforts should be scaled back before increasing workload. Prolonged symptoms may require additional formalized supports, such as an Individualized Educational Plan or a federal 504 plan (Lumba-Brown et al., 2018).

Return to Sports

The child should have returned to school prior to returning to sports. If any symptoms are present, the child should sit out physical education, physical activity at recess, and all practices and games. The child should avoid all strenuous exercise and any activity that triggers return of symptoms or activities that could potentially result in a second impact. Participation in low-risk, non-contact physical exercise should be gradually increased with close physician monitoring at each progressive level, staying below levels that do not exacerbate symptoms. If symptoms occur, the athlete may attempt the next level only after a minimum asymptomatic period of 24-hours (Lumba-Brown et al., 2018; McCrory et al., 2017).

Care Plan: Roadmap to Recovery

No concussed student should return to school without a formal plan prescribed by a qualified health care provider. The CDC Pediatric Guideline recommended that modifications outlined in the plan be customized to the individual child (CDC, 2018); however, successful implementation requires collaboration and communication among all school personnel, the family, the child's physician, and the athlete him/herself. The school nurse frequently serves as point of contact and coordinator of the child's team, liaison with the physician, and is often responsible for monitoring the child's changing needs in order to recommend continued modifications. Care plans are most effectively executed when the care team is knowledgeable about current concussion practice, when member roles are clearly defined, and when a standard management policy is in place and strictly followed (Gioia, 2016).