2.

5
Continuing Education
HOURS

Because these injuries can go unrecognized,

nurses stateside need to know how to recognize
possible cases and how to help.

injury
Overview: When traumatic brain
eously with more
(TBI) occurs simultan
ing wounds, it
obviously life-threaten
Civilians and military
may go unrecognized.
near combat zones are
personnel working in or
st-related and closed-
at risk for this injury. Bla
n penetrating injuries,
head injuries, rather tha
ion.
of TBIs in this populat
constitute the majority
experiences of the
The authors describe the
Brain Injury Center
Defense and Veterans
my Medical Center
team at Walter Reed Ar
d present a composite
in Washington, DC, an
rse’s role in the
case to illustrate the nu
the TBI patient.
assessment and care of

40 AJN ▼ April 2008 ▼ Vol. 108, No. 4 http://www.nursingcenter.com

By Elisabeth Moy Martin, MA, RN-BC, Wei C. Lu, MS, BSN, Katherine Helmick, MS, CNRN,
CRNP, Louis French, PsyD, and Deborah L. Warden, MD
T
raumatic brain injury (TBI) has been
called the “signature wound” of U.S.
troops serving in the wars in Afghan-
istan and Iraq, which have been ongoing
since October 2001 and March 2003,
respectively. TBI is called that because it “appears to
account for a larger proportion of casualties than it
has in other recent U.S. wars.”1 The use of more
protective equipment—such as body armor—and
advances in battlefield care—such as the establish-
ment of combat surgical hospitals—have reduced
the incidences of penetrating head injuries and
death. But closed-head TBIs, many resulting from
explosions, continue to occur. Some experts,
including one of us (DLW), have estimated the inci-
dence of TBI among wounded soldiers to be as
high as 22%.1 (Editor’s note: In recent testimony
before the U.S. House of Representatives, Matthew
ajn@wolterskluwer.com
S. Goldberg, deputy assistant director for national
security, stated that among all wounded troops, the
incidence of TBI is about 8%.2) In particular, mild
TBI, including concussion, has not been well docu-
mented. In combat zones, TBI often occurs simulta-
neously with more obviously life-threatening injuries;
therefore, cases may go unrecognized. And when TBI
occurs with no outward signs of trauma, service
members might not seek medical treatment.
Who is at risk? As of December 2006, more than
1 million active-duty military personnel and more
than 400,000 reservists (including those in the
National Guard) had served since the beginning of
the conflicts2 in Iraq and Afghanistan; those figures
have continued to rise. In addition, many American
civilians work as contract employees, providing secu-
rity, construction, and food services in or near com-
bat zones. They are also at risk for injury, including
Michael Kamber / The New York Times / Redux
AJN ▼ April 2008 ▼ Vol. 108, No. 4 41
 TBI. After fulfilling their military obligations or
civilian contracts, many of these individuals seek
health care within their home communities, present-
ing at outpatient clinics or EDs. Common complaints
include severe headaches, difficulty sleeping, and
mood swings, symptoms that may or may not be
related to concussion.
Patients rarely volunteer
information on unhealthy
behaviors unless
they’re asked.
The Centers for Disease Control and Prevention
has estimated that 5.3 million Americans are current-
ly living with TBI-related disabilities.3 It’s important
that all nurses know how to use TBI screening and
assessment tools effectively and implement the ap-
propriate evidence-based interventions.
BLAST-RELATED TBI
Explosions and TBI. When an explosion occurs,
ambient pressure rises suddenly and sharply above
normal, resulting in a blast wave. This has been
described as having two components—“a shock
wave of high pressure, followed closely by a blast
wind, or air in motion”—that move rapidly outward
from the point of explosion.4 As the initial overpres-
sure wave dissipates, ambient pressure plummets,
causing a pressure wave that is lower than the ambi-
ent pressure and a reverse blast wind.5
Although the pathophysiology of blast-related TBI
is complex and not fully understood, it’s thought that
these rapid pressure changes create shear and stress
forces that lead to trauma such as concussion, sub-
dural hematoma, and diffuse axonal injury.4, 5 Some
experts also believe that these pressure changes cause
gaseous embolisms to form in the brain, leading to
infarction.4, 5 The blast waves can move objects and
people, causing penetrating injuries or blunt trauma.4
The effects of an explosion are likely to be intensified
if it occurs in a confined space, such as a vehicle, as
42 AJN ▼ April 2008 ▼ Vol. 108, No. 4
the blast wave reflects and reverberates against
nearby objects instead of dissipating.
Blast injuries are categorized into four types.
Primary blast injuries (described above) are caused
by the blast wave. Secondary blast injuries (pene-
trating injuries) are caused by falling or windblown
debris. Tertiary blast injuries (impact injuries) are
caused by being thrown to the ground or against a
stationary object. And quaternary blast injuries,
such as burns, are caused by gases or heat released
by the explosion.4 (Editor’s note: Among troops in
Afghanistan, the Army has recently begun testing
helmets with sensors that measure the energy from
a blast wave and other events that could cause head
trauma. It’s hoped that such data will eventually
help in diagnosing TBI.)
Screening and assessment at the DVBIC. Most
military personnel who are injured in Afghanistan or
Iraq are medically evacuated to Landstuhl Regional
Medical Center, a U.S. Army hospital in Germany.
Once their condition has stabilized, they’re sent to
a military hospital or treatment center in the United
States for further evaluation and treatment. Most of
the patients at Walter Reed Army Medical Center
are inpatients. The DVBIC’s TBI team there consists
of nurses with master’s degrees in psychiatric or
neuroscience nursing, physicians, neuropsycholo-
gists, physician’s assistants, and care coordinators
(four of us—EMM, KH, LF, and DLW—have been
TBI team members). The team screens patients sus-
pected of having a TBI (either combat related or not)
and reviews their medical records; this includes all
wounded service members who have been injured
in an explosion, a fall, or a motor vehicle accident
(including helicopter crashes) or who have sustained
a gunshot wound to the head, neck, or face. Anyone
who was dazed or confused, “saw stars,” or lost con-
sciousness, even momentarily, is evaluated for a TBI.
In 1993 the American Congress of Rehabilitation
Medicine (ACRM) published its definition of mild
TBI.6 With minor changes, the DVBIC incorporates
part of this as a case definition of TBI: a traumati-
cally induced physiologic disruption of brain func-
tion, as indicated by at least one of the following:
• any period of loss of consciousness
• any loss of memory of events immediately before
or after the accident
• any alteration in mental state at the time of the
accident
• focal neurologic deficit(s) that may or may not
be transient
Medics in the field currently screen troops for TBI
using the Military Acute Concussion Evaluation
(www.dvbic.org/pdfs/DVBIC_documentation_sheet.
pdf), which establishes how, where, and when the
patient was injured and whether a loss of conscious-
http://www.nursingcenter.com
ness occurred. A similar tool, the 3 Question DVBIC
TBI Screening Tool (www.dvbic.org/pdfs/3-Question-
Screening-Tool.pdf), has also been used stateside with
troops who had not previously been assessed for TBI
by medical personnel. We begin with the information
culled by these tools and proceed from there.
Because the ACRM’s definition covered only
mild TBI, the DVBIC created a severity classifica-
tion system for use in confirmed cases of TBI. A case
is classified as mild, moderate, or severe according
to three factors: the duration of the loss of con-
sciousness, the duration of posttraumatic amnesia,
and the score on the Glasgow Coma Scale. (See
Table 1, at right.) Specific queries about loss of con-
sciousness and posttraumatic amnesia help in deter-
mining the severity of the brain injury. For example,
the patient might be asked,
• What’s the last thing you can remember clearly
before the event?
• Do you remember hearing an explosion or see-
ing or smelling smoke?
• Did you feel dazed or confused during the event?
Did you lose consciousness? Were you told by
others that they couldn’t wake you?
• What’s the first memory you have after the
event?
Posttraumatic amnesia refers to the loss of mem-
ory of events immediately after the trauma, and
sometimes during the trauma; its duration varies
greatly, from seconds to days or longer. Duration is
measured from the point at which memory was lost
(usually upon the triggering event) to the point at
which the person can again recall events clearly and
chronologically.
Once a patient is determined to have suffered
brain injury, she or he is assessed at the bedside for
common postconcussive symptoms using the Post
Mild TBI Symptom Checklist, a 22-item question-
naire.7 Symptoms can include headache, dizziness,
irritability, mood changes, fatigue, sleep difficul-
ties, memory impairment, and disordered thinking.
While most people with mild TBI return to full
functioning over time, transient consequences such
as reduced reaction time and persistent postconcus-
sive symptoms should be expected.8
Many combat veterans also suffer from acute
stress disorder (ASD) or posttraumatic stress disor-
der (PTSD); symptoms of both include nightmares,
avoidance of thoughts or activities associated with
the trauma, reexperiencing the trauma as if it were
happening now (flashbacks), increased irritability,
increased startle response, and hypervigilance. Some
of these symptoms (such as irritability and sleep dif-
ficulties) are also common in TBI. Whether and
how TBI and ASD or PTSD are associated is unclear.
Symptom frequency and severity are assessed using
ajn@wolterskluwer.com
Table 1. Determining the Severity of a
Traumatic Brain Injury (TBI)
Severity Glasgow Loss of Posttraumatic
Coma Scale consciousness amnesia
(total score) (duration) (duration)
mild 13–15 < 1 hr. < 24 hrs.
moderate 9–12 1–24 hrs. 24 hrs. to < 7 days
severe 3–8 > 24 hrs. 7 days or more
Helmick et al. Mild traumatic brain injury in wartime. Federal Practitioner Oct. 2007; 58-65.
Copyright 2007 Quadrant HealthCom Inc. All rights reserved. Reprinted with permission.
the Posttraumatic Stress Disorder Checklist–Civilian
Version, a 17-item questionnaire.9 If warranted, more
comprehensive cognitive or neuropsychological test-
ing and monitoring are scheduled. (For a relevant
article, see “PTSD in the World War II Combat
Veteran,” November 2003.)
Few descriptions of the clinical characteristics of
patients with blast-related TBI can be found in the lit-
erature. Since October 2001, more than 700 patients
have been evaluated for TBI and post-TBI sequelae
by DVBIC personnel at Walter Reed Army Medical
Center. In 2005 DLW and colleagues reported on
characteristics of the first 433 patients diagnosed with
TBI there between January 2003 and April 2005.10, 11
Initial data indicated that 88% were closed-head
TBIs (the rest were penetrating) and 68% were blast
related. Twenty-five percent of patients had a skull
fracture, 19% had a subdural hematoma, and 2%
had an epidural hematoma. Nineteen percent had a
limb amputation (lower-limb amputations were more
common than upper-limb amputations). Of all ser-
vice members, enlisted army personnel (of whom
95% are male) were found to incur TBI most often.
Headache, memory deficits, irritability, attention
deficits, and sleep difficulties were the most common
symptoms. According to the researchers’ unpublished
data, 51% of the closed-head TBIs were categorized
as mild. Long-term follow-up of these patients will
help to determine which symptoms, if any, are likely
to become chronic.
Treatment at the DVBIC. Once a patient has been
diagnosed and her or his symptoms have been char-
acterized, the team devises a treatment plan, which
includes symptom management, rest and return-to-
duty guidelines, institution of specialized therapies
when indicated, and patient and family education.
We provide patients and families with written
materials, review common post-TBI symptoms
with them, and counsel patients to resume their
AJN ▼ April 2008 ▼ Vol. 108, No. 4 43
 normal activities gradually. (Early education may
have protective value: one study of people with
mild TBI found that those who received a booklet
on post-TBI coping strategies within a week of
injury had fewer symptoms three months later than
those who did not.12) If the patient has attention or
memory deficits, we might suggest reading, starting
with periods of 10 minutes twice a day and gradu-
ally increasing the duration of each session by a few
Post-TBI symptoms can
interfere with personal
relationships, as well as with
the patient’s daily routine.
minutes. Some people with TBI find that strenuous
exercise triggers or worsens headaches; in such
cases we might advise a moderate workout with
small daily increases in intensity. When symptom
management includes pharmacologic intervention,
we review the medication with the patient and fam-
ily. We explain that post-TBI symptoms are com-
mon and tend to resolve over time.
Post-TBI symptoms can interfere with personal
relationships, as well as with the patient’s daily rou-
tine. We try to identify associations between symp-
toms: for example, disrupted sleep can result in
daytime fatigue, leading to worsened headache pain
and increased irritability, making arguments with
loved ones more likely. Interventions suggested to such
a patient might include minimizing ambient noise
and practicing deep breathing at bedtime. Patients
who are able to are encouraged to participate in a
weekly support group for survivors of TBI; family
members can join weekly support groups as well.
(See About the Defense and Veterans Brain Injury
Center, page 45.)
Patients with TBI who lost consciousness for
more than one hour or suffered posttraumatic
amnesia for more than 24 hours—symptoms indica-
tive of moderate-to-severe TBI—or who have pene-
trating brain injuries are usually referred to a
44 AJN ▼ April 2008 ▼ Vol. 108, No. 4
Veterans Health Administration hospital or rehabil-
itation facility near their home or family for further
evaluation and treatment.
Clinical follow-up by telephone with reassessment
of symptoms and progress occurs at six and 12
months after discharge.
A CASE SCENARIO
John Mills, a 22-year-old junior enlisted soldier on
duty in Iraq, sustained blast injuries when his vehi-
cle ran over an explosive device. (This case, a com-
posite based on our experiences, depicts injuries we
have often seen.) Mr. Mills lost consciousness for
several seconds and later recalled the event in bits
and pieces. He described the explosion as a massive
“vibration” that caused “a sucking and sinking feel-
ing, as if my brain was being split in two.” He
believed he was tossed into the air: “It felt like my
soul had jumped out of my body and was watching
things happen in slow motion.” He recalled trying to
crawl from the vehicle, smelling something burning,
and seeing his left arm hanging at his side at a strange
angle. Members of his squad provided immediate
first aid and called for a medical evacuation team. He
drifted in and out of consciousness for about 45 min-
utes before being sedated for air transport to a U.S.
Army hospital in Europe. This period of decreased
consciousness following a brief loss of consciousness
met the criteria for mild TBI.
Mr. Mills’s injuries included immediate below-the-
knee amputation of his right leg, left ulnar fracture,
retinal detachment in his left eye, tympanic mem-
brane rupture in his left ear, and burns over much of
his left thigh and the left side of his face and head. He
had small pieces of shrapnel embedded in his skin in
exposed areas, including his face. He also developed
pancreatitis and Acinetobacter bacteremia.
Three days later Mr. Mills’s condition had stabi-
lized enough to permit discharge to a U.S. Army hos-
pital stateside with a physical rehabilitation clinic.
After 10 weeks, when his other wounds had healed
sufficiently and his condition had further stabilized,
a more comprehensive, multidisciplinary evalua-
tion for TBI was performed; prosthesis fitting and
training were also initiated. In his initial assessment
interview, he reported symptoms of cognitive slow-
ing, saying that he didn’t feel as “sharp” as usual.
He also reported short-term–memory problems (he
sometimes forgot appointments or visitors) and dif-
ficulty falling asleep at night.
Nurses reviewed Mr. Mills’s sleep cycle with him
and explained that it’s common for people to have
trouble sleeping after a TBI. They suggested that he
limit caffeine and use relaxation techniques (such as
meditation) before bedtime. To address his memory
and attention difficulties, the nurses encouraged
http://www.nursingcenter.com
him to establish a routine schedule, write down his
appointments, and keep a calendar. They also sug-
gested reducing background noise (such as that
from a television or radio) during conversations to
minimize distraction. They explained what he might
expect as he recovered, monitored his progress, and
offered reassurance and support.
Mr. Mills’s mood and outlook were generally
optimistic. At the time of discharge from the hospi-
tal, no further immediate nursing interventions were
required. He told the nurses that once his medical
discharge from the military was final, he hoped to
resume his college studies. If he reports continuing
cognitive difficulties at his six-month follow-up
assessment, compensatory strategies will be reviewed
with him. Further neuropsychological testing might
be warranted. If he reports recurring headaches or
mood swings, weekly monitoring by telephone may
be helpful.13, 14
COORDINATING CARE
It’s imperative that nurses understand the immediate
and longer-term effects of an explosion on the
human brain. Closely working with affected patients
and accurately diagnosing TBI and documenting its
history and symptoms will help to improve the care
of survivors. Unfortunately, little is known yet about
the longer-term effects, and both follow-up and addi-
tional research are essential.
First, screening for concussion should be part of
care for all patients with multiple injuries. In part
because mild TBI has been underrecognized in such
patients, military medics and corpsmen are now
being trained to evaluate for it on the battlefield,
using new assessment tools developed by the DVBIC.
These are based on current, standardized concussion
assessment guidelines, which were originally devel-
oped for use with athletes.15 One, the aforementioned
3 Question DVBIC TBI Screening Tool, has shown
promising results in a study with 596 soldiers who
had recently returned from tours of duty in Iraq or
Afghanistan.16 The use of standardized tools will help
to generate evidence-based guidelines on screening for
and assessing TBI. Further research may yield effec-
tive, efficient interventions that can assist patients
with symptom management and self-care.
It’s now known that psychiatric sequelae can
also occur after TBI, with major depressive disorder
being the most common in both civilian and military
populations.17, 18 Other psychiatric diagnoses associ-
ated with TBI include generalized anxiety disorder,
PTSD, bipolar disorder, and personality changes.17, 18
For example, Hoge and colleagues assessed the men-
tal health of four groups of U.S. troops before
deployment to Iraq or after deployment to Iraq or
Afghanistan (the study did not include soldiers
ajn@wolterskluwer.com
About the Defense and
Veterans Brain Injury Center
T he Defense and Veterans Brain Injury Center
(DVBIC; www.dvbic.org) is a collaboration involving
eight traumatic brain injury (TBI) programs—seven
at Department of Defense or Department of Veterans
Affairs hospitals and one at a civilian facility. The
DVBIC’s mission is to offer active-duty service members
with TBI, their dependents, and veterans with TBI “state-
of-the-art” health care and opportunities to participate in
“innovative clinical research initiatives and educational
programs.”
Last November the DVBIC became part of the
Defense Center of Excellence for Psychological Health
and Traumatic Brain Injury. This new center is part of
an effort, spearheaded by the Department of Defense,
to create a “national collaborative network” of psycho-
logical health and TBI programs. Temporarily based in
Rosslyn, Virginia, it’s expected to become fully opera-
tional by October 2009.
Other resources:
Brain Injury Association of America
(800) 444-6443
www.biausa.org
Department of Defense Military OneSource
(800) 342-9647
www.militaryonesource.com
(The Department of Defense Military Severely Injured
Center, now part of Military OneSource, can be
reached at [888] 774-1361.)
U.S. Army Wounded Warrior Program
(800) 237-1366 or (800) 833-6622
https://www.aw2.army.mil
who were severely wounded and did not investigate
TBI).19 The Hoge group found significantly higher
incidences of major depression, generalized anxiety,
and PTSD in troops assessed after deployment to
Iraq than in those assessed before deployment to Iraq
or after deployment to Afghanistan (however, fewer
than a third of the troops who served in Afghanistan
reported being in a firefight, compared to between
71% and 86% of those who served in Iraq). They
also found that only 23% to 40% of those who
acknowledged having enough symptoms to meet
the criteria for major depressive disorder, general-
AJN ▼ April 2008 ▼ Vol. 108, No. 4 45
 ized anxiety disorder, ASD, or PTSD actually sought
mental health care. One of the main barriers to care
was concern about being stigmatized for seeking
treatment. Similar concerns about stigmatization
might prevent service members with TBI from seek-
ing assistance.
Nurses need to understand
the immediate and longer-
term effects of an explosion
on the human brain.
There is some evidence of an association between
TBI and substance abuse,20 but whether TBI makes
substance abuse more likely is unclear; at least one
review found that it did not.17 That said, at the DVBIC
we have found that patients with TBI sometimes self-
medicate with alcohol or drugs in an attempt to man-
age distressing symptoms, which can create additional
problems such as dependency or addiction. This can
complicate the longer-term effects of TBI, worsening
cognitive difficulties and emotional lability and inter-
fering with sleep. It’s important to provide support for
patients who have mental health or substance abuse
concerns in a manner and setting in which they’ll feel
comfortable accessing it; for example, a peer support
group for service members might meet at a local diner,
away from the military base.
Because nurses often perform initial screenings and
assessments of patients in the community, they need
to know when to suspect and how to recognize TBI.
This is also pertinent to understanding the effects of
TBI and planning nursing interventions. Early inter-
vention is best. The essential components of care are
symptom monitoring and management; referrals for
counseling or peer support and pharmacologic treat-
ment, as appropriate; and periodic follow-up after
discharge. Care coordination is particularly impor-
tant, especially for patients with TBI who have cog-
nitive difficulties, emotional lability, or both.
Nurses should be prepared to intervene to pre-
vent the development of unhealthy behaviors, such
46 AJN ▼ April 2008 ▼ Vol. 108, No. 4
as substance abuse or social isolation. In our experi-
ence patients rarely volunteer information on un-
healthy behaviors unless they’re asked. The nurse
might ask first whether the patient currently drinks
alcoholic beverages. If the answer is yes, the nurse
can ask, “How often do you drink alcohol?” and
“Do you have any concerns about the amount
you’re drinking?” When possible, it’s important to
talk with the patient’s spouse or partner, as well;
sometimes that person will view the patient’s be-
havior quite differently.
Currently the number of U.S. troops in Iraq
stands at about 190,00021 and is expected to rise fur-
ther. (Editor’s note: Another 26,000 are deployed in
Afghanistan.22) Several thousand U.S. civilian and
contract employees also continue to work in these
countries.23 They will eventually return home to
their communities, where they may need to be eval-
uated and receive follow-up care. When a patient
has a history of working in or near a combat zone
and complains of symptoms congruent with TBI, it’s
essential to consider that injury a possibility. ▼
Elisabeth Moy Martin is a clinical research nurse, Wei C. Lu
is a clinical research coordinator, Katherine Helmick is the
deputy director of Clinical and Education Affairs, and Louis
French is the clinical director, all at the Defense and Veterans
Brain Injury Center (DVBIC) at Walter Reed Army Medical
Center in Washington, DC. Deborah L. Warden, the national
director of the DVBIC from 2001 through 2007, was also
based at Walter Reed. The original manuscript submitted for
publication was reviewed and approved by officials at the
Walter Reed Army Medical Center and the U.S. Military
Operational Security. The views expressed in this article are
those of the authors and do not reflect the official policy of
the Department of the Army, the Department of Defense,
or the U.S. government. The authors have no significant
ties, financial or otherwise, to any company that might have
an interest in the publication of this educational activity.
Contact author: Elisabeth Moy Martin, lisamoymartin@
yahoo.com.
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2. Goldberg MS. CBO testimony. Statement of Matthew S.
Goldberg, Deputy Assistant Director for National Security:
Projecting the costs to care for veterans of U.S. military
operations in Iraq and Afghanistan. Washington, D.C.:
Congressional Budget Office 2007.
3. National Center for Injury Prevention and Control. Centers
for Disease Control and Prevention. Traumatic brain injury.
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4. DePalma RG, et al. Blast injuries. N Engl J Med 2005;
352(13):1335-42.
5. Taber KH, et al. Blast-related traumatic brain injury: what is
known? J Neuropsychiatry Clin Neurosci 2006;18(2):141-5.
6. Kay T, et al. Definition of mild traumatic brain injury.
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8. Warden DL, et al. Persistent prolongation of simple reaction
time in sports concussion. Neurology 2001;57(3):524-6.
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 9. Weathers FW, et al. The PTSD Checklist–Civilian Version
(PCL–C) for DSM-IV. Boston: National Center for PTSD,
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10. Warden DL, et al. War neurotrauma: the Defense and
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Reed Army Medical Center (WRAMC). J Neurotrauma
2005;22(10):1178.
11. Warden D. Military TBI during the Iraq and Afghanistan
wars. J Head Trauma Rehabil 2006;21(5):398-402.
12. Ponsford J, et al. Impact of early intervention on outcome
following mild head injury in adults. J Neurol Neurosurg
Psychiatry 2002;73(3):330-2.
13. Martin EM, et al. Telephonic nursing in traumatic brain
injury. Am J Nurs 2003;103(10):75-81.
14. Martin EM, Coyle MK. Nursing protocol for telephonic
supervision of clients. Rehabil Nurs 2006;31(2):54-7, 62.
15. McCrea M, et al. Standardized Assessment of Concussion
(SAC): manual for administration, scoring and interpreta-
tion. 2nd ed. Waukesha, WI: CNS, Inc.; 2000.
16. Schwab KA, et al. Screening for traumatic brain injury in
troops returning from deployment in Afghanistan and Iraq:
initial investigation of the usefulness of a short screening
tool for traumatic brain injury. J Head Trauma Rehabil
2007;22(6):377-89.
17. Gordon WA, et al. Traumatic brain injury rehabilitation:
state of the science. Am J Phys Med Rehabil 2006;85(4):
343-82.
18. Salazar AM, et al. Cognitive rehabilitation for traumatic
brain injury: a randomized trial. Defense and Veterans Head
Injury Program (DVHIP) Study Group. JAMA 2000;283(23):
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19. Hoge CW, et al. Combat duty in Iraq and Afghanistan,
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2004;351(1):13-22.
20. Walker R, et al. Screening substance abuse treatment clients
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J Head Trauma Rehabil 2007;22(6):360-7.
21. Sunshine RA. CBO testimony. Statement of Robert A.
Sunshine, Assistant Director for Budget Analysis: Estimated
costs of U.S. operations in Iraq and Afghanistan and of
other activities related to the war on terrorism. Washington,
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22. Associated Press. US official: military leaders believe al-
Qaida stepping up activities in Afghanistan. International
Herald Tribune, Asia-Pacific 2007 Dec 3. http://www.
iht.com/articles/ap/2007/12/03/asia/AS-GEN-Afghanistan-
Gates.php.
23. Snyder V. Statement of subcommittee chairman Vic Snyder.
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Washington, D.C.: U.S. House of Representatives 2007.
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To take the test online, go to our secure Web site at www.
nursingcenter.com/CE/ajn.
To use the form provided in this issue,
• record your answers in the test answer section of the
CE enrollment form between pages 56 and 57. Each
question has only one correct answer. You may make
copies of the form.
• complete the registration information and course evalu-
ation. Mail the completed enrollment form and registra-
tion fee of $24.95 to Lippincott Williams and Wilkins
CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723,
by April 30, 2010. You will receive your certificate in
four to six weeks. For faster service, include a fax num-
ber and we will fax your certificate within two business
days of receiving your enrollment form. You will
receive your CE certificate of earned contact hours and
an answer key to review your results. There is no mini-
mum passing grade.
DISCOUNTS and CUSTOMER SERVICE
• Send two or more tests in any nursing journal published
by Lippincott Williams and Wilkins (LWW) together, and
deduct $0.95 from the price of each test.
• We also offer CE accounts for hospitals and other
health care facilities online at www.nursingcenter.
com. Call (800) 787-8985 for details.
PROVIDER ACCREDITATION
LWW, publisher of AJN, will award 2.5 contact
hours for this continuing nursing education activity.
LWW is accredited as a provider of continuing nurs-
ing education by the American Nurses Credentialing
Center’s Commission on Accreditation.
LWW is also an approved provider of continuing
nursing education by the American Association of
Critical-Care Nurses #00012278 (CERP category A),
District of Columbia, Florida #FBN2454, and Iowa
#75. LWW home study activities are classified for
Texas nursing continuing education requirements as
Type 1. This activity is also provider approved by the
California Board of Registered Nursing, provider num-
ber CEP 11749, for 2.5 contact hours.
Your certificate is valid in all states.
TEST CODE: AJN0408
AJN ▼ April 2008 ▼ Vol. 108, No. 4 47