Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
129 Cards in this Set
- Front
- Back
|
def Traumatic Brain Injury
|
a serious and debilitating injury that permanently affects individual's lives and lives of their families
|
|
|
Epidemiology of TBI
|
-leading cause of death and disability among young adults
-1.7 million each year -TBI includes concussion -children and older adults= falls, teens=thrill seeking -more males than females -highest rates in males 0-4 years |
|
|
Consequences of TBI
|
Motor Impairments
-orthopedic, dec strength, impaired func mob, poor cordination/balance, speech impairment Sensory Impairments -taste, touch, hearing, vision, smell Autonomic Impairment -arousal, awareness, sleep disturbance Cognitive Impairment -memory, attention, difficult learning/problem solving, planning, judgment, safety Personality and Behavior Changes -disinhibition, impulsivity, anger Lifestyle Consequences -loss of independence, employment |
|
|
What happens in TBI?
|
injury to the skull, brain tissues, arteries or CSF causes swelling with accompanied BP increase. This results in increased intracerebral pressure
|
|
|
Intracranial pressure
|
fluids of the brain are non-compressible. Once pressure begins to build the intracerebral pressure increases rapidly. Life threatening!
-higher ICP leads to less cerebral perfusion or lower cerebral perfusion pressure. This, in turn can cause more damage to brain tissue -normally, if systemic BP rises, the cerebral vessels constrict to maintain even perfusion pressure -if systemic pressure falls, vessels will dilate to allow better flow. These 2 mechanisms fail after TBI -some compensation occurs by blood and CSF moving into the spinal column, but too much pressure can lead to brain tissue herniation into spinal column or midline shifting of the brain. This causes more damage!! |
|
|
Where is damage done with midline shift and brain herniation?
|
damage is done to BOTH sides of the brain because of the brain shift. (pic in ppt). The quicker pressure is relieved, the less damage
|
|
|
Types of brain herniation
|
1. uncal
2. central 3. cingulate 4. transcalvarial 5. upward 6. tonsillar 6 is the most common! Whole brain shifts down into the spinal cord |
|
|
What is normal intracranial pressure (ICP)
|
0-15 mmHg
|
|
|
treating ICP levels
|
-levels above 20mmHg usually treated
-25-30 usually fatal if prolonged, except in children -increased ICP leads to more brain damage *coughing when ICP is at 30 can be a big problem. Be careful about annoying or agitating pts on an ICP monitor. Agitation causes ICP rise |
|
|
Symptoms of ICP
|
-cranial nerve palsies
-headache with nausea/vomiting -mental status changes -confusion, agitation, lethargy *work closely with nurses, drs in ICU and notify if any of these signs occur *this is why we wake people up every couple hours to check for these signs. Sometimes bleeding is slow! |
|
|
How to Measure ICP
|
-spinal tap
-directly by calibrated device drilled intracranially |
|
|
3 ways to monitor pressure
|
1. Intraventricular catheter threaded into one of the lateral ventricles
(head of bed must be elevated 30-45 deg at all times) *height of the bag relevant to pts head determines whether csf is going to flow out. Bag must be kept in correct spot!! ASK!!! 2. Subarachnoid screw/bolt- placed through the skull. Not as accurate but done most often because they are least invasive. 3. Epidural sensor- less invasive but no fluid can be drawn from it. Least invasive but can't drain fluid. |
|
|
Do's and Don'ts with patients who have high ICPs
|
-check with the client's nurse before beginning therapy
-don't raise the person's legs, turn the person on his or her side, or move the neck unnecessarily -minimize prolonged procedures and monitor ICP while performing functional tasks -only address necessary therapy goals- wound care, splinting, occasional chest PT -may need to move slowly, stay quiet, take breaks ***do not stimulate them!!! |
|
|
Closed head injuries
|
When a person receives an impact to the head from an outside force, but the skull does not fracture or displace
-brain swells and there is no room for expansion so compression causes further injury -brain may expand through any available opening in the skull, including eye sockets -cranial nn controlling eye mm and function can become impaired |
|
|
What happens if CN III is compressed?
|
pupil will appear dilated
termed as "blown pupil" can assess ICP through pupil size in initial trauma |
|
|
Open Head Injury
|
if the force is great enough, skull can fracture
-Good: when the skull is open the brain has room to swell. This can assist in reducing compression of brain tissues. -Bad: because skull is damaged or open, it cannot protect brain. Exposed brain is vulnerable. -ugly: if skull is fractured or displaced, bone fragments from the skull can enter the brain and cause further injury |
|
|
Depressed skull fracture
|
broken piece of skull bone moves in toward the brain (open or closed head injury)
|
|
|
Compound Skull Fracture
|
scalp is cut and skull is fractured
|
|
|
Basilar Skull Fracture
|
-skull fracture is located at the base of the skull and may include the opening at the base of the skull
-raccoon eyes -worst kind to have. Life sustaining things happen in basilar area |
|
|
Types of TBI
|
concussion
contusion diffuse axonal injury coup-countercoup injury second impact syndrome penetration locked-in syndrome shaken baby syndrome |
|
|
Shearing injuries
|
synapses are torn from the brain moving in the head
|
|
|
Diffuse Axonal Injury
|
-caused by shaking or strong rotation of the head. Diagnosed by MRI, not CT
-injury occurs b/c unmoving brain lags behind the mvmt of the skull, causing brain structures to tear -extensive tearing of nn tissue throughout the brain -brain tissue damage can produce temporary, permanent, localized, or widespread brain damage, coma, or death -a person with diffuse axonal injury could have a variety of functional impairments depending on where the shearing occurred |
|
|
Concussion
|
-occurs when the brain receives trauma from an impact or a sudden momentum or movement change
-blood vessels in the brain may become stretched or torn (hemmorhage). Cranial nerve damage can also occur. -concussions are most common type of TBI -person may or may not experience a brief loss of consciousness *artery damage is much more severe than vein *brain hitting a hard object (ie. inside of skull) *may or may not show on a CT scan -can cause diffuse axonal type injury -may take a few months to a few years to heal |
|
|
Post-concussion syndrome
|
-patients may report problems with concentration, recent memory, abstract thinking
-dizziness, irritability, fatigue, double vision, personality changes -elderly pts particularly affected by disequilibrium and chronic dizziness even after minor trauma |
|
|
Contusion
|
-contusion can be the result of direct impact to the head
-localized bruise (bleeding) on the brain -large contusions may need to be surgically removed |
|
|
Coup-Contrecoup injury
|
-contusions that occur from the impact with damage at the site of the blow as well as rebound damage on opposite side
|
|
|
Second impact syndrome
|
-also termed "recurrent TBI"
-occurs when person sustains second brain injury before the first one has healed -may occur from days to weeks following the first. Loss of consciousness not required -Death can occur rapidly *advocate that TBI becomes part of pts medical record |
|
|
Penetration injury
|
-injuries occur from impact of a bullet, knife, or other sharp object that forces hair, skin, bone and fragments from the object into the brain
-can be through-and-through |
|
|
Locked in Syndrome
|
-rare neurological condition in which a person cannot physically move any part of the body except the eyes
-person is conscious and able to think -vertical eye mm and blinking can be used to communicate with others and operate environmental controls **not necessarily permanent but can be |
|
|
Acquired Brain Injury
|
-basket term describes any trauma that occurs to the brain after birth
-encompasses TBI, damage from disease, tumor, stroke, infection, substance disease -Acquired brain damage can also occur from anoxia *heart attacks, near drownings *probably the least potential for recovery are anoxic |
|
|
Symptoms of acquired brain injury
|
cognitive impairment
behavior problems mm movement disorders |
|
|
Anoxic acquired brain injuries
|
occurs when brain does not receive oxygen
|
|
|
Hypoxic acquired brain injury
|
results when brain receives some, but not enough, oxygen
posturing is a sign of pretty severe injury |
|
|
Causes of acquired brain injury
|
-airway obstruction
-near drowning, throat swelling, choking, strangulation, crush injuries to the chest -electrical shock or lightening strike -trauma to head and/or neck -TBI with or without skull fx, blood loss from open wounds, artery impingement from forceful impact, shock -vascular disruption- rupturing congenital malformations, aneurism -heart attack, stroke, surgery -disease, tumor, toxins |
|
|
Intracranial/Intracerebral Hematomas
|
can occur with or without brain injury
-trauma causes vessel to leak, can occur with a contusion or concussion -subdural, epidural, subarachnoid, or intraparynchemal |
|
|
Subdural Hematoma
|
collection of blood below the inner layer of the dura but external to the brain and arachnoid membrane
*most common type of traumatic intracranial mass lesion *arterial bleeds are usually immediate. Venous blood leaks more slowly, tend to happen when older people fall (usually within 24 hrs) |
|
|
Epidural hematoma
|
traumatic accumulation of blood between the inner table of the skull and the stripped off dural membrane
-often occur from a focused blow to the head -usually results in overlying fracture of the skull -prognosis excellent if treated affressively **good thing is that dura remains intact. Dr just has to drain the blood |
|
|
Subarachnoid hemorrhage
|
blood leaks into CSF within the delicate membrane called arachnoid, which gently rests against the brain itself
-"worst headache of my life" *bleeding within the brain itself *many times these are strokes |
|
|
Intraparynchemal hemorrhage
|
blood pools in white matter of brain
-can cause diffuse axonal injury *has the best prognosis of the hemorrhages |
|
|
Medical management of TBI
|
-diagnosed by CT, MRI, cerebral angiography
-craniotomy, blood evacuation, ICP monitoring -meds may be used to reduce brain swelling *head of bed normally elevated to relieve cerebral pressure *hydrate, but avoid fluid overload sidebar: people with shrapnel wounds can't have an MRI |
|
|
glasgow coma scale
|
used by most dr's
1-15 mild, moderate, severe |
|
|
Mild Brain Injury
|
Glascow 13-15
-loss of consciousness very brief (few sec or min) -brain scans may appear normal -change in mental status at time of injury-person is dazed |
|
|
Symptoms of mild brain injury
|
-headache, fatigue, sleep disturbance
-irritability, sensitivity to noise/light, balance issues -dec concentration -dec speed of thinking, memory -nausea, depression, anxiety -emotional mood swings *can be debilitating. Confusing to family as they are thinking brain injury is mild |
|
|
Moderate Brain Injury
|
Glascow 9-12
-loss of consciousness from few min to few hrs -confusion lasts days to weeks -60% good recovery, 25% mod disability -physical, cognitive, and/or behavior impairments last for months or are permanent |
|
|
Severe Brain Injury
|
Glascow 8 or less
-occurs when prolonged unconscious state or coma lasts days, weeks, or months. Further categorized into subgroups |
|
|
Subgroups of Severe Brain Injury
|
coma vegetative state
persistent vegetative state minimally responsive state akinetic mutism locked-in syndrome |
|
|
Coma
|
level of severe brain injury
-state of unconsciousness -individual cannot be awakened -responds minimally or not at all -no meaningful response *eyes can be open, can make faces or voices or fists but are not responding to outside stimulus |
|
|
Vegetative State
|
-arousal is present, but can't interact with environment
-general responses to pain (HR, sweating, posturing) -sleep/wake cycles and respiratory function -no test to specifically diagnose. Made by repetitive neurobehavioral assessments |
|
|
Persistent Vegetative State
|
term used for vegetative state that has lasted more than a month
-criteria the same for vegetative state *question of whether to turn off life support |
|
|
Minimally responsive state
|
-no longer in coma or vegetative state
-primitive reflexes -inconsistently able to follow simple commands -awareness of environmental stimulation 1. brief head turn to noise 2. notice lights/tv |
|
|
Akinetic Mutism
|
type of severe brain injury
-neurobehavioral condition that results when dopaminergic pathways are damaged -minimal amt of body movement -little or no spontaneous speech -speech can be elicited -eye opening and visual tracking -infrequent and incomplete ability to follow commands *different from minimally responsive bc lack of mvmt and speech with akinetic mutism is not due to neuromuscular disturbance |
|
|
Brain Death
|
type of severe brain injury
-brain shows no sign of functioning -physician performs special brain death exam *families asked for organ donation at this stage. Many legal issues |
|
|
Prognosis
|
-Pre-injury characteristics
(past medical hx, psych condition, money) -age -severity of injury -severity of other injuries -medical complications -length of time between injury and initiation of rehab -duration of coma |
|
|
How many days of coma predicts poor outcome?
|
>20
|
|
|
Models of Care in TBI
|
-acute medical rehab
-community integrated rehab -adapted lifestyle sustaining services *focus in long term care needs to be to prevent secondary issues. If they regain abilities but have contracture there is a problem |
|
|
Initial eval of person with BI in ICU
|
-thorough chart review
-visual scan -cognition, visual skills, behavior -communication -active and passive ROM, mm tone, edema -sitting balance -ADL -standing balance/transfer/gait -vital sign responses -talk to client as if they are awake -pain (verbal and nonverbal) -evaluate and treat vs ROM order -precautions *be as aggressive as medically able and be prepared to request order changes when appropriate |
|
|
BEFORE touching client with brain injury
|
-chart review and review with nurse
-pain, sleeping, arousal -do you need a second person |
|
|
Mechanical ventilators
|
airway created through mouth, nose, mash, throat (long term)
|
|
|
Therapist management of mechanical ventilation
|
-move tubes slowly and away from limbs as moving; move mechanical arm to place in best position
-when alarm sounds, check O2 sats & stop or slow activity. If client coughing, assist in a position to support this -use wall suction if coughing phlegm to keep airway clear -if tube falls off, replace immediately -can ambulate to extent of tube or with a second person aiding with ambu bag. -remain calm, alarming client will cause more anxiety and trouble breathing |
|
|
Vital Sign Monitors
|
-mechanical check of BP, heart rate, O2, respiratory rate, heart waves
-monitor changes with mobility & function; stop or slow as necessary -check with nurse for client's normals |
|
|
NG tube
|
short term nutrition
*ask if can be turned off for tx, tape onto face to avoid pulling *avoid getting tape wet in shower *HOB above 30 |
|
|
PEG tube
|
done by surgeon
through skin straight to stomach for feeding long term nutrition *prevent pt from pulling out *ask if can turn off for tx *tuck tube in pants for gait *be careful with prone positions |
|
|
Restraints
|
new order by nursing every 24 hrs
chemical restraints routinely used..schedule therapy around these *remove those in the way of therapy *document amt of time off *check for skin sores *avoid crossing over PRG sites |
|
|
Sequential compression devices
|
-prevention of DVT
-all ICU clients have unless they have current DVT *turn off machine before removal *remove during session and replace after *velcro straps should be on top of leg *can apply orthotics on top of devices |
|
|
ICU therapy basics
|
-physiologic stability with activity
-pain -motor issues -functional mobility -self care considerations -vision eval -low level cognitive eval and communication |
|
|
Non-verbal pain indicators
|
disruptive behaviors-agitation, restlessness
resistance to care facial grimacing or wincing bracing, rubbing, rocking limping, gait changes decreased appetite, insomnia, apathy changes in typical behavior inactivity or lying down |
|
|
Motor deficits following brain injury
|
-loss of strength, endurance, response and mvmt speed
-lack of coordination in gross and fine movement -mm tone changes usually significant with mod-severe injury -capsular flexibility issues -unilateral and bilateral motor issues may present like hemi or quadriplegia |
|
|
Tone following TBI
|
unilateral and bilateral
flexion and extension tone highly variable and can be related to stress of client modified Ashworth scale |
|
|
Decorticate Posturing
|
-UE adduction, int rot, pron, elbow/wrist and finger flex
-LE ext, add & int rot of hip, knee ext, ankle plantar flex -if painful stimulation elicits flexion of hips/knees, splinal reflex known as triple flexion -damage to internal capsule or cerebral hemispheres causing damage to corticospinal pathways |
|
|
Decerebrate posturing/rigidity
|
UE ext, adduc, int rot, elb ext hyperpronation, wrist and finger flex (pic in ppt)
LE ext, add, int rot, knee ext, plantarflex, inversion, trunk and neck ext Damage to upper midbrain and lower pons. Can also be a sign of brain herniation |
|
|
Tone management with posturing
|
-these forms of tone usually extreme/difficult to manipulate
-high risk for contracture and orthopedic injury -mod/severe tone managed with casting, dynasplints; mild tone with splints -need extreme ROM |
|
|
Splint use in the ICU for hypertonus
|
-splint in opposite position of tine, usually near neutral
-wearing times vary fron 2-4 hrs/day to 23 hrs/day. Post written schedule in room -mark splint with L/R, mark straps, fingers, ankle for knowing which joint to cross *low load prolonged stretch |
|
|
Edema Management in ICU
|
1. elevation- pillow to above 45 deg for hand
2. manual edema mobilization- lymphatics must be intact 3. A/PROM 4. UE resting hand splints (2on, 2 off) 5. Bed elevation for LE 6. SCD compression device (LE) *compression stocking, elevation combined with soft splint if needed to prevent foot drop |
|
|
"Extreme Attention" ROM
|
extreme attention to:
-diagnosis: ortho injuries (many have cervical precautions) -capsular vs muscular issues -tube interference -pain/agitation -what really needs ranged and why? |
|
|
Places of needed attention ROM in TBI
|
neck/face ROM
Oral ROM trunk rotation Chest expansion- blanket bt scapulas to facilitate retraction. Separation of upper and lower segments Scapular mobility-moving scap with UE to ensure good scapulohumeral rhythm and prevent pain UE/LE PROM (separate slide) Hand ROM (separate slide) |
|
|
UE/LE PROM in acute care
|
joint mob
nerve mob (ULTT) PAMs massage, tissue release tone inhibition sustained stretch (document mm response) |
|
|
Hand ROM in acute care
|
-maintain intrinsic mm lengths
-MP flex, IP ext -IP flex, MP ext -extrinsic mm |
|
|
Positioning in the ICU
|
comfort, pressure, ease with lines, tone, edema
-reposition every 2 hrs -regular checks for pressure -elevation, compression garments, splints -splints & positioning to relieve tone, minimize contracture and increase comfort; *check behind neck braces frequently for pressure -make sure all lines are hooked back up and pt at top of bed before leaving |
|
|
Functional mobility in the ICU
|
-slowly progressive, dependent on medical stability
-bed mob, sitting EOB, stand, transfer, gait -Plan several activities. Have everything prepared cause you can't leave them seated to get it! |
|
|
Sitting EOB in ICU
|
-check bed brakes, monitor vitals
-position tubes wisely -get help if needed -sit first without activity -add light ADL -progressive and individual exercise -sitting is excellent for normalizing tone and arousal, even if in coma or not alert *may need one therapist to hold pt up and one to arouse pt *spend time sitting to maintain mm length *progress to less control *sit in different positions to work different mm groups |
|
|
Standing/Gait in the ICU
|
-make sure vitals are stable and lines are long enough
-short sessions (seconds) -force arousal, may be total assist of 2 -briefly normalizing mm tone, stretches joints -progress to stand with activity -gait as tolerated with nursing permission to disconnect lines |
|
|
Transfers in the ICU
|
bed to/from recliner
bed to/from commode sit up to build endurance cover transfer surface (incontinence) recline chair back for balance give something to do while up if restrained in bed, restrain in chair reconnect all leads, monitors |
|
|
Progressive ADL in the ICU
|
-often dependent for all self care
Progress task requirements of: -hand over hand assistance -with or without AE -sitting with bed support vs chair vs EOB Vs stand -number of activities, time frames -pt attention to task, sequencing, problem solving support Eating: tube feeding progress to solid Toileting: hygiene, commode use Bathing: no showers! bed bathing Grooming: shave, deoderant, teeth Dressing: gown, socks, shoes |
|
|
Vision screening
|
When pt is alert/awake with eyes opened:
-visual tracking and fixation -visual field -visual acommodation -rule out double vision -incorporate anything pt is missing into your activities |
|
|
Double vision
|
-need convergence to prevent
-person cannot maintain alignment in all positions of gaze -may be constant or intermittent -may only occur when looking to the side *some pts wear a patch over one eye to correct |
|
|
Treatment for double vision
|
-yellow tinted glasses
-tape over one eye of glasses -prisms? Patching-may cause depth perception issues |
|
|
How many levels were on the original Ranchos scale?
|
I-VIII. Most clinicians still refer to this scale
|
|
|
How many levels were added on the new Ranchos scale?
|
2. Now has I-X
*IX and X will probably not be seen in therapy. Very high level. |
|
|
Purpose of RLA scale
|
used by therapists to guide plan of care
-useful gauge for cognitive and phychosocial recovery -many people fully recover physically but not cognitively and psychosocially "walking wounded" |
|
|
Things to keep in mind with Ranchos (RLA) scale
|
-level of pt functioning will vary with fatigue, stimulation, and predictability of environment
-not all pt's will fit strictly into one level -record appropriate levels together (3-4) |
|
|
Rancho Level I
|
NO RESPONSE
-complete absence of observable change in behavior with any type of stimuli |
|
|
Rancho Level II
|
GENERALIZED RESPONSE
-reflex to painful stimuli -inc or dec'd activity in response to auditory stimuli -generalized response to external stimuli(HR, body mvmt, non-purposeful vocalizing) -responses may be the same regardless of stimuli -responses may be significantly delayed **important to give extra time to respond! |
|
|
Impairment based goals at Rancho Level I, II
|
Increase level of responsiveness by providing stimulation for 10-15 min intervals
-talk in normal tones about familiar things -family education/interventions -positioning, ROM, Edema and tone mgmt, skin integrity, chest PT **don't over stimulate! They will habituate to tv being left on |
|
|
Rancho Level III
|
LOCALIZED RESPONSE
-withdrawal or vocalization to pain stimuli -turns toward or away from auditory stimuli -blinks with strong light crossing visual field -follows moving objects -pulling at tubes or restraints -responds inconsistently to simple commands -response directly related to type of stimulus -may respond to some persons but not to others |
|
|
Intervention at Rancho Level III
|
continue with level I and II plus...
-simple one step instructions "squeeze my hand" -give ample time to respond -provide frequent orientation to time, place -allow adequate rest time -reassure pt that they are safe *explain tx before, during, and after you finish |
|
|
Impairment based goals at Rancho Level III
|
-continued Level I and II goals
-continuous family education -positioning, ROM, edema/tone mgmt, skin integrity, chest PT *primary goals are to increase attention span, consistency, and speed of response |
|
|
Measuring progress at Rancho Level I-III
|
-Rappaport coma scale
-individualized response charts |
|
|
Scenarios for after acute care...
|
Worst Case
-long term care (level I-III) Best Case -inpatient rehab (at least III-IV) |
|
|
Additional motor issues addressed in Inpatient Rehab
|
-same motor theories apply
-lack of mvmt-facilitation theories -Has movement- motor learning theories -sustained abnormal tone will cause mm length issues and capsular deficits -correct mm length/capsular issues as they progress through orthopedic techniques like splinting, casting, joint mob, modalities, soft tissue mob, and ADL prescription/adaptation **keep in mind that mm tone is a positive sign and there's not much we can do about it |
|
|
Heterotrophic Ossification
|
-formation of bone in soft tissue and peri-articular areas
-common in TBI with prolonged coma, limb spasticity -usually in shoulder, elbow, hip, knee |
|
|
Early clinical signs of heterotrophic ossification
|
warmth, swelling, significant decrease in ROM, pain
|
|
|
Treatment for heterotrophic ossification
|
Medical management: Radiation, forceful joint mob under anesthesia, medication
Rehab Treatments: splints, ROM, positioning, avoid extremes of pain *once it occurs, it requires a surgical process to fix. We just try to keep it from getting worse |
|
|
Intrathecal Baclofen Pump
|
-mm relaxant
-works by blocking release of excitatory neurotransmitters in spinal cord. Allows more normal motor movement |
|
|
Overview of Rancho Levels
|
I- no response
II- generalized response III- localized response IV- confused-agitated V- confused- inappropriate VI- confused- appropriate VII- automatic-appropriate VIII- purposeful-appropriate IX- purposeful appropriate SBA on request X- purposeful appropriate Mod Ind |
|
|
Rancho Level Iv
|
CONFUSED/AGITATED
-alert and in a heightened state of activity -purposeful attempts to remove restraints and tubes -may sit, walk, reach but not on command -brief sustained and divided attention -decreased if any short term memory -may overreact to stimuli (crying, screaming) -may have aggressive or flight behavior -mood swings -incoherent, inappropriate verbalizations -unable to cooperate with tx *be very cautious with these patients *diversion is a good tactic. |
|
|
Intervention strategies at RLA IV
|
-provide calm atmosphere
-short, simple repeated directions -simple vocabulary, slow speech -don't expect pt to remember instructions -avoid questioning the pt -provide frequent orientation -don't argue or criticize (duh) *ex: how about we go look out the window |
|
|
Rancho Level V
|
CONFUSED, INAPPROPRIATE- NON-AGITATED
-alert, may wander randomly -may become agitated by stimuli -not oriented to person, place, or time -frequent brief periods of non-purposeful sustained attention -severely impaired recent memory with confusion of past/present -may be able to perform previously learned tasks with cues *many times will regress to IV as you're working with them -behavior is not goal directed ***unable to learn new information -response to simple commands is random -able to converse for brief periods -don't understand jokes, sarcasm -verbalizations about present events become inappropriate without external structure |
|
|
Intervention focus for RLA levels IV-V
|
Sensori-motor/Cognitive
-reduce agitation motor activity, ADL training, structured schedule Environmental modifications (may need 24 hr supervision) |
|
|
Tools used at RLA IV-V
|
Agitated behavior scale
-scored for entire day -14 items scored. Scores range 14-56 -useful to determine agitating factors -helps with med changes Staff Training -MANDT, CAPE -identify possible trigger behaviors and safety for staff |
|
|
Rancho Level VI
|
CONFUSED, APPROPRIATE
-inconsistently oriented to person, time, place -able to attend to highly familiar task in a structured environment for 30 min with moderate cues -able to use assistive memory aide with Max A -emerging awareness of appropriate response -shows carry over for relearned familiar tasks -able to follow simple directions consistently -appropriate verbal expressions in highly familiar and structured situations -unaware of impairments, disabilities, and safety risks *memory books, pics of family good at this stage *sometimes viewed as egocentric but can't help it |
|
|
Amnesia
|
-damage to the medial temporal lobes and hippocampus
|
|
|
Retrograde vs Anterograde amnesia
|
Retrograde- can't recall events prior to TBI
Anterograde- can't transfer new events to long term memory (50 first dates) |
|
|
Measuring severity of TBI using post-traumatic amnesia
|
-can be retrograde, anterograde, or mixed/transient
-every day is a new day -duration of amnesia is an indicator of cognitive and functional deficits: Mild TBI <24 hrs Moderate 1-7 days Severe 1-4 weeks Very severe >4 weeks |
|
|
Rancho Level VII
|
AUTOMATIC, APPROPRIATE
-consistently oriented to person, place in familiar environments. Moderate cues needed for orientation to time -able to attend to highly familiar tasks for 30 min with Min A -able to perform new learning with Min A -shallow recall after familiar task -superficial awareness of condition, not aware of deficits *unrealistic planning for the future |
|
|
Rancho Level VIII
|
PURPOSEFUL, APPROPRIATE
-consistently oriented to person, place, time - can attend to familiar task in distracting environment for 1 hr -able to recall and integrate past and recent events -use assistive memory devices with cues -aware of deficits *over or underestimate abilities -depressed, irritable, easily angered, argumentative, self centered -able to recognize socially appropriate behavior. Able to correct with Minimal assistance *this is when we work on what is and isn't socially appropriate. Don't understand before this. |
|
|
Intervention Strategies at RLA VI-VIII
|
Cognitive:
-reorient pt as needed -consistent staff response to confusion -use familiar objects, tasks to reinforce therapy -allow time to respond and self correct -begin previous vocational and educational training -use community based outings to work on psycho-social and cognitive skills Physical: -improve strength, coordination, endurance through activity -use physical tasks to decrease frustration **community based outings are important **ensure everyone on team is approaching pt the same |
|
|
Rancho Level IX
|
PURPOSEFUL APPROPRIATE SBA ON REQUEST
-independently shift back and forth b/t tasks for 2 hrs -use assistive memory devices independently -initiates and carries out familiar tasks ind, unfamiliar with SBA -accurately estimates abilities. Requires SBA to adjust task demands -able to monitor social appropriateness with SBA -may be depressed, easily irritable, low frustration tolerance |
|
|
Rancho Level X
|
PURPOSEFUL APPROPRIATE MOD IND
-able to handle multiple tasks simultaneously in all environments with breaks -accurately estimate abilities, adjust task demands -may use compensatory strategies or more time -socially appropriate -may have periods of depression, irritability when sick or stressed |
|
|
Long term considerations for TBI
|
-keep biomechanical advantage
-prevent mm from shortening -no real impact on time *cast is low cost alternative to dyna-splint |
|
|
Levels of assist in correlation with RLA scale
|
RLA I-III Total Assist
RLA IV-V Max A RLA VI- Mod A RLA VII- Min A RLA VIII-IX -SBA RLA X- Mod I |
|
|
Ongoing consequences of TBI
|
Residual physical impairments:
-contracture mgmt, skin integrity.. Chronic Medical Problems: -seizures, respiratory, pain mgmt... Post Concussion Syndrome -headache, fatigue, dizziness, irritability -cognitive difficulties critical for new learning |
|
|
Personality and Behavioral Consequences of TBI
|
limited coping skills
reduced insight loss of mental flexibility impaired perception unrealistic expectations out of sync with situation loss of social competence frustration, anger, apathy, depression, impulsivity, disinhibition difficulty with self modulation dual diagnosis early onset Alzheimers **often end up with substance abuse, bipolar **discharge dependent on support systems |
|
|
Lifestyle consequences of TBI
|
-limited social contacts
-no social life except with family -isolated over time -difficulty making new friends -dissatisfied with social interactions |
|
|
Intervention for Psychological and Behavioral consequences of TBI
|
Metacognitive Approaches:
-cognitive behavior therapy (tv and movies for non-threatening examples) -all approaches designed to improve social competence: role play, self awareness, rehearsal, strategy training... |
|
|
Community re-entry and supportive living post TBI
|
-some facilities provide resources, support and advocacy to assist members in achieving their goals for community living
-empower people with TBI to enhance self esteem, personal growth, independence, community involvement **what is developmentally appropriate for this pt at this level? |
|
|
Barriers to Independence after TBI
|
economic changes
housing choices most live with family and are dependent on their assistance limited services and access to service for people with TBI resources and social supports |
|
|
Settings for People with TBI
|
clubhouse model
therapy without walls transitional living family style living |
|
|
Disability Rating Scale
|
-scores at admission to rehav predict employment/return to school 1 yr post
|
|
|
Summary Points for TBI
|
-OTs and PTs have significant roles in lives of people with TBI
-from FIRST day of rehab, think about predictors for future -pt's recovery may stop at any of the levels affecting all members of family and friends -family's willingness to assist pt will determine final discharge setting and pt's outcome -more help is needed to assist people live more independent lifestyles |
