How The Brain Recovers

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TBI educational presentation for family/caretaker of a person with a traumatic brain injury

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How The Brain Recovers

  1. 1. Brain Injury and Recovery <ul><li>What is a brain injury </li></ul><ul><li>Types of brain injury </li></ul><ul><li>Levels of Brain injury </li></ul><ul><li>Factors that impact recovery </li></ul><ul><li>How are brain injuries treated </li></ul><ul><li>Stages of recovery and how to respond </li></ul>
  2. 2. Why is brain injury called the silent epidemic? <ul><li>Because of the magnitude of the problem, brain trauma has remained largely unknown by the American public. There are currently 5.3 million individuals—a little more than 2 percent of the U.S. population—living with a disability resulting from a traumatic brain injury. When considering an individual’s family and circle(s) of support, brain injury touches the lives of approximately one in every 10 persons in the United States . The annual statistics of brain injury are staggering: </li></ul><ul><ul><li>1 million people are treated and released from hospital emergency departments </li></ul></ul><ul><ul><li>230,000 people are hospitalized and survive </li></ul></ul><ul><ul><li>80,000 Americans experience the new onset of long-term disability following hospitalization for traumatic brain injury (TBI) </li></ul></ul><ul><ul><li>50,000 people die </li></ul></ul>
  3. 4. What Is a Brain Injury? <ul><li>The term refers to an injury to the brain that is usually the result of an accident, or sometimes and assault. Injuries can result from blows to the head such as suffered in an automobile accident or fall, as a result of lack of oxygen or blood supply to the brain. </li></ul>
  4. 5. Traumatic Brain Injury (TBI) <ul><li>A traumatic brain injury occurs when an outside force impacts the head hard enough to cause the brain to move within the skull or if the force causes the skull to break and directly hurts the brain. </li></ul>
  5. 6. Types of TBI –Closed Head Injury <ul><li>Closed Head Injury: the result of a bow to the head which causes the brain to move or shake within the skull. The sharp and hard internal surfaces of the skull can cut and bruise the brain. </li></ul><ul><li>Movement or shaking can cause the brain to be damaged in many areas, not only at the point of the blow. For this reason, persons with closed head injuries can show a wide range of problems. </li></ul><ul><li>Often called diffused injuries </li></ul>
  6. 7. Types of TBI- Open Head Injury <ul><li>An open head injury is the result of a sharp object entering the brain through the skull, such as a bullet. In this type of injury, damage to the brain tissue is seen mostly in one area-the area of penetration </li></ul><ul><li>These types of injuries are called focal injuries </li></ul>
  7. 8. Primary Injuries <ul><li>Diffuse Axonal Injury- A Diffuse Axonal Injury can be caused by shaking or strong rotation of the head, as with Shaken Baby Syndrome, or by rotational forces, such as with a car accident. Injury occurs because the unmoving brain lags behind the movement of the skull, causing brain structures to tear. </li></ul><ul><li>Concussion- caused when the brain receives trauma from an impact or a sudden momentum or movement change. The blood vessels in the brain may stretch and cranial nerves may be damaged. </li></ul><ul><li>Coup-Contrecoup Injury- This occurs when the force impacting the head is not only great enough to cause a contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, which causes the additional contusion </li></ul><ul><li>Penetration Injury- Penetrating injury to the brain occurs from the impact of a bullet, knife or other sharp object that forces hair, skin, bone and fragments from the object into the brain. </li></ul><ul><li>Contusion- A contusion is a bruise (bleeding) on the brain </li></ul>
  8. 9. Secondary Injuries <ul><li>When a TBI occurs, other factors can affect the brain, called secondary injuries. These can cause further problems in addition to the trauma </li></ul><ul><li>Bleeding (hemorrhage)- when deep blood vessels in the brain are injured an bleed causing injury from loss of blood or pressure </li></ul><ul><li>Blood clots (hematomas)- clots can form when there is bleeding. Clots can create pressure, which can lead to further damage </li></ul><ul><li>Swelling (edema)- causes pressure which can damage the brain </li></ul><ul><li>Lack of oxygen (anoxia)- because of bleeding in the brain or injury to other parts of the body, the flow of oxygen to the brain may be poor and cause damage . </li></ul>
  9. 10. Symptoms of a TBI <ul><li>Spinal fluid (thin water-looking liquid) coming out of the ears or nose </li></ul><ul><li>Loss of consciousness; however, loss of consciousness may not occur in some concussion cases </li></ul><ul><li>Dilated (the black center of the eye is large and does not get smaller in light)or unequal size of pupils </li></ul><ul><li>Vision changes (blurred vision or seeing double, not able to tolerate bright light, loss of eye movement, blindness) </li></ul><ul><li>Dizziness, balance problems </li></ul><ul><li>Respiratory failure (not breathing) </li></ul><ul><li>Coma (not alert and unable to respond to others) or semicomatose state </li></ul>
  10. 11. Symptoms of TBI cont. <ul><li>Paralysis, difficulty moving body parts, weakness, poor coordination </li></ul><ul><li>Slow pulse </li></ul><ul><li>Slow breathing rate, with an increase in blood pressure </li></ul><ul><li>Vomiting </li></ul><ul><li>Lethargy (sluggish, sleepy, gets tired easily) </li></ul><ul><li>Headache </li></ul><ul><li>Confusion </li></ul><ul><li>Ringing in the ears, or changes in ability to hear </li></ul>
  11. 12. Symptoms of TBI cont <ul><li>Difficulty with thinking skills (difficulty “thinking straight”, memory problems, poor judgment, poor attention span, a slowed thought processing speed) </li></ul><ul><li>Inappropriate emotional responses (irritability, easily frustrated, inappropriate crying or laughing) </li></ul><ul><li>Difficulty speaking, slurred speech, difficulty swallowing </li></ul><ul><li>Body numbness or tingling </li></ul><ul><li>Loss of bowel control or bladder control </li></ul>
  12. 13. Acquired Brain Injury An acquired brain injury is an injury to the brain, which is not hereditary, congenital, degenerative, or induced by birth trauma. An acquired brain injury is an injury to the brain that has occurred after birth .
  13. 14. Causes of Acquired Brain Injury <ul><li>Airway obstruction </li></ul><ul><li>Near-drowning, throat swelling, choking, strangulation, crush injuries to the chest </li></ul><ul><li>Electrical shock or lightening strike </li></ul><ul><li>Trauma to the head and/or neck </li></ul><ul><li>Traumatic brain injury with or without skull fracture, blood loss from open wounds, artery impingement from forceful impact, shock </li></ul><ul><li>Vascular Disruption </li></ul>
  14. 15. Causes Continued <ul><li>Heart attack, stroke, arteriovenous malformation (AVM), aneurysm, intracranial surgery </li></ul><ul><li>Infectious disease, intracranial tumors, metabolic disorders </li></ul><ul><li>Meningitis, certain venereal diseases, AIDS, insect-carried diseases, brain tumors, hypo/hyperglycemia, hepatic encephalopathy, uremic encephalopathy, seizure disorders </li></ul><ul><li>Toxic exposure </li></ul><ul><li>Illegal drug use, alcohol abuse, lead, carbon monoxide poisoning, toxic chemicals, chemotherapy (not all the time). </li></ul>
  15. 16. Levels of Brain Injury <ul><li>the severity of neurological injury to the brain by using an assessment called the Glascow Coma Scale (GCS) to. The terms Mild Brain Injury, Moderate Brain Injury, and Severe Brain Injury are used to describe the level of initial injury in relation to the neurological severity caused to the brain. There may be no correlation between the initial Glascow Coma Scale score and the initial level of brain injury and a person’s short or long term recovery, or functional abilities. </li></ul><ul><li>Keep in mind that there is nothing “Mild” about a brain injury—again, the term “Mild” Brain injury is used to describe a level of neurological injury. Any injury to the brain is a real and serious medical condition </li></ul>
  16. 17. Mild Traumatic Brain Injury Glascow Coma Scale score 13-15 <ul><li>Loss of consciousness is very brief, usually a few seconds or minutes </li></ul><ul><li>Loss of consciousness does not have to occur—the person may be dazed or confused </li></ul><ul><li>Testing or scans of the brain may appear normal </li></ul><ul><li>A mild traumatic brain injury is diagnosed only when there is a change in the mental status at the time of injury—the person is dazed, confused, or loses consciousness. The change in mental status indicates that the person’s brain functioning has been altered, this is called a concussion </li></ul>
  17. 18. Moderate TBI Glascow Coma Scale Score 9-12 <ul><li>A loss of consciousness lasts from a few minutes to a few hours </li></ul><ul><li>Confusion lasts from days to weeks </li></ul><ul><li>Physical, cognitive, and/or behavioral impairments last for months or are permanent. </li></ul><ul><li>Persons with moderate traumatic brain injury generally can make a good recovery with treatment or successfully learn to compensate for their deficits. </li></ul>
  18. 19. Severe Brain Injury Glascow Coma Score 8 or less <ul><li>Severe brain injury occurs when a prolonged unconscious state or coma lasts days, weeks, or months. Severe brain injury is further categorized into subgroups with separate features: </li></ul><ul><li>Coma </li></ul><ul><li>Vegetative State - Arousal is present, but the ability to interact with the environment is not. Eye opening can be spontaneous or in response to stimulation.General responses to pain exist, such as increased heart rate, increased respiration, posturing, or sweating Sleep-wakes cycles, respiratory functions, and digestive functions return </li></ul><ul><li>Persistent Vegetative State </li></ul><ul><li>Minimally Responsive State - demonstrate: Primitive reflexes,Inconsistent ability to follow simple commands, and an awareness of environmental stimulation </li></ul><ul><li>Akinetic Mutism - a neurobehavioral condition that results when the dopaminergic pathways in the brain are damaged. </li></ul><ul><li>Locked-in Syndrome </li></ul>
  19. 20. <ul><ul><li>Before we can understand what happens when a brain is injured, we must realize what a healthy brain is made of and what it does. The brain is enclosed inside the skull. The skull acts as a protective covering for the soft brain. The brain is made of neurons (nerve cells). The neurons form tracts that route throughout the brain. These nerve tracts carry messages to various parts of the brain. The brain uses these messages to perform functions. The functions include our thought processes, physical movements, personality changes, behavioral changes, and sensing and interpreting our environment. Each part of the brain serves a specific function and links with other parts of the brain to form more complex functions. </li></ul></ul>A Healthy Brain
  20. 21. Functions of the Brain: Frontal, Temporal, Parietal, Occipital, Brain Stem <ul><ul><li>The brain is divided into main functional sections, called lobes. These sections or brain lobes are called the Frontal Lobe, Temporal Lobe, Parietal Lobe, Occipital Lobe, The Cerebellum, and the Brain Stem. Each has a specific function, as described below. </li></ul></ul>                                                                                           
  21. 22. <ul><ul><ul><li>F rontal Lobe </li></ul></ul></ul><ul><ul><ul><ul><li>Initiation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Problem Solving </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Judgment </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inhibition of behavior </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Planning and anticipation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Self-monitoring </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Motor Planning </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Personality </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Emotions </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Awareness of abilities and limitations </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Organization </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Attention and concentration </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Mental flexibility </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Speaking (expressive language) </li></ul></ul></ul></ul>
  22. 23. <ul><ul><ul><li>Temporal Lobe </li></ul></ul></ul><ul><ul><ul><ul><li>Memory </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hearing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Understanding language (receptive language) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Organization </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sequencing </li></ul></ul></ul></ul>
  23. 24. <ul><ul><ul><li>Parietal Lobe </li></ul></ul></ul><ul><ul><ul><ul><li>Sense of touch </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Differentiation (identification) of size, shapes, and colors </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Spatial perception </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Visual perception </li></ul></ul></ul></ul>
  24. 25. Occipital Lobe <ul><ul><ul><ul><li>Vision </li></ul></ul></ul></ul>
  25. 26. Cerebellum <ul><ul><ul><ul><li>Balance </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Coordination </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Skilled motor activity </li></ul></ul></ul></ul>
  26. 27. Brain Stem <ul><ul><ul><ul><li>Breathing </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Heart rate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Arousal and consciousness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sleep and wake cycles </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Attention and concentration </li></ul></ul></ul></ul>
  27. 28. An Injured Brain <ul><ul><li>When a brain injury occurs, the functions of the neurons, nerve tracts, or sections of the brain can be effected. If the neurons and nerve tracts are effected, they can be unable or have difficulty carrying the messages that tell the brain what to do. This can result in Thinking Changes , Physical Changes , and Personality and Behavioral Changes . These changes can be temporary or permanent. They may cause impairment or a complete inability to perform a function. </li></ul></ul>
  28. 29. <ul><ul><li>Thinking Changes </li></ul></ul><ul><li>Memory Decision making Planning Sequencing Judgment Attention Communication Reading and writing skills Thought processing speed Problem solving skills Organization Self-perception Perception Thought flexibility Safety awareness New learning </li></ul><ul><ul><li>Physical Changes </li></ul></ul><ul><li>Muscle movement Muscle coordination Sleep Hearing Vision Taste Smell Touch Fatigue Weakness Balance Speech seizures Sexual Functioning </li></ul>
  29. 30. <ul><ul><li>Personality and Behavioral Changes </li></ul></ul><ul><li>Social skills Emotional control and mood swings Appropriateness of behavior Reduced self-esteem Depression Anxiety Frustration Stress </li></ul>Denial Self-centeredness Anger management Coping skills Self-monitoring remarks or actions Motivation Irritability or agitation Excessive laughing or crying
  30. 31. <ul><li>Right or Left Brain </li></ul><ul><ul><li>The functional sections or lobes of the brain are also divided into right and left sides. The right side and the left side of the brain are responsible for different functions. General patterns of dysfunction can occur if an injury is on the right or left side of the brain. </li></ul></ul>
  31. 32. <ul><ul><li>Injuries of the Right Side of Brain can cause : </li></ul></ul><ul><li>Visual-spatial impairment </li></ul><ul><li>Visual memory deficits </li></ul><ul><li>Left neglect (inattention to the left side of the body) </li></ul><ul><li>Decreased awareness of deficits </li></ul><ul><li>Altered creativity and music perception </li></ul><ul><li>Loss of “the big picture” type of thinking </li></ul><ul><li>Decreased control over left-sided body movements </li></ul><ul><ul><li>Left Side of the Brain </li></ul></ul><ul><li>Difficulties in understanding language (receptive language) </li></ul><ul><li>Difficulties in speaking or verbal output (expressive language) </li></ul><ul><li>Catastrophic reactions (depression, anxiety) </li></ul><ul><li>Verbal memory deficits </li></ul><ul><li>Impaired logic </li></ul><ul><li>Sequencing difficulties </li></ul><ul><li>Decreased control over right-sided body movements </li></ul>
  32. 33. <ul><ul><li>Diffuse Brain Injury </li></ul></ul><ul><ul><li>(The injuries are scattered throughout both sides of the brain) </li></ul></ul><ul><li>Reduced thinking speed </li></ul><ul><li>Confusion </li></ul><ul><li>Reduced attention and concentration </li></ul><ul><li>Fatigue </li></ul><ul><li>Impaired cognitive (thinking) skills in all areas </li></ul>
  33. 34. <ul><li>                                                             </li></ul><ul><ul><li>Just as no two people are alike, no two brain injuries are alike. Appropriate treatment and rehabilitation will vary from individual to individual. Programs and treatments change, as a person's needs change. It is important to recognize that &quot;more therapy&quot; does not make a person &quot;better&quot;, but that &quot;appropriate&quot; therapy may. </li></ul></ul>
  34. 35. Factors that Affect Recovery <ul><li>Age at the time of injury </li></ul><ul><li>Area and amount of injury </li></ul><ul><li>Time since the injury happened </li></ul><ul><li>Skills and behavior before injury </li></ul><ul><li>Motivation for recovery </li></ul><ul><li>Substance use and/or abuse </li></ul><ul><li>Past brain injury or concussion </li></ul>
  35. 36. How Are Brain Injuries Treated Medically (ICU) <ul><li>Treatment is aimed at stopping any bleeding, preventing an increase in pressure within the skull, controlling the amount of pressure and removing any large blood clots </li></ul><ul><li>Treatments may include: positioning, fluid restriction, medications, ventricular drain, ventilator, surgery (craniotomy, burr holes, bone flap removal) </li></ul>
  36. 37. The Recovery Process <ul><li>Ranchos Los Amigos Scale of Cognitive Functioning </li></ul><ul><li>As recovery progresses, the Ranchos Los Amigos Scale of Cognitive Function becomes the tool most widely utilized to assess cognitive and behavioral functioning. This describes the cognitive and behavioral status of the individual at the time, and directs the planning and evaluation of treatment plans and goals throughout the entire recovery process. It also represents a non-medical framework for family members to begin to understand brain injury in a way that helps them interact with their loved one in a more sensitive, positive manner, contributing to the rehabilitation process. </li></ul>
  37. 38. The Ranchos Los Amigos Scale consists of eight levels, and is described below. Individuals go through these levels at different rates, and improvement may vary at any level. Individuals may fluctuate between two levels at the same time. Suggestions for working with your family member at each stage of recovery is provided .
  38. 39. Stages of Recovery <ul><li>Level I - No Response Patient appears to be in a deep sleep and is completely unresponsive to any stimuli presented to him. </li></ul>
  39. 40. How to Respond to Level 1 <ul><li>It is not really known what an individual can hear and understand while in a coma or early stages of recovery. Family and staff should therefore monitor their interactions and conversations at bedside, always keeping in mind the possibility some activity may be remembered. </li></ul>
  40. 41. Stages of Recovery <ul><li>Level II - Generalized Response </li></ul><ul><li>Patient reacts inconsistently and non-purposefully to stimuli in a non-specific manner. </li></ul><ul><li>Responses are limited in nature and are often the same regardless of stimulus presented. </li></ul><ul><li>Responses may be physiological changes, gross body movements, and/or vocalization. </li></ul><ul><li>Often, the earliest response is to deep pain. Responses are likely to be delayed. </li></ul>
  41. 42. How to Respond to Level II <ul><li>During periods of wakefulness, provide simple and meaningful stimulation. </li></ul><ul><li>Describe activities to your loved one such as &quot;now I am washing your right hand&quot;. </li></ul><ul><li>Speak in slow, calm, and normal tones, and show affection often, in whatever way you can. </li></ul><ul><li>When eyes are opened, try to have him/her look at you and at other visitors. </li></ul><ul><li>Keep periods of stimulation brief (5-15 minutes), as your family member has to rest. </li></ul><ul><li>Family and friends should share stimulation responsibilities as you too have to rest. </li></ul>
  42. 43. Stages of Recovery <ul><li>Level III - Localized Response </li></ul><ul><li>Patient reacts specifically, but inconsistently, to stimuli. </li></ul><ul><li>Responses are directly related to the type of stimulus presented as in turning head toward a sound or focusing on an object presented. </li></ul><ul><li>The patient may withdraw an extremity and/or vocalize when presented with a painful stimulus. </li></ul><ul><li>May follow simple commands in an inconsistent, delayed manner such as closing eyes, squeezing or extending an extremity. </li></ul>
  43. 44. <ul><li>Once external stimuli is removed, patient may lie quietly. </li></ul><ul><li>May also show a vague awareness of self and body by responding to discomfort by pulling at nasogastric tube or catheter or resisting restraints. </li></ul><ul><li>Patient may show a bias toward responding to some persons (especially family, friends) but not to others . </li></ul>
  44. 45. How to respond to Level III <ul><li>Increase and direct stimulation efforts at reorienting your family member with who they are and what has happened. </li></ul><ul><li>At each visit, describe who you are, provide the date, where they are and why. </li></ul><ul><li>Bring familiar and significant objects to the individual; provide photographs of family and friends, identified by name on the back to assist staff who can also help stimulate his/her memory. </li></ul><ul><li>With increased periods of alertness, discuss significant past, such as school, employment, longtime relationships, hobbies. </li></ul>
  45. 46. <ul><li>Continue to ask for simple commands to be followed, initiate and assist with self-care tasks. </li></ul><ul><li>Ask simple questions that require only &quot;yes&quot; or &quot; no &quot; answers, allowing time to respond. </li></ul><ul><li>Remain patient and sensitive to signs of frustration. </li></ul>
  46. 47. Stages of Recovery <ul><li>Level IV - Confused/Agitated </li></ul><ul><li>Patient is in a heightened state of activity with severely decreased ability to process information. </li></ul><ul><li>Is detached from the present and responds primarily to his/her own internal confusion. </li></ul><ul><li>Behavior is frequently bizarre and non-purposeful relative to his/her immediate environment. </li></ul><ul><li>May cry out or scream out of proportion to stimuli even after removal, show aggressive behavior, attempt to remove restraints or tubes, or crawl out of bed in a purposeful manner. </li></ul><ul><li>Patient does not, however, discriminate among persons or objects and is unable to cooperate directly with treatment efforts. </li></ul>
  47. 48. <ul><li>Verbalization is frequently incoherent and/or inappropriate to the environment. </li></ul><ul><li>Confabulation may be present; patient may be euphoric or hostile. Thus, gross attention to environment is very short and selective attention is often nonexistent. </li></ul><ul><li>Being unaware of present events, patient lacks short-term recall and may be reacting to past events. </li></ul><ul><li>Is unable to perform self-care (feeding, dressing) without maximum assistance. </li></ul><ul><li>If not disabled physically, he/she may perform motor activities such as sitting, reaching, and ambulating, but as part of his/her agitated state and not as a purposeful act or on request, necessarily . </li></ul>
  48. 49. Responding to Level IV <ul><li>The goals of this stage are to decrease agitation and increase awareness. </li></ul><ul><li>Use calm, soft speech and slow careful movements to lessen the tendency for agitation. </li></ul><ul><li>Continue to provide opportunities for the individual to respond to stimuli and simple commands, encourage and assist with self-care tasks, continue to associate the individual with familiar things. </li></ul><ul><li>Remove distractions such as TV or radio, to restrict stimulation to one sense (auditory, visual or tactile) at a time. </li></ul><ul><li>Attempt to correct an inappropriate or inaccurate response, but do not argue the point. </li></ul>
  49. 50. Responding to Level IV cont <ul><li>If confusion and agitation is ongoing, do not try to rationalize with the person, allow him/her time to relax. </li></ul><ul><li>Do not ignore them however, instead provide human contact and soothing reassurances. </li></ul><ul><li>Avoid sedatives as they can slow the thinking process, and add to the confusion. </li></ul><ul><li>Seeing a family member engage in unusual and aggressive behavior is very difficult to endure. </li></ul><ul><li>Try to remember not to take any of the comments and behaviors personally. </li></ul><ul><li>The Confused-Agitated stage is a sign of improvement, and a necessary step towards recovery. </li></ul>
  50. 51. Stages of Recovery <ul><li>Level V - Confused, Inappropriate Non-Agitated </li></ul><ul><li>Patient appears alert and is able to respond to simple commands fairly consistently; however, with increased complexity of commands or lack of any external structure, responses are non-purposeful, random, or, at best, fragmented toward any desired goal. </li></ul><ul><li>May show agitated behavior, but not on an internal basis (as in Level IV), but rather as a result of external stimuli, and usually out of proportion to the stimulus. </li></ul><ul><li>Has gross attention to the environment, but is highly distractible and lacks ability to focus attention to a specific task without frequent re-direction back to it. </li></ul><ul><li>With structure, person may be able to converse on a social-automatic level for short periods of time. </li></ul>
  51. 52. <ul><li>Verbalization is often inappropriate; confabulation may be triggered by present events. </li></ul><ul><li>Memory is severely impaired, with confusion of past and present in patient’s reaction to ongoing activity. </li></ul><ul><li>Patient lacks initiation of functional tasks and often shows inappropriate use of objects without external direction. </li></ul><ul><li>May be able to perform previously-learned tasks when structured, but is unable to learn new information. </li></ul><ul><li>Responds best to self, body, comfort, and, often, family members. </li></ul><ul><li>The patient can usually perform self-care activities, with assistance, and may accomplish feeding with maximum supervision. </li></ul><ul><li>Management on the ward is often a problem if the patient is physically mobile, as patient may wander off, either randomly or with vague intentions of &quot;going home &quot;. </li></ul>
  52. 53. Responding to Level V <ul><li>Continue to help the individual get back in touch with the world, discuss family and friends, and events he/she has experienced during the day. </li></ul><ul><li>Try to have information recalled, providing hints to stimulate memory, for example, ask immediately after breakfast what he/she ate. </li></ul><ul><li>If unable to remember, be more specific. Ask what he/she drank. If it was milk, describe it as white. </li></ul><ul><li>Encourage success with generous praise, noting accomplishments. </li></ul>
  53. 54. <ul><li>Do not allow tasks to become overwhelming however, as tolerance for frustration is decreased. </li></ul><ul><li>Simple memory and card games may be tried at this stage. </li></ul><ul><li>Try to keep routines consistent to help organize the individual. </li></ul><ul><li>Discuss problems he/she is having related to the brain injury honestly and matter-of-factly. </li></ul><ul><li>Use a calm soothing manner always remembering to address the individual in an age-appropriate fashion. </li></ul>
  54. 55. Stages of Recovery <ul><li>Level VI - Confused, Appropriate </li></ul><ul><li>Patient shows goal-directed behavior, but is dependent on external input for direction. Response to discomfort is appropriate and patient is able to tolerate unpleasant stimuli (as NG tube) when need is explained. </li></ul><ul><li>Follows simple directions consistently and shows carry-over for tasks he has relearned (as self-care). </li></ul><ul><li>Is at least supervised with old learning; unable to maximally be assisted for new learning with little or no carry-over. </li></ul><ul><li>Responses may be incorrect due to memory problem, but they are appropriate to the situation. </li></ul><ul><li>They may be delayed to immediate and shows decreased ability to process information with little or no anticipation or prediction of events. </li></ul><ul><li>Past memories show more depth and detail than recent memory. </li></ul>
  55. 56. <ul><li>May show beginning immediate awareness of situation by realizing he doesn't know an answer. </li></ul><ul><li>He no longer wanders and is inconsistently oriented to time and place. </li></ul><ul><li>Selective attention to task may be impaired, especially with difficult tasks and in unstructured settings, but is now functional for common daily activities (30 min. with structure). </li></ul><ul><li>He may show a vague recognition of some staff, has increased awareness of self, family and basic needs (as food), again, in an appropriate manner as in contrast to Level V. </li></ul>
  56. 57. Responding to Level VI <ul><li>Work towards increasing independence during this stage, by gradually decreasing assistance provided for simple activities. </li></ul><ul><li>Offer games and crafts that become more mentally challenging but not frustrating. </li></ul><ul><li>Discuss TV shows, conversations, and events immediately after he/she has seen or heard them. </li></ul><ul><li>Use each situation as a learning experience to help the individual begin to arrange and understand each part of daily life. </li></ul>
  57. 58. <ul><li>Activities we take for granted may be difficult for the individual to accomplish. </li></ul><ul><li>Ask to have familiar tasks such as making coffee, changing money, or washing clothes described in steps; or well-traveled trips such as to school, stores, or friends' homes mapped out. </li></ul><ul><li>Be sensitive to tolerance levels and signs of fatigue. </li></ul><ul><li>Keep activities at a moderate pace, and always allow time for rest. </li></ul>
  58. 59. Stages of Recovery <ul><li>Level VII - Automatic, Appropriate </li></ul><ul><li>Patient appears appropriate and oriented </li></ul><ul><li>goes through daily routine automatically, but frequently robot-like, with minimal-to-absent confusion, but has shallow recall of what he has been doing. </li></ul><ul><li>He shows increased awareness of self, body, family, foods, people, and interaction in the environment. </li></ul><ul><li>He has superficial awareness of, but lacks insight into, his condition, decreased judgment and problem-solving and lacks realistic planning for his future. </li></ul>
  59. 60. <ul><li>Patient shows carry-over for new learning, but at a decreased rate. </li></ul><ul><li>Requires at least minimal supervision for learning and for safety purposes. </li></ul><ul><li>Patient is independent in self-care activities and supervised in home and community skills for safety. </li></ul><ul><li>With structure, Patient is able to initiate tasks as social or recreational activities in which he/she now has interest. </li></ul><ul><li>Judgment remains impaired; such that he/she is unable to drive a car. </li></ul>
  60. 61. Responding to Level VII <ul><li>The major goals of this and the next level of recovery are to promote independent skills to permit supervision to be safely withdrawn. </li></ul><ul><li>During this stage, &quot;real-life &quot; activities of increasing complexity such as shopping or use of a telephone directory and/or map should be attempted. </li></ul><ul><li>Situations of daily living at home and in the community should be discussed, with multistep planning and possible dangerous aspects explored. </li></ul><ul><li>Use and expansion of judgment skills should be emphasized. </li></ul><ul><li>Patience during interactions is needed as the processing of new information may be slowed . </li></ul>
  61. 62. Stages of Recovery <ul><li>Level VIII - Purposeful, Appropriate </li></ul><ul><li>Patient is alert and oriented, is able to recall and integrate past and recent events, and is aware of, and responsive to, his culture. </li></ul><ul><li>Shows carry-over for new learning if acceptable to him/her and his/her life role, and needs no supervision once activities are learned. </li></ul><ul><li>Within physical capabilities, person is independent in home and community skills, including driving. </li></ul><ul><li>Vocational rehabilitation, to determine ability to return as contributor to society (perhaps in a new capacity) is indicated. </li></ul>
  62. 63. <ul><li>May continue to show a decreased ability, relative to premorbid abilities, in abstract reasoning, tolerance for stress, judgment in emergencies or unusual circumstances. </li></ul><ul><li>Social, emotional, and intellectual capacities may continue to be at a decreased level, but functional in society . </li></ul>
  63. 64. Responding to Level VIII <ul><li>Max imum involvement in home, school, or job within the individual's physical and intellectual capabilities should be encouraged. </li></ul><ul><li>Responsibilities for one's own needs as well as in home and community should be resumed. </li></ul><ul><li>Complex tasks such as total meal planning and preparation, organizing chores into a daily routine, and planning leisure activities can be initiated independently. </li></ul><ul><li>The individual should be encouraged to develop and utilize aids such as memory books or reminder lists to assist him/her with accomplishing goals. </li></ul>
  64. 65. <ul><li>During these later stages, counseling may be indicated to assist the individual in gaining insight into the changed levels of functioning that he/she may be experiencing, and to develop coping strategies if deficits preclude a return to previous educational or vocational status. </li></ul>
  65. 66. Acute Rehabilitation <ul><li>In the Acute Rehab setting, a team of health professionals with experience and training in brain injury rehabilitation work with the person and their family. The goal of Acute Rehabilitation is to assist persons with brain injuries to achieve their highest level of independent life skills used in activities of daily living. Activities of daily living include dressing, eating, toileting, walking, speaking, and several other basic, yet essential activities that we perform in our daily lives. After a brain injury, people may have to relearn how to do these types of tasks. Rehabilitation requires the expertise of several healthcare professionals and Acute Rehab team members. </li></ul>
  66. 67. Subacute Rehabilitation <ul><li>Subacute Rehabilitation provides services for persons with brain injury who need a less intensive level of rehabilitation services, over a longer period of time. </li></ul><ul><li>Sub-acute rehabilitation programs may also be designed for persons who have made progress in the acute rehabilitation setting and are still progressing, but are not making rapid functional gains. </li></ul><ul><li>Subacute rehabilitation may be provided in a variety of settings, but is often in a skilled nursing facility or nursing home </li></ul>
  67. 68. Outpatient Therapy <ul><li>Following acute rehabilitation or sub-acute rehabilitation, a person with a brain injury may continue to receive outpatient therapies to meet continued goals. Additionally, a person with a brain injury that was not severe enough to require inpatient hospitalization may attend outpatient therapies to address functional impairments. </li></ul>
  68. 69. Rehabilitation Treatment Team <ul><li>Physiatrist is a doctor of physical medicine rehabilitation. The physiatrist typically serves as the leader for the rehabilitation treatment team and makes referrals to the various therapies and medical specialists as needed. The physiatrist works with the rehabilitation team, the person with a brain injury, and the family to develop the best possible treatment plan. </li></ul><ul><li>Physical Therapists evaluate and treat a person’s ability to move the body. The physical therapist focuses on improving physical function by addressing muscle strength, flexibility, endurance, balance, and coordination. Functional goals include increasing independent ability with walking, getting in and out of bed, on and off a toilet, or in and out of a bathtub. Physical therapists provide training with assistive devices such as canes or walkers for ambulation. Physical therapists can also use physical modalities, treatments of heat, cold, and water to assist with pain relief and muscle movement. </li></ul>
  69. 70. Rehabilitation Treatment Team <ul><li>Occupational Therapists </li></ul><ul><li>use purposeful activities as a means of preventing, reducing, or overcoming physical and emotional challenges to ensure the highest level of independent functioning in meaningful daily living. </li></ul><ul><li>Areas addressed by occupational therapists include: Feeding; swallowing; grooming; bathing; dressing; toileting; mobilizing the body on and off the toilet, bed, chair, bathtub; thinking skills; vision; sensation; driving; homemaking; money management; fine motor (movement of small body muscles, such as in the hands); wheelchair positioning and mobility; home evaluation; durable medical equipment assessment and training (such as, use of a raised toilet seat to assist with getting on and off the toilet easier). </li></ul><ul><li>The occupational therapist also fabricates splints and casts to reduce deformities and optimize muscle functioning </li></ul>
  70. 71. Rehabilitation Treatment Team <ul><li>Speech/language pathologist : </li></ul><ul><li>responsible for evaluating and treating language and cognitive difficulties that may cause challenges your daily life. Language refers to the skills of comprehension, verbal expression, reading, and writing. Cognitive skills refer to thinking skills such as attention/concentration, memory, reasoning, problem-solving, etc. </li></ul><ul><li>work with any motor speech or swallowing difficulties. Therapy will focus on improving and working around any difficulties to make you more independent in the home, work, educational, and community environments . </li></ul>
  71. 72. Rehabilitation Treatment Team <ul><li>Rehabilitation Nurses </li></ul><ul><li>monitor all body systems. </li></ul><ul><li>attempts to maintain the person’s medical status, anticipate potential complications, and work on goals to restore a person's functioning. </li></ul><ul><li>responsible for the assessment, implementation, and evaluation of each individual patient's nursing care and educational needs based on specific problems as well as coordinating with physicians and other team members to move the patient from a dependent to an independent role. </li></ul>
  72. 73. Rehabilitation Treatment Team <ul><li>Social Worker: </li></ul><ul><li>provides you and your family with information from weekly team staffings so that you remain updated on your progress, your discharge goals, and your estimated length of stay. </li></ul><ul><li>can also give you information on community resources that you might need, such as support services in the home or Social Security Disability. </li></ul><ul><li>will help you and your family set up your discharge to home or, if needed, will assist you in finding a living arrangement that provides you with more assistance. </li></ul>
  73. 74. Rehabilitation Treatment Team <ul><li>Recreational Therapists </li></ul><ul><li>provide activities to improve and enhance self-esteem, social skills, motor skills, coordination, endurance, cognitive skills, and leisure skills. </li></ul><ul><li>plan community outings to allow the person to directly apply learned skills in the community. </li></ul><ul><li>Additional programs may include pet therapy, leisure education, wheelchair sports, gardening, special social functions or holiday functions for persons and their family. </li></ul>
  74. 75. Rehabilitation Treatment Team <ul><li>Neuropsychologist : </li></ul><ul><li>The Neuropsychologist has specialized training in evaluating and understanding how brain injuries affect thinking, behavior, and emotions. </li></ul><ul><li>works with the rehabilitation physician to monitor your progress and response to medications. </li></ul><ul><li>conducts formal tests to measure progress in thinking, behavior, and emotions. </li></ul><ul><li>works closely with the treatment team to assist with recommendations on how independent you can be and how, or when, you can return to work. </li></ul><ul><li>can help you and your family understand what long term difficulties you may have as a result of your injury. </li></ul><ul><li>available to provide support to you and your family as you adapt to your injury and to the changes in your life. </li></ul>
  75. 76. Other Community Based Treatment/services <ul><li>Home Health Services </li></ul><ul><li>Vocational Rehabilitation </li></ul><ul><li>Support Groups: BIAI every 4 th Thursday at IERH 7-9pm </li></ul><ul><li>Brain Injury Association of Idaho </li></ul><ul><li>1-888-336-7708 www.biausa/idaho.org </li></ul><ul><li>Brain Injury Association, Inc. www.biausa.org </li></ul><ul><li>1-800-444-6443 </li></ul>
  76. 77. HOW DOES BRAIN INJURY AFFECT BEHAVIOR? <ul><li>The majority of TBI’s result in some degree of behavior change </li></ul><ul><li>It is very important that the family realizes that misbehavior can be the result of brain damage as well as the frustration and anger that the survivor feels </li></ul><ul><li>Impairments seen in self-care skills, cognition, and interpersonal skills </li></ul>
  77. 78. Personality traits may become exaggerated or more extreme after a brain injury. A reserved, quiet person may become even more even more withdrawn and quiet An assertive, active person may become aggressive and even more outspoken
  78. 79. Behavior and Personality Issues <ul><li>Fatigue </li></ul><ul><li>Amotivation </li></ul><ul><li>Agitation </li></ul><ul><li>Emotional Lability </li></ul><ul><li>Impulsivity </li></ul><ul><li>Perseveration </li></ul><ul><li>Sexual behavior </li></ul><ul><li>Memory Problems </li></ul><ul><li>Poor concentration </li></ul><ul><li>Lack of Awareness </li></ul><ul><li>Lack of emotion </li></ul><ul><li>Self-centered thinking </li></ul>
  79. 80. Emotional Responses to TBI <ul><li>Irritability </li></ul><ul><li>Fear/Anxiety </li></ul><ul><li>Anger </li></ul><ul><li>Depression </li></ul><ul><li>Role changes </li></ul><ul><li>Self-Esteem </li></ul>
  80. 81. FATIGUE <ul><li>Fatigue is tiredness of the body (physical) or mind (mental). All people feel fatigue but it is especially common after an injury. The body use a lot of energy to recover. This tiredness may come and go, lasting for a few months to many years </li></ul><ul><li>Symptoms of fatigue include: </li></ul><ul><li>Takes more energy to do everyday things like brushing teeth walking, and dressing </li></ul><ul><li>Activities normally done without thinking may take great care and planning </li></ul><ul><li>Simple communication may take more effort </li></ul><ul><li>May take more than one try and a lot of energy to finish a task </li></ul><ul><li>People often have a lot of sadness, fear, and anger after an illness or injury. These feelings use up a lot of energy. </li></ul>
  81. 82. Causes of Fatigue <ul><li>Things that can use up a person’s energy include the following: </li></ul><ul><li>Stress </li></ul><ul><li>Poor sleep </li></ul><ul><li>Pain </li></ul><ul><li>Medications </li></ul><ul><li>Depression </li></ul><ul><li>Lack of exercise </li></ul><ul><li>Poor nutrition </li></ul>
  82. 83. What Are the Types of Fatigue? <ul><li>There are different areas of life that fatigue (tiredness) can affect: </li></ul><ul><li>Physical </li></ul><ul><li>Emotional </li></ul><ul><li>Mental </li></ul><ul><li>Spiritual </li></ul>
  83. 84. Ways to Increase Energy <ul><li>The first step to increasing energy is to identify the causes of the tiredness </li></ul><ul><li>Follow a regular schedule for activity and rest. Make sure it does not affect nighttime sleeping </li></ul><ul><li>Celebrate progress, no matter how small </li></ul><ul><li>Find something enjoyable in everyday life </li></ul><ul><li>Keep track of your schedule to see when you tend to be most awake and most fatigued </li></ul>
  84. 85. How to Use Energy Better <ul><li>Make a daily schedule and follow it </li></ul><ul><li>Do harder tasks (high energy and/or thinking tasks) at times when you are most energetic </li></ul><ul><li>Have two plans for the day. One for high-energy days and one for low energy days </li></ul><ul><li>Use aids, such as notebooks for memory and wheelchairs to go long distances, to help save energy </li></ul><ul><li>Find a way to let go of anger, sadness, and fear. Holding these feelings in uses energy. Do the following: talk, relax, meditate, exercise, get counseling, if needed </li></ul><ul><li>Ask for help </li></ul>
  85. 86. Amotivation/Apathy <ul><li>Past Studies state that it is common for individuals with traumatic brain injury to experience apathy as a result of neurological changes. </li></ul><ul><li>Apathy refers to a syndrome of disinterest, disengagement, inertia, lack of motivation, and absence of emotional responsivity. The negative affect and cognitive deficits seen in patients with depression are not seen in patients with apathy. Apathy may be secondary to damage of the mesial frontal lobe </li></ul>
  86. 87. Agitation/Irritability <ul><li>Damage to several areas of the brain can lead to difficulty controlling one’s behavior, including control of temper </li></ul><ul><li>Irritability after brain injury sometimes relates to difficulties and frustration in doing things that the person was able to do easily before. </li></ul><ul><li>Person may become angry over seemingly small matters </li></ul>
  87. 88. Ways to Manage Anger <ul><li>After the person calms down, encourage them to write down what happened to cause the anger, what the person thought and did when angry, and what happened after he/she was angry. </li></ul><ul><li>Encourage the injured person to take a “time-out” when anger starts to build. The person can say “I am beginning to feel angry angry and would like to take a time out” </li></ul><ul><li>Get enough sleep </li></ul><ul><li>Avoid caffeine or alcohol </li></ul><ul><li>Identify triggers then change or avoid them </li></ul>
  88. 89. Ways to Diffuse Hostile Behavior <ul><li>Remain calm as you can, ignore the behavior </li></ul><ul><li>Agree with the person (if appropriate). </li></ul><ul><li>Validate feelings- let person know their feelings are legitimate </li></ul><ul><li>Do not challenge or confront person. Rather, negotiate. </li></ul><ul><li>Offer alternative ways to express anger </li></ul><ul><li>Try to understand source of anger- is there a way to address the person’s need/frustration </li></ul><ul><li>Ask person if there is anything that would help them feel better </li></ul>
  89. 90. <ul><li>Isolate the disruptive impaired person </li></ul><ul><li>Try to establish consistent, nonconfrontational responses from all family members </li></ul><ul><li>Seek support for yourself as a caregiver </li></ul>
  90. 91. Suggestions to Prevent Agitation <ul><li>Keep noise levels down </li></ul><ul><li>Adjust lighting in room </li></ul><ul><li>Limit visitors to one or two at a time for no more than 20 minutes </li></ul><ul><li>Follow rest schedule set by team </li></ul><ul><li>Allow no visitors in room during rest times </li></ul><ul><li>Give simple directions </li></ul><ul><li>Show calm behavior </li></ul><ul><li>Respect the person’s right for space and privacy </li></ul>
  91. 92. REMEMBER <ul><li>Physical contact may increase aggression </li></ul><ul><li>Call for help if aggression is escalating </li></ul><ul><li>Do not leave person alone </li></ul><ul><li>Keep person in sight </li></ul><ul><li>Remove objects that may be thrown (maintain a safe environment) </li></ul>
  92. 93. Emotional Lability <ul><li>Feelings are often show in an extreme and inappropriate way </li></ul><ul><li>Expressions and moods may change suddenly </li></ul>
  93. 94. Helpful Suggestions <ul><li>Keep a “matter-of-fact” attitude </li></ul><ul><li>Ignore inappropriate emotions. It is natural to want to comfort the person, but this type of attention may make unwanted emotions last longer </li></ul><ul><li>Change the topic </li></ul><ul><li>Praise the person when he or she controls unwanted emotions </li></ul><ul><li>Have the person take many rest periods </li></ul>

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