Traumatic Brain Injury (Answered) A+ Guarantee, Exams of Nursing

Download Traumatic Brain Injury (Answered) A+ Guarantee and more Exams Nursing in PDF only on Docsity! Traumatic Brain Injury (Answered) A+ Guarantee Define traumatic brain injury Disruption of normal brain function caused by external force to the head or body 4. Suicid e 5.Assaul t List the causes of traumatic brain injury 1. Motor vehicle accidents 2. Unintentional falls 3. Striking or struck by an object Describe the characteristics of an open brain injury 1. Caused from penetration into the brain (e.g.; knife; bullet) 2. Damage more limited to area that comes in contact with penetrating object 3. Higher risk of infection Define closed brain injury 1. Injury to head in which brain is damaged, but the skull and meninges remain intact 2. Rapid acceleration/deceleration Define coup lesion Contusion on same side of brain as an impact Define countercoup Contusion on opposite side of brain as an impact Describe diffuse axonal injury 1. Shearing or twisting of axons in white matter areas of brain 2. May cause widespread damage resulting in moderate to severe TBI 3. Often not seen on initial MRI or CT scan Define epidural hematoma Blood collects between dura mater and skull Define subdural hematoma Blood collects between dura mater and arachnoid mater Describe blast injury 1. Blast pressure damages the brain - Direct pressure wave goes through brain tissue - Oscillation of pressure within brain blood vessels - Elevation in CSF pressure 2. Head may be struck by (or penetrated by) flying objects 3. Individual may strike head when propelled by blast force 2. Hypoxia 3. cerebral edema List secondary injury results from biochemical, cellular, and molecular events after TBI 1. Neuronal injury causes inflammatory response and free-radical release 4. Elevated intracranial pressure State normal and abnormal intracranial pressure values 1. More than 20 mmHg 2. Normal is 5-10 mmHg 4. Irritability List symptoms of elevated intracranial pressure 1. Decreased responsiveness 2. Severe headache 3. Vomiting 5. Swelling of optic nerve 6. Increased BP/decreased HR Define heterotopic ossification Abnormal bone formation in soft tissues surrounding joints Describe vegetative state 1. Individual remains unconscious, but may have spontaneous eye opening without racking 2. Brainstem reflexes present (e.g.; respiration; digestion; control of BP) 3. May respond to painful stimulus with increased heart rate, increased respiration, sweating, abnormal posturing 4. Persistent vegetative state: more than 30 days Minimally conscious state 1. Individual is aware of self and environment 2. Localized responses to sensory stimulus 3. Some comprehension and communication Impaired cognition of moderate/severe TBI 1. Disorientation 2. Short attention 3. Poor memory 4. Diminished executive functions Behavioral deficits of moderate/severe TBI 1.Apathy 2. Irritability 3. Sexual inhibition 4.Aggression 5. Low frustration 6. Emotional lability Impaired motor functions of moderate/severe TBI 1. Decerebrate rigidity: UEs and LEs in extension posturingterm-33 2. Decorticate rigidity: UEs in flexion posturing, and LEs in extension posturing 3. Muscle weakness 4.Abnormal muscle tone 5. Reemergence of primitive and tonic neck reflexes 6.Apraxia 7.Ataxia 8. Diminished balance 9. Incoordination 4. Impaired vision 5. Loss of smell Other impairments of moderate/severe TBI 1. Impaired tactile sensation 2. Perceptual deficits 3. Impaired proprioception 6. Impaired communication Define Rancho Los Amigos levels of cognitive functioning 1. Scale used to track cognitive and behavioral recovery as patients emerge from coma 2. Patients may plateau at any level Level I 1. Coma/no response 2. Complete absence of observable change in behavior when presented with visual, auditory, tactile, proprioceptive, vestibular or painful stimuli 3. No sleep/wake cycles, all behaviors reflexive, no evidence of eyes opening (spontaneous or stimulus induced) Level II 1. Vegetative state/generalized response 2. Demonstrates generalized reflex response to painful stimuli 3. Responds to repeated auditory stimuli with increased or decreased activity 3. Responds to external stimuli with physiologic changes generalized, gross body movement, and/or non-purposeful vocalization 4. Responses noted above may be the same regardless of type and location of stimulation 5. Responses may significantly be delayed Level III 1. Minimally conscious state/localized response 2. Demonstrates withdrawal or vocalization to painful stimuli 3. Turns head toward stimuli 4. Blinks when strong light crosses visual field 5. Follows moving objects passed within visual field 6. Responds to discomfort by pulling tubes or restraints 7. Responds inconsistently to simple commands 8. Responses directly related to type of stimulus 9. May respond to some persons (especially family and friends), but not to others Level IV 1. Confused/agitated: maximal assistance 2.Alert and in heightened state of activity 3. Purposeful attempts to remove retrains or tubes or crawl out of bed 4. May perform motor activities, such as sitting, reaching and walking, but without any apparent purpose or upon another's request 5. Very brief and usually non-purposeful moments of sustained alternatives and divided attention 6.Absent short-term memory 7. May cry out or scream out of proportion to stimulus even after its removal 8. May exhibit aggressive fight or flight behavior 9. Mood may swing from euphoric to hostile with no apparent relationship to environmental events 10.Unable to cooperate with treatment efforts 11.Verbalizations are frequently incoherent and/or inappropriate to activity or environment Level V 1. Confused, inappropriate non-agitated: maximal assistance 2.Alert, not agitated but may wander randomly or with a vague intention of going home 3. May become agitated in response to external stimulation, and/or lack of environmental structure 4. Not oriented to person, place, or time 5. Frequent brief periods, non-purposeful sustained attention 6. Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity 7.Absent goal-directed, problem-solving, self-monitoring behavior 8. May be able to perform previously learned tasks when structured and cues provided 9. Unable to learn new information 10.Able to respond appropriately to simple commands, fairly consistently with external structures and cues 11.Responses to simple commands without external structures are random and non- purposeful in relation to command 12.Able to converse on a social, automatic level for brief periods of time when provided external structure and cues 13.Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided Level VI 1. Confused, appropriate: moderate assistance 2. Inconsistently oriented to person, time, and place 3.Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection 4. Remote memory has more depth and detail than recent memory 5. Vague recognition of some staff 6.Able to use assistive memory aide with maximum assistance 7. Emerging awareness of appropriate response to self, family, and basic needs 8. Moderate assist to problem solve barriers to task completion 9. Supervised for old learning (self care) 10.Shows carryover for relearned familiar tasks (self care) 11.Maximum assistance for new learning with little or no carryover 12.Unaware of impairments, disabilities and safety risk 13.Consistently follows simple directions 14.Verbal expressions are appropriate in highly familiar and structured situations Level VII 1.Automatic, appropriate: minimal assistance for daily living skills 2. Consistently oriented to person and place within highly familiar environments 3. Moderate assistance for orientation to time 4.Able to attend to highly familiar task in a non-distracting environment for at least 30 minutes with minimal assist to complete task 5. Minimal supervision for new learning 6. Demonstrates carryover of new learning 7. Initiates and carries out steps to complete familiar personal and household routine but has shallow recall of what he/she has been doing 8. able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance 9. Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work and leisure ADLs 1.Assess vital signs 2. Maximize patient comfort 3. Minimize distractions 4. 15-30 minute sessions, several times per day 5. Use sensory stimulation that is meaningful to patient 6.Allow sufficient time for patient response (up to a minute) 7.Assess nature, quantity, and quality of response When to stop sensory stimulation 1. Flushing of the skin 2. Perspiration 3. Elevated vital signs 4.Agitation 5. Increased postural tone or spasticity Visual stimulation 1. Familiar objects 2. Colorful objects 3. Photos of family or pets 4.Assess focusing and tracking on objects Auditory stimulation 1. Greet patient by name 2. Explain what you are doing with them in all care activities 3. Play familiar music (15 minutes max at a time) 4. Engage family members when present 5. Play recordings of family members 6. Only have one person speak to patient at a time Tactile stimulation 1. Rub lotion on hands 2. Move washcloth over body when bathing 3.Apply PROM exercise or stretching 4.Ticklish stimulation to face 5.Apply warm or cool objects with gentle pressure to skin Olfactory stimulation 1. Use familiar soaps, lotions, perfumes, or colognes 2. Use favorite flavors (e.g.; lemon; vanilla; coffee; chocolate) 3. Provide stimulus for 10 seconds max 4. Not effective if patient has NG tube or tracheostomy Provide taste stimulation during oral cares Treatment considerations for Level IV 1. Provide a calm, low-distraction environment 2. Provide a lot of structure and consistency 3. Provide frequent orientation 4. Keep verbal instructions simple 5. Provide choices in treatment 6. Redirect with inappropriate behavior 7. Start with shorter treatment sessions 8. Give frequent, short breaks within a session 9. Keep patient safe (e.g.; low bed; seat belt on wheelchair; wander guard monitor) 10.Expect no carryover 11.Stay calm Treatment considerations for Levels V and VI A. Assess orientation 1. Person: do they know their name 2. Place: do they know where they are (city; type of facility; name of facility) 3. Time: Do they know day of week, month, year, season 4. Situation: Do they know why there are in therapy, what happened to them B. Assess ability to follow motor commands 1. Follow one-step commands consistently/inconsistently 2. Follow two-step commands consistently/inconsistently 3. Follow multistep commands consistently/inconsistently C. Provide consistent routine and schedule 1. Provide frequent orientations 2. Use calendar or planner to assist with orientation and memory 3. Use repetition 4. Expect little carryover Treatment considerations for levels VII-X A. Focus on functional task re-training 1. Home care activities - Cooking - Cleaning - Yard work 2. Community activities - Shopping - Going to a restaurant B. Use dual-task activities 1. Carry laundry basket up stairs 2. Talk while walking on uneven surface C. High intensity gait training