FINAL EXAM - TBI Flashcards
Acquired Brain injury (ABI)
an injury to the brain that is not hereditary, congenital, or degenerative
Causes of Non traumatic brain injury (5)
- anoxia
- infections
- strokes
- tumors
- metabolic disorders
Causes of Open TBI -5 (penetrating injuries)
- assaults (gun shots, stabbint)
- falls
- accidents
- abuse
- surgery
Cause of Closed TBI - 4 (internal pressure and shearing)
- assaults
- falls
- accidents
- abuse
TBI
an alteration in brain fn or toher evidence of brain pathology caused by an external force
Open TBI causes an increased risk of (3)
- infection
- hematomas
- cranial nerve damage
Mechanics of TBI - Coup-Contre Coup injury
Coup = blow to the brain anteriorly Contrecoup = conunter-blow posteriorly (contusion, swelling, blood clots)` Rotational forces (shearing, twisting)
Mechanics of TBI - diffuse axonal injury Cause Results in Axons Zone of axons
caused by twisting, stretching, and sometimes tearing of nerve fibers
Once an axon is damaged it causes permanent death of the brain cell
Axons are responsible for sending signals away from the brain.
Zone of axons die = “swiss cheese” - holes in the brain
Primary injuries occur at the time of impact. Includes:
- skull fx
- intracranial hematomas
- cortical contusions
- lacerations, and penetrating wounds
Hematomas
bleeding in the brain which can cause shifting or compression of the brain matter. Pressure pushes down on brainstem. Can cause death
Types of hematomas (4)
- epidural
- subdural (most dangerous)
- intracerebral
- subarachnoid
Secondary injuries evolve over a pd of hrs or days. Include (6)
- increased intracranial pressure effects (caused by cerebral edema, hydrocephalus, brain herniation syndromes)
- focal ischemia
- decreased cerebral perfusion pressure
- risk of infection with open injuries
- risk of seizure
- other acute effects (DVT, HO, …)
Diagnosis of Brain injury
- CT scan or MRI - evidence of gross damage to the brain
- xray
- eeg
- neurological exam
- ICP monitor
- angiogram
Decerebrate posture results from
damage to the upper brain stem
Decerebrate
arms are adducted and extended, with wrist pronated and the fingers flexed. legs are stiffly extended, with plantar flexion of the feet. Higher level of fn on motor scale
Decorticate posture results from
damage to one or both corticospinal tracts
Decorticate posture presentation
arms are adducted and FLEXED, with wrist and fingers flexed on the chest. Legs are stiffly extended, ir, with planter flexion of the feet
Glasgow coma scale
tests eye opening, motor, and verbal commands. Score is out of 15, the higher the better
Rancho Los Amigos: Level I
No Response: Total Assist
No response to pain,touch, sound or site
Rancho Los Amigos: Level II
Gerealized Response: Total Assit
Generalized reflex response to pain
Rancho Los Amigos: Level III
Localized Response: Total Assist
Demonstrates withdrawal or vocalization to pain full stimuli. Responds inconsistently to commands
Rancho Los Amigos: Level IV
Confused/Agitated: Max Assist
Agitated. Very active, alert, or bizarre behaviors, performs motor activities but behavior is not purposeful. Extremely short attention span
Rancho Los Amigos: Level V
Confused Inappropriate, Non-Agitated: Max Assist
Gross attention to the environment, highly distractible, required continual redirection, difficulty learning new tasks, agitated by too much stimulation, may engage in social conversation but with inappropriate verbalization
Rancho Los Amigos: Level VI
Confused Appropriate: Mod Assist
Inconsistent orientation to time and place, retention span /recent memory impaired, recall past, consistently follows simple direction, goal directed behavior with assistance
Rancho Los Amigos: Level VII
Automatic Appropriate: Min Assist
Perform daily routine and highly familiar environment in non confused but automatic robot like manner. Skills noticeable deteriorate in unfamiliar environment. Lacks realistic planning for own future
Rancho Los Amigos: Level VIII
Purposeful, Appropriate: Stand by assist
Consistently orientated to person, place, time. Initiates and carries out steps to complete familiar personal, house hold, community, work, and leisure routines with standby assistance and can modify the plan when needed with minimal assistance
Rancho Los Amigos: Level IX
Purposeful, Appropriate: Stand by assist on request
Able to think of consequences or decisions or actions with assistance when requested. Initiates and carries out steps to complete familiar personal, household, community, work, and leisure routine independently and unfamiliar personal, household, community, work and leisure tasks with assistance when requested
Rancho Los Amigos: Level X
Purposeful, Appropriate: Modified Indep.
Able to think about consequences of decisions or actions with assistance when requested
Impairments of the parietal lobe
Inability to attend to more than one object at a time
Inability to name an object
Inability to locate the words to write
Problems with reading
difficulty drawing objects
Difficulty distinguishing left from right
Difficulty doing mathematics
Lack of awareness of certain body parts and or surrounding space
Inability to focus visual attention
Difficulty with eye hand coordination
Impairment of the occipital lobe
Deficits and vision
Difficulty locating objects in the environment
Difficulty identifying colors
Hallucinations
Visual illusions, or inaccurately seeing objects
Word blindness or inability to recognize words
Difficulty recognizing drawn objects
Inability to recognize the movement of an object
Difficulty reading and writing
Impairments of the cerebellum
Loss of ability to coordinate fine movements Loss of ability to walk Inability to reach out and grab objects Tremors Dizziness Slurred speech Inability to make rapid movement
Impairments of the brain stem
Difficulty swallowing food and water Difficulty organizing or proceeding the environment Problems with balance and movement Dizziness and nausea Sleeping difficulties
Impairment of the frontal lobe
Loss of simple movement of various body parts
Inability to plan a sequence of complex movie needed to complete multi-step tasks making coffee, sequencing
Loss of spontaneity and interaction with others
Loss of flexibility in thinking
Persistence of single thought
Inability focus on a task
Mood changes
Change in social behavior
Change in personality
difficulty with problem solving
Inability to express language
Impairments of the temporal lobe
Difficulty recognizing faces
Difficulty understanding spoken words
Disturbance with selective attention to what the person sees and hears
Difficulty with identification of verbalization about objects
Short term memory loss
Interference with long term memory
Increased or decreased interest in sexual behavior
Inability to categorize objects
Persistent talking
Increased aggressive behavior
Client Factors in person with TBI
Cardiovasuclar System
Can have changes in regulation of blood pressure and postural hypotension
Client Factors in person with TBI
Respiratory system
Can be impaired with brain stem damage; acute stage - potential need for artificial respiration
Client Factors in person with TBI
Voice and speech fn
Can be impaired due to the effects of intubation, vocal cord paralysis, impaired UMN control of the muscle movements required for these functions (swallowing, dysphagia management)
Client Factors in person with TBI
Endocrine Disorders
Patient show evidence of gonadotropin deficiency
growth hormone deficiency
Corticotrophin deficiency
Patient demonstrates vasopressin abnormalities leading to diabetes insipidus or the syndrome of inappropriate anti diuresis
Client Factors in person with TBI
Digestive Function
Have difficulty reflexes required to coordinate swallow; acquire use of NG tube or PEG tube feeding in acute stage; abnormal bowel movements due to dietary changes, motility issues, sensation required to feel the need
Client Factors in person with TBI
Genitourinary fn
May require use of catheters during acute State; may have incontinence issue do to reduce sensation and reduced control
Client Factors in person with TBI
Reproductive fn
Due to motor control issues, hormone issues, behavioral issue
Client Factors in person with TBI
dysphagia
Swallowing problems are generally pervasive throughout the early stages of recovery
Disruption to any of the three phases of normal swallowing is serious and can be life-threatening
Aspiration pneumonia may develop due to the presence of foreign material in the lungs; may occur silently
Client Factors in person with TBI
Neuromuscular & Movement Related Fn : Tone
Defined as resistance to stretch or movement across a joint when the patient is relaxed
Client Factors in person with TBI
Neuromuscular & Movement Related Fn : Rigidity
Is a function of time, but it is defined as the non velocity-dependent increase in tone; common with damage to the basal ganglia
Client Factors in person with TBI
Neuromuscular & Movement Related Fn :Spasticity
Is a function of town and is defined as velocity-dependent increase in tone; found with lesions of the upper motor neurons
Client Factors in person with TBI
Neuromuscular & Movement Related Fn : joint mobility
May be reduced from changes in the muscle tone but also from prolonged non use during early coma
Client Factors in person with TBI
Neuromuscular & Movement Related Fn : Motor Reflexes
reemergance of ATNR (Fence) TLR, STNR
Client Factors in person with TBI
Neuromuscular & Movement Related Fn : involuntary movement reactions
Difficulty with postural reactions, body adjustment reactions, supporting reactions; loss of reflexes action to protect self
Client Factors in person with TBI
Neuromuscular & Movement Related Fn : control of voluntary movement
Difficulty with eye hand, eye-foot coordination, bilateral integration, crossing midline, fine and gross motor cantrol
Client Factors in person with TBI
Neuromuscular & Movement Related Fn : gait patterns
Asymmetric gait, ataxia,
Stiff gate
Client Factors in person with TBI
Neuromuscular & Movement Related Fn : muscle fn
Muscle power and muscle endurance can be affected if the individual with TBI has had limited motor mobility while in coma
Client Factors in person with TBI
Sensory Fn : hearing
Due to cranial nerve damage, eardrum rupture, and/or central auditory processing issue (temporal lobe damage)
Client Factors in person with TBI
Sensory Fn : taste
Due to damage to cranial nerve and central processing of taste
Client Factors in person with TBI
Sensory Fn : smell
Potential shear injury to the olfactory bulb damage to the medial temporal lobe
Client Factors in person with TBI
Sensory Fn : vestibular
Damage to cranial nerves and or dislodging of rocks; and or central processing damage with links to visual system and postural system
Client Factors in person with TBI
Sensory Fn : Touch
Damage to the sensory cortex can cause lack of or reduced awareness of touch
Client Factors in person with TBI
Sensory Fn : Proprioceptive
Reduce responsiveness or lack of responsiveness of the feedback loops involved which tells us our body alignment and joint sense - If you can’t feel your leg you can’t feel secure
Client Factors in person with TBI
Sensory Fn : Pain
Headaches are common; may also have reduced or increased threshold to pain. Pain reactions can be hypo or hypersensitive due to mid brain damage
Seizures
If a patient has one post traumatic seizure the likelihood of having another is 50%
Generalized tonic-clonic seizure
Abnormal electrical activity and whole body; results in loss of consciousness and body stiffening, which is followed by shaking of the arms and legs.
Drop, stiffen, jerk
Partial seizure
Involves a localized area of abnormal electrical activity changes can occur and attention, movement, and or behavior.
Absence seizure
Brief stares; may have increased eye blink, and temporary shift in attention
Post-Traumatic Agitation
Ranchos Level IV
Agitation is a subtype of delirium unique to survivors of TBI in which the patient is in the state of PTA and in which excesses of behavior include some combination of aggression,akathisia, disinhibition, and/or emotional lability
Diagnosis of post-traumatic agitation
rule out other causes of agitation behavior: pain, noise, environment, sleep pattern disrupted
Mild TBI
No loss of consciousness (LOC) or briefs LOC less than 30 minutes GCS greater than 12 PTA less than 30 minutes Dazed vacant stare right after injury normal neurological exam
Prognosis of Mild TBI
Rarely require inpatient rehab
Cognitive and behavioral changes improve within three to six months
Post concussion syndrome
Treatment involves patient and family education for use of compensatory strategies reassurance and psychological support
Moderate TBI
LOC between 30 minutes and 6 hours
GCS 9 to 12
PTA up to 24 hours
Moderate TBI effects
Physical cognitive psychosocial and emotional changes
Moderate TBI prognosis
Sometimes require acute inpatient hospitalization followed by a period Of outpatient rehabilitation may require community support
Severe TBI
Loc greater than 6 hours
GCS less than 9
PTA greater than 24 hours
Effects of severe TBI
Severe deficits in all areas
Affects all domains of daily living skills
Prognosis of Severe TBI
All require inpatient hospitalization and frequently extended inpatient and outpatient rehabilitation
Results highly variable, most patients have long-lasting impairment
Longer the length of the comment and PTA the poorer the outcome
Some never regain cognitive function
Dependent on caregiver
Consequences of TBI
Impacts basic and instrumental ADLs. results are highly variable across individuals. Consider the following variables: Severity of injury and stage of recovery, age, comorbidities, and pre-injury strength, personality, coping mechanisms, learning styles, preferences, roles and routines, and resources or support system
Impact of TBI on person
Depending on a person’s level of deficits, it can affect all or any of the occupations, performance skills, habits, routines, rituals, roles, and influence on context and environmental factors
Acute Care Safety precautions
Monitor: vitals ICP parameters Negative changes in neurological response Seizures Skin breakdown prevention Aspiration prevention
Seizure Safety precautions
Slowly initiate use of tactile stimulation
Slowly initiate range of motion exercises
Monitor vitals
Look for changes in facial color
Look for autonomic changes - sudden perspiration, breathing rate
Avoid: Rapid repetitive stimulation
ICP safety precautions
If an ICP monitor is in please do not:
Turn head
Flex or extend neck
Place in prone
Give fluids unless clear to do so
Do:
Keep neck in neutral
Position HOB at neutral or elevated to 30 degree
Place patient in side lying to avoid extensor tone which can increase in supine
Encourage supported set at 90 degrees is permitted by MD
Encourage family members and significant others to engage and gentle touch quiet talking stroking patients face
Client Factors in person with TBI
Sensory Fn : Vision
Mechanical problems with eyes can cause; light sensitivity, eyestrain, blurred vision accommodative dysfunction, double vision, difficulty with fixation, tracking, and seccades
Client Factors in person with TBI
Sensory Fn : Vision-Damage to the occipital lobe/visual system
- hemianopsia
- neglect
- reduced speed, patter, accuracy of scanning
- impaired visual discrimination, spatial relations, figure ground, form constancy, visual closure
- impaired planning and organization of visual information
- reduced visual abstract reasoning
Partial Seizure: Simple
person remains conscious, may remember details of seizure - feeling before it comes on
Partial Seizure: Complex
person loses consciousness; symptoms confined to a localized area of brain
Mild TBI Effects
Delayed response to questions or commands Headaches dizziness or nausea Slurred speech Ringing in the ears blurred vision Disorientation and unclear memory
Note; the effects of repeated concussions are cumulative
