Intervention of TBI Flashcards
What is the cognitive recovery process (pyramid)
Wakefulness -> Awareness: arousal, attention, purpose -> Perception and recognition of information -> Speed of information processing -> Memory -> Reasoning and problem-solving -> Executive functioning
What should not impact your functional goals?
Cognition - augment your approach
What is included in the observation of an exam for a TBI patient?
Varies depending on clinical setting and patient
- Surveying the room
- Identifying and documenting lines/monitors and vitals, surgical incisions, and obvious trauma
- Patient response when you enter the room or talk (e.g., no response, turn head, conversant)
What should be included in the history of an exam for a TBI patient?
Mechanism of injury
Acuity of injury
Prognosis/goal setting
May find out new PMH information if not in patient chart
Previous neurologic insults?
Clarify any precautions (WB, helmet or bracing, drains)
Diagnostic imaging/CT/MRI
Orthopedic injuries
What should be included in the social history of an exam for a TBI patient?
Social supports and home setup
- Social supports may dictate disposition upon d/c
- With social supports: home/rehab
- Without social supports: SNF
Life roles and interests
- May change significantly after TBI
- Get full/realistic picture of daily activities
- Principle of salience
What should be included in the systems review of an exam for a TBI patient?
Cognition
Cardiovascular:
Vitals and/or Impaired upright tolerance
Integumentary:
Effects of trauma and or surgical sites
Bony prominences if immobile
Implications of increased tone
Increased pressure in certain areas
Musculoskeletal:
Orthopedic precautions or fractures
ROM restrictions
Pain
Neuromuscular:
Gross coordination of movements/motor control
Spontaneous vs to command
Muscle overactivity
What are some resources to decided which outcome measures to use for patients with TBIs?
TBI EDGE
Rehabilitation Measures Database
COMBI website
What is the core set of outcome measures for patients with neurological conditions?
Berg Balance Scale
Functional Gait Assessment
Activities-Specific Balance Confidence Scale
10-Meter Walk Test
6-Minute Walk Test
5 Times Sit-to-Stand Test
TBI EDGE recommended outcome measures for acute care
Agitated behavior scale
COMA recovery scale-revised
Moss attention rating scale
Rancho levels of cognitive function
Ambulation issues include:
Functional Assessment Measure
FIM
TBI EDGE recommended outcome measures for inpatient only?
COMA recovery scale-revised
Moss attention rating scale
TBI EDGE recommended outcome measures for outpatient only?
High level mobility assessment
What is the typical timeline to emerge from a coma?
2-4 weeks
Many are slow to recover consciousness from that point forward
Why would patients get denied admission to an IRF after waking up from a coma?
Deemed to have limited active participation in rehab and if documentation fails to detect progress beyond VS and MCS
What is a level 1 responsiveness?
Complete absence of observable change in
behavior when presented visual, auditory, tactile,
proprioceptive, vestibular or painful stimuli
What is a coma responsiveness?
Complete failure of the arousal system with NO
spontaneous eye opening and inability to be awakened by application of vigorous sensory stimulation
What is a level II responsiveness?
“generalized response”
Demonstrates generalized reflex response to painful stimuli
Responds to repeated auditory stimuli with increased or decreased activity
Responds to external stimuli with physiological changes generalized, gross body movement, and/or not purposeful vocalization
Responses noted above may be same, regardless of type and location of stimulation
Responses may be significantly delayed
What is the criteria for Vegetative State/Unresponsive Wakefulness Syndrome?
All of the following criteria must be met:
1. No evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile or noxious stimuli
2. No evidence of language comprehension or expression
3. Intermittent wakefulness manifested by the presence of sleep–wake cycles
4. Sufficient preservation of autonomic functions to permit survival with adequate medical care
5. Bowel/bladder incontinence
6. Variable preservation of cranial nerves and spinal reflexes
What is a level III responsiveness?
Demonstrates withdrawal or vocalization to painful stimuli
Turns toward or away from auditory stimuli
Blinks when strong light crosses visual field
Follows moving object passed within visual field
Responds to discomfort by pulling tubes or restraints
Responds inconsistently to simple commands
Responses directly related to type of stimulus
May respond to some persons (especially family and friends) but not to others
What is the criteria for Minimally Conscious State?
Occasionally demonstrates clear-cut signs of self or environmental awareness
Diagnosis requires clearly discernible and reproducible evidence of one or more of the following:
1. Simple command following (e.g., mouth opening when instructed)
2. Gestural or verbal “yes/no” responses
3. Intelligible verbalizations
4. Movements or affective behaviors that occur in contingent relation to relevant environmental stimuli
What are some examples of contingent behavioral responses?
-Crying, smiling, or laughter in response to the linguistic or visual content of emotional, but not neutral topics or stimuli
- Vocalizations or gestures that occur in direct response to the linguistic content of comments or questions
- Reaching for objects that demonstrates a clear relationship between object location and direction of reach
- Touching or holding objects in a manner that accommodates the size and shape of object
- Pursuit eye movements or sustained fixation that occurs in direct response to moving or salient stimuli
What is the criteria for Emergence From MCS?
Diagnosis requires return of reliable and consistent interactive (functional) communication or functional object use
