TBI 1: Intro Flashcards
(25 cards)
What are the 2 types of brain injury?
Closed - no skull fracture, and dura mater is not penetrated
Open - skull fractured. Tiny bones penetrate dura mater.
Sources of damage for TBI?
> Mechanical force
- tension + compression - blunt force trauma
> Acceleration + deceleration
- Rebounding effect =leads=> coup + contre coup - coup => damage @ site of impact - countre coup injure => opp. - Frontal + occipital lobes damaged - Frontal contusions - V common
> Haemorrhage
Cause:
- Damaged sinus and/or
- Bleeding –> burst aneurysm, weakened vessel
- Swelling & pressure increase
> Diffuse axonal injury
- Stretching, deformation and shearing of axons - Widespread area damage of white matter - Extensive lesions
Classifications of external haemorrhages
> Subdural (SDH)
- Blood gathers between dura mater + brain
> Extradural (EDH)
- Blood gathers btw skull + dura mater - Can occur in spine - Leads to brain shift
Internal haemorrhages
> Sub-arachnoid (SAH)
- Bleed in subarachnoid space
> Intra-cerebral (ICH)
- Occurs within brain tissue
> Intra-ventricular (IVH)
- Bleeding in brains ventricular system
===> where cerebrospinal fluid produced
- Blood is circulated towards subarachnoid space
What are the secondary effects of brain injury?
Mainly due to lack of oxygen. Cause further brain damage.
> Increased intercranial pressure > Acute hydocephalus > Infection > Hypoxia > Seizures
Due to these secondary effects, it’s essential that the client’s condition fist stabilises before the beginning of treatment.
Whats the rehab pathway?
Injury > acute care > rehab > return home
What is post traumatic amnesia?
> Period TBI where confused + disorientated
- unable to lay down new memories
> Can be measured retrospectively/prospectively
- Retro mostly used in UK
==> pre-injury
> Stage follows emergence from coma
> Considerable behaviour variation patient 2 pat.
> 20-40% of cases develop aphasia during PTA
PTA severity scale
Severity + duration
> V mild => less than 5 mins > Mild => 5-60 mins > Moderate => 1-24 hours > Severe => 1-7 days > V Severe => 1-4 weeks > Ex Severe => 1 month +
Some people never leave PTA
Describe management during PTA
> Quite + low stim environment => reduce aggression
Encourage fam to bring photos + personal items
- See what they remember
- Family should avoiding pressing patient to
remember.
- Identify agitation triggers
Avoiding asking questions about past
Manage behavioural triggers in environment
Non-confrontational group work?
Physical changes of TBI?
> Epilepsy
- Drinking/drugs incr risk
- Reason why x driving for 1 year
Headaches (frontal common)
Fatigue and reduced pain tolerance
- Aim for morning/afternoon sessions
Sensory deficits
- Visual disturbances (VF deficits, blurred, tunnel)
Auditory disturbances
- Sensory overload - see what like in busy setting
- Uni/bilateral, tinnitus
Diminished taste and smell
- Work on food textures
Balance and proprioception disturbances
Why may people with TBI experience behavioural changes?
What damage causes what?
> frontal lobe regulates emotions and behaviours
- this area may be damaged
> Orbito-frontal area
- aggression and frustration
> Dorsolateral
- Low motivation and drive as initiation damaged
Medical management of TBI
> ICP monitor > Pharmological treatments > Decompressive craniectomy > Craniotomy > Cranioplasty > Ventriculo-peritoneal shunt (VP shunt) > Lobectomy
Examples of behaviours as a result of TBI
> Dis-inhibition, impulsiveness, poor self-control > Ego-centricity, self-aborption > Rigidity + inflexibility > Perseveration > Poor self monitoring > Apathy and inertia > Blunt > Restlessness + agitation > Verbal + physical aggression > Reduced social skills > Reduced insight + awareness
Managing behavioural problems
> Observe & record to identify triggers
> Work w family and MDT
- Training & education => eff comm
> Medication
> Behaviour control
- positive reinforcement
- avoid negative reinforcement
- Consider insight + awarenessCognitive changes that may occur
Hierarchical (top to bottom of pyramid)
> Executive functioning > Memory > Spatial + lang ability > Attention + concentration > Sensory + motor skills > Arousal + alertness
> Significant overlap btween these domains.
What is executive functioning?
Umbrella term => broad range of higher order capacities for planning, initiation, regulation, and verification of complex goal directed behaviour.
> self awareness - strengths + needs > realistic + concrete goal setting; planning steps > Self-initiated plans > Self-evaluation of progress > Flexibility + problem solving
What are the psychosocial (?) consequences of TBI?
> Unable to resume pre injury activities
> Not being to return to work
- 4/50%, don't return 2 years post-injury
> Not driving
> Stress, anxiety, and depression
> Loss of friendships, failure of marriage
> Suicide
> Loss of self + low self-esteemHow do cognitive-communication impairments PRESENT
> Verbose (talk too much) + tangential > Repetitive + perseverative > Interrupts others during convos > Doesn't listen, self focused > Lack of facial exp, flat affect > Inaccurate + inefficient content > Not taking the hint to finish convo > Reduced verbal output > Difficulty starting + maintaining topic > Impolite and rude; blunt, tactless > Poor social awareness
What are some cognitive-communication impairments pwTBI may have?
MCDONALD + WISEMAN-HAKES
> Auditory comprehension/ info processing
- imp compr w increased length + complexity - Failure to pick up indirect content - Struggle to follow instructions, directions
> Verbal instructions
- word retrieval + vocab - syntax and sentence formation
> Reading comprehension
- Attention + scanning problems - Reading different - Interpretation of text
> Written expression
- Formulation of sentences - Spelling - Functional writing - note taking
> Social communication
- Non-verbal - Social perception: ToM, emotional processing - Discourse, pragmatics
What do cognitive-communication impairments cause?
> Social anxiety/avoidance > Low self esteem/confidence > Loss of friendship; struggle to make new friends > Poor awareness of impact of TBI > Stress, anxiety, depression
Impact of impaired executive functioning on communication
x
How does impaired awareness factor in w treatment and rehabilitation?
Impaired awareness
- Compromises the success of rehabilitation
- Either passive, noncompliant or resistant
- Reluctant to learn compensatory strategies
===> or use external aids
- Set unrealistic goals and less motivated
> Timing of treatment => take level of insight into account
Those with good awareness can set more realistic goals and typically achieve better levels of community integration
What factors contribute to poor awareness?
FLEMING ET AL
> Neuro-cognitive
- Damage to areas involved in awareness - Impaired EF
> Psychological
- Denial of disability - Personality may => denial
> Socio-cultural
- Behaviour interpretation shaped by environment
Model of Awareness
Crossen et al (pyramid)
Anticipatory awareness
Emergent awarenes
Intellectual awareness
