|
DEAR REHAB PATIENT AND FAMILY
MEMBERS: Welcome to the The material in this booklet is designed to help you
understand traumatic brain injury and its possible effects. Please ask questions of any team member and
make suggestions as you progress in your recovery. We value your thoughts and ideas and are
sincerely interested in working with you toward your rehabilitation goals. Sincerely, The
Rehabilitation Team Updated: 3/07 :OWD |
|
|
TABLE OF CONTENTS
[To go to a particular section:
CTRL + Click on ⊕] |
1. Your Care Team and other Key
Information ⊕
2. Brain
Injury Program Description ⊕
Inpatient
Rehabilitation Program ⊕
Typical Day in
Rehabilitation ⊕
3. The
Rehabilitation Team ⊕
4. Anatomy
of the Brain ⊕
5. Traumatic
Brain Injury and Recovery ⊕
6. Consequences
of Brain Injury
A. Physical Consequences ⊕
B. Medical problems ⊕
C. Swallowing and feeding problems ⊕
D. Communication deficits ⊕
E. Cognitive consequences ⊕
F. Behavioral and emotional changes behavioral ⊕
7. Medications
used after Brain Injury ⊕
8. Family
Adjustment Following TBI ⊕
9. Smoking
and Brain Injury ⊕
10. Preventing Re-Injury ⊕
11. Alcohol/Drug Abuse and Brain Injury ⊕
12. Driving and Brain Injury ⊕
13. State and Community
Resources
Brain
Injury Organizations ⊕
14. TBI Internet Resources ⊕
15. Glossary of Terms ⊕
16. Appendix
Rancho Levels of
Cognitive Functioning ⊕
Fatigue Following TBI
(Handout) ⊕
Overstimulation &
TBI (Handout) ⊕
|
|
Patient Name:
____________________________________________
Room #: _______ Room Phone Number:_________________
Patient Mailing Address: Fletcher Allen Health Care
Rehabilitation Unit – 2nd
Floor
Fanny Allen Campus
Attending Physician: ________________________________
847-5387
Internal Medicine Physician:__________________________ 847-5387
Nurse Care Coordinator: _____________________________
847-5387
Physical Therapist (PT):
_____________________________ 847-6887
Occupational Therapist (OT):
_________________________ 847-6925
Speech-Language Pathologist (SLP):
____________________ 847-3970
Recreational Therapist (RT):
__________________________ 847-5314
Medical Psychologist (MED Y): _______________________ 847-4378
Social Worker (SW):
_______________________________ 847-3553
Spiritual Resources: ________________________________847-2770
|
|
The
Brain Injury Rehabilitation Program is designed to provide care, support, and
retraining to persons who have had a traumatic brain injury. We strive to assist the patient in reaching
the highest level of functioning possible considering the extent of his or her
particular injury. As part of the
program, we also provide training and
education to family members and other persons important in the patient’s life,
particularly those that will be caregivers after the patient is discharged from
the Rehabilitation Unit.
Goal
areas typically addressed in the patient’s rehabilitation include mobility, activities
of daily living, communication, cognition (thinking skills), perception,
swallowing, health management, emotional adjustment, recreation, and return to
work/community.
Patient
care is managed by a physician who specializes in Physical Medicine and
Rehabilitation and a nurse care coordinator.
Additional support and therapeutic services are provided by appropriate
team members in the areas of Physical Therapy, Speech-Language Therapy,
Occupational Therapy, Therapeutic Recreation, Medical Psychology, Social
Services, Nutrition Services, and Pastoral Care (these services are described
in detail in Section 3
of this manual).
The Intensive Inpatient Rehabilitation Program
The
intensive rehabilitation program includes:
(1) pre-admission screening, (2) initial evaluation, (3)
intensive treatment, (4) patient and family education / training, (5)
pre-discharge planning, and
(6) discharge and follow-up.
Admission Criteria: Patients are admitted to the
Rehabilitation Unit when they have needs which require acute rehabilitation
therapy of about three hours a day. For admission to the Brain Injury Program on the Rehabilitation Unit, a
patient:
·
Has a brain injury resulting in significantly
decreased functional abilities.
·
Is medically stable (no longer requires acute
hospital care).
·
Requires an intensive interdisciplinary
inpatient rehabilitation program in order to make functional gains.
·
Has a reasonable expectation for improvement.
Evaluation: A
comprehensive evaluation will take place during the first few days of
admission. A treatment plan will be
established by team members of each individual discipline. Team members will meet to share their findings
and formulate a treatment plan with the individual to ensure a comprehensive
and consistent approach.
Patient Care and Treatment
Program: The rehabilitation program
will include an average of three hours of therapy daily, and management of
medical care needs. Occasionally
patients may not tolerate this intensity, generally due to fatigue, and their
care will be clustered (all done around the same time), or therapists may
combine their time into what we call a co-treatment
session. The intensity will be increased
as the patient’s endurance improves.
Sessions may be individual or group oriented.
Patient / Family Education
and Training: Patient and family education
by all team members is an ongoing part of the overall rehabilitation
program. Family/Team Meetings may be
scheduled periodically to discuss patient progress, discharge planning, and
specific needs, goals and concerns of the patient, family, and/or staff. Family attendance during therapies is
frequently encouraged. However, at
times, therapists may ask family members not to attend treatments; typically this occurs when we need to keep
stimulation to a minimum, or to otherwise optimize benefit from a session.
Discharge Planning: Discharge
planning begins as soon as the patient is admitted and involves the patient,
the caregivers who will be helping the patient at home, and all members of the
rehabilitation team. Plans are made for continued nursing care, medications,
prescriptions, supplies, outpatient or home-based therapy, special equipment
needs, home modifications, community resources, and follow-up appointments
after discharge. Occasionally, patients
are referred to long term care facilities once the patient's acute
rehabilitation goals have been met.
If needed, a Functional Capacity Evaluation is completed at WERC (Work
Enhancement and Rehabilitation Center of FAHC) by their occupational and
physical therapists and a return to work program is coordinated with the
inpatient brain injury program. Work
Site Evaluations and consultations with employers are part of the discharge
planning, if appropriate.
In addition, referrals can be made to Vocational Rehabilitation for
patients who can return to work but are in need of retraining, special
assistance, and/or environmental adaptations.
They are seen by the physician, psychologist, and by speech-language
pathologist, occupational therapist and physical therapists if needed. The first appointment is arranged after
discharge from the Rehabilitation Unit.
Continued outpatient therapy can be provided through FAHC after
discharge, or therapy services may be arranged with other hospitals, clinics,
and home health agencies in the patient’s home community.
Discharge Criteria: Rehabilitation
is an evolving process that continues beyond the inpatient stay. Patients are discharged from the
·
The patient’s progress has slowed, or
intensive inpatient therapy is no longer needed to achieve functional gains.
·
Patient/Family education and training have
been completed.
·
Equipment and immediate safety needs have
been addressed.
·
Follow-up medical and therapy services have
been arranged, if needed.
·
Another setting better meets medical,
behavioral, social and/or physical needs of the patient.
Typical Day on the Rehabilitation Unit
Weekday activities: In addition to 24-hour
nursing care, the typical weekday for a patient on the Rehabilitation Unit
involves a variety of treatments and activities. Below is a sample schedule (although this may
vary depending on an individual patient’s needs).
·
·
·
·
and rest.
·
·
Evening. Leisure activities, and
optional therapeutic recreation activities.
Other
services, such as psychological counseling and diagnostic testing, are
scheduled as needed. The above schedule
can be adjusted according to the patient's need to balance rest and activity.
Family
and friend involvement in therapy is encouraged throughout the day. Requests may be made to limit this to one or
two people at a time. Social visits are recommended between
Weekend Activities: During the weekends, the
Nursing and Recreational Therapy staff will work with patients to practice
activities learned during the week. In
addition, group therapeutic recreation, fitness activities, and a modified
schedule of therapies are offered on Saturday.
|
|
Patient: One of
the most important members of the team is the patient. The patient actively participates with the
rest of the team in the evaluation, goal setting and discharge planning
process.
Family: Family members and/or friends typically
play a critical role as the primary caregivers when the patient returns
home. In addition, family members
provide an invaluable source of support and encouragement. Family education and participation in therapy
sessions are strongly encouraged.
Attending Physician: Each patient is under the direct care of a physiatrist, an attending
physician whose medical specialty is physical medicine and rehabilitation. The focus of this specialty is restoring
function. The physiatrist coordinates
and leads the rehabilitation team to enable patients to reach the highest level
of functioning possible, and is also responsible for diagnosing and treating
medical problems that occur during recovery from brain injury. The physiatrist may prescribe medications,
devices, specific therapies or exercises to aid recovery.
Speech-Language Pathologist
(Communication Therapist): After a brain injury, an individual's
ability to think, communicate, understand others, read, write and swallow may
be altered. The role of the
speech-language pathologist is to evaluate and improve these areas. Treatment involves assisting patients to
understand their current environment, and to make sense of past and daily
events. Strategy teaching with patients
and families occurs, to maximize safety and independence with communicating,
remembering, self-monitoring, decision-making, organizing, problem-solving and
reasoning.
Medical Psychologist: The
medical psychologist provides counseling and support to patients and their
family members. The goal is to help people emotionally adapt to the changes
that occur with brain injury. Also, the
psychologist works with the treatment team to develop behavior management plans
to address behavioral problems that are sometimes associated with brain injury.
Nursing Care Coordinator: Rehabilitation nursing supports the patient
and family in many ways. Each patient
will be assigned one registered nurse care coordinator for the entire stay. This nurse coordinates the care provided by
the therapy team members and nursing staff.
This will assure continuity and support for the many rehabilitation
learning activities. The care
coordinator will regularly discuss progress with the patient and family, assist
in identifying personal needs, develop teaching strategies, and help plan for
discharge.
Nurse Aide: Patients who have had
a traumatic brain injury can have periods when they are confused, disoriented,
and agitated. During those times the
patient may require increased supervision which is provided by a nurse aide.
Nutrition Services: Clinical and dietetic technicians assist
patients with the selection of nutritious meals for both regular and special
diets, screen and make recommendations for patients at nutritional risk, and
provide general nutritional counseling.
Occupational Therapist: The
occupational therapist evaluates and treats patients whose ability to perform activities of daily living is impaired because of difficulties
in physical functioning or thinking skills. Treatment typically includes participation in
functional activities such as feeding, dressing, bathing, home management,
leisure skills, work related activities and community living skills. In addition, treatment may also include
learning new ways of performing activities, using adaptive devices to aid in
completing tasks, arm and hand use, visual skills, and functional mobility.
Physical Therapist: The role of the physical therapist is to
maximize movement, mobility, and safe function in daily living activities.
After completing an evaluation to determine a patient's needs, the physical
therapist uses a variety of different techniques, devices, braces, and
practices to assist in maximizing control of the body movements affected by the
brain injury. These techniques are also used to increase overall strength,
endurance, and balance. The primary focus is on improving function in necessary
activities (transfers, bed mobility, walking, stair climbing, and wheelchair
management).
Pastoral Care: Spiritual care is available to all patients
and their families as they cope with the effects of a traumatic brain
injury. This can be as simple as a
listening presence for feelings, or the opportunity to receive prayer support
and the sacraments of a faith group.
Recreational Therapist: Participation in
recreational interests or hobbies is an important part of the recovery
process. The role of the recreation
therapist is to evaluate the patient's special interests and hobbies, help the
patient continue those activities (sometimes with the assistance of adaptive
equipment), and suggest new recreational activities that may stimulate the
recovery process.
Social Worker: Patients and their families frequently need
someone to talk with when they face the impact that illness has had on their
lives. Social workers assist patients and families with accepting and adjusting
to the disability, identifying new options for living a meaningful life, making
the transition back into the family unit and connecting the patient and/or
family to appropriate resources.
|
|
The
brain is divided into two halves, or hemispheres, which have specialized
functions. The left hemisphere controls
movement and perceives touch on the right side of the body. It is the center for logic, a variety of verbal skills (language
comprehension, speaking, reading and writing). The left hemisphere is
responsible of memory of language related information, such as conversations
you hear or material you read. The right
hemisphere controls the left side of the body and deals with spatial
orientation – the ability to process distance, shape, form and body position in
space – as well learning and memory of spatial material.
The
brain stem is at the base of the cerebral hemispheres and connects the spinal
cord and the brain cortex.
Nerve tracts pass through the brain stem carrying sensory information
from the body up to the brain and movement instructions from the brain down to
the body. The brain stem contains
centers which automatically regulate wakefulness and sleep, breathing and heart
function. Cranial nerves
travel from the brain stem to the head and neck to control muscles of the face,
eyes, lips and tongue. Smell, sight and
sound are transmitted through the cranial nerves to the brain cortex.
The
cerebellum
is behind the brain stem and controls muscle coordination. Motor movements, such as walking, talking and
writing, are generated by the cortex, but are finely adjusted by the
cerebellum.
Inside
the brain are four open areas called ventricles which
are filled with cerebrospinal fluid, a clear
liquid. The system of brain ventricles
connect to the spinal cord and share the flow of fluid.
|
|
Mechanisms
of Brain Injury
A closed head injury is a brain injury that generally occurs
from some type of accidental event such as a fall or motor vehicle
accident. Specific types of brain damage
resulting from closed head injury include contusion
(bruising), hematoma (blood clot), and diffuse shearing
(very small tearing of brain cell structures).
A penetrating head injury results when the skull is broken and
some object (e.g. bullet, bone fragment) penetrates the brain tissue. A
penetrating head injury causes brain damage to the specific areas torn, plus
possible combinations of contusion, hematoma, and/or shearing. Examples of closed and penetrating injuries
are shown in Figures A to D.
Closed
head injuries range in severity from mild concussion,
with very brief or no loss of consciousness, to very severe in which the
individual may remain in a coma or is nearly
comatose. The amount of recovery and the
length of recovery are determined by a number of factors. The general rule is the more severe the
initial injury, the longer the period of recovery will be and also the greater
the likelihood of long-term physical and/or mental difficulties. Other factors, such as specific areas of brain damage, patient age, involvement of
alcohol, amount of family support, and availability of specialized brain injury
rehabilitation, also determine the duration and quality of recovery.
Other
types of brain injury and neurological disorders are treated at the
Course of Recovery
Although
recovery from brain injury varies from one individual to the next, for most
severe injuries the individual will spend some period of time in a coma, where he or she is largely unresponsive. During this time, the person’s eyes are
closed and speech may be absent or limited to groaning. The person does not respond to even simple
instructions (e.g., “Squeeze my
hand”). As the coma lightens, the
person shows more responses to stimulation, such as to physical discomfort,
sounds, or people in the room.
Some
individuals experience a period of significant agitation,
restlessness, and confusion once they have emerged from the coma. Participation in rehabilitative therapies is
often disrupted during this phase, as the person's ability to cooperate is limited. This typically resolves after a relatively
short period as the patient's arousal, awareness, and orientation improve.
Once the patient becomes less
agitated, confusion may continue, but the person is more easily involved in the
rehabilitation program. In most cases,
problems with orientation, attention, memory, and safety judgment become
apparent at this point ( please refer to
Section 6:
Consequences of Brain Injury).
These problems become the focus of therapy along with the treatment of
physical (mobility, strength) and self-care (eating, dressing, grooming)
skills. As the confusion decreases,
brain-injured patients generally continue to have some problems with new
learning and memory, but most show an increasing awareness of their
difficulties and their need for rehabilitation.
The FAHC Rehabilitation team uses the Rancho Los Amigos Cognitive Levels (RLA) ratin