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Shepherd Center
Acquired Brain Injury Program
Introduction
 What is Neuropsychology?
 What happened to your loved one?
 Part 1:
    Basics of the Brain
    What happens with a brain injury
 Part 2:
    Brain injury rehabilitation at Shepherd
    Your entire rehab team
    2 Tracks: Patient-specific
        PREP (Pre-Rehabilitation Education Program)
        Rehab Program
    Discharge- What happens when you leave here?
Brain Anatomy
 Brain is soft & has the consistency of a Jello mold
 Fits relatively snuggly in the skull
 Attached to the skull by small veins and meningies
 Floats in Cerebral Spinal Fluid (CSF)
    Provides a cushion, “shock absorber”
 Enclosed environment
    Other than veins and arteries, there is only one
     exit—where brain stem exits the base of the skull to
     become the spinal cord
    This is why we have the pressure problem
Brain Anatomy
 Surface of the brain is wrinkled
 with deep folds
   Increase the surface area of the
    brain in a small space
   Compact, efficient
   Allows for more connections
 Cortical structures on surface
 Subcortical structures deeper in
 brain
Brain Anatomy
 Two relatively symmetrical hemispheres (halves)
 Contralateral Control
    Left side of brain controls Right side of body, etc.
Brain Anatomy
 Neo-cortex or Cortical
 Structures
   Each hemisphere divided into 4 lobes
         Frontal, temporal, occipital, parietal
   “Thinking” portion of the brain
 Subcortical Structures
   Life sustaining structures/functions
   Brain stem controls heart rate,
    breathing, temperature,
    arousal/wakefulness
   White matter – communication
    between different brain regions
   May be affected by focal damage or
    generalized mechanisms (swelling,
    compression, diffuse/shear injury,
    anoxia)
Brain Anatomy
Frontal Lobes
• Common site of injuries due to bony shelf
  structures in skull
• Facilitates executive functions/goal-directed
  thoughts:
  •   Attention/concentration
  •   Planning, organization, sequencing
  •   Abstract reasoning/thinking/adjustment
  •   Judgment/decision-making
  •   Self-monitoring/stopping & starting
  •   Personality/ Behavioral & emotional regulation
• Motor strip at back of frontal lobe controls body’s
 ability to move itself
  • Weakness (hemiparesis) or paralysis (hemiplegia)
• Some expressive language abilities
Injury to the Frontal Lobes
 Decreased initiation
    Difficulty getting started
        The “gas” is not working properly: “Abulia”
        Cueing can help
 Disinhibition
   Problem with “social filter”, opposite of initiation
    problems
       colorful language, socially inappropriate behaviors
    Can be difficult to remember it is due to brain injury
      Not intentional, usually not directed towards any particular
        person
    Unaware of inappropriateness of behavior
    Or as recovery progresses, may become more aware, but
     still unable to control behavior= can lead to guilt
Injury to the Frontal Lobes
 Confabulation
    Disorientation & confusion  “neurological lying”
 Perseveration
    Repetitive topics, phrases, or behaviors
 Emotional lability (mood swings)
 Behavioral dysregulation
 Fatigue, over-stimulation, frustration
 Decreased insight and awareness
   May deny physical and/or cognitive deficits

 Remember: your loved one is not doing it on
  purpose.
Parietal Lobes
 Sensory strip at front of parietal
  lobe, behind motor strip
   Organized similarly to motor
    strip
   Detects pain, touch, pressure
   Senses where the body is in space,
    movements
 Visuospatial judgments
 Attention to entire environmental
  field
   Inattention vs. neglect
       “Left Sided Neglect”
Occipital Lobes
 Processes basic visual
   information
 Visual problems common
  after brain injury
 Input enters through eyes,
  but you “see” with your brain
 Many injuries affect vision
   Double vision, blurred vision
   Visual field cut
Temporal Lobes
 Auditory processing cortex
    Recognizing/Discriminating
     between sounds
 Expressive and Receptive
  Language abilities
   Expressive or Receptive “aphasia”
 Hippocampus facilitates memory
  storage
   Short-term vs. long-term memories
Cerebellum
 Fine motor coordination and
  balance
    Fluid motor movements
    Eye-hand coordination, timing,
     adjustment
    Posture, gait
    Motoric memory (e.g., how to play
     an instrument, walk)
 Ataxia, balance problems when
  damaged
 Contains half of all neurons of the
  nervous system
    Condensed; more neurons here
     than in the neocortex
Nomenclature
 Acquired Brain Injury (ABI):
   Any injury that happens within the brain itself at
    the cellular level
       Traumatic Brain Injury (TBI):
          Outside force impacts head hard enough to cause brain
          to move within the skull or the force directly hurts the
          brain
          Examples: motor vehicle collisions, falls, firearms,
          sports, physical violence, etc.
        Closed Head Injury vs. Open Head Injury
       Non-Traumatic Brain Injury (TBI):
         Does not involve external mechanical force
          Examples: stroke, aneurysm, insufficient oxygen
          (anoxia/hypoxia) or blood supply (ischemia), infectious
          disease, AVM, etc.
Mechanisms of TBI
Coup-Contrecoup
Back-n-Forth contact with skull
Diffuse Axonal Injury
•“Shear injury”
•Results from rotating, twisting
and tearing of axons of neurons
•Tears capillaries & blood
vessels
•Doesn’t always show up
immediately on CT scans
•Usually present in TBI,
especially MVA
•Axons/neurons don’t repair, per
se, and leads to cell death
•Some neuroplasticity can
compensate
Diffuse Axonal Injury in TBI
(What Grace has)
Neuropathology of TBI
 Contusions: Bruising
    blood vessels in or around
     brain are damaged or
     broken
 Hemorrhage
    bleeding from blood vessel
     leakage rupture
 Hematoma
    Localized pooling of blood
     that occurs from
     hemorrhaging.
 Can be large or small
Neuropathology in TBI
 Edema
    Swelling in brain tissue
    Causes increased intracranial
     pressure (ICP)
    Enclosed space: Increased
     pressure on all brain tissue
 Treatments:
    Medically induced coma
    Brain diuretic (reduce
     fluid/water)
    Placement of shunt (drain)
    Craniectomy (remove portion of
     skull bone to allow extra space for
     swelling)
Anoxia/Hypoxia
 Anoxic Brain Injury
    Brain does not receive any oxygen. Cells in the brain need
     oxygen to survive
    Anoxic Anoxia: no oxygen supplied to the brain
    Anemic Anoxia: blood that does not carry enough
    oxygen
   Toxic Anoxia: toxins that block oxygen in the blood
 Hypoxic Brain Injury
    Brain receives some, but not enough oxygen
 Common causes:
    Cardiovascular disease or trauma, asphyxia (e.g., drowning),
     chest trauma, electrocution, severe asthma attack, poisoning,
     substance overdose
Chemical Changes
 Brain is very efficient—produces at the cellular level
  only what it needs and needs everything it produces
 Brain injury may cause neurochemical imbalance
   Neurotransmitters:
     E.g., Serotonin  mood
   Medications may be given:
     Parlodel for arousal

     Ritalin for focused attention & arousal

     Mood stabalizers, antidepressents may be beneficial

 Damage to pituitary gland can result:
   hormone disruptions,
       sleep/wake cycles can be affected
Post-traumatic Amnesia (PTA)
 Patients with PTA may:
    Not be able to lay down new memories
    Be disorientated
    Have a short attention span
    Be agitated or have more mood swings
    Perseverate on words, ideas, or activities
    Need more structure
        probably better working on one activity at a time
    Have difficulty processing complex information about
     the accident
    May not have the capacity to assign Power of Attorney
        Power of Attorney vs. Guardianship
Neuropathology of Stroke
 Loss of brain function due to interruption in blood supply
  to all or part of the brain
 Results in depletion of oxygen and glucose in affected area
 Two types:
Neuropathology of Stroke
   Infarct: Area of damaged or dead tissue
   Ischemia: Lack of adequate blood flow
   Thrombosis: Solidified blood plugs/clots a blood vessel
   Embolism: A plug/clot brought through the blood from a
    larger vessel and forced into a smaller one where it
    obstructs circulation
Neuropathology in Stroke
 Aneurysm: Balloon-like expansion of blood vessel
    Usually weak and prone to rupture
    Risk factors: hypertension, arteriosclerosis, embolisms, or
     infections
    Prior to rupture, may be treated with stent or clipping
Neuropathology in Stroke
 3rd most common cause of death
    After heart disease and cancer
 Risk Factors:
    Hypertension
    Smoking
    High Cholesterol
    Diabetes
    Poor diet
    Age (especially from 60’s on)
 Stroke Prevention:
    Diet
    Exercise (physician approved)
    Smoking cessation
    Medication compliance
Tbi rehab family_lecture
Tracks at Shepherd Center
 PREP Program (Pre-Rehabilitation Education
 Program)
   Rancho Levels 1-3, passive therapies to keep body
    conditioned, and ready for progression to full rehab
   Stimulation for coma emergence
 Rehabilitation Program
 Dual diagnosis SCI patients
   Patient has both a spinal cord injury and brain injury
   They frequently co-occur (e.g., car accidents, falls, etc)
Rehabilitation Program
 Increase independence as much as possible
 Return to meaningful life
 Short-term goals (daily or weekly)
 Long-term goals (discharge home, return to work, etc)
 Relearn skills
 Learn new ways to do things, compensate
 Increase mental & physical endurance/stamina
 3 hours of therapies daily (plus groups, outings,
  psychology)
 Reduced therapies on weekends for rest and family time
Rehabilitation Treatment Team
 The Rehab team works together:
    Medical doctors
    Nursing
    Neuropsychology
    Occupational Therapy (OT)
    Physical Therapy (PT)
    Speech and Language Therapy (ST/SLP)
    Therapeutic Recreation/Other Therapists (TR)
    Case Managers
    Technicians
    Nutrition
    Chaplaincy/Spiritual Guidance/Therapy
Individualized Treatment Plan
 Occupational Therapy (OT)
   Rehabilitation for arms, hands, fine motor skills, vision
   Casting
   Basic and advanced activities of daily living (ADL’s)
        Showering, grooming, hygiene, dressing, toileting,
         home management skills, kitchen skills, money
         management, structuring routines
    Assess for safety
 Physical Therapy (PT)
    Rehabilitation for legs, torso, balance, walking and gait,
     sequencing movements, wheelchair training, transfers
    Casting
    Assess for safety
Individualized Treatment Plan
 Speech & Language Therapy
    Swallowing, consistency of liquid and diet orders, safe
     eating behaviors, speech and language, cognition,
     memory, attention, functional problem solving
 Therapeutic Recreation
    Fun activities to maximize progress
      toward goals and integrate skills
    Practice what is learned in OT, PT,
      S&LT, Neuropsych, etc.
 Nutrition
    Diet, weight, nutritional aspects of wound healing
    Importance of/Education for nutrition habits for discharge
Neuropsychological Screening
 Formal, standardized assessment of thinking skills
 Targets major cognitive domains:
    Attention/concentration, memory, visuospatial
     abilities, language, executive functioning
    Mood functioning
 Findings & Recommendations
    Ability/Capacity to make decisions, need for
     supervision, return to work/school recommendations,
     treatment and discharge planning
    Baseline for comparative follow-up testing
    Often used for disability claims
Power of Attorney vs. Guardianship
 Power of Attorney: Legal document that allows a person
  (the “principal”) to name another person to act in their place
 Patient must:
    Be fully oriented
    Demonstrate
      Understanding of what PoA is
      Full appreciation of the situation
    Reliably identify whom they want to have PoA
 Positives: inexpensive; revocable; patient retains ability to
  manage their affairs when able to do so
 Negatives: some financial institutions don’t honor PoA;
  agents can abuse their power
Power of Attorney vs. Guardianship
 Guardianship: Legal process in which the court
 appoints an individual/association/corporation to act
 on behalf of another who has been declared
 incompetent or incapacitated
   Applicable when patient is in acute stage of recovery
   Patient’s rights are (temporarily) taken away
   Emergency guardianship – required when consent for
    medical treatment is needed; hearing not required
   Temporary vs. Permanent Guardianship
       3-month temporary guardianship can be considered, as
        patient’s cognition may improve over time
   However, it is expensive; process is lengthy; court
    hearing required
Discharge from Rehab Track
 Family Training Day
 Shepherd Pathways or other outpatient therapy
  clinics
 Importance of supervision
   Due to deficits in judgment, memory, safety
    awareness, problem solving, insight into limitations,
    distractibility, impulsivity and behavioral regulation
   Help make the environment safe, training (e.g.,
    praise safe decisions, provide explanations, external
    memory devices, etc)
After Discharge
 Recovery does not end at discharge
    First 6 months: most rapid recovery
    Continued recovery for 1 – 2 years after injury
 Residual differences: cognitive, emotional,
  behavioral, interpersonal
    Physical limitations are easier to see and to watch
     heal
 Retest cognitive functioning to identify changing
  strengths and areas for improvement
Ongoing Difficulties & Limitations
 Physical
    Movement, coordination, balance
    Stamina and endurance
 Cognitive
    Safety awareness, impulsivity
    Memory, Post-traumatic Amnesia, Confusion
    New learning can be difficult
 Emotional and behavioral issues
    Dysregulation, depression, anxiety, adjustment
     issues
 Other cognitive issues & difficulties
Factors That Can Affect Recovery
   Age
   Prior brain injury
   Previous health status
   Length of PTA
   Time since injury
   How much tissue was damaged
   Focal injuries are more resistant to recovery
   Language, executive functions, ataxia are more resistant
   Substance abuse, ETOH & smoking tobacco etc.
   Adaptive functioning before injury
   Positive Family involvement
   More therapy hours are not related to amount of recovery
Post-traumatic Epilepsy
 10% risk with closed head injury
 50% risk with open head injury
 Learn what to do
 Know when to call 911
 Drinking alcohol increases risk
 May receive medications/medical management
 See attachment for “What to do in an emergency”
Substance Use
 Use of alcohol (in any amount) increases risk for
  seizures
 Drinking alcohol increases risk for falls
   Second brain injury likely to be much more severe, even
    if actual injury is mild
 Substance abuse is more common after brain injury,
  even if not present before
   More stress, losses
   Fewer coping strategies
   Poor decision making/judgment
   Be more aware- patients may try to hide substance use
Family
 You know your loved one better than we do
 Your knowledge about their emotional and physical
  needs is valuable to us and to their recovery
 Your participation and involvement is helpful
 Feelings of loss, sadness, anger, guilt, and frustration
  are common and normal
 You do not have to go through this alone- help is
  available
Self Care is Essential
 You have to be healthy in order to be able
  to take care of someone else
 Break the stress response cycle
    Rest, eat well, get some exercise
    Practice whatever gives you strength, peace, hope
 Manage your physical & emotional energy
   Asking for help is a valuable skill, not a weakness
   Find people who will help you and then let them
   Share your feelings with trusted others
    This is your chance for a break before your loved
     one is discharged
Some Last Housekeeping Notes…
 Time off
    Please respect visiting hours on the unit
    Reduces distraction, provides structure,
     promotes independence, promotes rest
       For your loved one
       For other patients
       For yourself

 Meal time expectations
   No family/visitors during breakfast & lunch
   1 family member/visitor during dinner
Tbi rehab family_lecture

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Tbi rehab family_lecture

  • 2. Introduction  What is Neuropsychology?  What happened to your loved one?  Part 1:  Basics of the Brain  What happens with a brain injury  Part 2:  Brain injury rehabilitation at Shepherd  Your entire rehab team  2 Tracks: Patient-specific  PREP (Pre-Rehabilitation Education Program)  Rehab Program  Discharge- What happens when you leave here?
  • 3. Brain Anatomy  Brain is soft & has the consistency of a Jello mold  Fits relatively snuggly in the skull  Attached to the skull by small veins and meningies  Floats in Cerebral Spinal Fluid (CSF)  Provides a cushion, “shock absorber”  Enclosed environment  Other than veins and arteries, there is only one exit—where brain stem exits the base of the skull to become the spinal cord  This is why we have the pressure problem
  • 4. Brain Anatomy  Surface of the brain is wrinkled with deep folds  Increase the surface area of the brain in a small space  Compact, efficient  Allows for more connections  Cortical structures on surface  Subcortical structures deeper in brain
  • 5. Brain Anatomy  Two relatively symmetrical hemispheres (halves)  Contralateral Control  Left side of brain controls Right side of body, etc.
  • 6. Brain Anatomy  Neo-cortex or Cortical Structures  Each hemisphere divided into 4 lobes  Frontal, temporal, occipital, parietal  “Thinking” portion of the brain  Subcortical Structures  Life sustaining structures/functions  Brain stem controls heart rate, breathing, temperature, arousal/wakefulness  White matter – communication between different brain regions  May be affected by focal damage or generalized mechanisms (swelling, compression, diffuse/shear injury, anoxia)
  • 8. Frontal Lobes • Common site of injuries due to bony shelf structures in skull • Facilitates executive functions/goal-directed thoughts: • Attention/concentration • Planning, organization, sequencing • Abstract reasoning/thinking/adjustment • Judgment/decision-making • Self-monitoring/stopping & starting • Personality/ Behavioral & emotional regulation • Motor strip at back of frontal lobe controls body’s ability to move itself • Weakness (hemiparesis) or paralysis (hemiplegia) • Some expressive language abilities
  • 9. Injury to the Frontal Lobes  Decreased initiation  Difficulty getting started  The “gas” is not working properly: “Abulia”  Cueing can help  Disinhibition  Problem with “social filter”, opposite of initiation problems  colorful language, socially inappropriate behaviors  Can be difficult to remember it is due to brain injury  Not intentional, usually not directed towards any particular person  Unaware of inappropriateness of behavior  Or as recovery progresses, may become more aware, but still unable to control behavior= can lead to guilt
  • 10. Injury to the Frontal Lobes  Confabulation  Disorientation & confusion  “neurological lying”  Perseveration  Repetitive topics, phrases, or behaviors  Emotional lability (mood swings)  Behavioral dysregulation  Fatigue, over-stimulation, frustration  Decreased insight and awareness  May deny physical and/or cognitive deficits  Remember: your loved one is not doing it on purpose.
  • 11. Parietal Lobes  Sensory strip at front of parietal lobe, behind motor strip  Organized similarly to motor strip  Detects pain, touch, pressure  Senses where the body is in space, movements  Visuospatial judgments  Attention to entire environmental field  Inattention vs. neglect  “Left Sided Neglect”
  • 12. Occipital Lobes  Processes basic visual information  Visual problems common after brain injury  Input enters through eyes, but you “see” with your brain  Many injuries affect vision  Double vision, blurred vision  Visual field cut
  • 13. Temporal Lobes  Auditory processing cortex  Recognizing/Discriminating between sounds  Expressive and Receptive Language abilities  Expressive or Receptive “aphasia”  Hippocampus facilitates memory storage  Short-term vs. long-term memories
  • 14. Cerebellum  Fine motor coordination and balance  Fluid motor movements  Eye-hand coordination, timing, adjustment  Posture, gait  Motoric memory (e.g., how to play an instrument, walk)  Ataxia, balance problems when damaged  Contains half of all neurons of the nervous system  Condensed; more neurons here than in the neocortex
  • 15. Nomenclature  Acquired Brain Injury (ABI):  Any injury that happens within the brain itself at the cellular level  Traumatic Brain Injury (TBI): Outside force impacts head hard enough to cause brain to move within the skull or the force directly hurts the brain Examples: motor vehicle collisions, falls, firearms, sports, physical violence, etc. Closed Head Injury vs. Open Head Injury  Non-Traumatic Brain Injury (TBI): Does not involve external mechanical force Examples: stroke, aneurysm, insufficient oxygen (anoxia/hypoxia) or blood supply (ischemia), infectious disease, AVM, etc.
  • 16. Mechanisms of TBI Coup-Contrecoup Back-n-Forth contact with skull Diffuse Axonal Injury •“Shear injury” •Results from rotating, twisting and tearing of axons of neurons •Tears capillaries & blood vessels •Doesn’t always show up immediately on CT scans •Usually present in TBI, especially MVA •Axons/neurons don’t repair, per se, and leads to cell death •Some neuroplasticity can compensate
  • 17. Diffuse Axonal Injury in TBI (What Grace has)
  • 18. Neuropathology of TBI  Contusions: Bruising  blood vessels in or around brain are damaged or broken  Hemorrhage  bleeding from blood vessel leakage rupture  Hematoma  Localized pooling of blood that occurs from hemorrhaging.  Can be large or small
  • 19. Neuropathology in TBI  Edema  Swelling in brain tissue  Causes increased intracranial pressure (ICP)  Enclosed space: Increased pressure on all brain tissue  Treatments:  Medically induced coma  Brain diuretic (reduce fluid/water)  Placement of shunt (drain)  Craniectomy (remove portion of skull bone to allow extra space for swelling)
  • 20. Anoxia/Hypoxia  Anoxic Brain Injury  Brain does not receive any oxygen. Cells in the brain need oxygen to survive  Anoxic Anoxia: no oxygen supplied to the brain  Anemic Anoxia: blood that does not carry enough oxygen  Toxic Anoxia: toxins that block oxygen in the blood  Hypoxic Brain Injury  Brain receives some, but not enough oxygen  Common causes:  Cardiovascular disease or trauma, asphyxia (e.g., drowning), chest trauma, electrocution, severe asthma attack, poisoning, substance overdose
  • 21. Chemical Changes  Brain is very efficient—produces at the cellular level only what it needs and needs everything it produces  Brain injury may cause neurochemical imbalance  Neurotransmitters:  E.g., Serotonin  mood  Medications may be given:  Parlodel for arousal  Ritalin for focused attention & arousal  Mood stabalizers, antidepressents may be beneficial  Damage to pituitary gland can result:  hormone disruptions,  sleep/wake cycles can be affected
  • 22. Post-traumatic Amnesia (PTA)  Patients with PTA may:  Not be able to lay down new memories  Be disorientated  Have a short attention span  Be agitated or have more mood swings  Perseverate on words, ideas, or activities  Need more structure  probably better working on one activity at a time  Have difficulty processing complex information about the accident  May not have the capacity to assign Power of Attorney  Power of Attorney vs. Guardianship
  • 23. Neuropathology of Stroke  Loss of brain function due to interruption in blood supply to all or part of the brain  Results in depletion of oxygen and glucose in affected area  Two types:
  • 24. Neuropathology of Stroke  Infarct: Area of damaged or dead tissue  Ischemia: Lack of adequate blood flow  Thrombosis: Solidified blood plugs/clots a blood vessel  Embolism: A plug/clot brought through the blood from a larger vessel and forced into a smaller one where it obstructs circulation
  • 25. Neuropathology in Stroke  Aneurysm: Balloon-like expansion of blood vessel  Usually weak and prone to rupture  Risk factors: hypertension, arteriosclerosis, embolisms, or infections  Prior to rupture, may be treated with stent or clipping
  • 26. Neuropathology in Stroke  3rd most common cause of death  After heart disease and cancer  Risk Factors:  Hypertension  Smoking  High Cholesterol  Diabetes  Poor diet  Age (especially from 60’s on)  Stroke Prevention:  Diet  Exercise (physician approved)  Smoking cessation  Medication compliance
  • 28. Tracks at Shepherd Center  PREP Program (Pre-Rehabilitation Education Program)  Rancho Levels 1-3, passive therapies to keep body conditioned, and ready for progression to full rehab  Stimulation for coma emergence  Rehabilitation Program  Dual diagnosis SCI patients  Patient has both a spinal cord injury and brain injury  They frequently co-occur (e.g., car accidents, falls, etc)
  • 29. Rehabilitation Program  Increase independence as much as possible  Return to meaningful life  Short-term goals (daily or weekly)  Long-term goals (discharge home, return to work, etc)  Relearn skills  Learn new ways to do things, compensate  Increase mental & physical endurance/stamina  3 hours of therapies daily (plus groups, outings, psychology)  Reduced therapies on weekends for rest and family time
  • 30. Rehabilitation Treatment Team  The Rehab team works together:  Medical doctors  Nursing  Neuropsychology  Occupational Therapy (OT)  Physical Therapy (PT)  Speech and Language Therapy (ST/SLP)  Therapeutic Recreation/Other Therapists (TR)  Case Managers  Technicians  Nutrition  Chaplaincy/Spiritual Guidance/Therapy
  • 31. Individualized Treatment Plan  Occupational Therapy (OT)  Rehabilitation for arms, hands, fine motor skills, vision  Casting  Basic and advanced activities of daily living (ADL’s)  Showering, grooming, hygiene, dressing, toileting, home management skills, kitchen skills, money management, structuring routines  Assess for safety  Physical Therapy (PT)  Rehabilitation for legs, torso, balance, walking and gait, sequencing movements, wheelchair training, transfers  Casting  Assess for safety
  • 32. Individualized Treatment Plan  Speech & Language Therapy  Swallowing, consistency of liquid and diet orders, safe eating behaviors, speech and language, cognition, memory, attention, functional problem solving  Therapeutic Recreation  Fun activities to maximize progress toward goals and integrate skills  Practice what is learned in OT, PT, S&LT, Neuropsych, etc.  Nutrition  Diet, weight, nutritional aspects of wound healing  Importance of/Education for nutrition habits for discharge
  • 33. Neuropsychological Screening  Formal, standardized assessment of thinking skills  Targets major cognitive domains:  Attention/concentration, memory, visuospatial abilities, language, executive functioning  Mood functioning  Findings & Recommendations  Ability/Capacity to make decisions, need for supervision, return to work/school recommendations, treatment and discharge planning  Baseline for comparative follow-up testing  Often used for disability claims
  • 34. Power of Attorney vs. Guardianship  Power of Attorney: Legal document that allows a person (the “principal”) to name another person to act in their place  Patient must:  Be fully oriented  Demonstrate  Understanding of what PoA is  Full appreciation of the situation  Reliably identify whom they want to have PoA  Positives: inexpensive; revocable; patient retains ability to manage their affairs when able to do so  Negatives: some financial institutions don’t honor PoA; agents can abuse their power
  • 35. Power of Attorney vs. Guardianship  Guardianship: Legal process in which the court appoints an individual/association/corporation to act on behalf of another who has been declared incompetent or incapacitated  Applicable when patient is in acute stage of recovery  Patient’s rights are (temporarily) taken away  Emergency guardianship – required when consent for medical treatment is needed; hearing not required  Temporary vs. Permanent Guardianship  3-month temporary guardianship can be considered, as patient’s cognition may improve over time  However, it is expensive; process is lengthy; court hearing required
  • 36. Discharge from Rehab Track  Family Training Day  Shepherd Pathways or other outpatient therapy clinics  Importance of supervision  Due to deficits in judgment, memory, safety awareness, problem solving, insight into limitations, distractibility, impulsivity and behavioral regulation  Help make the environment safe, training (e.g., praise safe decisions, provide explanations, external memory devices, etc)
  • 37. After Discharge  Recovery does not end at discharge  First 6 months: most rapid recovery  Continued recovery for 1 – 2 years after injury  Residual differences: cognitive, emotional, behavioral, interpersonal  Physical limitations are easier to see and to watch heal  Retest cognitive functioning to identify changing strengths and areas for improvement
  • 38. Ongoing Difficulties & Limitations  Physical  Movement, coordination, balance  Stamina and endurance  Cognitive  Safety awareness, impulsivity  Memory, Post-traumatic Amnesia, Confusion  New learning can be difficult  Emotional and behavioral issues  Dysregulation, depression, anxiety, adjustment issues  Other cognitive issues & difficulties
  • 39. Factors That Can Affect Recovery  Age  Prior brain injury  Previous health status  Length of PTA  Time since injury  How much tissue was damaged  Focal injuries are more resistant to recovery  Language, executive functions, ataxia are more resistant  Substance abuse, ETOH & smoking tobacco etc.  Adaptive functioning before injury  Positive Family involvement  More therapy hours are not related to amount of recovery
  • 40. Post-traumatic Epilepsy  10% risk with closed head injury  50% risk with open head injury  Learn what to do  Know when to call 911  Drinking alcohol increases risk  May receive medications/medical management  See attachment for “What to do in an emergency”
  • 41. Substance Use  Use of alcohol (in any amount) increases risk for seizures  Drinking alcohol increases risk for falls  Second brain injury likely to be much more severe, even if actual injury is mild  Substance abuse is more common after brain injury, even if not present before  More stress, losses  Fewer coping strategies  Poor decision making/judgment  Be more aware- patients may try to hide substance use
  • 42. Family  You know your loved one better than we do  Your knowledge about their emotional and physical needs is valuable to us and to their recovery  Your participation and involvement is helpful  Feelings of loss, sadness, anger, guilt, and frustration are common and normal  You do not have to go through this alone- help is available
  • 43. Self Care is Essential  You have to be healthy in order to be able to take care of someone else  Break the stress response cycle  Rest, eat well, get some exercise  Practice whatever gives you strength, peace, hope  Manage your physical & emotional energy  Asking for help is a valuable skill, not a weakness  Find people who will help you and then let them  Share your feelings with trusted others  This is your chance for a break before your loved one is discharged
  • 44. Some Last Housekeeping Notes…  Time off  Please respect visiting hours on the unit  Reduces distraction, provides structure, promotes independence, promotes rest  For your loved one  For other patients  For yourself  Meal time expectations  No family/visitors during breakfast & lunch  1 family member/visitor during dinner