Diagnosis for head & brain injury

Posted by Nurse Linda in Daily Dose on March 04, 2019 # Health, Rehabilitation

It is not uncommon to have a head injury in addition to your spinal cord injury. Medical diseases that affect the spine can affect the entire central nervous system. If trauma is the source of your spinal cord injury, the force of trauma will affect other parts of your body including your head, which can lead to trauma in the brain. The higher the level of spinal cord injury, the higher your risk of head or brain injury. However, individuals with lower level injury should not just forget about the risk of head trauma because any force of impact can affect the brain.

A head injury might be on the outside of the skull such as a bump or scratch or a larger injury within the skull. A brain injury is an injury to the brain. Often, these terms are used interchangeably. Some terms that you might hear are brain injury (BI), traumatic brain injury (TBI) which is a brain injury acquired after or during birth, or mild traumatic brain injury (mTBI) which is a less severe brain injury that still requires treatment.

Some brain injuries are easy to see like a gash in the skin. Internal brain injuries are not always apparent. If someone is unconscious after an accident, they have a brain injury. This can be difficult to ascertain in the field because when you are unconscious, you do not know it. At the site of an accident or even loss of consciousness from medical issues, you will not know if you have lost consciousness. It takes someone being there to observe it. You might pass out and regain consciousness without being aware of the loss of mentation.

When admitted acutely to the hospital, there are brain injury assessments that should be undertaken. One of the basic bedside tests is called the Glasgow Coma Scale. A person is evaluated for their responses to motor, eye, and verbal cues. From the score of the Glasgow Scale, a determination of the level of brain injury is made. This can range from mild brain injury, moderate, severe, or even imminent death. There are other measurements that are used but the Glasgow Coma Scale is the most common.

In your rehabilitation stay, evaluations are made about functional abilities using the Functional Independence Measure (FIM) and Functional Assessment Measure (FAM), which is specially designed to assess cognitive abilities. The Disability Rating Scale is another assessment. The Rancho Los Amigos Level of Cognitive Functioning Scale (RLAS) is designed to assess a person through their recovery from brain injury. There are additional measurements that might be used in the hospital, rehabilitation facility, or in the community. The important factor is that the same measurement scale should be used each time the person is evaluated to follow progress.

Beside bedside observation, neuropsychologic assessments are also conducted. This testing is done by a specialized professional who has advanced education in assessment techniques, interpretation, and creation of a plan that is specifically designed for the unique needs of the individual. Neuropsychologic testing covers a large variety of brain functioning from awareness, orientation, language, processing information, math, new learning, spatial awareness, motor function, sensory awareness, problem-solving, to social adjustment and behavioral issues.

The healthcare team will review the results of this testing, so they can incorporate a unified strategy for approaching the needs of the individual. Family members should be aware of the testing as it can be very fatiguing for the individual as well as frustrating when difficulty areas appear. Family members will be provided with the same strategies for consistency in helping the individual accomplish their goals.

Physiologic testing is conducted to look for structural issues such as blood clots, bruising, tears in or around brain tissue, skull fractures or blockages. Some anatomical functions of the brain can be examined in these tests which include x-rays, CT scans, MRIs and EEGs.

If testing was initiated in the hospital, rehabilitation facility or in the community, starting treatment is imperative. Early treatment helps the brain adapt as it recovers. Retesting may be conducted at various points in recovery to see how the individual is progressing.

When testing is complete, an assessment is made and treatment begins. In the emergency room, things happen quickly. The purpose of the ER is to stabilize the individual and move them to a treatment setting. You might see brain injury assessments being conducted or you might not notice it among the numerous hectic procedures. Treatment will include informing the individual about what is going on in the simplest terms for their understanding.

Sometimes with a brain injury, information cannot be processed quickly or what is happening is not understood. Life-saving treatment might appear to the individual as harmful, so they resist. There might not be time to save life and have time to gain understanding. The individual may need to be physically or medically restrained for their own safety. If a patient becomes so resistant, medications may be used to calm the individual which will allow their life to be saved. Precautions for spinal cord injury will be continued from the field.

In the ICU, staff will attempt to inform the individual, however, maintaining life will be the goal along with spinal stabilizing precautions. Surgery may have been completed. Protection of the surgery site needs to be maintained. Mental stimulation through talking, orientation, and music might be used to help rouse someone from a coma. The music should be the type that the individual enjoys. Simple commands should be provided. Brief explanations should be described. The level of the brain injury will indicate if instruction should be provided in one statement or multiple steps. Prevention of secondary complications of spinal cord injury is continued.

In the rehabilitation stage, integration of therapies for the treatment of spinal cord injury and brain injury are combined. Information from neuropsychological testing will guide therapy and nursing care. Level of instruction will be indicated by the level and location of the brain injury. For example, when learning about mobility, simple commands, brief explanations, repeated explanations, and visual cues may be added to the instruction.

Although seemingly simple to someone without a brain injury, the person with a brain injury may have difficulty navigating the day. They may take some time before understanding that breakfast comes in the morning, lunch at noon and dinner in the early evening. The structure will help keep the individual organized throughout the day. Written or verbal cues for the next activity should be provided. Some individuals will benefit from verbal instructions, others will need to watch videos about activities of daily living such as how to dress. Many will need combinations strategies but consistency among staff and families will help the individual with structure.

Frustration and anger can appear at any point in the recovery process. It is not that the individual is being difficult, rather it is the difficulty in processing information. An understanding of what is happening to the person might not be fully grasped or internalized. They may see themselves as pre-injury and it is everyone else who is being difficult. You can see how frustrating this can be. This does not mean that any behavior should be tolerated. A plan for addressing aggressive, abusive, or hostile behavior must be set. Agreement to the plan is necessary so staff and families each approach the situation in a consistent manner.

Plans for care should be advanced as the individual progresses. Family members should have a good grasp of the interventions and treatments needed for the individual as they transition to the home setting. Prior to discharge, you should have the opportunity to meet with each therapist, the nursing staff and psychologist to learn approaches that will help the individual improve as well as activities that are appropriate stimulation for the individual.

At home, it is a good idea to stick to the schedule used in the rehabilitation facility. This can ease the transition to the home environment. You can slowly adjust the schedule to your normal home routine, but remember, with brain injury, consistency is critical. You might need to provide home therapy by playing some therapeutic games, doing some ‘homework’ assigned by the therapist but especially provide times when decreased stimulation is needed. Periods of quiet or rest will help the individual decompress from the challenges of daily living. If indicated, keep a notebook of important information and schedule of the day’s activities so the person can have ready access to the information.

In the community, there are many opportunities that can keep the progress of recovery going. This can include home health care, community centers for individuals with brain injury, adult day care centers, or in-home care. Not everyone will qualify financially for these services. Check with your payor to see what funding is available. The Brain Injury Association of America has local offices in many cities. They also have information on their website that can assist you and your family members. The Christopher & Dana Reeve Foundation has information as well, as brain injury and spinal cord injury are often seen together.

Medication is another subject to talk about with brain injury. Some of the same medications used to treat brain injury are also used to treat spinal cord injury. Muscle relaxants might help both the spasms of spinal cord injury and brain injury. Anticoagulants (blood thinners) will help with blood clots as a secondary condition. Anticonvulsants and antidepressants taken for seizure control and possible depression from brain injury will also help reduce neuropathic pain from spinal cord injury. Antipsychotics and sedatives are not usually taken for spinal cord injury but might be required to treat mental health issues from a brain injury.

Be wary of self-medication by the individual and the caretaker. Alcohol, street drugs, and prescription drugs are sometimes inappropriately used by people to deal with difficult issues. If the individual with a brain injury or if the caretaker is turning to these options, intervention should occur to learn what the underlying issues are. Talk to your healthcare professional to gain help through counseling. This is critical for success.

Being a family member of a person with a brain injury can be challenging as well. Your consistent approach is necessary. For most, all will go well. The individual with brain injury and the caregiver will reach a point of successful living.

However, know that brain injury is sometimes unpredictable. Significant brain injury symptoms can interrupt family life to a point where intervention must occur. You need to critically review your situation to see if the current living situation is viable. Alternative living settings are available. This does not mean failure, it just means that functioning in a home setting is not yet appropriate.

It takes a long time to recover from brain injury. It is not a continual process. The individual may have a leap of improvement and then stay at that level for months or years before additional improvement is seen. Keeping up with strategies for treating brain injury is imperative.

Pediatric Consideration
Brain injury in the developing brain presents a unique situation. On one hand, the brain is still developing so alternative pathways might be developed. On the other hand, brain injury can hamper some new learning depending on injury location. Taking advantage of research and therapeutic techniques can help improve the progress of your child.

Schools have special processes in place to assist children with brain injuries and other healthcare issues. This includes the Individual Education Plan (IEP). A team made up of school representatives, principal, nurse, teacher and assistants, family members and healthcare professionals provide input into approaches, treatments, and techniques that will best enhance the learning issues that the child may have. As a parent, you know your child best. Be sure to be an advocate for your child to meet their daily needs.

-- Nurse Linda

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