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TBI

scorebuilders ch 2

TermDefinition
Open Injury An injury of direct penetration through the skull to the brain. Location, depth of penetration, and pathway determine the extent of brain damage. Exasmples include GSW, knife or sharp object penetration, skull fragments, and direct trauma
Closed Injury An injury to the brain without penetration through the skull. Examples include concussion, contusion, hematoma, injury to extracranial blood vessels, hypoxia, drug overdose, near drowning, and acceleration and decelleration Injuries.
Primary Injury Initial injury to the brain sustained by impact. Examples include skull penetration, skull fractures, and contusions to gray and white matter
Coup Lesion A direct lesion of the brain under the point of impact. Local brain damage is sustained
Countercoup Lesion An injury that results on the opposite side of the brain. The lesion is due to the rebound effect of the brain after impact.
Secondary Injury Brain damage that occurs as a response to the initial injury. Examples include hematoma, hypoxia, ischemia, increased intracrainial pressure, and post traumatic epilepsy
Epidural Hematoma A hemmorhage that forms between the skull and dura mater
Subdural Hematoma A hemmorhage that forms due to venous rupture between the dura and arachnoid
Coma A state of unconsciousness and a level of unresponsiveness to all internal and external stimuli
Stupor A state of general unresponsiveness with arousal occuring from repeated stimuli
Obtundity A state of consciousness that is characterized by a state of sleep, reduced alertness to arousal, and delayed response to stimuli
Delirium A state of conciousness that is characterized by disorientation, confusion, agitation, and loudness
Clouding of Conciousness A state of conciousness that is characterized by quiet behavior, confusion, poor attention, and delayed responses
Conciousness A state of alertness, awareness, orientation, and memory
Glasgow Coma Scale A neurological Assesment tool used initially after injury to determine arousal and cerebellar cortex function. A total score of 8 or less correlates to coma in 90% o patients. Scores of 9-12 indicate moderate brain injuries and scores from 13-15 indicate mild brain injury
Glassgow Coma Scale Eye Opening -spontaneous =4 -To speech =3 -To pain =2 -Nil =1 Best Motor Response -Obeys Commands =6 -Localizes Pain =5 -Withdrawls =4 -Abnormal Flexion =3 -Extensor Response =2 -Nil =1 Verbal Response -Oriented =5 -Confused converstion =4 -Inappropriate Words =3 -Incomprehensible Sounds =2 -Nil =1
I. No response patient appears to be in a deep sleep and is compltely unresponsive to any stimuli
II. Generalized Response Patient reacts inconsistently and non-purposefully to stimuli in a nonspecific manner. Responses are limited and often the same regardless of stimulus presented. Responses may be physiological changes, gross body movements, and or vocalization
III. Localized Response Patient reacts specifically but inconsistently to stimuli. Responses are directly related to the type os stimulus presented. May follow simple commands such as closing the eyes or squeezing the hand in an inconsistent, delayed manner
V. Confused-Inappropriate Patient is able to respond to simple commands fairly consistently. However, with increased complexity of commands or lack of any external structure, reponses are non-purposeful, random or fragmented. Demonstrates gross attention to the environment but is highly distractable and lacks the ability to focus attention on a specific task. With structure, may be able to converse on a social automatic level for short periods of time. Verbalization is often innapropriate and confabulatory. Memory is severely impaired, often shows inappropriate use of objects, may perform previously learned tasks with structure, but is unable to learn new information.
VI. Confused-Appropriate Patient shows goal-directed behavior, but is dependent on external input or direction. Follows simple directions consistently and shows carryover for relearned tasks such as self-care. Respones may be problems,due to memory problems but they are appropriate to the situation. Past memories show more depth and detail than recent memory
VII. Automatic-Appropriate Patient appears appropriate and oriented within the hospital and home settings; goes through daily routine automatically but frequent robot-like. Patient shows minimal to no confusion and has shallow recall of activities. Shows carryover for new learning, but at a decreased rate. With structure is able to initiate social or recreational activities, judgement remains impaired.
VIII. Purposeful Apropriate Patient is able to recall and past and recent events and is aware of and responsive to environment. Shows carryover for learning and needs no supervision once activities are learned. May continue to show a decreased ability relative to premorbid abilities, abstract resoning, tolerance for stress, and judgement in emergencies or unusual circumstances.
Anterograde Memory The inability to create new memory. Anterograde memory is usually the last to recover after a comatose state. Contributing factors include poor attention, distractability, and impaired perception of stimuli.
Post-traumatic amnesia The time between the injury and when the patient is able to recall recent events. The patient does not recall the injury or the events leading up until this point of recovery. Post-traumatic amnesia is used as an indicator of the extent of damage.
Retrograde Amnesia An inability to remember events prior to the injury. Retrograde amnesia may progressively decrease with recovery.
TBI Treatment -Emphasis on motivation -Promote Independence -THerapy should be goal=directed, functional, and recreational - Focus on orientston =Focus on behavior midification activities -THe use of repetiition may be helpful -Educate the patient in compensatory strategies for sucess -Strucon the level of the patient structure is essential depending on the level if the patient -Avoid overstimulation during therapy -Use of calm voice and simple commands -Perform activities that are both familiar and enjoyable to the patient -Family education and support can enhance and assist in the rehab process -Allow the patient to choose activities on occassion -Flexibility in treatment is needed based on patient's immediate needs and state ofmind
Diuretic Agents Decreases the volume of fluid in the brain and the intracranial pressure Ex: Mannitol, and Glycerol
Antidepressant Agents Reduce disruptive or agressive behavior Ex: Elavil, Prozac
Anticonvulsant Agents Preventipn of early seizures in head injury Ex: Dilantin, Tegretol, Klonopin
Electrolytes Adequate stores are needed during the acute phase of head injury Ex: Magnesium Sulfate
Calcium Channel Blocker Agents May improve trauma for subarachnoid hemorrhage Ex: Nimotop
Selective Serotonin Reputake Inhibitor Agents May benefit patients with head injury and emotional inhibition/impairment Ex: Zoloft, Paxil
TBI Examination -past medical history -history of current condition -Social history (caregiver support) -Medications -living environment -Systems Review -Cognitive and language Assesment -Behaviral Assessment Safety Assessment -Skin Assesssment -Postural tone Assessment -Sensation, Proprioception, and kinesthesia -ROM -Motor Assessment -Endurance Assessmnet -Mobility Skills
TBI Intervention -Cognitive and orientation training -Therapeutic Exercise -Positioning -Sensory Integrity -Balance and vestibular training -ROM -Motor function training - WC and AD prescription -Splinting and serial casting -Mobility training
TBI Goals -Maximize functional mobility -Maximize community independence -Maximize strength -Maximize ROM and prevent hetertrophic ossification -Maximize static and dynamic balance -Maximize endurance -Maximize patient/caqregiver competence with: -positioning -Use of AD and orthotic/splinting devices -HEP
Acute Diagnostic Management Glasgow Coma Scale: level of arousal and cerebral cortex function Cat Scan: observe intracranial structures X-Ray: Fractures MRI: Observe intracranial structures Cerebral Angiography: Observe blood vessels and internal anatomy of the brain Evoked Potential/Electroencephalogram: localizing structural damage PET: cerebral metabolic abnormalities Ventriculography: radiography used to observe cerebral ventricles following CSF removal. Radioisotope Imaging: allows for a 2D view of brain
IV. Confused-Agitated Patient is in a heightened state of activity. Behavior is bizzare and non-purposeful relative to the immediate environment. Does not discriminate among persons or objects, is unable to cooperate directly with treatment efforts. Verbalizations frequently are incoherent and/or inappropriate to the environment, confabulation may be present. Gross attention to environment is very breif; selective attention is often nonexistent. Patient lacks short and long term recall