THE ESSENTIAL BRAIN INJURY GUIDE Medical and Physical - PDF document

8/25/2017 THE ESSENTIAL BRAIN INJURY GUIDE Medical and Physical Complications Section 3 Director of Brain Injury Presented by: Bonnie Meyers, CRC, CBIST Programs & Alliance of Services Connecticut Certified Brain Injury Specialist Training – October 26 & 27, 2017 This training is being offered Presented by Brain Injury Alliance of Connecticut staff: as part of the Brain Injury Rene Carfi, LCSW, CBIST, Education & Outreach Manager Alliance of Connecticut’s & ongoing commitment to Bonnie Meyers, CRC, CBIST, Director of Programs & Services provide education and outreach about brain injury in an effort to improve services and supports for those affected by brain injury. Contributors David Anders, MS, CCC-SLP, CBIS Helen Carmine, MSN, CRNP, CRRN Heather Ene, MD Lawrence Horn, MD Susan Ladley- O’Brien, MD Emily McDonnell Mary Pat Murphy, MSN, CRRN, CBIST Grace Nolde-Lopez, NP Denise R. O’Dell, PT, DSc, NCS Jennie L. Ponsford, BA, MA, PhD, MAPsS Benjamin Siebert, MD 1

8/25/2017 Medical Complications Gain an understanding Be able to describe of medical dysphagia and the complications importance of tube frequently seen in feeding in persons persons with brain with brain injury injury Be able to articulate Be able to discuss the common prevention and issues related to treatment of pressure elimination in the sores TBI population Know the symptom clusters of different types of headaches frequently observed in the TBI population and appropriate Be able to distinguish between epileptic treatments for each seizures and post-traumatic seizures Brain Injury and Body Systems Neurol olog ogical Cardiop opul ulmon onary y & Vascul ular Sleep ep Muscul ulos oskel eleta etal Elimina nation on Infec ection on Skin Gastroi ointes ntestina nal Reprod oduc uctive Metabol olic & Endoc ocrine ne 2

8/25/2017 Complications involving the heart (cardiac) CARDIOPULMONARY and breathing (respiratory) Can occur immediately, chronically, or emerge as late complications Associated with increased mortality and morbidity Chronic Cardiopulmonary Issues  Orthostatic hypotension  Aspiration pneumonia  Deep vein thrombosis Dysautonomia Sometimes called “autonomic storming ” 3

8/25/2017 MUSCULOSKELETAL COMPLICATIONS Identification and Management of Chronic and Late Emerging Complications ELIMINATION 4

8/25/2017 Urinary Incontinence Management Essenti tial al TIP! Signs of UTI Frequent/painful urination  Fever  Possibly increased  agitation Possibly decreased level of  alertness Bowel and Fecal Incontinence Management GASTROINTESTINAL 5

8/25/2017 Early Issues: Nutrition and Feeding Essenti tial al TIP! Swallowing Process Soft Palate Blocks Nasal Cavity Bolus Tongue Blocks Oral Cavity UES Opens Epiglottis UES Closes UES Closes blocks larynx Phase 1 is the oral preparatory/oral Phase 2 is the pharyngeal phase which Phase 3 is the esophageal phase stage which includes mastication, includes movement of the bolus past where the bolus moves through bolus formation, and propulsion of the epiglottis, through the pharynx, and the esophagus toward the lower the bolus into the pharynx past the upper esophageal sphincter esophageal sphincter Swallowing is a complicated A study that examined severe 65% had problems in the Oral process, and dysfunction can TBI found disorder rates of 90% Phase; 73% in the pharyngeal lead to aspiration early after injury phase National Dysphagia Diet Levels: Food Level Dyspha sphagia Severity Descr cript ption Level 1 Moderate to Consists of pureed, homogenous and cohesive foods, and Dyspha sphagia Severe are similar to a pudding consistency. Foods requiring bolus Pureed formation, controlled manipulation and chewing are not allowed. Level 2 Mild to Moderate All foods from level one, plus foods that are moist, soft Dyspha sphagia and/or pharyngeal textured, and easily form a bolus. Food pieces no larger Mechanica cally dysphagia than ¼ inch. Some chewing required. Altered Level 3 Mild This level includes most textures except hard, sticky or Dyspha sphagia crunchy foods. This level includes soft foods that require Advance ced chewing ability. Level 4 N/A All foods as tolerated Regular Diet 6

8/25/2017 National Dysphagia Diet Levels: Liquids Lev evel el Description on Thin No alteration Nectar-like Slightly thicker than water, the consistency of un- set gelatin Honey-like A liquid with the consistency of honey Spoon on-thick A liquid with the consistency of pudding METABOLIC/ ENDOCRINE Diabetes Insipidus/ Metabolic and Endocrine Disorders Individuals may present with Essenti tial al TIP!  Metabolic syndrome  Hypothalamic-pituitary changes These problems tend to be diagnosed a year or more post-  Growth hormone dysfunction injury and occur in up to 30% of individuals with moderate-severe injuries who are greater than one  Hypopituitarism year post injury  Gonadotropin deficiency 7

8/25/2017 REPRODUCTIVE SYSTEM Reproductive Health Challenges Wounds Common Skin Abrasions Problems Lacerations Pressure sores Acne Fungal and Sweating Bacterial Infections Rashes INTEGUMENTARY 8

8/25/2017 Pressure Sores Pressure sores can be prevented by:  Keeping skin clean and dry  Changing position every two hours Essenti tial al TIP! Using pressure-relieving devices both  preventatively as well as after the development of a pressure ulcer, including:  Specialty mattresses  Specialty cushions Pressure-relieving tilt-in-space  wheelchairs Stages of Pressure Sores Normal Skin Stages of Pressure Ulcers STAGE I STAGE IV Intact skin with non-blanchable redness of Full thickness tissue loss with a localized area usually over a bony exposed bone, tendon or muscle. prominence. Darkly pigmented skin may Slough or eschar may be present. not have visible blanching; its color may Often includes undermining and differ from the surrounding area. May tunneling. indicate “at risk” persons. STAGE II UNSTAGEABLE Partial thickness loss of dermis presenting Full thickness tissue loss in which as a shallow open ulcer with a red pink actual depth of the ulcer is completely wound bed, without slough. May also obscured by slough (yellow, tan, gray, present as an intact or open/ruptured green or brown) and/or eschar (tan, serum-filled or sero- sanginous filled brown or black) in the wound bed. blister. *bruising indicates deep tissue injury. DEEP TISSUE INJURY STAGE III Purple or maroon localized area of Full thickness tissue loss. Subcutaneous fat discolored intact skin or blood-filled may be visible but bone, tendon or muscle blister due to damage of underlying soft are not exposed. Slough may be present tissue from pressure and/or shear. The but does not obscure the depth of tissue area may be preceded by tissue that is loss. May include undermining and painful, firm, mushy, boggy, warmer or tunneling. cooler as compared to adjacent tissue. 9

8/25/2017 Essenti tial al TIP! COMMON INFECTIONS Individuals with brain injuries are susceptible to infection when they have open wounds, use in- dwelling devices, or are immuno-suppressed Seizure Pain Headache Neurologic Complications The segregation of seizure Occurrence events according to time of ranges from appearance after the initial 4-53% impact is based partially upon the observed future risk of seizure reoccurrence and ideas regarding the physiological Seizures events that underlie their emergence Essenti tial al TIP! Seizures are caused by an abnormal, disorderly discharge After TBI, individuals are 22 of electrical activity in the nerve times more likely to die of a cells of the brain seizure disorder as compared to the general population 10

8/25/2017 Status Epilepticus The Epilepsy Foundation has revised the definition of Status Epilepticus to include seizures that last too long (any seizure lasting longer than 5 minutes), as well as those so close together that the person does not recover from one before another begins. Status epilepticus carries a high mortality risk Seizure First Aid Do not force any object into the  person’s mouth or try to hold the tongue Clear the environment of harmful  objects Ease the individual to the floor to  prevent injury from falling Turn the person to the side to keep  the airway clear and allow saliva to drain from mouth Put something soft under the head  and along bedrails, if in bed Loosen tight clothing around the neck  Seizure First Aid Do not attempt to restrain the person  Do not give liquids during or just after the  seizure Continue to observe the person until fully alert,  checking vital signs such as pulse and respirations periodically Give artificial respiration if person does not  resume breathing after seizure For Status Epilepticus call 911 within 3-5  minutes or based on physician recommendations For Seizures that are prolonged or different  than a person’s normal baseline seizure, call 911 11