ABOUT BRAIN INJURIES

Acquired brain injury is damage to the brain due to an injury or illness that is not inherited and not something that a person is born with. Medical problems such as a stroke, disease, a brain tumor, or lack of oxygen can cause acquired brain injury.

Sometimes brain injury is the result of trauma. The cause could be a motor vehicle accident, a blow to the head during a fight, a sports accident, or a fall. This type of acquired brain injury is called traumatic brain injury, or TBI. These terms can be confusing and different organizations may use slightly different definitions for them. This education program will concentrate on TBI and the care of clients following a TBI.

INCIDENCE

Brain injuries are very common.

• Over 50,000 Canadians sustain brain injuries each year.
• It is estimated that 5.3 million Americans live with disabilities caused by brain injury.
• Over 50,000 clients die from TBI each year.

Brain injury can cause little or no permanent damage or it can leave a person with serious and permanent disabilities. Up to 40% of clients with mild TBI suffer from some type of impairment that lasts for one year or longer.

LESSON TWO: RISK FACTORS AND CAUSES

Outlined below are facts about the risk factors and causes of TBI:

• TBI is about twice as common in males as in females.

• The risk of TBI is highest in teenagers, young adults, and in people who are older than 75. 

• The leading cause of TBI is motor vehicle accidents.

• About half of the TBIs that occur are the result of accidents involving motor vehicles, bikes, or a person being struck by a vehicle.

• Falls are another common cause of TBIs, especially among young children and older adults. People over the age of 75 are very prone to falls. Falls are actually the leading cause of TBI in older people.

• About 20% of TBIs are caused by violent acts such as firearm usage. Assault, including child abuse, is an important cause of TBI in young children. Forceful shaking of infants and young children can result in TBI.

• 3% of hospital admissions from TBI are sports-related incidents.

COSTS

The cost of providing immediate and follow-up care to someone with a TBI can be very high.  The cost of providing care is often long-term, as the person left with a disability may need help for the rest of his or her life. The average cost of providing care to someone with TBI over a lifetime can be well over a million dollars. 

TYPES OF INJURY

The brain is the most important part of our body’s control system.  It controls breathing, heartbeat, and our ability to see and hear.  It also controls how we move, how we think, how we feel, and how we behave.  The brain is involved in everything we do and say. Brain injury can cause serious damage that may change the way we live for the rest of our lives.

There are several different types of TBI. They include the following:

Concussion
A blow to the head that makes the brain move around within the skull can cause a concussion. The person may lose consciousness for a brief time. Symptoms, such as mental confusion, poor balance, or vision problems will occur. Some concussions are more serious than others. Anyone who experiences a concussion should be seen by a doctor.

Contusion
A contusion is a more serious brain injury. In a contusion the brain is actually bruised, and the symptoms are more serious. The client who has a contusion needs follow-up medical care on a regular basis.

Skull fracture
A fracture of the skull (the bone that surrounds the brain) causes damage to the skin and bone of the skull as well as the brain. Treatment is based on the location of the fracture and how severe the fracture is. Skull fractures can cause very mild to very severe problems.

SYMPTOMS

Brain injury can cause a variety of symptoms. Outlined below are some of the symptoms that TBI survivors may experience. As each injury is unique, your client may have any or all of the symptoms or they may have others not mentioned below (NCIPC, 1999; NIH, 1998).

• Memory loss that can last for just a short time or a very long time

• Trouble concentrating and thinking

• Inability to pay attention

• Poor judgment which may affect driving, work, and other aspects of everyday life

• Seizures 

• Vision problems such as blurred vision, double vision, or increased sensitivity to light

• Loss of the sense of smell or taste

• Language problems

• Headaches

• Extreme fatigue

• Depression or anxiety

• Becoming angry and upset very easily

These problems may last for only a few hours. Some of them can also last for days, weeks, months, or perhaps forever. Problems with memory often last for a long time as do difficulties with attention and concentration. Even a mild injury can result in a variety of symptoms that can have a major impact on a person’s life. Sometimes people do not realize that the injury has had a lasting effect on their abilities until long after the event.

MAKING A DIAGNOSIS

Some signs and symptoms of TBI may be obvious.  There may be bruises, cuts, or bumps on the head and face.  At other times, there may be no obvious sign of injury but the client may seem irritable, anxious, or confused.  Headache, dizziness, vomiting, loss of memory, and confusion may occur. The client may become unconscious or be difficult to wake up. All persons with a head injury should be assessed by a healthcare professional.

Many older persons live alone in their own home. They may fall and injure themselves.  An elderly person who suffers a TBI from a fall may act confused or display odd behaviors even if the injury is minor. When sudden symptoms of confusion or unusual behaviors appear, the older person should be assessed for a TBI.

Two tests often used to diagnose a TBI are a CT (CAT) scan and an MRI. A CT scan is a special X-ray of the brain.  The client lies on a flat table that slides into a scanner, and X-rays are taken.  Usually, the client receives an injection of a dye that helps to get better images of the brain. It is important to find out if the client is allergic to the dye before it is injected.

MRI means magnetic resonance imaging.  An MRI also shows images of the brain, but it is not an X-ray.  The client lies very still while in a scanner because any movement might interfere with the test. There is not a lot of room in the scanner so it is important to know if the client is uneasy or frightened in small, tight places. The test is performed using a special powerful magnet so that the client should not wear anything made of metal such as metal jewelry.

Testing can be very frightening for clients.  Help them to understand what is happening to them. Explain that the tests will help to find out what is wrong so that the best treatment can be given.

CARE CONSIDERATIONS

Clients recovering from TBI go through different stages or levels of recovery. Each client may not go through all of these stages. For example, not everyone who has a head injury becomes unconscious or goes into a coma. Recovery can take a very long time. Many people never fully recover from a brain injury.

Recovery in an elderly person may be complicated by factors such as poor stamina and the presence of various medical conditions such as heart disease, diabetes, or Alzheimer’s disease. Complications are likely to be more common among the elderly.

There are different ways to assess how a client responds after a head injury. One of these ways is called the Glasgow Coma Scale. This scale assesses how well clients respond with respect to opening their eyes, talking, and moving. Another way to assess a client’s recovery is by using the Rancho Levels of Cognitive Functioning. This scale describes how clients with TBI respond at different stages of their recovery. There is no way to know how long it will take someone to get better from a head injury or if they will ever fully recover. Outlined below are care issues in various stages of recovery following a TBI:

Client in a Coma

At this stage there is no response to stimulation and the client is described as being in a coma. The unconscious client does not open the eyes. There is no response to pain or to the spoken word, even when the voice belongs to someone who is known and loved by the client. The client may be in a coma for hours, days, weeks, or months. Or the client may never come out of the coma.

The unconscious client will not be able to meet personal needs for comfort, safety, and well-being. Proper positioning, frequent turning, skin care, and mouth care are all important aspects of care. The client will not be able to eat or drink so will receive nourishment through feeding tubes and/or intravenous fluids. Intravenous (IV) means that a needle is placed in a vein in the client’s arm or hand. The needle is attached to a clear plastic tube that is connected to bags of fluid. The fluid contains substances that are important to properly nourish the body. Since the client lacks bladder control, a tube (catheter) may be placed in the bladder to collect the urine.

The client who is in a coma needs to be stimulated and encouraged to wake up. Talk to the client as you provide care. Explain what you are doing and why. Nobody knows if the coma client can hear you or how much he or she understands. Some clients who have awakened from a coma, however, have reported that they were able to hear what others said while they were in the coma. A regular schedule may be established to help stimulate the patient. Try and stimulate as many senses as possible. Here are some ideas to help with this stimulation:

• Play the client’s favorite music.
• Turn on the television to the client’s favorite programs.
• Find out what type of work the client did and what he/she enjoyed doing for fun. Talk to the client about these things.
• Use touch to stimulate the client. This can be done by turning and positioning the client, giving a back rub, or holding the client’s hand.
• Allow the client to smell flowers, perfumes, or scented lotions (make sure that the client is not allergic to these items).
• Suggest that the family bring in pictures of loved ones and place them close to the client’s bed.
• Encourage visitors to talk to the client.

Help the family to understand how important it is for them to keep talking to the client. Involve them in the client’s care as much as possible. Listen to them and be supportive as they talk about their concerns.

Client Starts to Respond

At this stage the client starts to respond. Clients may come out of a coma slowly or quite suddenly.  There is no way to really be sure.  Observe the client carefully.  The eyes may open once in a while.  The first response may be from pain. As they improve, clients may be able to follow simple commands such as, “open your eyes” or “squeeze my hand.”  Here are some things to keep in mind as your client starts to come out of the coma:

• The client may be frightened and confused.  Always talk to your client and explain everything that you are doing even if you are not sure that the person can hear or understand you.

• The client will still need help with activities of daily living such as bathing and eating. 

• Help the client to understand what has happened to him/her.  Explain any procedures that you must do.  Use short, simple sentences. 

• Help family and friends to deal with the client.  The client may respond more to certain people (maybe family and friends) than to others.

• Encourage family members to continue to stimulate the client.

• Keep the client safe. 

Client Agitated and Confused

Clients may go through a stage of recovery when they become very confused and agitated (upset).  Their behavior may be very strange and even hostile at times. They may have a limited attention span and may not remember their family members or friends.  Even if you tell them who you are, they may soon forget.  Here are some ways to help the confused and agitated client:

• Keep the client safe. Monitor the client closely. Pay attention to safety factors. Make changes before an accident happens.

• These clients sometimes have a lot of energy and may need very little sleep.  They can be so restless and confused that they may need a healthcare worker with them all the time.   

• Do not take the client’s odd behaviors as a personal insult.  These clients are very confused and have no idea who you are or what you are doing to them. 

• Clients may strike out at you or call you names.  Try to remember that this is part of the recovery stage of head injury.  Clients cannot help behaving this way. Assist your co-workers as well as the clients’ families and friends to understand and deal with this difficult time.

• While clients are in this agitated and confused stage, you must make their surroundings as quiet as you can.  Speak slowly and gently. Do not shout.  Do not play music or do other activities that may excite the client.  Help their families and friends to understand why it is now important that they do not stimulate the client.

• Explain everything that you or others are doing to the client.  These clients may have a very poor memory so be prepared to explain the same thing over and over.

• Clients will need to have a lot of help with activities of daily living.  They may not remember what a toothbrush is or what to do with it.  Be very patient and supportive.

• Help the clients to perform small tasks.  Do not give several directions at a time. For example, do not instruct your client to brush his teeth, gather towels and washcloths, and take a shower.  That is too much information for your client to understand. Give one instruction at a time and explain each step in the activity. For example, you could say: “Now you need to brush your teeth.  Pick up your toothbrush.”  Once the client has done so, you can say: “Put some toothpaste on your toothbrush.”  Remember, one step at a time. Sometimes clients are too confused and agitated to do even the simplest tasks. You may need to do these tasks for them.

Client Confused

At this stage, clients remain confused with behaviors that are not appropriate (not exactly right for the situation). They are not agitated at this point. They may not remember how to behave when they have to go to the bathroom and may pass urine in odd places such as in a wastebasket.  They have a poor memory and a poor attention span.  They may not remember loved ones.  They may wander away and get lost.  Be aware of the following tips when caring for these clients:

• Remind clients where they are and who they are.  Help them to remember loved ones.  At this point, they may be able to tolerate music and other stimulation in small amounts.

• Help them to develop a regular routine.  Assist them to perform activities such as bathing, eating, and dressing in the same way and at the same time each day.

• At this stage, it is best to limit the number of people that the client has to deal with. For example, it would be helpful to have consistent caregivers. 

• Keep directions and tasks simple. 

• Be patient and realize that you will probably need to explain the same things over and over.  Be supportive!

• Although clients are still confused in this stage of their recovery, different types of therapies may be started at this time. The sooner therapies can be started the better! Clients may need speech therapy to help them if they are having trouble talking.  They may need physical therapy to increase their strength and to help them walk and move normally.  They may need occupational therapy to learn to do their activities of daily living.  They may need emotional counseling to deal with the results of head injury.  They may need help finding a new job if their injuries make it impossible for them to go back to their old jobs. 

Client Acts Appropriately

Hopefully, clients will recover enough to reach this stage.  Clients are not confused or agitated at this point of recovery. They are aware of their surroundings and their behavior is nearly normal. Some disabilities may remain, however, and some of them may last forever. As clients continue to make progress in their recoveries, remember the following points:

• Clients may be left with disabilities that are physical such as trouble speaking, walking, hearing, or seeing.  These problems may be temporary or permanent.

• Some disabilities are related to thinking and emotions.  Clients may have ongoing memory loss.  They may be more forgetful than they were before their injuries and/or they may have trouble concentrating.

• Clients may behave differently emotionally.  For example, someone who was always calm and logical may be nervous, anxious, and easily excited.  They may make decisions without thinking them through.

• If clients reach this stage of recovery, they behave appropriately and are able to interact with their families and friends.  However, they may be depressed and irritable at times. 

• At this stage, clients are able to handle multiple tasks and take care of themselves. 

• Clients with ongoing physical or emotional disabilities may have trouble keeping a job or having good relationships with family and friends.  They may need emotional counseling.

• Clients’ families and friends may also need help to deal with their loved ones disabilities.  Clients, families, and friends must work together with the healthcare team to recover from the effects of a brain injury.

• Clients may not realize that they have changed after their injuries, especially if these changes are emotional.  It will take a lot of work and patience to deal with these changes. It may be helpful for them to meet others who have also recovered from a head injury.   

MORE ABOUT BEHAVIORIAL PROBLEMS

Problems with behavior are often the most troublesome aspects of caring for clients following a brain injury. Remember, clients may have many deficits that can lead to misunderstandings and frustration. They may not be able to process information well or to completely understand what is happening in any situation. There may be problems with judgment, problem solving, vision and hearing, the ability to control impulses and many other areas. Clients may act on impulse. They may lack emotional control. They may yell, use foul language, strike out at others, and refuse to comply with treatments. These types of behaviors are disturbing to family, friends, and others providing care to the client. Sometimes it is hard to remember that the behaviors are not done on purpose.

Many different healthcare professionals can assist in developing and carrying out a plan of care for client who displays problem behaviors as a result of a brain injury. There is, however, no easy way to change the problem behaviors. They may last a long time. In some cases they never go away. In order for the behavior to change, there must be a change in:

• The client,
• The people who come into contact with the client (includes healthcare workers,  family, visitors), or
• The environment.

Be flexible in your approach with your client. Be willing to make changes in areas that may improve your client’s behavior. Find out what was happening before your client becomes upset. You may be able to find a pattern and detect the cause of the outbursts. For example, does the client usually lash out at others in the late afternoon? If so, perhaps fatigue is creating frustration and an inability to cope with minor stress. Try a rest period in the afternoon. Is the client confused and fearful at night? Perhaps keeping a light on at night might improve the situation. Does the client become startled and upset when someone approaches suddenly from behind? Remind others to approach the client from the front so that he/she can see them.

Your client’s plan of care may include providing feedback on inappropriate behaviors. That could involve letting the client know when behavior is not appropriate, telling the client why the behavior is not proper, and explaining how the client’s actions made you feel. Sometimes the damage from a brain injury makes it difficult for clients to learn from the outcomes of their behaviors. In those cases, it is even more important to identify outside factors that may be leading to the problem behaviors and to change those where possible.

IMPACT ON THE FAMILY

TBI impacts not only the client but also the family. When a TBI occurs, family roles change. The person with TBI may have been the major wage earner in the family. If so, the resulting loss of income may create financial problems. Daily routines may change. Perhaps the injured person was the one who picked the children up after school. Now the mother has to leave work early in order to do so.

When clients are discharged from hospital and require a high level of care, they may be placed in a facility or other type of care center as they recover. Some clients are discharged directly to the home. In either case, family members may be heavily involved in the client’s care. Time demands can be enormous. These demands can have a negative effect on a person’s work and personal life. It is not uncommon for family members to become depressed. They may lose contact with friends and become frustrated and angry about their situation.

The family needs to find out about and access any help that is available to them, including offers from family and friends. They need to know that it is important that they take care of themselves. They need to eat a balanced diet, keep fit, and get involved in things they enjoy. Support groups are available for survivors of brain injury as well as for their family and friends. Two good sources of information about TBIs that families can access are:

Brain Injury Association
1776 Massachusetts Ave.
NW Suite 100
Washington, D.C., 20036
(202) 296-6443
1-800- 444-6443
http://www.biausa.org

Ontario Brain Injury Association
P.O. Box 2338
St. Catharines, ON Canada L2R 7R9
1-800-263-5404
http://www.obia.on.ca

IN CONCLUSION

This inservice has mainly focused on the challenges faced by clients, families, and healthcare workers following a brain injury. Remember, though, that many clients do make a full recovery. Others are able to recover to the point that they can care for themselves and perhaps return to work. In working with clients and families, remember that “different” does not necessarily mean “worse”. Sometimes clients can find new strengths or build on existing ones in ways that may offset some of their challenges. 

CHECK YOUR KNOWLEDGE

1. How common are brain injuries?
2. Identify three possible causes of TBI.
3. Name three types of TBI.
4. Identify the symptoms of TBI.
5. Identify several care considerations for TBI.
6. How might TBI affect the family?

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