TBI Case Study

Question 1

47-year old male unbelted driver was involved in a single vehicle rollover while intoxicated. He was thrown from his vehicle and found in ditch.
-GCS was initially 3
-Question as to whether he suffered a seizure. He progressed to a GCS 12-13 and combative but deteriorated again to a GCS 7 in ER and required intubation and ventilation.
-Injuries included: Rt. frontal subdural hematoma, traumatic subarachnoid /intraventricular hemorrhage and bifrontal and bitemporal contusions, not considered a surgical candidate, suffered a brachial plexus injury and road rash, admitted to rehab day 14 post-injury.
-Upon admission to rehab was oriented to name only and unable to complete the mini-mental exam. Could inconsistently understand what was being said to him, fluent speech, it was often tangential or nonsensical.
-Not able to properly use common objects (toothbrush, comb, cup) and was observed to attempt to eat soap and paper. Required 2 persons moderate-maximum assist to stand and ambulate for short distances.
-Falls twice in the first 24 hours before restraints were applied (to abdomen and limbs); he also continually wants to pull out G-J tube. He had failed an early swallowing study, had aspirated without coughing and was NPO but perseverates on the need to drink.
The patient at time of admission to rehabilitation was deemed to be an RLA-IV. On the rehabilitation unit he is argumentative and is not easily redirected. His voice will quickly escalate in volume and he will begin yelling. He makes less sense when he is agitated. Unfortunately, he cannot be physically re-directed as he will strike out at staff or attempt to pull them in to bite them. His most clear vocalizations are shouted profanity which is disturbing to others on the unit.
On the rehabilitation unit, the patient is on the following medications: •Trazodone 50mg HS (Nurses also asked for Ativan, which he received on an as need basis, outside of the treatment plan)

Answer 1

Examining the case:

1. Create a problem list for this client
2. Describe the GCS.
3. Define aphasia and apraxia.
4. Describe the Ranchos Los Amigos (RLA) Level of Cognitive Functioning Scale
5. How would an RLA-IV typically present?
6. What are some therapeutic implications of this patient’s current medication?

Question 2

Case Summary: Problem List

Answer 2

• Rt. frontal subdural hematoma
• Traumatic subarachnoid /intraventricular hemorrhage
• Bifrontal and bitemporal contusions
• Brachial plexus injury
• Road rash
• Oriented x1, cognitive impairments
• Aphasic
• Apraxic
• Impaired balance, 2 person assist to ambulate
• Impulsive
• Perseverative
• Aspiration (silent)

Question 3

Glasgow Coma Scale (GCS)

Answer 3

GCS score is a quick, simple and objective tool used during the initial examination to estimate severity of TBI.
-Assessment is based on eye opening, verbal response, and motor response.
-Rating scale consisting of 15 items in three basic categories: motor response (6 items), verbal response (5 items) and eye opening (4 items).
-A score < 8 is typically regarded as coma
Other categorical divisions are:
-Scores of 13 – 15= mild injury
-Scores of 9 – 12= moderate injury
-Scores of 8 or less= severe injury 1

Question 4

Aphasia

Answer 4

A language disorder that can happen when you have damage to the left side of the brain. Aphasia may make it hard for individuals to understand, speak, read or write.

Question 5

Apraxia

Answer 5

A disorder of voluntary movement where one cannot execute a purposeful activity despite the presence of adequate mobility, strength, sensation, coordination and comprehension.

Question 6

Ranchos Los Amigos Level of Cognitive Functioning Scale

Answer 6

• Describes 8 stages of cognitive function that brain injury patients typically progress during their rehabilitation.
• Not an outcome measure but rather a global index used to describe awareness, environmental interaction and behavioral competence.
• Focuses on the impact of cognitive dysfunction on arousal and overall behavior but does not provide information regarding specific domains of cognitive impairment.
• Quick and simple way to provide a snapshot of an individual’s level of recovery.

Question 7

How would an RLA-IV typically present?

Answer 7

A patient who has been diagnosed at RLA-IV may…

• Be confused or frightened not be able to understand what he feels
• Not be able to understand what is happening around him
• Overreact to what he is seeing or hearing
• Be seen hitting, screaming, using abusive language, etc
• Need to be restrained to avoid injuring himself
• Not understand that people are trying to help him
• Have difficulty following instructions; not be able to focus for more than a few minutes
• Not be able to follow direction or have difficulty when expected to follow direction
• Show difficulties in recognizing family and friends
• Be able to feed or dress self with assistance
• Have difficulty talking

Question 8

Current Medications:

Answer 8

The patient has been prescribed Trazodone daily and Ativan PRN.

Question 9

Trazodone:

Answer 9

• Antidepressant with sedation effect and may be useful for treating insomnia & agitation after TBI.
• Side effects: drowsiness, seizures

Question 10

Ativan (Lorazepam)

Answer 10

• Benzodiazepine anti-anxiety medication.

- Side effects: possibility of rebound insomnia if medication is suddenly withdrawn

Question 11

The Interdisciplinary Team and Role of Occupational Therapy

Answer 11

-Reflect upon who may be a part of the interdisciplinary team working with this patient.
(What is the role of occupational therapy?, Read the AOTA Fact Sheet: “Occupational Therapy and Community Reintegration of Persons With Brain Injury” found on Blackboard)

Question 12

Watch Unit 10 Page 6 Videos

Answer 12

no actually