Brain Injury Program Crisis Prevention Management

Do range of motion exercises every day

Wear TED hose if they have been ordered by your doctor

Stay as active as possible

Drink 6-8 glasses of water a day

Cut down or stop smoking in order to improve circulation

Do not strain during a bowel movement

Check the legs for signs of DVT every morning before getting out of bed

Do not wear tight garters, girdles, tight jeans, socks or knee high boots

Stay in a cool, shady spot if outdoors for a long time

Avoid being in direct sun or very hot weather for more than 15-20 minutes at a time.

Do not drink alcohol (it increases loss of body fluids)

Drink plenty of water and/or juice when out in the heat

Use water spray bottle to keep cool

Wear a hat or sun visor

Wear light, loose fitting clothing

Wear sunscreen

Avoid very active exercise in hot weather

Move to a warmer place.

Cover up with warm blankets

Dress in layers

Wear hats and gloves/mittens

Keep skin dry

Drink warm liquids like coffee, tea, hot chocolate

Take the medicines your doctor ordered to control the spasms. Take them as directed. It is not good to stop taking the medicines or miss doses unless under the advice of your doc.

Keep the body temperature at a "normal" level.

Prevent skin sores and other infections (these may also increase your chances of having spasms)

If your spasms are causing skin problems, notify your doctor.

Sit up slowly, prop your body on some pillows for about 15 minutes before actually getting up

Wear TED hose if your doctor has ordered them

Wear an abdominal binder if your doctor has ordered one

Do not move the body too fast when doing weight shifts because it may make dizziness worse

Drink 1 or 2 glasses of fluids prior to getting up

Remember to get out of bed slowly!

Sometimes swelling happens because of loss of movement/muscle tone and decreased blood flow from the legs. Swelling can also happen if there is a blood clot. The blood clot may be called a deep vein thrombosis (DVT).

Swelling can also be caused by extra calcium forming around a joint. When this type of swelling happens, it is called heterotopic ossification (H.O.). A blood clot or calcium problem should be seen by the doctor right away.

A blood clot is a medical emergency...get help immediately.

If swelling is present, you may try the following:

This information applies to swelling not caused by a blood clot...if you suspect a blood clot, call your doctor immediately.

Call the doctor quickly if:

Heterotopic Ossification

H.O. is a build up of calcium similar to bone around the joints in the body. It causes decreased range of motion in that joint. It can affect the knees, elbows and shoulders but is most commonly found in the hip joint. The cause is unknown.

1. Real Effects that can be caused TBI &/or SCI

1. Emotional Response

Use some examples of lability and flat.
 

Ways to Help

Ways to Help

1. Cognitive Issues

Example

Arousal

It is important to realize that decreased arousal does not mean a person is sleepy.

Sensory Input and Motor Output

Sensory input and motor output refers to sensing incoming information and reacting to it. People with brain injuries may have trouble seeing parts of a word or they may have trouble hearing. They may also have problems moving or feeling certain body parts.
 

Attention and Concentration

Visual-Spatial Skills

Communication

Aphasia

When a person communicates thoughts by talking, writing, listening, or reading, language symbols are used. For example, the word "pencil" is the language symbol for the object known as a pencil. It is said by combining sounds. The person can write "pencil" by combining letters in a specific order. He/she can read these letters and understand that the word "pencil" means "the thing that you write with." A person has learned to understand the word when someone says, "Give me a pencil, please," and he/she hands the speaker a "pencil" and not an "umbrella."

General Communication

Communication Techniques for Caregivers to Use

Many individuals can give accurate information if the questions are kept short and simple. Sometimes it might be necessary to repeat or rephrase a question asked, especially if the patient appears not to understand, or makes a sound to show that they do not understand. A speech-language pathologist will help to develop a communication system that best suits the patient.  .The following techniques may be helpful when attempting to communicate:

1. Use yes/no questions.

The therapists or family members may need to obtain information from the patient to complete certain tasks or to give the patient information or directions. A useful approach is to phrase questions that can be answered with a simple "yes" or "no" verbal or gestural reply. For example, if the patient is having trouble seeing, the caregiver must first find out whether the person has eyeglasses. If the patient says "yes," the caregiver needs to locate the eyeglasses. One could ask, "Where are your eyeglasses?" However, we cannot expect an answer such as "My eyeglasses are in the second drawer of my night table in my room." Rather, we should establish conversation with the patient such as the following: "Are your glasses here in your room?" "Yes." "Are they in your bedside table?" "Yes." It is important to establish the same form of the yes/no response for all persons who communicate with the patient. For example, if the person cannot use words, they may respond to yes/no questions with a head nod or eye blink. However, do not confuse the person by asking for a head nod one time and an eye blink the next time.

2. Prevent the person from becoming isolated.

Try to engage the person in some form of communication every day. A daily greeting such as "Hello," Thank you," or "I'm fine" can be a pleasant exchange for a person with a communication impairment.

3. Put yourself in a face-to-face position with the patient.

Encourage the person to watch your face when you speak.

4. Speak in a normal tone of voice.

Do not shout or raise your voice when speaking with the person. The patient hears you, unless there is a hearing impairment. Instead, the patient is having trouble understanding you, and the shouting will be an additional source of misunderstanding.

5. Talk with the person as you would with any other adult. Remember, do not "talk down" to the person.

6. Try non-speech types of communication.

Some persons can write words they cannot say, or draw pictures representing their thoughts. Others can point to pictures or words in a communication chart or in a notebook, or point to things in the room. Gestures and facial expressions are a very common and effective way to communicate non-verbally.

7. Use short, simple sentences.

All communication should be kept short and grammatically simple. "Do you want a sweater?" is easier to understand than the more complex statement, "The sweater is in the drawer in your room, and it is cold in here. Why don't you put the sweater on to keep warm?"

8. Change the topic / Redirect

If the person has outbursts during discussion, it is important to remain calm. It may also be helpful to change the subject to avoid confrontation and continued emotional outbursts.

9. Provide clear feedback.

Provide clear feedback to the person about whether you understood or did not understand what was said.

10. Be patient.

Give the person time to understand you and time to form their thoughts.

Helping with Language Problems

Receptive Language Disorders

Expressive Language Disorders

Very Important!

Let your local authorities know of your situation. For example, if your loved one needed to call 911, he/she may not be able to get the words out right to help the situation. If they know ahead of time, they may have an arrangement to just send someone out to check on him/her.

Problem Solving and Reasoning


Problem solving and reasoning are very complex skills. A person must think about many things at a time.

Encourage socializing with familiar people such as family or very close friends who understand about the injury. Socialize in small groups at first until they get better with memory and abilities to interpret other people's emotions in conversation. Balance social situations with quiet time and a regularly structured day. Sometimes a lot of people may all want to visit at the same time. Encourage small, brief gatherings at first.

Avoid becoming "overdone" with too much socialization. After awhile, client may get tired and begin to think less clearly. If you notice they are having trouble thinking, paying attention or noticing other people, you may want to consider ending the social visit.

It is important to get out of the house and/or have family/friends over to the house. Practicing social interactions in slow doses that will help them get better at them.

Social skills or "social competence" relate to one's ability to focus on another person and understand that person's mood, feelings and unspoken messages.

Problems with social skills are common after brain injury and often result in isolation for the patient and the patient's family. This only compounds the losses associated with the brain injury.

Good social skills also involve behaving according to the commonly accepted social rules. This includes exercising self-control when it is necessary, being courteous, waiting for a turn and using appropriate language.

Example 1

The inability to take other's point of view may lead to saying or doing something inappropriate for the situation. Others who are not aware of the person's brain injury may react negatively and even inappropriately.

For example, if a person is telling about a recent death in the family and the injured person laughs, it could result in anger and/or sadness for the other person whose loved one has died.

Another example of good social skills is participating appropriately in a conversation.

A person with a brain injury may not take turns talking or not follow the topic of the conversation.

There are strategies that can be learned to improve social skills. For example, a person with a brain injury can be taught to listen actively through repetition, to identify facial expressions of emotions, and to avoid interrupting the person who is speaking.

Sometimes lack of initiation can be very troubling to family members of the brain injured person. Even though a person may be physically able to perform a task, he/she may fail to perform it despite a lot of help or prompting.

The person may seem content just sitting and doing little to nothing during the day. This lack of initiation is usually caused by an injury to the frontal lobes of the brain. The frontal areas help a person plan, organize and begin an activity. In other words, it helps motivate the person to "get started."

Problems with initiation are not the same as "laziness."

It can be difficult to know if a person is having problems with initiation or motivation. If the person expresses a desire to quit or give up, it may be lack of motivation.

-Be supportive and encouraging

-Set up a schedule with the person who has a brain injury (encourage participation)

-Offer 2 good choices when it is difficult to get the person going such as:

"It is time for lunch now. Do you want to eat in the kitchen or in the dining room?"
"It is time for lunch now. Do you want a sandwich or soup today?"

-Offer incentives for performing activities or staying on schedule such as:

"If you make your lunch now, there will be time for you to take a nap or watch some TV.

-Be sure to make the rewards meaningful to the person...things he/she really likes to do or have

-Provide creative rewards & be consistent in your follow through.

-If necessary, help the person get started with the activity. (example, set bread and peanut butter in front of him and hand him the spreader knife to begin making his own lunch)

-Maintain scheduled rest periods as suggested by the therapy team to avoid fatigue.

Some people have a lack of awareness or insight into the problems resulting from the brain injury. Changes or limitations since the brain injury that are obvious to family members may not be at all obvious to the person with the injury. The person may have some awareness but it may be limited.

It may seem like the person is "denying" that any problems exist or "under-estimates" the severity of these problems. This occurs mostly because the injury may have affected the part of the brain (the frontal lobes) that controls self awareness.

This does not happen because the person is intentionally trying to be stubborn or difficult. It is also not a problem with psychological "denial".

When lack of awareness/insight is an issue, a person may not show normal reactions when making a mistake (like saying, "Oh Darn!") or may not even realize that a mistake was made. The person thinks that he is fine and that anything he does is also fine. Because of this, the person may refuse help from caregivers.

A person with this problem may set unrealistic goals and expect to keep the same lifestyle/goals as before the injury. This lack of awareness may pose great threats to a person's safety.

Driving, using heavy machinery, being left alone and climbing tall ladders are all examples of activities that pose safety risks after a brain injury. Please follow the safety guidelines / precautions explained by the treatment team

Example 1

Frank had a traumatic injury to the right side of his brain. He has severe left sided weakness that affects his legs and arms. He also has some trouble with balance. Frank needs a wheelchair to get around and 1 person to assist him on and off the toilet. He cannot be left alone in the bathroom because he has fallen twice when he tried to go alone.

Frank has a new caregiver today. He tells the nurse he can get on the toilet by himself and needs no help. He says, "I can't understand what all the fuss is about in the bathroom. I'm fine and I can do this myself." The nurse asks him about his recent fall and Frank replies, "Oh, I didn't fall. I just lost my balance. Everyone is overreacting. I'm fine." Frank has a problem with awareness.

Remember SAFETY FIRST

Keep surroundings safe and free of potential hazards
-keep keys out of reach
-keep dangerous machinery locked up
-consider safety issues in the kitchen (knives, stove, etc)
-keep firearms out of reach and out of sight

Avoid confrontation. Do not argue or try to reason. Instead, offer 2 safe choices such as:
"Would you like to use the urinal in bed or would you like for me to assist you to the bathroom?"
"I would really appreciate your help in the yard. Would you like to pull the weeds or plant the border grass?" (instead of driving the lawn tractor)

When giving feedback, praise efforts first, then offer suggestions for improvements such as:
"You made a great effort this time. Here is one thing I have found really helpful when getting out of the bed. Maybe we can try it next time."

Never leave a person with decreased awareness/insight alone until cleared by the doctor and/or rehabilitation team. Keep in mind that safety issues may re-appear in new environments in an otherwise safe patient.

Alert other caregivers and emergency personnel of the person's limitations as well as what to do to promote safety.

Observe the person for improvements. The person may be ready to start practicing to be more independent. Speak with the doctor if you think it is time to re-evaluate the situation.

Impulsivity is a tendency to act very quickly without taking time to plan or think about consequences.

The action may be sudden or occur in response to a strong urge/idea to do/say something. Impulsive behaviors can be seen anywhere. They are common in social situations, at work, school or at home.

Impulsivity is a fairly common problem after brain injury. It is caused by an injury to the part of the brain that controls a person's ability to plan, organize and perceive. Injuries to the frontal areas of the brain often cause problems with impulsivity.

The following examples will illustrate different ways that a person can be impulsive. Please notice the lack of planning and unawareness of consequences.

Example 1

Karen is at the grocery store with her mother. They are shopping without any problems until Karen sees some Popsicles that look tasty. Karen decides to open the box and have a Popsicle. She puts the rest of the box back in the freezer section at the store.

Example 2

Mike and his brother are on their way to a baseball game. They have parked the car and are walking to the front gate. Mike suddenly begins to cross the very busy city street without stopping or looking at traffic . His brother quickly grabs him and saves him from an approaching vehicle.

Example 3

Mary and her husband Jeff are dining out. They are at an upscale restaurant when Jeff suddenly notices the attractiveness of the waitress. When the waitress leans over to fill his water glass, Jeff says "Oh honey. You sure do look good." He makes an attempt to fondle her breast, but Mary quickly redirects his reach.

Ways to Help

Make a schedule (example: 8:00 - take kids to school, 9:00 - grocery shopping, 10:00 - go home and unpack groceries)

Plan ahead and be prepared; remove dangerous tools, appliances and keys to cars/machinery; remove weapons and household poisons from general area; make sure that rooms are well lit.

Stay alert when out of the home with the person to prevent wandering or injury. Walk close together when in large crowds/public areas where it might be possible to get lost.

Stand close when crossing streets or using public transportation (getting on & off buses)

Plan things together.

Be supportive and non-confrontational

If sexual impulsivity happens, approach it with a "matter of fact" attitude. Using our earlier example, do not appear shocked or angry. Say, "Jeff, we're here for dinner. This is the waitress. I am your wife. Let's talk about what we're going to order for dinner tonight. I hear they serve a great steak here."

Always remember...Safety 1st!

Agitation is a loss of control over one's behavior. It often occurs in response to frustration or overstimulation. In a person with brain injury, agitation may represent an overreaction to even minor frustration. There are often identifiable factors that cause the agitation.

Determining what these factors are will provide clues on how to minimize/avoid agitation in the future.

Example 1

In the course of getting dressed for a family gathering, Sam noticed a large stain on his pants. He became very angry with his wife for not having his pants clean. He started cursing loudly and pacing around the room. Finally he threw his pants across the room and kicked the bedpost. Sam was mumbling under his breath about how things never go his way. He would not put on other pants to go to the gathering; instead he stayed mad all day.

Example 2

During supper at a restaurant, Mary had trouble getting her pasta on a fork. She tried a second time, but the food slipped off the fork. She became very frustrated and yelled out to the other customers in the restaurant, "What are you looking at?" Mary then began eating with her hands.

Give simple directions to tasks

Offer tasks within the person's general abilities to limit frustration

Follow a schedule suggested by rehabilitation team, including rest times

Limit visitors to 2-3 people at a time for shorter visits (30 minutes) until better control of behavior is established

Allow the person to have some "space"

Avoid noisy places with large crowds

Keep household noise level to a minimum (avoid multiple noises at one time...TV, radio, video games etc)

Speak softly and calmly

Maintain a safe distance.

Ignore the behavior if it is safe to do so.

Direct attention away from the cause of agitation (change the subject)

Eliminate extra noise in the surrounding area if possible (TVs, radios, noisy guests)

Direct the person away from crowds to a more quiet area

Show support by acknowledging his/her frustration...
"I know this has really upset you." - - Good Example

Do not challenge, confront or scold the person. For example, do not say...
"Stop it. You're acting like a fool." -- Bad Example

Remove dangerous items that may be used as weapons

Never leave a confused or agitated person alone - Keep them in sight but at a safe distance

If possible, let a physically aggressive person move freely in a safe, large space. Avoid trying to restrain or touch.

Get help if the person is a danger to himself or others (ask someone nearby to call, if possible)

Inform the doctor /health care provider