Nursing intervention in cognitive retraining of the traumatic brain injury client

This paper deals with nursing intervention in cognitive retraining for the traumatic brain injury client in acute care rehabilitation. Clients in these settings usually receive therapeutic treatment during conventional working hours. The proposal of this article is to institute a more comprehensive approach based on nursing therapeutic intervention for cognitive remediation during evenings, weekends, and holidays. The nurse implements and maintains specific recommendations of the client's treating team, which includes the primary nurse. This results in a more intensive approach with maximum consistency of treatment, continuity of care, ongoing feedback to the therapist about the client's achievements on the nursing unit, continuous reassessment of the client's needs, and more involvement of the client's family. A case study is presented that exemplifies this concept.     

Sexual dysfunction of persons after traumatic brain injury: perceptions of professionals

The purpose of this paper was to study the perceptions of professionals in the field of rehabilitation in Israel concerning sexual dysfunction of persons after traumatic brain injury. Thirty professionals filled out an open-ended questionnaire that focused on problems of sexual functioning, dyadic and social relationships, and suggestions for the most appropriate interventions for these problems. The results indicated that for persons with TBI, the physical changes were not identified as the primary obstacle preventing persons after TBI from achieving sexual satisfaction, but rather the cognitive and emotional sequelae of TBI. A number of possible intervention techniques were also suggested.     

Working with a brain injury: personal experiences of returning to work following a mild or moderate brain injury.

OBJECTIVE: Most brain injuries occur in people of working age. Individuals with mild or moderate injuries may have unrecognized problems affecting return to work. Previous studies have focused on factors that predict return to work after brain injury. There is limited information about the experiences of individuals returning to work. DESIGN: Individual interviews explored the work-related expectations and experiences of workers who had sustained mild to moderate brain injury. A sampling frame ensured a spread of participants by age, injury severity and work type. METHODS: Thirty-three interviews were conducted 4-6 months post-injury. Most participants had returned to work. Interviews were transcribed verbatim for thematic analysis. RESULTS: Key emerging issues for participants were the invisibility of their injury, continuing symptoms affecting their ability to do their job and lack of advice and guidance on returning to work. Return to work support systems were considered to be poorly coordinated and managed. CONCLUSION: It is important that healthcare professionals anticipate the vocational rehabilitation needs of patients who have sustained mild to moderate brain injury. These patients may require additional coordinated interventions and specific person-centred information to ensure a successful and, most importantly, a sustained return to work.     

Adding insult to brain injury: young adults’ experiences of residing in nursing homes following acquired brain injury

Purpose: There is general consensus that adults under age 65 with acquired brain injury residing in nursing homes is inappropriate, however there is a limited evidence base on the issue. Previous research has relied heavily on third-party informants and qualitative studies have been of questionable methodological quality, with no known study adopting a phenomenological approach. This study explored the lived experiences of young adults with brain injury residing in aged care facilities.

Methods: Interpretative phenomenological analysis was employed to collect and analyze data from six semi-structured interviews with participants regarding their experiences of living in nursing homes.

Results: Two themes were identified, including “Corporeal prison of acquired brain injury: broken selves” and “Existential prison of the nursing home: stagnated lives”. Results illustrated that young adults with acquired brain injury can experience aged care as an existential prison in which their lives feel at a standstill. This experience was characterized by feelings of not belonging in a terminal environment, confinement, disempowerment, emptiness and hope for greater autonomy through rehabilitation.

Conclusion: It is hoped that this study will provide relevant professionals, services and policy-makers with insight into the challenges and needs of young adults with brain injury facing these circumstances.

• Implications for rehabilitation

• This study supports the contention that more home-like and age-appropriate residential rehabilitation services for young adults with acquired brain injury are needed.

• As development of alternative accommodation is a lengthy process, the study findings suggest that the interim implementation of rehabilitative care in nursing homes should be considered.

• Taken together with existing research, it is proposed that nursing home staff may require training to deliver evidence-based rehabilitative interventions to those with brain injury.

• The present findings add support to the call for systemic change in Ireland, to clarify the acquired brain injury care pathway and establish integrated rehabilitation services.

     

Predictors of family functioning one year following traumatic brain injury in children.

This study examined changes in family functioning and predictors of family outcome during the year following traumatic brain injury (TBI). The families of 94 children with TBI (mild = 50, moderate = 25, severe = 19), ages six to 15, were consecutively enrolled from two regional medical centers. Family interview ratings and standard measures of family and child functioning were completed three weeks after injury (measuring preinjury status), as well as three and 12 months. Two-thirds of families had moderate to good preinjury global functioning and coping resources, but more than half exhibited high levels of stress and at-risk family relationships. No significant preinjury differences by injury severity were seen on any measure. Whereas few changes in family functioning were observed over the year in the mild or moderate groups, greater deterioration occurred in the severe group. From one third to one half noted moderate to severe strain in 13 problem areas often seen in individuals with TBI. Preinjury family global functioning, however, was more strongly predictive of 12-month family functioning (R2 = .38 to .68) than was injury severity (R2 = .05 to .09). In four out of five outcome areas assessed at 12 months, preinjury status in each area was the strongest single predictor. Preinjury coping was the best predictor of stress. Families at risk can be identified and need ongoing support for optimal functioning.     

A study of the perceptions of hospice day care patients: my phenomenological methodology.

This paper describes the phenomenological methodology used to evaluate a hospice day care service from the perspective of twelve patients attending a UK hospice in June/July 1996. It briefly compares and contrasts a variety of phenomenological methodologies, then gives an account of the development and application of the phenomenological methodology used for the study.     

Use of antidepressant medication following acquired brain injury: concise guidance

Depression is increasingly recognised as a common sequel to acquired brain injury and the use of antidepressant medication in this context has increased markedly over recent years. However, these drugs are not without side effects--some of them serious--and they should not be used without proper evaluation and monitoring. This set of concise guidance was developed jointly by the British Society of Rehabilitation Medicine, the British Geriatrics Society and the Royal College of Physicians, to guide clinicians working with people who have brain injury of any cause (i.e. stroke, trauma, anoxia, infection etc). The guidance covers (a) screening and assessment of depression in the context of brain injury, (b) issues to consider and discuss with the patient and their family before starting treatment, and (c) proper treatment planning and evaluation--including planned withdrawal at the end of treatment.     

利多卡因对大鼠脑损伤后脑组织水通道蛋白4表达的影响

背景：近年关于利多卡因脑保护作用的研究较多，但对创伤性脑水肿的治疗效果研究较少。水通道蛋白4在脑组织含量最高，并已证实水通道蛋白4参与了各种原因如脑创伤、脑梗死．脑肿瘤等所致的脑水肿形成。 目的：观察利多卡因对实验大鼠脑损伤后水通道蛋白4的影响，分析利多卡因对脑水肿的治疗作用。 设计：随机对照动物实验。 单位：青岛大学医学院附属医院麻醉科。 材料：实验于2004—01／07在青岛大学医学院附属医院脑病研究所完成。实验动物为3月龄健康雄性Wistar大鼠65只，随机数字表法分为3组，正常组5只，模型组和治疗组各30只，再分为脑损伤后1，4，6，12，24，48h 6个时间点组，每个时间点各5只。 方法：采用Feeney法建立右顶叶脑损伤动物模型，正常组仅做相应部位的手术致伤。大鼠于手术后2-8h均恢复饮食。治疗组大鼠分别于致伤后1，4．6，12，24，48h腹腔内注射利多卡因，每个时间点5只大鼠首次用量为30mg／kg，后维持用量15mg／kg，首次给药后每6h给药一次，共维持3d；模型组腹腔内注射30mg／kg生理盐水；正常组不给予特殊处理。脑损伤后5d采用于湿重法计算脑含水量。免疫组织化学法检测各组大鼠脑组织水通道蛋白4的表达（吸光度值）、光学显微镜下观察脑组织细胞形态学改变。 主要观察指标：①各组大鼠的脑含水量。②各组大鼠脑组织水通道蛋白4的表达。⑧各组大鼠脑组织的病理学结果。 结果：实验过程中无动物意外死亡或其他因素导致脱失，65只大鼠全部进入结果分析。①与模型组比较，大鼠脑损伤后6h之内给予利多卡因能显著降低脑组织含水量[脑损伤后1h：（81．09&;#177;0．29）％，（83．04&;#177;0．25）％，P〈0．05]；[脑损伤后4h：（81.34&;#177;0.35）％，（83.31&;#177;0．48）％，P〈0．05];[脑损伤后6h：（82．01&;#177;0．21）％．（83．25&;#177;0．37）％，P〈0．05]。与模型组比较，治疗组脑损伤后1，4．6h水通道蛋白4的表达显著降低[脑损伤后1h：（0．19&;#177;0．02），（0．24&;#177;0．03），P〈0．05]；[脑损伤后4h：（0．21&;#177;0．05），（0．25&;#177;0．05），P〈0．05]；[脑损伤后6h：（0．21&;#177;0．03），（0．24&;#177;0．02），P〈0．05]。与模型组比较，脑损伤后12，24，48h给药，水通道蛋白4的表达和脑组织含水量差异无显著性意义俨〉0．05）。②水通道蛋白4阳性细胞镜下呈空泡状，主要位于创伤周边的水肿区、创伤侧的皮质和血管周围及白质的星形胶质细胞．脉络丛、室管膜等处。③在创伤中心区细胞多表现出坏死，在损伤周围区，细胞多表现为凋亡，创伤后6h之内给予利多卡因治疗组坏死及凋亡细胞数较模型组明显减少。而创伤后12，24，48h给予利多卡因治疗组坏死及凋亡细胞数较模型组减少不明显。 结论：大剂量利多卡因有减少大鼠脑损伤后水通道蛋白4的表达及减轻脑水肿的作用，但应在脑损伤后尽早用药。     

Levels of self-awareness after acute brain injury: how patients' and rehabilitation specialists' perceptions compare

OBJECTIVE: To examine self-awareness regarding performance on 4 daily living tasks and to test theoretical predictions for a model of self-awareness in persons with acquired brain injury. DESIGN: A comparative design examining the level of self-awareness recorded by patients and actual patient performance as judged by rehabilitation clinicians. SETTING: A community-based residential center providing comprehensive rehabilitation services to persons with acquired brain injury. PARTICIPANTS: Fifty-five persons with acquired brain injury and the identified potential to return to independent function in the community. Ten subjects without brain injury provided comparison data. INTERVENTION: Information was collected by using patient self-report, clinician rating of patient performance, patient rating of non-brain-injured subjects, and clinician rating of non-brain-injured subjects. MAIN OUTCOME MEASURES: Three self-awareness criteria were examined: intellectual, emergent, and anticipatory. Self-awareness was rated for 3 tasks: dressing, meal planning, and money management. RESULTS: Statistically significant differences (p <.05) were found for all levels of self-awareness across the 3 tasks. Persons with brain injury judged their abilities higher than clinician ratings of actual performance. No statistical support was found for a hierarchy among intellectual, emergent, and anticipatory self-awareness. CONCLUSIONS: No evidence was found supporting a hierarchy among levels of self-awareness as defined and measured in the present study. New methods for operationally defining intellectual, emergent, and anticipatory self-awareness are necessary to examine the relationship between self-awareness and performance.     

Treatment of alcohol dependence in Swedish primary care: perceptions among general practitioners

ObjectiveTo describe general practitioners’ (GPs) attitudes to the management of patients with alcohol dependence in primary care and current treatment routines and their view on a new treatment approach; internet-based Cognitive Behavioral Therapy (iCBT).DesignA qualitative interview study with ten GPs participating in a randomized controlled trial. The interviews were analyzed using qualitative content analysis.SettingThe participating GPs were recruited via purposeful sampling from primary care clinics in Stockholm.SubjectsThe GPs were participants in an RCT investigating if iCBT when added to treatment as usual (TAU) was more effective than TAU only when treating alcohol dependence in primary care.ResultsThe GPs found alcohol important to discuss in many consultations and perceived most patients open to discuss their alcohol habits. Lack of training and treatment options were expressed as limiting factors when working with alcohol dependence. According to the respondents, routines for treating alcohol dependence were rare.ConclusionGPs believed that iCBT might facilitate raising questions about alcohol use and thought iCBT may serve as an attractive treatment option to some patients. The iCBT program did not require GPs to acquire skills in behavioral treatment, which could make implementation more feasible.

KEY POINTS

• Alcohol dependence is highly prevalent, has a large treatment gap and is relevant to discuss with patients in many consultations in primary care.
• This study is based on interviews with 10 GPs participating in a randomized controlled trial comparing internet-based Cognitive Behavioral Therapy (iCBT) for alcohol-dependent patients to treatment as usual.
• GPs viewed alcohol habits as important to discuss and they perceived most patients are open to discuss this.
• The access to iCBT seemed to increase GPs’ willingness to ask questions about alcohol and was viewed as an attractive treatment for some patients.
• The iCBT program did not require GPs to acquire skills in behavioral treatment, which might be timesaving and make implementation more feasible.

     

"Nurse, my head hurts": a review of childhood headaches.

Headache, a frequent occurrence during childhood, can have a number of etiologies. Most headaches are benign, but all require appropriate assessment. Common types include sinusitis, migraine, and muscle contraction (tension). Headache assessment includes both history and physical examination. The headache history consists of the history of present illness, past history, family history, and environmental and social history. Physical examination begins with general observation and vital sign measurement and proceeds to specific inspection of the head, neck, and facial structures. The nursing interventions carried out are dependent on the interpretation of assessment findings. Pharmacologic interventions, commonly acetaminophen or ibuprofen, may be appropriate if pain management protocols exist. Nonpharmacologic strategies for headache relief include reassurance, rest, ingestion of simple and complex carbohydrate foods, relaxation exercises, or home care. Children with migraine headaches benefit from specific interventions, and children exhibiting headache warning signs should have emergency measures instituted.     

Support for children following traumatic brain injury: the views of educational psychologists

Purpose : For many years, neuroscientific research appeared to support the view that the young brain was more resilient and better able to withstand damage than the mature brain. More recent neuroscience research has questioned this view. Nevertheless, the view that 'younger is better' continues to be accepted by many medical practitioners. The present study sought to establish whether the training and experience of educational psychologists has made them aware that young children are particularly vulnerable to long-term effects of brain injury.

Method : Educational psychologists were asked to estimate the need for additional social/family and educational support, and how long such additional support would be needed, in four fictitious but clinically-based case studies which differed only in the reported age of the child/adolescent at the time of the injury.

Results : Educational psychologists consistently rated young children with brain injuries as needing more additional social/family support for longer than adolescents.

Conclusions : These results suggest that there is an appreciation of the additional needs of young children who have sustained brain injuries within our educational system.     

Gastric emptying following brain injury: Effects of choice of sedation and intracranial pressure

Objective To compare the effects of opioid and nonopioid sedation on gastric emptying.Design Prospective, randomized trial.Setting University teaching hospital ICU.Patients 21 brain injured patients requiring sedation, mechanical ventilation and intracranial pressure (ICP) monitoring for >24h.Interventions Patients were randomized to receive infusions of either morphine plus midazolam (M), or propofol (P). Gastric emptying was assessed by the paracetamol absorption technique and by residual volumes following a 200 ml test feed.measuerments and results Pre-sedation Glasgow Coma Score, mean ICP and the presence of bowel sounds were noted. Plasma concentrations of paracetamol were measured over 3 h following a 1 g gastric dose. There were no differencese in median peak paracetamol concentration (M, 18.5 versus P, 20.8 mg/l), median time to peak concentration (M, 20 versus P, 25 min), median area under the concentration-time curve (AUC), or in the median residual volumes at 1 h (M, 14 versus P, 10.5 ml) and 2 h (M, 5 versus P, 3 ml). In patients with ICP>20 mmHg, paracetamol concentrations were lower (p<0.05), and AUC after 30 min was lower (165 mg·min/l versus 411 mg·min/l,p=0.023). Mean ICP was correlated with AUC (Kendall rankp=0.027). Gastric emptying did not correlate with initial Glasgow Coma Score or presence of bowel sounds.Conclusions Gastric emptying is not improved in patients with brain injury by avoiding morphine (1–8 mg/h) in the sedative regimen. Intracranial hypertension is associated with reduced gastric emptying.     

脑外伤伴随骨折组织构建过程中生物活性因子的作用

目的：分析筛选脑外伤对骨折组织构建过程影响的体液生物活性因子。方法：检索中国期刊全文数据库、Pubmed数据库文献，然后对资料进行初审，并查看每篇文献后的引文。纳入标准：脑外伤后体液改变或体液因素影响骨折愈合过程；以近5年且发表在较权威杂志者优先。排除标准：重复研究文章。结果：①骨折具有加速愈合潜能，继发于创伤性脑损伤的骨折能够加速愈合。脑损伤、脊髓损伤、脊髓不同部位损伤、神经损伤时对骨折愈合影响不同。脑外伤后体液中存在促进骨髓基质干细胞有丝分裂和增殖的细胞因子。②骨形态发生蛋白是骨折成功愈合的极重要的因素，然而骨形态发生蛋白似乎并非是脑外伤后骨折愈合加速因素之一。③转化生长因子B既与颅脑损伤有关，也与骨折愈合有关，可能是脑损伤时促进骨折愈合的细胞因子之一。④脑外伤后碱性成纤维细胞生长因子阳性表达提前出现，与血管内皮细胞生长因子有明显的时间和浓度关系，通过血管内皮细胞生长因子、转化生长因子B的表达促进成骨。⑤血管内皮细胞生长因子只是创伤性脑损伤时多种生长因子网络中的一员，单一因子在体内的真实作用如何还有待于今后深入研究。⑥血清生长激素与胰岛素样生长因子之间相互作用促进骨折愈合机制有待进一步研究。⑦神经生长因子、催乳素、褪黑激素在脑损伤患者血清中浓度显著改变，可能是影响骨折愈合体液因素，其确切机制有待深入研究。结论：脑外伤后伴随的骨折愈合加速现象与全身、局部因素有关，目前关于各种体液因素的研究水平不同步。有些体液因素如骨形态发生蛋白、转化生长因子β、碱性成纤维细胞生长因子等、与骨折愈合的关系研究已开展得较为深入；另外更多的可能促进骨折愈合的体液因素还有待于筛选，进一步证实。