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Jennifer Lemke RN, CRRN
Anju Deut-Aggarwal, B.A. Psych, B.S.T
Toba Miller RN, MScN, MHA, GNC(C), CETN(C)
Brain Injury Statistics Present our Rehabilitation Program and
Identify team members Case Presentation Define Errorless Learning Describe how errorless learning was utilized Share our success
1.3 million survivors living with Brain Injury 1 in 26 Canadians living with Acquired Brain
Injury #1 cause of death or disabler for those under
44 years of age ( Ontario Brain Injury Association www.obia.ca)
> 18,000 Ontarians will suffer an brain injury this year
Every hour 6 Canadians will suffer a brain injury
1 of every 10 people will know some one with a brain injury
( Ontario Brain Injury Association www.obia.ca)
1.7 million Americans sustain a traumatic brain injury each year
> 3.1-5.3 million children and adults live with a lifelong disability as a result of traumatic brain injury
Economic cost is estimated at 60 Billion Dollars
(US department of health and human services centers for disease control and prevention. www.cdc.gov/TraumaticBrainInjury)
12 bed inpatient unit (8 Acquired Brain Injury
and 4 Behavioural Service) Treatment programs to assist with deficits in
planning, memory, attention, perception, learning and judgement as well as physical deficits
Assist patients to gain control over behavioural challenges associated with their brain injury
Help patients become more independent in the areas of employment, education, meaningful daily activities and relationships with family and others
Physiatrist Rehabilitation therapists Rehabilitation nurses Clinical psychologists Occupational therapists Physiotherapists Speech language
pathologists
Admission coordinator Social Workers Manager Recreational therapy Respiratory therapists Pharmacist
Physician specializing in Rehabilitation that provides necessary medical care and supervises care
Collect, analyze and interpret data on behaviours, which serves as a baseline upon which treatment plans are developed and outcomes are evaluated
Work with the team to develop and conduct individualized, realistic treatment plans and implement cognitive behavioural strategies
Implements individualized strategies according to cognitive, behavioral or physical deficits
Recognizes the client’s resources and abilities in all aspects of care
Acts as an advocate for clients and their significant supports
Assist clients and their significant supports in adapting to the physical, emotional and cognitive changes related to disability and chronic illness
Assess and develop treatment plans to assist with depression, anxiety, pain and changes in memory and thinking
Assess and develop treatment plans to assist with activities of daily living such as dressing, bathing, homemaking
Provide assistive devices to facilitate return to home
Assess and develop treatment plans to assist in return to work
Work with clients and their significant supports by evaluating and developing a plan to restore strength, endurance, movement and physical abilities affected by injury or disability
Assess and treat difficulties in communication- reading, writing, understanding and speaking
Assess and treat swallowing deficits
Collaborates with physician to determine client’s appropriateness for admission
Communicates admission information with team
Collaborates with the patient and their family regarding discharge options
Provides family counseling and support
Oversees the program and provides clinical and administrative support
Specializes in caring for clients with respiratory difficulties
Assist in transition to community
Assist clients and their significant supports in adapting to leisure activities and promoting active community living
Reviews medication regime throughout hospitalization
Provides support for clients and their families and assist with transition to community pharmacist
Provides assessment, treatment and counselling for clients and their significant support for nutritional needs
44 year old married male Motor vehicle collision Glasgow Coma Scale at scene 4/15
Injuries : Right Subarachnoid Haemorrhage Left Frontal Hemorrhagic Contusion Left Frontal and Right Temporal Lacerations Right Temporal and Left Frontal skull
fractures extending into the Left Orbit
Other Injuries and Complications: Pneumocephalus Bilateral Pneumothoaraces Pneumomediastinum Optic Nerve Abnormalities with significant
Visual Deficits Bilateral optic nerve shear injuries Fractured Ribs
Acute Hospital Course Bilateral Chest Tubes Tracheostomy Percutaneous Endoscopic Gastrostomy
(PEG)Tube Deep Vein Thrombosis and Pulmonary
Embolus IVC filter placement
Acute Hospital Course Mechanical Ventilation Pseudomonas Pneumonia Hyperglycaemia Hydrocephalus Ventricular Peritoneal Shunt Placement
Admitted to
Acute Inpatient Rehabilitation
Key Deficits: Disorientation to person/place/time Post Traumatic amnesia Confabulation Visual Hallucination Legal blindness Agitation Aggression Severe cognitive deficits
Burden: objectively is the amount of time and the number of tasks involved in care giving and subjectively is the caregiver’s emotional feelings, attitudes and overall perception of care giving responsibilities
The severer the deficits in the patient’s cognition and self care abilities the greater the burden on the care giver
(Watson,R, Modeste, N, Catolico, O, Crouch, M, (1998) The Relationship
Between Caregiver Burden and Self-Care Deficits in Former Rehabilitation Patients. Rehabilitation Nursing, Vol. 23, No. 5, 258-262)
At admission client required 2-4 staff members for all activities due to safety concerns, disorientation and visual deficits
Burden to significant family to large for client to return to home at this time
Orientation and self care identified by team and family as barriers to discharge
Team decision to set up an Errorless Learning Program to improve orientation and increase independence
Implementation of care treatment plans to communicate with staff and provide framework for consistency
Collaboration with family
Is the process of learning a procedure without allowing the individual to make any mistakes
The information to be learned is presented in the same way each time and any opportunity to guess is eliminated
Each task is broken down into specific components
Repetition/Consistency is the key Often very time intensive Family/care taker carryover into learning
process very important
Implicit versus Explicit Memory Implicit Memory: is a form of information recovery which
happens automatically without the knowledge of the subject Explicit Memory: subject intentionally tries to remember the
information requested as well as the context when the information was learned
(Bier, N.. Vanier. M., Meulemans, T. (2002). Errorless Learning: A Method to Help Amnesic Patients Learn
New Information. Journal of Cognitive Rehabilitation, 12-18)
Research shows that clients with significant deficits in explicit memory respond positively to Errorless techniques and the severer the memory dysfunction the better response as there is no interference by the explicit memories
(Kessels, R.P.C. de Hann, E.H.F, (2003) Implicit Learning I Memory Rehabilitation: A Meta-Analysis on Errorless Learning and Vanishing Cues Methods. Journal of Clinical and Experimental Neuropsychology, Vol. 25, No. 6, 805-814)
Consistency and repetition is of great importance Important to provide ongoing feedback Specific set of instructions for staff to facilitate
consistency Visual support for clients when required Withdrawing supports as performance improves
The Rehabilitation Centre
Behavioural Rehabilitation Service
Treatment Plan
Date: xxxxxxxxx
Target Behaviour: Confusion / Disorientation
Goal: Increase orientation and decrease length of confusion and disorientation (PTA).
Operational Definition:
Confusion / Disorientation is defined as disturbed awareness of ones environment in regard to time,
place, and or person.
Rational for addressing this goal:
There is research suggesting that reality orientation may help reduce the amount of time a client is
in Post Traumatic Amnesia. The method used in this treatment plan was reviewed in a research
article entitled “Effect of an integrated reality orientation program in acute care on post-traumatic
amnesia in patients with traumatic brain injury”.
Treatment procedure: (see Orientation Sequence Handout on his bulletin board)
An Orientation Sequence will regularly be verbally reviewed with Client.
In part of the orientation sequence to assist in decreasing Client’s confusion/ disorientation priming
Client before his scheduled activity will be added to the orientation sequence.
Procedure:
Each staff member orients the patient when they first approach him and whenever appropriate
during their interactions with him.
Given his ongoing level of disorientation do not continuously reorient him when is behaviour or
verbalizations indicate that he is disoriented. Continuous orientation as been noted to lead to
increased agitation. Do not however agree with any false information but simply refrain from
commenting.
Regular visitors are asked to follow the Orientation Sequence when they first speak to the patient
and whenever appropriate during their visit.
Requires commitment by team and significant support as time consuming in beginning of process
Development of scripts and tools to assist staff in consistency
When completing routine it is important to prompt client when they are about to make an error so that errors are not built into the memory
Labelling of client’s space provides prompts for client and helps staff and family maintain consistency
Data was collected during each routine and tabulated into graphs for comparison over 5 weeks
Client’s need for prompts showed a decrease during process
Client was able to independently perform ADL in a controlled environment
Orientation to place and situation improved Topographical orientation to facility
improved
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HC Prompting for Morning Routine July 9- August 15, 2009
Verbal Prompts
Physical Prompts
Linear (Verbal Prompts)
Client able to transition to a residential program
Program consists of 6 private rooms in a home-like atmosphere
Provides community based life skills to facilitate community reintegration and independent living
Although this client continues to have severe cognitive and visual deficits the client has been able to successfully return to his home environment with his family
He is completely independent in activities of daily living but continues to require assistance with instrumental activities of daily living
He continues physiotherapy twice per week and intermittent speech and occupational therapy.
He also participates in and Acquired Brain Injury day program twice a week.
Jennifer Lemke RN, CRRN [email protected]
Anju Deut-Aggarwal, B.A. Psych, B.S.T [email protected]
Toba Miller RN, MScN, MHA, GNC(C), CETN(C) [email protected]
