NeurotraumaManaging Patients with

Head Injuries

NeurotraumaManaging Patients with

Head InjuriesEdited by

Nadine Abelson-MitchellAssociate Professor (Senior Lecturer)

PhD, BSc (Nursing), RN, RM, Dip Nursing Education, RT, Dip Nursing Administration, DNA, Dip ICU, ENB148, FHEASchool of Nursing and Midwifery

Faculty of Health, Education and SocietyPlymouth University

Plymouth, UK

A John Wiley & Sons, Ltd., Publication

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Library of Congress Cataloging-in-Publication Data

Neurotrauma : managing patients with head injuries / edited by Nadine Abelson-Mitchell. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4051-8564-6 (pbk. : alk. paper) I. Abelson-Mitchell, Nadine. [DNLM: 1. Craniocerebral Trauma–therapy. 2. Craniocerebral Trauma–rehabilitation. 3. Evidence-Based Medicine. WL 354] 617.5'1044–dc23

2012027830

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover images courtesy of iStockphotoCover design by Steve Thompson

Set in 9.5/12 pt Times by Toppan Best-set Premedia Limited, Hong Kong

1 2013

Contents

Preface xiDedication xiiAcknowledgements xiiiContributorDetails xivAbbreviations xviiiListofTablesandFigures xx

Section 1 Foundations for Practice 1

Introduction 1

1 ThePatient’sJourney 3NadineAbelson-Mitchell

Introduction 3Carepathways:policiesandguidelines 4Integratedcarepathways 4

2 Philosophy 6NadineAbelson-Mitchell

Introduction 6Conclusion 9

3 TheNeedsApproachModel 11NadineAbelson-Mitchell

Introduction 11Whatisaneed? 11StructureoftheNeedsApproachModel 11Useofthemodel 12Assessingthepatient’sneeds 12

Planning 13Goalsetting 14Implementation 14Evaluation 14Risk 14Themiraculousrecovery 23Nursingdiagnosis 26Conclusion 28

4 ThePatientMatters 31NadineAbelson-Mitchell,ananonymouscarerandSueMottram

Thepatient 31Familyandcarers 31Conclusion 37

5 MultidisciplinaryManagement 38NadineAbelson-MitchellandKatieSearle

Introduction 38Staffing 39Speechandlanguagetherapyservices 40

6 Physiotherapy 43JudeFewings

Introduction 43Respiratorycare 43Positioning 43Musculoskeletalintegrityandneuromuscular

status 44

v

vi Contents

Summary 44Rehabilitationandmotorcontroltheories 45Postureandseating 45Conclusion 46

7 Neuropsychology 47MichelleSmith

Introduction 47Whatisclinicalneuropsychology? 47Whoisaclinicalneuropsychologist? 47Whatistheroleoftheclinical

neuropsychologistinthemanagementofTBI? 47

Neuropsychologicalfunctions 47Thepatient’sneuropsychologicaljourney 49Additionalfactorsinfluencing

neuropsychologicalfunctioning 50Otherissuesandconsiderations 51

8 SocialConsiderations 52JudiThomsonandAnthonyGilbert

Theroleofthesocialworker 52Socialissues 54Conclusion 56

9 OccupationalTherapy 57DanielleWilliams

Section 2 Pre-requisite Knowledge 61

Introduction 61

10 Epidemiology 63NadineAbelson-Mitchell

Introduction 63Severityofinjury 63Hospitalattendance 64Incidence 64Prevalenceofheadinjury 64Agedistribution 65Genderdistribution 65Raceandethnicity 65Mechanismofinjury 65Seasonalvariation 66Predisposition 66Useofalcohol 66Headinjurymortality 66Conclusion 66

11 PreventionofHeadInjuries 68NadineAbelson-Mitchell

Introduction 68Recommendations 68Roadtrafficaccidents(RTAs) 69Actionregardingtheuseofprescription,

overthecounterandillicitdrugs 70Preventionofsportsinjuries 71Careofolderpeople 71Interpersonalviolence 71Conclusion 72

12 AppliedAnatomyandPhysiology 74NadineAbelson-Mitchell

Introduction 74Thenervoussystem 74Thescalp 74Theskull 75Structureofthebrain 84Additionalconceptsrelatedto

neurophysiology 102Acid-basebalance 102Summary 105Conclusion 106

13 Investigations 108NadineAbelson-Mitchell

14 PharmacologyforNeurotraumaPatients 126NadineAbelson-MitchellandPennyFranklin

Introduction 126Anaestheticagents 127Analgesics 127Diuretics 127Anti-epilepticdrugs 127Anticoagulants 127Antiemetics 127Laxatives 127Conclusion 127

15 AppliedMicrobiology 129NadineAbelson-Mitchell

Introduction 129Meningitis 129Encephalitis 130Brainabscess 131Conclusion 133

Contents vii

Section 3 Features of Neurotrauma 135

Introduction 135

16 ClassificationofTraumaticBrainInjury 137ZuhairNooriandNadineAbelson-Mitchell

Introduction 137Primaryandsecondarybraininjury 137Openandclosedheadinjury 139Conclusion 140

17 RaisedIntracranialPressure 141NadineAbelson-Mitchell

Introduction 141Definition 141Causeofincreasedintracranialpressure 141Diagnosis 141Investigations 142Treatment 142Managementofthepatient 142Conclusion 143

18 AssessmentofthePatientwithNeurotrauma 144NadineAbelson-Mitchell

Introduction 144Generalprinciples 144Neurologicalobservations 146Vitalsigns 151Recordingtheobservations 152UndertakingacomprehensiveCNS

examination 152Recordingtheassessment 160Conclusion 160

Section 4 Management of Neurotrauma 161

Introduction 161

19 ManagementofNeurotraumaattheScene 163HenryGuly

Introduction 163Severeandmoderateheadinjury 163Airwaywithcervicalspineprotection 164Breathing 164Circulation 164Disability 165Exposureandenvironment 165Minorheadinjury 166

20 ManagementofNeurotraumaonTransfer 168HenryGuly

Introduction 168Airwaywithcervicalspineprotection 168Breathing 169Circulation 169Disability 169Exposure 169Other 169Whoshouldaccompanythepatient? 169

21 ManagementofNeurotraumaintheEmergencyDepartment 171HenryGuly

Introduction 171Preparingforthearrivalofaseriously

injuredpatient 171Severeandmoderateheadinjury 171Minorheadinjury 176Admission 178DischargefromtheED 178Managementofpatientswhoareadmitted

forobservation 178Socialaspects 179

22 HospitalManagementofNeurotrauma 182KevinTsangandPeterWhitfield

Introduction 182Initialassessmentoftraumapatients 182Managementintheneuroscienceunit 184Intensivecaremanagement 185Furthermanagementandprognosis 191

23 NursingthePatientwithNeurotrauma 194NadineAbelson-Mitchell

Introduction 194Advocate 194Essentialnursingskills 195Therapeuticpractice 195Co-ordination 196Clinicalgovernance 196Advice/counselling 196Politicalawareness 196Education 196Research 196Ethicalconsiderations 196Rehabilitationnursing 196Activities 234

viii Contents

24 PrognosisandPatientOutcome 235ZuhairNooriandNadineAbelson-Mitchell

Introduction 235Factorspredictingprognosisafterheadinjury 236Outcomemeasures 236Returntowork 237Qualityofeverydaylife 237Conclusion 237

25 DyingandDeath 238ZuhairNooriandNadineAbelson-Mitchell

Introduction 238Thefamily 239Braindeath 239Conclusion 241Activities 241

Section 5 Neurorehabilitation 243

Introduction 243

26 SequelaeofNeurotrauma 245NadineAbelson-Mitchell

Introduction 245Additionalinformationaboutsomesequelae 247Conclusion 249

27 Neurorehabilitation 250ZuhairNooriandNadineAbelson-Mitchell

Introduction 250Definitionofrehabilitation 251Levelsofrehabilitation 251Settingsforrehabilitation 252Rehabilitationcosts 252Staffingforrehabilitation 252Standardsofrehabilitationpractice 254Rehabilitationcriteria 254Therehabilitationprocess 255Goalsofrehabilitation 256Conceptsunderpinningrehabilitation 256Planningtherehabilitationprogrammecontent 256Schedulingtheprogramme 257Community-basedrehabilitation(CBR) 257Conclusion 260

28 EarlyStimulationProgrammes 263NadineAbelson-Mitchell

Introduction 263Definitionofearlystimulationprogramme 263

Background 263Objectivesofintroducinganearly

stimulationprogramme(ESP) 263SettinguptheESP 264ContentoftheESP 264Specifictechniques 265Howtoencouragetheinvolvementof

familyorfriends 265

29 DischargePlanning 266NadineAbelson-Mitchell

Introduction 266Whatisdischargeplanning? 266Benefitsofdischargeplanning 266Dischargeplanningprocess 266Criteriafordischargeplanning 267Selectingthedischargedestination 267Thedayofdischarge 267Conclusion 267

30 LivingintheCommunity 270NadineAbelson-Mitchell

Introduction 270Integratingintothecommunity 270

31 LegalMatters 271AndrewWarlowandSimonParford

Introduction 271Compensationclaimsarisingoutofhead

injuries 271Braininjuryandmedicalnegligence 273Headinjuries 273Thecostofbraininjury 276

32 MeetingTomorrow’sChallenges 277NadineAbelson-Mitchell

Conclusion 277

Section 6 Appendices 279

Appendix1 Pre-AdmissionAssessment 281Instructions 281Pre-admissionassessment 282Familyinformation 282Previoushealthhistory 283Currenthealthstatus 283Healthneeds 286

Contents ix

Appendix2 DischargeReport 293Instructions 293SectionA 293SectionB 294SectionC 294SectionD 294

ActivityAnswers 299AdditionalResources 309Glossary 315References 317Index 333

Colourplatesectioncanbefoundbetweenpages106and107

Preface

This book is designed to provide a holistic, evidence-based approach to the primary, secondary and tertiary care of a person with neurotrauma in all settings.

It uses a patient-centred needs approach to enhance the quality of care of head injured patients, their family and carers.

The book content enables the reader to apply the knowl-edge, skills and attitudes learned to the practice of neuro-trauma in all settings.

In addition, as many of the neurosurgical procedures that are undertaken result in trauma to the brain, this neu-rotrauma book can also be used in wider neuroscience practice by health professionals, families, carers and all personnel committed to the care of a patient with neurotrauma.

Nadine Abelson-Mitchell

xi

Dedication

This book is dedicated to my inspirational father Harry Abelson (z”l), who taught me to cope with adversity, my wonderful mother, Hilda Abelson, husband, John Mitchell whose help is immeasurable, sister Marissa Rittoff and my aunt Miriam Brener (z”l), a fine nurse.

It is also dedicated to my patients and their families who have strived to achieve their maximum potential.

People who have suffered a head injury ‘must have accessible, available, and appropriate health care and wellness promotion services’ to enable the person to lead a ‘full life in the community’ (Office of the Surgeon General [US] and Office on Disability [US] 2005: v).

xii

Acknowledgements

I wish to acknowledge the following for their contribution to the book:

The authors and co-authors who have contributed to the knowledge within the book.

My husband, John Mitchell, for his unstinting support and hours of proof reading.

A special thank you to Claire Butcher for editing the manu-script, Esther Hughes and Hannah Paddon for their continued support and to Fiona Carmichael for the drawings.

The companies who provided me with images for the book:

• SECA Ltd for the ECG images• Codman Ltd for the ICP monitoring images• Toshiba Medical Systems for the images of the MRI

Scanner and CT Scanner.

The Publishers for agreeing to publish the book.

My patients with whom I have shared many hours of practice.

xiii

Contributor Details

NADINE ABELSON-MITCHELL

Nadine is an Associate Professor in the School of Nursing and Midwifery, Faculty of Health, Education and Society at Plymouth University, Devon, UK. She is also an Honor-ary Nurse Consultant for the Plym Neurorehabilitation Unit, Plymouth Community Healthcare CIC, Plymouth, UK.

Nadine has been actively involved in neurotrauma prac-tice since 1976. In 1987, Nadine completed a PhD entitled the ‘Comprehensive care of adults with moderate and severe head injuries’.

Nadine lived in South Africa before moving to the United Kingdom where she was responsible for develop-ing post-registration neurotrauma programmes for Regis-tered Nurses. Her expertise in neurotrauma management has enabled her to be an expert witness and prepare medico-legal reports with regard to medical negligence and road traffic accidents. She opened a very successful nurse-led community-based practice managing neuro-trauma patients in the community.

She has written book chapters, has published numerous articles and undertaken national and international confer-ence presentations and workshops. She is a Trustee of Headway, Plymouth, UK.

Having written this book she is preparing a workbook on her experience of community-based rehabilitation for use by all.

JUDE FEWINGS

Jude Fewings qualified in 1992 from Caledonia Univer-sity (formally Queen’s College) Glasgow. Following a

three year general rotation in Newcastle-upon-Tyne, she moved to a post on the Neuroscience rotation in Sheffield in 1995, working almost exclusively within Neurosurgery and the Neurosurgical ICU. Subsequent promotion culmi-nated in being appointed Team Leader in Neurosciences in 1999.

In this Clinical Specialist role, Jude led the integrated teams of physiotherapists and occupational therapists in the assessment and treatment of all neurological patients and worked closely with Hallam University regularly lec-turing on the under- and postgraduate therapy courses, herself gaining a Postgraduate Certificate in Neurological Physiotherapy.

In 2005 Jude was appointed to the post of Consultant Therapist in Neurosurgery at Plymouth. As an experienced clinician she was able to comment on, and therefore influ-ence, the relevant strategic direction of the Trust and its policies whilst remaining involved in the clinical aspects of physiotherapy.

PENNY FRANKLIN

Penny Franklin is an independent and supplementary nurse prescriber as well as a community practitioner nurse pre-scriber and a Fellow of the Institute of Teaching and Learn-ing in Higher Education. She is also an Associate Professor in Health Studies, Medicines Management and Prescribing at Plymouth University.

She is a member of the BMA and British National For-mulary Subcommittee for the Community Practitioners Formulary for Prescribing; secretary of the Association for Nurse Prescribing; expert advisor to the National Prescrib-

xiv

Contributor Details xv

She was then based solely at the Plym Neurorehab Unit in Plymouth where, barring a brief spell working on a Stroke Unit, she has been ever since.

SUE MOTTRAM

Sue Mottram is Chief Executive of Headway Dorset, a charity for the support and rehabilitation of people with acquired brain injury living in the county of Dorset. At the time of her son’s accident, she was managing a mental health rehabilitation unit in Bournemouth. She is a state registered mental nurse, has a 2.1 honours degree in psychology and a postgraduate degree in personnel management.

ZUHAIR NOORI

Zuhair Noori is a Consultant in Neurorehabilitation in Croydon’s Healthcare Trust for in-patient and community neurorehabilitation and has previously been a consultant neurosurgeon in England and overseas. He holds a Special-ist Certificate (CCST) in Rehabilitation, London as well as a Certificate of the European Board in Physical Medicine and Rehabilitation. He is trained in neurosurgery, spinal cord injuries and spinal disease rehabilitation. He has had training in amputation medicine. His expertise relates to tone, neurological pain and biomechanics of mobility. He also has experience in the neuropsychological aspects of neurological diseases and more specifically in conversion reactions.

SIMON PARFORD

Simon Parford is a member of the Law Society’s Clinical Negligence Specialist Panel and Action Against Medical Accidents Clinical Negligence Specialist Panel.

He has undertaken claimant clinical negligence litiga-tion since 1986 and has specialised exclusively in this area of work since 1991. Specialist areas of interest are child and adult brain injury claims and spinal injury claims. He investigates Brain Injury Claims involving failures and/or delays in diagnosing and/or treatment. He has investigated dozens of such claims and has achieved many multi-million pound settlements; the largest to date being in excess of £6 500 000. These claims are almost always dif-ficult, complicated claims involving complex medical issues and very substantial quantum.

MICHELLE SMITH

Michelle Smith is a Consultant Clinical Neuropsycholo-gist, a full member of the British Psychological Society Divisions of Clinical Psychology and Neuropsychology,

ing Centre (NPC) and NICE for the Updating of Informa-tion for Designated Medical Practitioners; practice advisor to the CPHVA for non-medical prescribing/medicines management; academic link for Non-Medical Prescribing for Non-Medical Prescribing Leads in the Southwest Peninsula; external examiner for Prescribing at the Univer-sity of Reading; education committee member for Com-munity Practitioners and Health Visitors Association and clinical practice as public health nurse.

Penny has co-authored The Oxford Handbook of Non-medical Prescribing for Nurses and Allied Health Profes-sionals with S. Beckwith (2011).

ANTHONY GILBERT

Tony Gilbert is Deputy Head of the School of Social Science and Social Work at Plymouth University, UK. Prior to taking an appointment in higher education, Tony worked for approximately 17 years in health and social care mainly with people with intellectual disability. His research interests are in applied social sciences and social policy where he has been involved in a number of studies in areas such as mental health, safeguarding and the sus-tainability of community-based organisations.

HENRY GULY

Henry Guly was a Consultant in emergency medicine at Derriford Hospital, Plymouth, retiring in 2011. He quali-fied in 1974 and, after initially training in general practice, he started in emergency medicine in 1980 and was appointed a Consultant in Wolverhampton in 1983 and moved to Plymouth in 1986. Before he retired he was a civilian consultant in emergency medicine and civilian advisor in resuscitation to the Royal Navy.

KATY LEWIS

Katy Lewis was born in Cornwall, where she completed school and sixth form before gaining a BSc in English and Psychology 1997–2000 at Cardiff University, followed by an MSc in Language Pathology at the University of Reading 2001–2003.

Her first post (2003) was as a Research Speech & Lan-guage Therapist (SLT) on a research project for the Penin-sula Medical School into the intensity of SLT in post-stroke aphasia.

Her second post (2004) comprised a split between the acute hospital setting and a post-acute neurorehab unit, working with clients post ABI, and some MS, GBS and others.

xvi Contributor Details

effective advocate for anyone who she comes in contact with.

KEVIN TSANG

Mr Kevin King Tin Tsang was born in Hong Kong and read medicine at Guy’s and St Thomas’ Hospitals. He is currently working at Frenchay Hospital, Bristol. Previ-ously he worked at Derriford Hospital, Plymouth, as a specialist registrar (ST6) in neurosurgery.

He has also worked in the neurosurgical departments in Queen’s Hospital, Romford, and Addenbrooke’s Hospital, Cambridge, and also worked with the spine team in Oxford, both at the Nuffield Orthopaedic Centre and at John Rad-cliffe Hospital.

He has a particular interest in trauma care, both cranial and spinal, and will be looking to further his career in that direction.

ANDREW WARLOW

Andrew Warlow is a Partner and leads the Head and Spinal Injuries Unit at Wolferstans. He specialises in complex, catastrophic injury claims. He is the contact partner for Wolferstans and has been for a number of years on the Headway – The Brain Injury Association Personal Injuries Solicitors List, as well as the Spinal Injuries Association Directory for Personal Injuries Solicitors. He is also the contact partner for Wolferstans in the Child Brain Injury Trust Legal Directory. Andrew is a Fellow of the Associa-tion of Personal Injury Lawyers and a member of The Law Society’s Specialist Personal Injury Panel.

Andrew is a member of The Management Committee of Headway Plymouth, a local charity promoting awareness of and helping the victims of acquired brain injury and their carers.

PETER WHITFIELD

Peter Whitfield is a Consultant and Associate Professor in Neurosurgery at the South West Neurosurgery Centre, Derriford Hospital/Peninsula College of Medicine and Dentistry, Plymouth. His interest in neurosurgery was fuelled by undergraduate training in Southampton. He undertook Basic Surgical Training in Glasgow and Win-chester before being appointed a Registrar in Cambridge. He was awarded an MRC Clinical Training Fellowship and undertook a PhD on the molecular mechanisms under-pinning cerebral ischaemia. He has a longstanding interest in head injury management and is the lead editor of ‘Head Injury: A Multidisciplinary Approach’ (Cambridge Uni-versity Press). He has a keen interest in surgical training

and registered with the Health Professions Council. Current clinical practice is part-time at the Wessex Neurological Centre, University Hospital Southampton, with the adult specialist epilepsy surgery team, and at Glenside Hospital and Care Homes leading the psychology service and team for the rehabilitation of adults with acquired brain injuries or progressive conditions, complex care and high depend-ency, and neurobehavioural programmes. Before this she was Head of the Neuropsychology Rehabilitation and Counselling Services for Neurotrauma and Neurological Disease in Southampton for many years, with clinical experience ranging from acute, and in-patient, to long-term community settings. This experience was, and still is, pri-marily based on multidisciplinary team collaboration. Current professional interests include epilepsy and surgery, impaired consciousness after acquired brain injury, quality of life in people on long-term mechanical ventilation, with previous research regarding rehabilitation of memory problems in Multiple Sclerosis.

JUDI THOMSON

Judi Thomson qualified as a social worker in 1981 and obtained a Degree in Social Science and a Certificate of Qualification in Social Work. She has worked in a wide range of settings but her core work has been hospital social work. She has worked with adults with disabilities and life threatening illness. She has also worked in local offices in the community and has spent a short time working with children with cancer and their families – a post funded by the Malcolm Sargent Cancer Fund for Children.

Whilst working in hospital she developed an interest in strokes and this led to a post being created dedicated to working with stroke survivors and their carers. It was funded jointly by Health and Social Services and enabled her to carry out a truly multidisciplinary role. She went on to become a Care Coordinator for the Primary Care Trust in the Continuing Health Care team reviewing and assess-ing eligibility for continuing healthcare and also contribut-ing to multidisciplinary panels.

She then went on to become Carer Support Worker for Headway Dorset where she now remains, supporting carers, families and friends of adults who have an acquired brain injury. She is able to provide support to those with an ABI and help families. Part of her role is to provide education, information and advice but also to assist in navigating the myriad of services which exist and are ever changing. Her background in social work has provided her with extensive knowledge and she feels able to be an

Contributor Details xvii

and is the Deputy Chair of the Specialists Advisory Com-mittee in Neurosurgery, a member of the National Neuro-surgical Selection Panel and an examiner for the Royal College of Surgeons and the European Association of Neurological Surgeons.

DANIELLE WILLIAMS

Danielle Williams is a senior II occupational therapist at the Royal Hospital for Neuro-disability in Putney, London, specialising in long-term care in disability management of individuals with complex neurological disabilities and is a Bachelor of Science in Occupational Therapy.

Previously she was employed by Headway Dorset for 18 months, following a placement with the organisation during her training and work through the summer as part of the rehabilitation team. The charity is unusual, if not unique in regards to other Headway groups across the UK,

in that it has a multidisciplinary team of professionals providing rehabilitation across the county. Working with clients who have survived brain injuries is a challenging and rewarding vocation, and Headway Dorset delivers a fantastic service to its client group. Danielle has found working with the experienced team, including occupa-tional therapists, neurophysiotherapists, neuropsycholo-gists and nurse specialists with decades of experience between them, an excellent learning experience for a newly qualified healthcare professional.

She has a particular interest in the dynamics between the physical, cognitive and psychological challenges experi-enced by survivors of brain injury, and gets great pleasure from facilitating change and progress in clients’ recovery. She also has a keen interest in vocational rehabilitation, and a strong belief in the health benefits of having a productive role in our society, whether it be paid or otherwise.

Abbreviations

ABCDE Airway,Breathing,Circulation,Disability,ExposureandEnvironment

ABI AcquiredbraininjuryA&E AccidentandEmergencyDepartmentACTH AdrenocorticotropichormoneADH AntidiuretichormoneADL ActivitiesoflivingAMPLE Allergies,Medication,Pasthistory,Lastate

ordrank,EventsARN AssociationofRehabilitationNursesATLS AdvancedtraumalifesupportATMIST Age,Time,Mechanismofinjury,Injuries,

Signs,TreatmentgivenBBB BloodbrainbarrierBP BloodpressureBSRM BritishSocietyofRehabilitationMedicineBSDT BrainstemdeathtestingCBF CerebralbloodflowCBR Community-basedrehabilitationCBV CerebralbloodvolumeCN CranialnerveCNS CentralnervoussystemCPAP ContinuouspositiveairwayspressureCPP CerebralperfusionpressureCSF CerebrospinalfluidCTscan ComputerisedtomographyscanCVA CerebrovascularaccidentCVP CentralvenouspressureDH DepartmentofHealth

DAI/TAI Diffuseaxonalinjury/Traumaticaxonalinjury

DVT DeepveinthrombosisEBIC EuropeanBrainInjuryConsortiumECF ExtracellularfluidECG ElectrocardiogramED AccidentandEmergencyDepartment/

CasualtyEEG ElectroencephalogramESP EarlystimulationprogrammeETT EndotrachealtubeFASTscan Focusedabdominalsonographyfortrauma

scanFAM FunctionalassessmentmeasureFIM FunctionalindependencemeasureFSH Follicle-stimulatinghormoneGBS Guillain-BarrésyndromeGCS GlasgowComaScaleGOS GlasgowOutcomeScaleHDU HighDependencyUnitICF IntracellularfluidICP Intracranialpressure↑ICP IncreasedintracranialpressureICSH Interstitialcell-stimulatinghormoneICU IntensiveCareUnitINR InternationalnormalisedratioIV IntravenousLH LuteinizinghormoneLOC Levelofconsciousness

xviii

Abbreviations xix

LMA LaryngealmaskairwayMAP MeanarterialpressureMC&S Microscopy,cultureandsensitivityMRIscan MagneticresonanceimagingscanMS MultiplesclerosisMSH Melanocyte-stimulatinghormoneMVA MotorvehicleaccidentNANDA-I NANDAInternationalNIC NursingInterventionsClassificationNICE NationalInstituteforHealthandClinical

ExcellenceNOC NursingOutcomesClassificationNNN (NANDA,NIC&NOC)OPD Out-patientdepartmentP PulsePCWP PulmonarycapillarywedgepressurePCS Post-concussionsyndromePEEP Positiveend-expiratorypressurePEG PercutaneousendoscopicgastrostomyPNS Parasympatheticnervoussystem

PTA Post-traumaticamnesiaRAS ReticularactivatingsystemRNF RehabilitationNursingFoundationR/RR RespirationRCP RoyalCollegeofPhysiciansRTA RoadtrafficaccidentRTC RoadtrafficcollisionRSI RapidsequenceinductionSAH SubarachnoidhaemorrhageSALT SpeechandLanguageTherapistSNS SympatheticnervoussystemT TemperatureTBI TraumaticbraininjuryTSH Thyroid-stimulatinghormoneUK UnitedKingdomU&E UreaandelectrolytesUSA UnitedStatesofAmericaWHO WorldHealthOrganizationWTE Wholetimeequivalent

List of Tables and Figures

TABLES

1 Estimatedcostsin18–25yearoldsexperiencingheadinjury 2

3.1 Comprehensiveneedsofanindividual 145.1 Roleoftherehabilitationmedicine

Consultant 4110.1 NumberofA&EattendancesforEngland 6411.1 Worldwideacceptablebloodalcoholcontent

(BAC)levels 6911.2 SpeedlimitsintheUK 7012.1 Functionsofneuroglia 8712.2 Hormonesofthepituitarygland 9112.3 Clinicalmanifestationsofcerebellar

disease 9112.4 Cranialnerves 9212.5 Propertiesofcerebrospinalfluid 9812.6 Differencesbetweenupperandlower

motorneuronelesions 10012.7 EffectsofSNSandPNSonthebody 10113.1 Investigations 10914.1 Listofpharmaceuticalagents 12815.1 Classificationofmeningitis 12915.2 AppearanceofCSF 13116.1 Typesofprimaryinjuries 13816.2 Effectonneurochemicalmediators 13816.3 Typesofintracranialsecondarybrain

injury 13916.4 Typesofextracranialsecondarybrain

injury 139

18.1 GlasgowComaScalecategoriesandscoringsystem 146

18.2 Elicitingaresponsetoeyeopening 14618.3 Elicitingtheverbalresponse 14618.4 Elicitingthemotorresponse 14718.5 Cranialnervescontrollingeyemovement 15018.6 MRCgradingsystem 15018.7 Observationoftherespiratorysystem 15118.8 Enquiryregardingbehaviourpatterns 15518.9 Enquiryregardingmemory 15518.10 Testforsignsofagnosia,apraxia

andaphasia 15618.11 Typesofagnosia 15618.12 Typesofaphasia 15618.13 Positionoflimbs 15818.14 Muscletone 15818.15 Typesofinvoluntarymovement 15918.16 Deepreflexes 15918.17 Superficialreflexes 15921.1 IndicationsforimmediateCTscan 17721.2 IndicationsforCTscanwithin8hours 17722.1 Criteriaforintubationandventilation 18223.1 Nursingcareplan 19726.1 Sequelaeofneurotrauma 24627.1 Minimumstaffingforadistrictspecialist

in-patientrehabilitationservice 25327.2 Minimumstaffingprovisionfor

communityspecialistrehabilitationservices 253

xx

List of Tables and Figures xxi

12.15 TheCircleofWillis 9412.16 DiagrammaticrepresentationoftheCircle

ofWillis 9512.17 Venousdrainage 9712.18 Cerebrospinalfluidcirculation 9812.19 Intracranialpressurewaveforms 9912.20 Pressurevolumecurve 9912.21 SympatheticNervousSystemshowingthe

pre-ganglionicfibre 10112.22 SympatheticNervousSystemshowingthe

post-ganglionicfibre 10112.23 Simpleionexchange 10312.24 Haemoglobinbufferingsystem 10412.25 Respiratorycontrol 10512.26 Kidneyreabsorption 10513.1 CTScanner 10913.2 NormalCTScan 11013.3 NormalCTScan 11113.4 Extraparietalbleed 11113.5 Intracranialbleed 11213.6 MRIscanner 11213.7 NormalMRIscan 11413.8 NormalMRIscan 11413.9 Depressedfractureofskull 11513.10 EEGelectrodeapplication 11613.11 EEGbrainactivity 11713.12 ECGmachine 11713.13 CorrectplacementofECGleads 11813.14 NormalECG 11913.15 Sinustachycardia 11913.16 Normalchestx-ray 12113.17 Pneumothorax 12118.1 Pictureofpupilsizes 14818.2 Diagramofopticchiasm 14918.3 Normalappearanceofopticdisc 14918.4 Acopyofaneuro-observationschartused

atDerrifordHospital,Plymouth 15322.1 IndicationsinNICEguidelinesfor

CTscanninginheadinjury 18322.2 CTscanshowingaright-sidedacute

subduralhaematoma(ASHD)withsignificantmidlineshift 184

22.3 CTscanshowingpetechialhaemorrhagesatthegrey-whitemarginandinthecorpuscallosum,inkeepingwithtraumaticaxonalinjury(TAI) 185

22.4 Apost-operativeCTscanshowingtheextentofadecompressivecraniectomy 186

22.5 Protocolforcontrolof↑ICP,South-West,NeurosciencesUnit,Plymouth 187

FIGURES1.1 Carepathwayfortraumaticbraininjury 41.2 The‘Slinky’modelofphased

rehabilitation 52.1 Modelofneurotraumamanagement 72.2 Wheelofwellness 82.3 Illness–wellnesscontinuum 92.4 TheIcebergModel 92.5 ModelofWellness 103.1 NeedsApproachModel 123.2 Humanneeds 133.3 Safetyandenvironmentalneeds 153.4 Mentationneeds 163.5 Respiratoryneeds 163.6 Haemodynamicneeds 173.7 Communicationneeds 173.8 Psychological/Cognitiveneeds 183.9 Thermoregulationneeds 183.10 Comfortneeds 193.11 Fluidneeds 193.12 Nutritionalneeds 203.13 Eliminationneeds 203.14 Hygieneneeds 213.15 Skinintegrityneeds 213.16 Dressingneeds 223.17 Mobilityneeds 223.18 Spiritualneeds 233.19 Socialneeds 243.20 Leisureandrecreationneeds 243.21 Sexualhealthneeds 253.22 Vocational/Educationalneeds 253.23 Restandsleepneeds 265.1 Themultidisciplinaryteam 4112.1 Anteriorviewoftheskull 7612.2 Superiorandrightlateralviewof

theskull 7712.3 Posteriorviewoftheskull 7812.4 Lateralviewoftheskull 7912.5 Medialviewofsagittalsectionof

theskull 7912.6 Baseoftheskull 8112.7 Inferiorviewoftheskull 8212.8 Themeninges 8312.9 Sagittalsectionofthebrain 8512.10 Anteriorsectionofthebrain 8612.11 Functionalareasofthebrain 8612.12 Graphicdemonstratingprimary,secondary

andassociationareasofcerebrum 8712.13 Pictureofhomunculus 8812.14 Thelimbicsystem 88

xxii List of Tables and Figures

22.6 Graphshowingrelationshipbetweencerebralbloodflow(CBF),arterialpressure(MAP),andautoregulationbetween50–150mmHg 188

22.7 SchematicdiagramshowingthecontentsofthecraniumaccordingtotheMonro–Kelliedoctrine 188

22.8 ICPmonitorandprobeinsertion 18922.9 Schematicdiagramshowingtheset-up

ofanexternalventriculardrain 19022.10 CTscanshowingapatientwith

bitemporalcontusions,worseontherightthantheleftassociatedwithathinright-sidedacutesubduralhaematoma 192

22.11 Post-operativeCTscanofthesamepatientasinFigure22.10showingsatisfactoryresolutionofthecontusions 193

23.1 Theroleofthenurse 19527.1 TheICFModel 25227.2 ExtendedNeedsApproachModel 25527.3 Extractofobjectivesrelatedtotheneed:

safety 25927.4 Extractofprescribedinterventionrelated

totheneed:safety 25927.5 Extractofindividualisedtimetable 26027.6 Anexampleofmultidisciplinaryrecord 261

Section 1FOUNDATIONS FOR PRACTICE

This book examines the journey related to health, illness and recovery, in particular for neurotrauma. In order to maximise outcome, cost-effectiveness, efficiency and quality of care, it is necessary to accompany the patient along the journey in the primary, secondary and tertiary settings.

INTRODUCTION

This book has been designed to empower health and other professionals with applicable knowledge in neurotrauma practice, to support and manage patients, families, carers and communities throughout all stages of a patient’s journey to recovery. This is accomplished using a multi-disciplinary approach to facilitate recovery and maximise potential, whatever this level may turn out to be.

The management of patients with neurotrauma has improved over the last decade. This has resulted in patients, who previously would not have survived, surviving their head injuries and requiring extensive rehabilitation (House of Commons 2001). This has had a major effect on the use of available resources (Christensen et al. 2008). Services, including rehabilitation, are neither equitable nor accessi-ble to all neurotrauma patients (Aronow 1987; Beecham et al. 2009; British Society of Rehabilitation Medicine [BSRM] 2008a; Bulger et al. 2002; RCP 2010; United Kingdom Acquired Brain Injury Forum (UKABIF) 2004; Zampolini et al. 2012). Not all patients with moderate or severe head injuries are able to access neurosurgical centres (Treacy et al. 2005). The majority go home, some with a follow-up appointment or a GP referral, others without any follow-up, yet patients requiring rehabilitation should be able to access this at any stage within their journey (RCP 2010).

It is said that the costs for a person injured in a road traffic accident can vary between £35 000 and £60 000 per incident (Beecham et al. 2009) and costs for an injured pedestrian are estimated at £57 400 per incident (Crandall et al. 2002). The estimated cost per patient experience is presented in Table 1.

People with neurotrauma may achieve a good recovery. However, a lack of recovery, or partial recovery, may be devastating for them, their families and communities.

Key objectives

On completion of this section you should be able to achieve the following:

• Define neurotrauma.• Define the patient’s journey.• Describe factors that affect the patient’s journey.• Determine how to ensure the patient has a seamless

journey regarding neurotrauma.• Evaluate the various care pathways for neurotrauma

patients.• Describe various models of wellness.• Apply these models to neuroscience practice.• Apply the Needs Approach Model in practice.• Determine how using the Needs Approach Model

will assist in providing holistic, patient-centred care in a multidisciplinary milieu.

• Describe effective multidisciplinary management.• Describe the role of the neuropsychologist.• Describe the techniques one can use to provide a

therapeutic milieu.• Manage difficult patients.• Describe behaviour modification.• Describe how to communicate with patients, families

and carers.

2 Neurotrauma: Managing Patients with Head Injuries

Table 1 Estimated costs for 18–25 year olds experiencing head injury.

Severity of injury

Admission location

Discharge location

Sequelae Use of health and social services

Costs

Per annum Per person

Mild head injury

A&E Return home

1:5 have follow-up appointment

Up to 6 months Low £23.8 million £240

Moderate–severe head injury

Neurosurgical unit

Rehabilitation centre

Return home <1 year

Need some personal support

Require frequent OPD visits

Low–moderate £6 million £17 160

Moderate–severe head injury

Live in supported accommodation

Paid carers

Community housing

Limited independence – independence

Moderate–high £30.9 million £32 900

Severe head injury

Home/

residential facility/

nursing home

Severely disabled £10.4 million £33 900

Beecham et al. (2009).

Ethical/legal considerations

Debate the ethical issues related to this section.

Consider and apply the legal and ethical issues highlighted in these chapters to neurotrauma practice:

• Patient Charter.• Human Rights.• Accountability and responsibility.

• Consent.• Confidentiality.• Record-keeping.

Chapter 1The Patient’s Journey

Nadine Abelson-MitchellSchool of Nursing and Midwifery, Faculty of Health, Education and Society, Plymouth University, Devon, UK

INTRODUCTION

A person is on a journey through life which runs from the ante-natal period to the time of death. It is to be anticipated that, through experience, a person can manage obstacles in their pathway and continue on their journey in a produc-tive and positive manner. This life journey contains a number of pathways. These pathways, such as financial circumstances, interpersonal relationships and health, do not always run smoothly and may lead to various devia-tions. The health pathway is a continuum of wellness, illness, recovery or death and includes all occasions of ill-health.

Primary prevention is an important aspect of the patient’s journey. Preventing disease or ill-health through early education will decrease morbidity and mortality. A particu-lar pathway along the patient’s journey commences once the patient has been diagnosed with a particular health condition/problem. Unfortunately, due to the nature of neu-rotrauma, there is seldom a pre-arranged plan in place as there is for elective surgery. This part of the health journey usually comes as a shock and ‘emergency resources’ may need to be called upon to be able to continue the journey. It is important to provide a smooth route throughout the patient’s journey in order to ensure that quality care is provided, decrease stress, increase compliance and decrease deviant or destructive behaviour. The patient’s journey takes place within a particular environment and involves the patient, family and the wider community. It is a journey that needs to be patient-centred and focused on the patient’s perspective, expectations, motivation and

behaviour. When considering the journey the patient’s life experience, their strengths, abilities, capabilities and any fears or weaknesses must be considered. The patient’s health journey, interrupted by the neurotrauma, is influ-enced by a number of existing factors:

The patient:

• Age.• Gender.• Pre-existing conditions.• Social practices.• Health status.

The factors:

• Peri-natal care.• Environment.• Education.• Family support.• Community support.

Planning the patient’s journey may be referred to as ‘process mapping’ whereby the team and the patient work out the pathway a patient is expected to follow. This requires taking into account all aspects of holisitic, person-centred care that the patient may require, as well as the resources needed to achieve the proposed plan. The team is then able to examine the patient’s situation in terms of patient outcome and consider and identify potential chal-lenges that may occur along the pathway that may hinder achievement of the patient’s goals.

Neurotrauma: Managing Patients with Head Injuries, First Edition. Edited by Nadine Abelson-Mitchell.© 2013 Blackwell Publishing Ltd. Published 2013 by Blackwell Publishing Ltd.

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4 Neurotrauma: Managing Patients with Head Injuries

making, prevention, diagnosis and management, including rehabilitation, of patients with neurotrauma. Guidelines make specific practical recommendations based upon rig-orous and available scientific data (RCP 2010).

The health professional is responsible and accountable for the quality of care a patient receives. Basic care in today’s climate is often protocol driven, particularly as many basic tasks are undertaken by non-professional per-sonnel under the direct or indirect supervision of registered personnel.

INTEGRATED CARE PATHWAYS

Internationally (Espinosa-Aguilar et al. 2008; Seeley et al. 2006; Sesperez et al. 2001) and nationally (BSRM 2002; BSRM 2008a; 2009; NICE 2007; Royal College of Physi-cians [RCP] and BSRM 2003) interprofessional, integrated care pathways have been developed to improve the management of patients with neurotrauma and are useful in managing specific issues such as depression (Turner-Stokes et al. 2002).

CARE PATHWAYS: POLICIES AND GUIDELINES

Numerous care pathways have been developed to ensure cost-effective, efficient patient care to help create a seam-less journey through this episode of altered health. Interna-tionally, specific policies and standards have been developed that focus on neurotrauma throughout the patient’s journey (Espinosa-Aguilar et al. 2008; Seeley et al. 2006; Sesperez et al. 2001; Zampolini et al. 2012). The National Institute for Health and Clinical Excellence (NICE) (NICE 2007) has developed guidelines for the management of head-injured patients. The National Service Framework for Long-term Conditions (DH 2005a) has a particular focus on the needs of people with neurological disease and con-siders some of the generic issues, including rehabilitation, that are of relevance to people with long-term conditions and disabilities. The introduction of these policies addresses some of the inequities for patients requiring rehabilitation (Pickard et al. 2004).

Guidelines have been produced by a number of sources, nationally and internationally, to assist in clinical decision

Figure 1.1 Care pathway for traumatic brain injury (RCP 2010: p. 28). Reproduced from: Royal College of Physicians. Medical rehabilitation in 2011 and beyond. Report of a working party. London, RCP, 2010. Copyright © 2010 Royal College of Physicians. Reproduced by permission.

ACUTE CARE~

ITUNeurosurgeryOrthopaedics

Neuropsychiatricservice

highlycomplexneedsmore

complexneeds

lesscomplexneeds

A&E DGHward

Acute head injury

Hospital at homeEarly community rehabilitation

Enhanced participation DEA – supported return to work

Long term supportSingle point of contactJoin health and social service planningMulti-agency care

Hospital

Community

NEUROLOGICALREHABILITATIONINPATIENT UNIT

TERTIARYUNIT

(e.g. neuro-behavioural

unit)

Supported discharge

Community reintegration

Integrated care planning

REHABILITATION MEDICINESPECIALIST

COMMUNITYSERVICES

Multi-disciplinarymulti-agency

Head Injury Team

Chapter 1 / The Patient’s Journey 5

The National Service Frameworks stress the importance of integrated care pathways in the development of quality healthcare. These pathways, if developed and implemented effectively, will increase interprofessional co-ordination, efficiency of healthcare, reduce sequelae of head injury and reduce healthcare costs (Coetzer 2009; Singh et al. 2012; Vitaz et al. 2001; Zampolini et al. 2012).

Patients able to access these recommended pathways should experience a seamless transition from incident to home or final destination.

Activity 1.1

Scenario

An 18 year old boy was admitted with a GCS of 14/15 with a scalp injury that required suturing after a skate boarding accident in the park.

Exercise

1. Interview the patient and his mother to gain a picture of the patient’s life journey thus far.

2. Plan a session with the mother and son to decrease the risk of further head injuries.

Activity 1.2

1 Select a patient in the unit who has had neurotrauma (GCS 5/15) and plot the patient’s journey.

2 Are there any aspects related to professional practice that you need to consider in the patient’s journey?

3 Develop a communication plan for patient.4 Develop a communication plan for family and

carers.

Activity 1.3

1 Do you use an integrated care pathway in the unit?2 If yes, see Chapter 16, Activity 16.1 and describe a

possible pathway for Trevor.3 If no, why does your organisation not use an inte-

grated care pathway?4 Would you consider developing such a pathway with

a team of colleagues?

Figure 1.2 The ‘Slinky’ model of phased rehabilitation (RCP and BSRM 2003: p.10). Reproduced from: Royal College of Physicians and British Society of Rehabilitation Medicine. Rehabilitation following acquired brain injury: National clinical guidelines (Turner-Stokes, L. ed). London, RCP, BSRM, 2003. Copyright © 2003 Royal College of Physicians. Reproduced by permission.

Acute care/neurosurgery

Post-acute inpatient

Community-based rehabilitation

Longer-term community support

Home

Hospital

Ward-based therapy

Reducedimpairment and pathology

Improvedactivity (reduced disability)

Goals andmeasures of outcome

Enhancedparticipation

Specialist rehabilitation

Day centre/outpatientsOut-reach/home-basedVocational rehabilitation

Re-access as required

Specialist case/care managementMaintenance of gainsReview/drop-in clinics

Chapter 2Philosophy

Nadine Abelson-MitchellSchool of Nursing and Midwifery, Faculty of Health, Education and Society, Plymouth University, Devon, UK

INTRODUCTION

Beliefs and values determine the philosophy that underpins the quality of service provided to neurotrauma patients. Neurotrauma practice is an approach, an attitude and a process. The philosophy behind neurotrauma practice is one of ensuring comprehensive quality holistic care that spans all ages and applies to all settings, individuals, fami-lies and communities. It is a philosophy that believes in the worth and value of each human being as an individual, family member and member of a community.

A model of care, or a particular approach to care, under-pins this philosophy. There are numerous models of care that can be applied to neurotrauma practice. There are models that provide a framework, a logical systematic approach to quality care. The most commonly used are the ‘medical model’ (Mountain and Shah 2008), with a focus on functional ability, and the social model (Sharpf 2002) that encompasses the whole person. In their pure form, most models do not include all that is required in nursing. In order to achieve the goals of nursing an adapted, inte-grated model (Joubert et al. 2006) of care is appropriate. This integrated model takes into consideration the World Health Organization (WHO) International Classification of Functioning (ICF), Disability and Health components (WHO 2001). The integrated model is a patient-centred model that enables a comprehensive holistic approach to

the patient incorporating a multidisciplinary team rather than an illness/disease orientated model.

The focus of the model changes as the patient progresses throughout their journey. Within secondary health services acute and sub-acute management is the priority. As the patient progresses along their journey to tertiary services, the focus changes to a wellness model of care (Hattie et al. 2004; Hettler 1984; Myers and Sweeney 2004; Myers et al. 2000).

The wellness model focuses on health and lifestyle and includes aspects such as:

• Holistic health that encompasses the integration of body, mind and spirit.

• Making informed choices.• Approaches to wellness.• Facing challenges.• Changing lifestyles.

The WHO (1958: p. 1) defines health as ‘a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity’. This definition enables a holistic approach to healthcare and engenders the concept of wellness. It may require a culture change to embrace a wellness model rather than a disease-based, medical model. The concept of wellness implies that the individual will be proactive, aware of the advantages of a healthy lifestyle and

Neurotrauma: Managing Patients with Head Injuries, First Edition. Edited by Nadine Abelson-Mitchell.© 2013 Blackwell Publishing Ltd. Published 2013 by Blackwell Publishing Ltd.

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