Let s s talk about behaviour

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3 Let s s talk about behaviour Common Terms: Coma Restless Agitated Disoriented Confused Disinhibition Disrupted sleep cycle Amnestic Combative Inappropriate Vocalizing

4 Some less accurate terminology Rude Ignorant Belligerent Pervert Pre-morbid personality Drug addict/alcoholic/abuser Was a risk taker before

5 GCS RLA GOAT PTA ABS Speaking a Common Language

6 Glasgow Coma Scale Score 3-15 Most useful when broken down into E, V, M Not of much utility once a person is awake & agitated Once more than 9 technically not in coma, but LOC still impaired

7 Rancho Los Amigos Scale (RLA) Descriptive scale of patient cognitive recovery Guides the development of therapeutic medical and rehabilitation treatment plans Two versions (8 or 10 Level) I No response II Generalized response III Localized response IV Confused, agitated V Confused, inappropriate VI Confused, appropriate VII Automatic, appropriate VIII Purposeful, appropriate

8 RLA IV Level IV- Confused/Agitated: Maximal Assistance Alert and in heightened state of activity. Purposeful attempts to remove restraints or tubes or crawl out of bed. May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another s request. Very brief and usually non-purposeful moments of sustained and divided attention.

9 RLA IV Absent short-term memory. May cry out or scream out of proportion to stimulus even after its removal. May exhibit aggressive fight or flight behavior. Mood may swing from euphoric to hostile with no apparent relationship to environmental events. Unable to cooperate with treatment efforts. Verbalizations are frequently incoherent and/or inappropriate to activity or environment.

10 RLA IV May be focused on basic needs: eating, drinking, smoking, getting home. Have difficult following directions. Recognize family/friends some of the time. Wander.

11 RLA IV Strategies for care Approach in calm, soothing manner. Reassure the person that they are safe. Orient patient to who you are and what you are doing and repeat frequently. Keep environment calm and quiet. No TV, No Telephone, Addition of music only if has a calming effect. Limit visitors to 2 at a time for short visits.

12 RLA IV Strategies Continued Give frequent breaks between activities including therapy and personal care these may be scheduled. Have family bring in familiar personal items, pictures etc to help him feel comfortable. Pick your battles pursue activities which are deemed essential but may further agitate patient: continence care vs grooming activities.

13 RLA IV Strategies Continued Allow patient sufficient time to calm down after becoming agitated. Their threshold tolerance for stimulation will remain lowered following an outburst. As much as possible avoid escalation of agitation by being able to anticipate potential triggers. Remember that increased stimulation during the day can result in increased confusion and agitation at night.

14 How I see the role of the nurse: PAIN Noise N U R Fatigue Confusion S E

15 Post Traumatic Amnesia (PTA)

16 Post Traumatic Amnesia (PTA) A period of anterograde and retrograde amnesia coinciding with a neurological event Duration often used as an indicator of injury severity

17 GOAT

18 Galveston Orientation and Amnesia Test Scored out of 100 Two scores of 75 or greater indicate that the patient is out of PTA

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20 ABS

21 Bryan Charnley Delirium

22 Assessment Definition of agitation Confirm that etiology of agitation is caused by ABI Rule out other etiologies Verify severity of ABI in collaboration with MDs and multidisciplinary team Determine contributing factors/triggers to agitation Identify agitated behaviours by using an agitation scale Consistency, common language Agreement on which scale to utilize Enhance knowledge about pharmacological/nonpharmacological interventions to manage agitation

23 Intervention: Assumptions Guiding Practice Expect egocentricity Behavioural outcome cannot be predicted on pre-morbid personality Monitor your own reaction and do not take personally PTA/STM: pt is confused with limited capacity to remember and learn new things. Expect no carry over!! Limited attention span: Be prepared with numerous activities

24 Intervention: Behaviour Management Strategies Structure, predictability, consistency, familiarity Include the patient in basic decision-making Offer simple choices 1-2 step command Repetition, repetition and routine At this stage, pts cannot manage complex tasks Move the patient gently into new activities Focus on pt s level of physical functioning & improving endurance If able, increase the pts physical activity by pacing the hall Caution with physical restraints?sitter/attendant

25 Private room Dim lights Intervention: Restructure the Care Environment Promote rest No TV or telephone Reduce visitors If possible, discourage visitors with whom the patient has not had prior positive communication Remove excessive visual/auditory stimulation

26 Intervention: Communicating with the Agitated Patient Establish eye contact Speak softly and in a low voice One person speaking to pt at a time Orient the pt Present a genuine sense of concern Do not display your own anxiety and fears Ignore, whenever possible, verbal outbursts Do not take personally Inform the patient what you will do before you do it

27 Intervention: Communicating with the Agitated Patient Break down commands into simple tasks Allow excessive talking Inappropriate behaviour: Set limits, ignore Preseverative behaviour: Redirect Praise all efforts at self-control often

28 Intervention: Family Education and Support Counsel family about behavioural and physiologic changes but not in front of the patient Work with family to identify triggers; assist them to stick to the plan Monitor family interactions Set mutual goals Emphasize that the pt is not in control of his/her behaviour Reinforce that agitation is a normal part of TBI recovery Social work/psychological support Teach management techniques described previously Develop and disseminate written information

29 Documentation Care Plan/Kardex Effective strategies Desired outcomes Agitation Flow Sheet Behavioural log Triggers Describe what worked & especially what didn t Use objective terminology based on standardized scales Brief attendants/others involved in pt s care

30 Questions? (519) x 42485