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neurobehavioral sequelae following TBI
Nurses facilitate social/occupational adjustment through holistic assessments and interventions
By ELISABETH MOY MARTIN, MA, RNC, and MARY COYLE, MS, RN, CS
C, a 22-year-old active-duty (AD) military male, was not wearing a seat belt when he was involved in a rollover motor vehicle accident. A passenger in the back seat at the time of the accident, C was partially ejected through the back window.
It was uncertain whether he lost consciousness. What is certain is that post-traumatic amnesia was approximately seven days. CT of head showed frontal lobe contusion, supraorbital fracture and C7 facet fracture.
After stabilization and physical rehabilitation for extremity strengthening, C was referred to our facility (eight months post injury) for postconcussive symptoms. Nursing assessment found C had no previous history of psychiatric illness despite a history of child abuse. He had been on active-duty status 1.5 years as physically and emotionally fit for duty, progressing within the ranks as a mechanic.
During the assessment interview, he expressed great frustration at his physical limitations, with suicidal and homicidal ideations (with access to weapons). He described increased irritability, pain, anxiety of becoming paralyzed if assaulted, post-traumatic stress disorder related to childhood abuse and cognitive deficits of decreased concentration and short term memory loss. However, he did feel better when he was around others. Unfortunately, family members were not available to us at the time of evaluation.
While establishing a basic trusting relationship with the psychiatric nurse, C was able to reveal critical and sensitive information he had not previously discussed with caregivers. This allowed the therapeutic relationship to develop so that safety issues (not to harm self or others) were addressed via verbal contract, as were issues of adjustment to his functional deficits.
C was followed weekly by the psychiatric nurse, who educated and reinforced use of prescribed antidepressants, explored his behavior and reactions to situations and reinforced his use of relaxation tapes to reduce his level of anxiety and stress. Relaxation tapes also helped improve his sleep patterns.
When the suicidal and homicidal ideations were first identified C agreed to participate in a structured psychiatric day program for safety and therapeutic interventions. He also participated in a structured cognitive rehabilitation research program to address his cognitive deficits. This included both group activities and individual therapies--speech, occupational therapy and physical therapy. The nurse was also able to help C to identify specific behaviors as they related to his thoughts and feelings. He was then able to recognize his behavioral patterns and expectations.
Two months later, all of C's complaints had lessened in severity; and he returned to his unit with mental health follow up and copies of relaxation tapes. This vignette demonstrates that clinical interventions were possible following nursing/mental health assessments.
Neurobehavioral Sequelae
So much has been written about the assessment and treatment of head injuries immediately following the injury. But there is another component to head injury--the neurobehavioral sequelae, which often occur in individuals who have survived mild to severe traumatic brain injury (TBI).
These sequelae include increased irritability with or without aggression, symptoms of anxiety or depression, sleep disorders, headache, interpersonal distress or personality changes.1 This cluster of symptoms is part of the medical diagnosis of postconcussive syndrome/disorder (PCS).2 The diagnosis of PCS, according to DSM IV, also includes cognitive deficits. In one study of individuals with mild injuries, up to 50 percent reported PCS.3 It also occurs in more severe head injuries, however, there is some thought that those more severely injured under-report their symptoms in the first year post injury.4
Possible behavioral changes are underreported unless the patient or family is specifically asked. These behavioral symptoms can distress and affect the quality of life for both the patient and his family.
Frequently, families feel burdened by the individual's altered behaviors and are uncertain how to provide care and seek information or support. Nurses have the opportunity to assist in social/ occupational adjustment through holistic assessments and interventions focusing on neurobehavioral sequelae.
Nursing Assessment
Nursing assessments of individuals with brain injury include: level of daily functioning, headache, sleep disturbances and altered mental status. The presence of anxiety, depression and fearfulness may affect interpersonal relatedness. Worries and expectations of recovery from all parties may influence functional outcomes. Altered family functioning may be anticipated due to the crisis of TBI, role changes and disruption of family patterns.
Interventions, which include the "real-world" environment, may increase a person's motivation and acceptance of treatment while supporting transferability of skills to the home environment.3
After injury, a perception of inadequate social support and/or difficult working conditions caused by fatigue, decreased concentration and memory, may impact parenting skills and coping. It has been our experience that in order to cope with changes, individuals or family members may turn to alcohol consumption, illegal substance use or other behaviors detrimental to the health and well-being of the family system.
Spectrum of Severity
It is important to recognize the spectrum of severity for any symptom a patient acknowledges. For instance, an individual may describe mild symptoms of depression, anxiety or irritability that likely will not need any pharmacological intervention or medical treatment.
Nurses continue to assess the spectrum of severity and offer suggestions to stabilize the mood state and provide information and feedback on the individual's ability to process the TBI event and integrate the event in a healthy manner into their life. Severe symptoms of depression may include suicidal ideations, hopelessness, impaired sleep and appetite and an inability to function in social or occupational settings.
Interventions may include advocating for mental health assessment and intervention, supportive and cognitive therapy for individual and family, further education, pharmacological treatment and education about this treatment, activation of the social network of support and identification of effective coping strategies. Specific interventions also include preventing harm to self or others and preventing further social withdrawal.
Further Symptoms
Patients may subjectively report an increase in irritability with the family or friend validating the behavior. Patients may report a range of emotions from irritability, snapping at or cursing another person, to verbally threatening to hit or actually hitting someone or something.4 The clinician assesses verbal outbursts or threats made at spouses, children, friends or strangers. Intentional physical attacks against property, people and self are assessed.
Interventions help individuals and families recognize times when there is an increase in frustration. Limiting access to these situations could prevent outbursts. For instance, loud noises may trigger headaches, which then may lead to irritability. It may be useful to set behavioral expectations for expressing anger and instruct the patient on calming measures such as relaxation and deep breathing. Family can be counseled to avoid arguing with the patient to prevent situations from escalating. Nurses can encourage all involved to recognize and discuss their thoughts and feelings and help identify positive coping strategies.
Clinical use of antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and anticonvulsants has been helpful not only in stabilizing mood state but also in decreasing levels of irritability. Methylphenidate has also been used to decrease anger.5
Fatigue is a common occurrence following TBI, and an individual may need more sleep at night or naps during the day. This generally resolves as healing occurs. However, some individuals may discover that it is difficult to fall asleep at night and often toss and turn for hours or experience disturbed sleep. Obviously, this results in fatigue in the morning, which makes the patient vulnerable to frustration, pain or cognitive slowing. A review of sleep hygiene and a sleep log may be helpful in identifying a disorder. Appropriate interventions may include limits on caffeine, relaxation exercises, soothing music and, if necessary, medications.
Headaches/Personality Changes
Headaches are the most reported form of pain experienced in the rehabilitation phase. Pain management and tolerance differ for each person; some refuse to take any medications--even acetaminophen or ASA for headaches. Patients may resort to alcohol and other drugs to cope. Assessing each person's pain tolerance and means for alleviation is essential in understanding how pain affects daily activities, mood and cognition.
Though well-designed studies regarding efficacy are still lacking, adjunct therapies such as relaxation techniques, music therapy or acupuncture have been beneficial to many patients.
Personality changes and symptoms following TBI fall into these subtypes: apathetic (lacks motivation), aggressive, labile, uninhibited, paranoid, combined or other. A person experiencing these changes is often described by himself and others as "not myself/himself."
Once problematic behaviors have been identified, appropriate interventions, such as behavior modification, cognitive therapies or pharmacological therapies, may be selected and implemented. Personality changes will affect the family, so therapies and support are critical.
Conclusion
Neurobehavioral sequelae need to be assessed with specific focus on depression, anxiety, and irritability as well as other postconcussive symptoms that may be under-reported. Depression, anxiety and irritability do affect interpersonal relationships, the ability to handle stress at home and work, and quality of life. Nurses have the opportunity to educate individuals with head trauma and their families for realistic adjustment during personal recovery and social/occupational reintegration. Often the "return to normal" does not happen as quickly as patients and their families would like. Small steps are made. Assisting in the recognition of these steps forward instill hope and facilitate the patients' and families' incorporation of a personal trauma into their lives. Early identification and consequent nursing interventions help the return to normalcy happen sooner, not later. *
For references, see our Web site at www.nursing.advanceweb.com and click on References or call 800-355-5627, ext. 260.
(The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.)
Elisabeth Martin is a psychiatric research nurse and nurse coordinator for the Henry M. Jackson Foundation, the Defense and Veterans Head Injury Program at Walter Reed Army Medical Center, Washington, DC. Mary Coyle is also a psychiatric research nurse for that facility as well as an associate professor of community nursing at Prince George's Community College Department of Nursing.
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