Please help: TBIs in acute rehab setting

  1. Hi all, I'm looking for some feedback and advice. I work on an acute rehab floor and have recently had some challenging TBI patients. Our therapy team has all kinds of advice for, and requests of, the nursing staff when it comes to these patients, yet each therapy session is only 30-60 minutes; and the patient can refuse therapy, which means the sessions may not even last that long. (The patient won't stay on our unit very long if he/she continually refuse therapy because in order to stay, they must participate in a minimum number of hours of therapy per week...but I digress). What I'm getting at here, is that it feels like the therapy team is making suggestions based on their 30-60 minute interactions with these patients, while nursing is responsible for the patients for the entire 12-hour shift.

    At any rate, I'm looking for some feedback/support on dealing with TBI patients from a nursing perspective. My most recent TBI patient was screaming at any time that he wasn't occupied with a staff member. He was so agitated and restless that he would request to go to the bathroom, be taken to bathroom, and then start screaming to go to the bathroom again before I even left the room. He was successful in voiding or having a BM 25% of the time he was taken to the bathroom. He would press the call light WHILE I was in the room talking with him. And that behavior was ALL DAY. I wish I was exaggerating. I gave him all the PRN anti-anxiety meds available to me, but they didn't touch him, and the docs are fully aware of his behavior. He's got other underlying physical triggers (nausea, abdominal pain, etc) that are likely contributing to his behavior, but he's also essentially bored when not in therapy. He requires 1:1 in order to stop screaming. I don't believe that the therapy staff understands just HOW needy patients like this are because all they see is how the patient behaves during their session.

    Can the rehab RNs, LVNs, and Techs offer some guidance to me on how to deal with a patient like this so that I'm able to get my other work done? He is on restraints: netted bed and wheelchair belt.

    Many thanks for any advice or feedback you can give. I'm struggling and feeling alone in dealing with this at work. (Incidentally, I'm a relatively new RN -- I've been in acute rehab for almost 2 years and it is my first RN job.)
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  2. 1 Comments

  3. by   jenn_the_rn
    Be sure to look at the different levels of TBI, sounds like your patient is a Rancho Level 4. He's inappropriate, perseverative, uninsightful, and agitated. Present to therapy that this is what's going on with your patient and they can help by setting up low stimulation times between therapy, with tv off, shades down, and a calm and quiet environment, as well as times to work and be stimulated. They can also help by assigning simple tasks, homework, and games he can do to keep himself busy when not in therapy. He's on PRN anti-anxiety but does he have scheduled antipsychotics such Risperdal or Seroquel? This can be beneficial with agitated behavior. Brain injury patients are the most difficult and most misunderstood patients there are, as most of this behavior is part of their injury. Good luck!

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