Case Study Analysis Traumatic Brain Injury

A CASE STUDY OF A PATIENT WITH A TRAUMATIC BRAIN INJURY WHO SUBSEQUENTLY DEVELOPED POST-TRAUMATIC SEIZURES

Student’s name

Student’s number

Date

Table of Contents

Introduction

This essay presents the case of inpatient rehabilitation of a 65-year-old woman, "Patient X", who sustained Traumatic Brain Injury (TBI) and later developed post-traumatic seizures (PTS). The overall essay discusses the aspects of the patient's case. It uses a pseudo-name under the NMC Code of Confidentiality and GDPR standards to protect the patient's right to privacy and respect Patient X's identity. The GDPR states that the personal information of an individual should be protected and fairly collected for specified purposes and cannot be processed without their knowledge (Finck, 2020). This case was under supervision while working as an adult nurse at organisation ABC. She had a surgical intervention to remove hematoma caused by TBI in the frontal lobe subdural area. After the craniotomy, Patient X had several complaints that implied various physical and cognitive changes, such as memory impairment, problems with balance, a decrease in mobility, and an increase in muscle tone of the left and right upper and lower extremities. The case study analysis aims to identify the strategies used during inpatient rehabilitation and analyse the efficacy of the treatment as well as Patient X’s improvement. For this, the essay has critically explored the role of nurses in providing care to TBI and PTS patients concerning the findings of the past literature.

Overview of the case study

While working as an adult nurse in the organisation ABC in Nigeria, the nurse has experienced several cases of Traumatic brain injuries (TBI). For instance, the consolidation of the adopted treatment approaches is illustrated through a detailed examination of the case of a 65-year-old female patient, X, who had sustained TBI and was left with post-traumatic seizures. Additional challenges emerged, such as situations with a subdural hematoma that requires a surgical operation in the frontal lobe. She was able to start inpatient rehabilitation two weeks after surgery. She underwent a craniotomy; she had no fluctuations in her vital signs. On the first evaluation of that patient, the nurse noticed signs of memory dysfunction, poor balance, minimum voluntary movements, and rigidity in the left and right arm and the left leg. Fears and postural concerns were treated through balance training, superior exteroceptive orientation re-training, agility exercises, strength training, flexibility training, gait re-training, and posture control training. Assessment of the present case was done during the fourth week of inpatient rehabilitation using the Berg balance scale and Ranchos Los Amigos scale. Then, the multidisciplinary team finished the mobilisation planned at the onset of the course of inpatient rehabilitation and offered a re-evaluation at week 4. Significantly, the patient's Functional Independence Measure (FIM) increased from 68 on admission to the beginning of rehabilitation to 106 on the day of discharge and the beginning of a home-based rehabilitation program.  

Systematic Analysis of Patient Data

Table 1 Initial screening

The patient's screening obtained for them after admission to inpatient rehabilitation presented normal Heart Rate (76 bmp), Blood Pressure (115/76), and SpO2 (97%). The nurse then went on to choose different outcome measures for engaging the patient to evaluate their mental status at this initial encounter and then in subsequent contact with the patient. The Galveston Orientation and Amnesia Test (GOAT) were used to assess the patient's orientation and memory of events before and post-occurrence, as similarly directed in the study by Spiteri et al. (2021). The GOAT is commonly used to measure cognitive orientation and memory in cases of traumatic brain injury (TBI) (Spiteri et al. 2021). Use of this tool is widely documented in clinical practice that seeks to monitor recovery from PTA, it provides valid and reliable estimates of oriented patients and their ability to recall information (Hennessy et al. 2021). To that end, Bi et al. (2021) stress the use of GOAT for longitudinal research to assess shifts in cognition defining its applicability to both research and practice. Through the use of GOAT, other clinician-researchers can measure the severity and duration of impairments in a way that is credible and consistent with the standard operating procedures of clinical evaluations to validate results from various tests (Tate, 2020). Therefore, since GOAT has been proven to be both effective and reliable in the evaluation of attention as well as memory in the context of post-occurrence orientation, it was employed in this study.

The GOAT was chosen for its ability to provide a comprehensive assessment of the patient's memory and orientation, which are crucial aspects of cognitive function affected by TBI. Thus, the assessed membrane GOAT score of the patient was found to be 60/100, further showing a value below 66 that represented the cut-off point on the memory domain.

Table 2 GOAT outcomes

Particularly, the patient had conjugate current memory, and they can recall the majority of the events after she woke up in the ICU. However, retrograde amnesia for events occurred within a week before the event. For evaluating oligophrenia, the Ranchos Los Amigos scale may be employed to evaluate the patient’s cognitive level after a TBI the moment the patient regains consciousness (Amein et al. 2022). The Ranchos Los Amigos scale was chosen for its ability to provide a comprehensive assessment of the patient's cognitive function, which is crucial for determining the patient's readiness for rehabilitation (Berro, 2024). Thus, the Ranchos Los Amigos Scale is the most famous for assessing a person's cognitive function; accordingly, it is quite useful in the rehabilitation process (Lowenstein and Halloran, 2024). Besides, this scale is helpful to assess the different degrees of awareness, and cognitive and behavioural responses to help differentiate a patient for rehabilitation readiness. In this regard it helps provide clinicians with objective stages of interaction from no response to purposeful and appropriate, to help plan specific rehabilitation programmes (Gokeler et al. 2020). Further, because it documents a patient’s progression over time, it offers the flexibility each individual needs for treating therapeutic strategies for rehabilitation. At the first evaluation, Ranchos Los Amigos scale identified a level VI, which she found confusing.

Therefore, the patient was fit for rehabilitation as she was capable of following even simple commands, showing generalisation of relearned activities of daily living and being able to attend to other well-known tasks for some duration of time. However, the physiotherapist realised that every one required the highest level of help relearning new tasks since there is no generalisation across different days or sessions. In addition, the physiotherapist maintained appropriate safety precautions (i.e., maximum observation) because the patient appeared cognitively impaired and was disoriented to person, time, and place. As she was later suffering from PTS due to brain injury, the nurse took her for Electroencephalography. EEG is an ambulatory diagnostic technique that records brain electrical activity from scalp electrode placement. In comparison, there are two other most commonly used diagnosis tools Computerized tomography and Magnetic resonance imaging (Florkow et al. 2022). According to the investigations, TBI causes neural alterations that are observable with EEG and helpful in assessing cognitive and emotional dysfunctions linked to PTS (Wagner et al. 2021). The advanced evaluation of electrodes on the subject’s aura can detect abnormalities that indicate symptoms of PTS; thus, contributing to its treatment plan. It is a non-invasive procedure which enables researchers to get accurate information during clinical periods whereby knowledge of patient neurological conditions is a prerequisite to managing them accordingly. Therefore, the decision of the nurse to use EEG seems rational as it assists in the collection of data about the individual state of the patient and helps to make proper clinical decisions to enhance patients’ outcomes. The Glasgow Coma Scale helps in assessing impaired consciousness and coma under TBI severity scoring systems (Bodien et al. 2021). Meanwhile, the nurse has used ECG to assess the brain health of the patient. It is commonly used in cases of post-traumatic seizures to determine abnormal activity in the brain, identify the origin of epilepsy and assess treatment results (Hasan et al., 2021). EEG can also be used to diagnose epilepsy or other forms of seizure in a given individual who has had traumatic brain injury (Greenblatt et al., 2023). Thus, it helped assess the condition of patient X and confirm PTS.

Comparison of Interventions and Current Evidence-Based Practice with Clinical decision-making and Rationale

She was found to have a Ranchos level VI cognitive status, where the patient displayed confusion along with adequate actions. Likewise, Goldman et al. (2022) stated that after brain injury, the patient's ability is affected by difficulties in understanding and processing. The patient takes a long to grasp the surrounding things due to neuronal dysfunctions. This state of confusion required not only adherence to the patient's desires but also to the medical plan of the chosen healthcare facility concerning the rehabilitation of Traumatic Brain Injury (TBI) patients (Ludmer, 2022).

 The article by Souesme et al. (2022) documents the goal of inpatient rehabilitation, which is to regain the patient's ability to go home safely with her husband. As a result, the outlined program incorporated the dependency on task-oriented training, balance and gait re-training, strength training, as well as aerobic fitness training within the context of a functional task, as also highlighted in a study by Ahmed et al. (2021). Thus, to enhance the impact of the treatment, the inpatient rehabilitation program included learning approaches that the patient can accommodate due to her cognitive level. The first procedure involved the application of a highly prescribed schedule, which comprised distributed practice, initial feedback, closed contexts, and clear, unambiguous directions. Because of the improvements made by the patient in both the cognitive and physical domains, new forms of practice schedules, context randomisation, feedback implicitness, and escalating levels of cognitive load were incorporated into the treatment (Silva, 2024). To make sure that the patient did not get tired, the program also constantly checked her energy level and made the necessary adjustments for her treatment. Flexibility was introduced in the treatment program concerning the type, duration, and volume of exercises according to the patient's needs that may exist at a particular period (Stefanakis et al. 2021). Further, due to the concept that it is preferred to have the patients perform only the necessary exercises, the rehabilitation program combined the Upper extremity Range of Motion (ROM) and strengthening into dynamic sitting exercises (Morris, 2024). The use of Upper Extremity ROM or strengthening exercises incorporated with dynamic sitting exercises in the rehabilitation programs is based on the principle of least time and most effective treatment for the affected patients (Srinayanti et al. 2021). This approach certainly concerns fundamental exercises thereby decreasing the stress odds while at the same time enhancing the treatment effects (Abdillah et al. 2022). By performing compound movements acquired by the blend of ROM and strength training, improved motor control and muscle endurance in functional positions are achieved (McSweeney et al. 2020). Scholarly works reveal that dynamic sitting exercises are more beneficial prerequisites to overall functional independence in contrast to isolated exercises due to the similarity of the movement to daily tasks (Fyfe et al. 2022). Through this method, patients can fit exercises that correspond to real-life tasks, which maximizes the outcomes of the rehabilitation processes and saves resources (Ehioghae et al. 2024). Also included were both patient and spouse teaching parts focusing on physical, cognitive, behavioural, and emotional consequences of TBI, as well as TBI symptoms and prognosis. This approach was important so that the husband could know the areas of treatment where she could contribute positively and the ways that she could support his wife as she continues her recovery process dimension (Lobo et al., 2023).

 Therefore, this inpatient rehabilitation program for a patient with a Ranchos level VI cognitive state presented effective and flexible management of TBI. The intervention that replaced the major component of the total program was an evidence-based clinical practice guideline that provided the approach to address the patient's needs and, thus, reach the proposed primary goals, which were to help the individual regain functions and safely return to the home setting. In addition, by providing education sessions for the patient as well as her husband, the program guaranteed patient-centred recovery and positive results. In comparison to the chosen intervention, past literature has indicated effective therapeutic strategies that include gaze stabilization exercise, repositioning techniques, and binocular vision training (Hoppes et al. 2023). These interventions are effective in reducing dizziness and balancing problems that may increase the risk of falling and causing a second brain injury.

Plan of Action and Implementation

The interventions for the patient with traumatic brain injury (TBI) consist of the development of an interdisciplinary inpatient rehabilitation plan of care tailored to her goals and preferences as well as the rules of the facility, using current clinical practice implementations. Some particular parts of the program included training-specific tasks, balance exercises, gait, strength training, and aerobic fitness for functional tasks. Treatment implementation was standardised according to the patient's cognitive skills using instructional strategies that included the acquisition of organised methods, training in distributed and random practice schedules, methods that incorporated both explicit and implicit feedback and the use of closed and open environments methods (Powell et al. 2021). Another component of the programme, as described by MacIntosh et al. (2021), is the frequency, Intensity, and volume of exercises. Dynamic sitting exercises also include upper extremity range of motion and strengthening in order not to overemphasise them (Reece et al. 2021). Further, the extensive program of the stay embraced extensive educational sessions for the patient and the husband to be informed about the possibilities of TBI and its physical symptoms, cognitive and behavioural changes, emotional dysregulation, signs, and prognosis (Haney, 2024). The works presently available to researchers and clinicians prove the effectiveness of these interventions in the rehabilitation of TBI subjects (Holmes et al., 2020). It has been established that task-specific training and balance re-training help in the regain of motor function and reduction of disability levels (Wan et al. 2024). Gait re-education, strength training, and aerobic fitness training help respond to the specific patient's need for mobility, strength, and cardiovascular health (Quadrado et al. 2024).

The training methodologies that help address particular cognitive deficits contribute to the best rehabilitation results (Orgeta et al., 2020). Lending the upper extremity into dynamic sitting exercises may help eliminate exercise duplication, as well as increase one’s involvement in daily tasks (Seidi et al. 2020). Furthermore, patients and families are educated and get to know the injury and treatment procedures early enough, thus improving the support and outcome (McRae et al. 2020). The nurse had the lead responsibility as a nurse when caring for Patient X. Using teamwork and observation data, the nurse participated in creating a detailed care plan. A comprehensive evaluation was made where the nurse observed Patient X’s neurological signs, vital signs and seizures. These data were useful for the decisions of a multidisciplinary team when prescribing and administering medications, preventing seizures, and searching for rehabilitation interventions (Alrowiliy et al. 2024). Some of the interventions entailed the recommendation of changes in the medical administration schedule by consulting with the medical team, managing and preventing possible seizures, and counselling Patient X's family regarding the identification and management of seizures. The nurse also provided an interface with other caregivers, aimed at achieving a smooth handover and thus ensuring continuity of care (NMC, 2018). NMC Code of Conduct helped me to incorporate legal requirements like the Mental Capacity Act to improve Patient X's autonomy, dignity, as well as level of safety.

Continuing Care Needs and Multidisciplinary Team (MDT) Liaison

The patient developed a subdural hematoma and needed a surgical operation in the frontal lobe that worsened her neurological conditions. On admission, patient X presented memory impairment, impaired gait, bed-bound, minimal skilled movements, and rigidity in both upper and lower limbs, which led to episodes of seizures. Therefore, it was imperative to pay much attention to postoperative care and the creation of an adequate rehabilitation strategy. The care for patient X was informed by a multidisciplinary team and a team of nurses, including me, which enhanced the completion of the care. The team including nurses, neurologists and radiologists coordinated care by handling different domains of management for her: balance, superior exteroceptive orientation, agility, strength, flexibility, gait, and posture control training. The nurse measured patient X’s progress with the help of The Berg balance scale and Ranchos Los Amigos scale.

The mobilisation plan was developed by the MDT at admission to inpatient rehabilitation and revised in the fourth week. MDT, fostered by the organisation of patient care, played a part in enabling the improvements of patient X, who took inpatient reformation. Because of the transfer from inpatient to home-based rehabilitation, there needed to be an effective handover and liaison concerning the patients' care. As the nurse saw from the FIM scores for patient X data, the patient's FIM changed from 68 on admission to 106 at discharge, which reflects the good cooperation of the МDT. This unlinking shows how much healthcare personnel need to be in constant communication to meet patients' successive care needs. Thus, the main key to restoring the patient with a TBI is the constant work of a team of doctors, comprehensiveness of actions, and mutual understanding within the team. This case demonstrates the need for such a collaborative approach to manage the multiple chronic needs of TBI patients in clinical practice. The nurse also believes that the involvement of many individuals has affected the overall procedure of care, which has resulted in further PTS. One of the best neurologists was called during her rehabilitation to come up with an effective process of care for TBI and PTS.

Evaluation of Outcomes and Reflection

The neurologist collaborated with the nurses to provide the correct medical care for the subdural hematoma and surgery. The initial objective was to keep them safe and treat any presenting symptoms. Nurses were involved in assessing the areas of disintegration in patient X, including memory, balance, and voluntary motor tasks. These imbalance dyscontrol problems were then managed through an extensive individualised program of balance training, exteroceptive orientation re-training, agility, strength training, flexibility training, ambulation re-training, and posture stability training (McConnell, 2020). Neurologists and nurses' cooperation enabled patient X's Functional Independence Measure (FIM) to improve by 38 points before her discharge from the hospital. Such progress evidences the successful application of the varied multifaceted approach to the treatment of TBI patients (Karunarathna et al. 2024).

 In addition, the successful delivery of the rehabilitation program meant that patient X was to move to home-based rehabilitation, which would mean constant follow-up till they fully recovered. Therefore, such successful handling of patient X, in this case, is an indication that both neurologists and nurses need to work together in handling TBI patients. Using several instruments with the integration of the different treatment specialists allowed the team to establish an adequate treatment plan and follow the patient's functioning changes resulting in meaningful improvements. It was worthwhile to care for Patient X with post-traumatic seizures and traumatic brain injury. It enabled me to put into practice what was learned on the course, such as critical thinking, problem-solving and communication. In this context, the nurse realized some strength that helped me to deliver good quality care to the clients. Another self-expertise the nurse recognized in herself was communication and coordination with other members of the scrum team for a holistic approach. The nurse also proved good observing abilities that prevent delays in detecting the onset of seizures or other activities in the vicinity. Also, the nurse cared for patients and completed many errands, confirming that the change of shifts was smooth.

Finally, the nurse proactively learned how to be emotionally sensitive to the family of Patient X and how to console them emotionally. But, in turn, the nurse specified some of the opportunities for further development as well. First of all, the nurse used to be unsure of herself and found it difficult to evaluate severe neurological signs and manifestations. One of the tough things that the nurse discovered was the dilemma between patient self-determination and risks. Furthermore, the nurse became informed and confused by the amount of data and the numerous healthcare providers. However, it was not an easy endeavor and there are lessons that the nurse learned in the process. The nurse realized that knowledge can never be enough and that training as well as consulting experienced professionals is crucial. The nurse learned about the benefits of communicating with colleagues and other members of staff towards delivering the best quality healthcare to the patients. The nurse also began to understand what is certainly called Psychological Safety stress management and coping strategies in organizations. Moreover, the nurse was able to negotiate between patient self-determination and security by weighing the particular circumstances more thoroughly.

Conclusion

In conclusion, the successful enactment of the adopted treatment strategies for the management of a TBI patient like patient X validates the essence of multidisciplinary management and holistic rehabilitation strategies in tackling the emerging complications of TBI. Such indicators were assessed at a proper level by using tools like The Berg Balance Scale and the Ranchos Los Amigos Scale and, therefore, the further enhancements of aforementioned functional results like a patient's FIM score augmentation on its further stage. Thus, this essay underscores the possible and necessary positive change when patients with TBI get adequate treatment and support from the health care professional.