Nursing Care of the Brain Injury Patient on a Locked Neurobehavioral Unit

Abstract

Abstract

Behavioral problems after a brain injury can be extremely challenging for those working with brain injured people. Nursing staff must be familiar with commonly used post brain injury medications and their effects, behavioral management plans, appropriate use of restrictive devices, and verbal or physical crisis intervention techniques when necessary. Rehabilitation nurses caring for brain injured patients on a locked neurobehavioral unit must maintain continual training and specific competence in this environment to ensure patient and staff safety.

“Rehabilitation nursing is a philosophy of care, not a work setting or phase of treatment” (Association of Rehabilitation Nurses, 2011, para. 3). Rehabilitation nurses who work with brain injured patients face special challenges that require continuing education and training. Brain injury rehabilitation nursing units are specialized areas that may contain locked, low-stimulation neurobehavioral units (NBU) keeping the special physical, cognitive, behavioral, and emotional needs of this population in mind. Treatment plans and length of stay are as individual as the patient admitted to the unit. Rehabilitation staff must continually address patient care plans for achievement of greatest outcome potential.

Brain Injury

Brain injury is one of the most common causes of death and disability in adults aged 45 or younger (Rangel-Castilla et al., 2011). The two different types of brain injury are traumatic and acquired. Traumatic brain injury (TBI) is trauma to the brain caused by external physical force. The force may penetrate the skull or be concussive and cause the brain to shake within the skull resulting in shearing or tearing of the brain. Traumatic injuries occur from motor vehicle collisions, bicycle/motorcycle collisions, gunshot wounds, assaults, and falls. Each year an estimated 1.7 million Americans sustain a traumatic brain injury (Centers for Disease Control & Prevention, 2011).

Acquired brain injury is damage to the brain caused by conditions other than degeneration, hereditary, congenital defect, or external force. Causes of acquired brain injury include hemorrhagic or ischemic stroke, anoxia or hypoxia, tumors, toxins, and various diseases. Every 45 seconds someone in the United States has a stroke, the incidence of brain tumors is 14 per 100,000 people, and up to 1 in 15 people will develop a brain aneurysm (Fisher, 2008). Every injury has different effects and consequences. Changes after a brain injury depend on which areas of the brain are affected and the severity of the injury. These changes include:

• Physical consequences, such as sensory changes, seizures, sleep disturbance, swallowing or appetite changes, weakness or paralysis, balance/coordination difficulties.
• Communication consequences, such as difficulty with speech, word finding, and comprehension issues.
• Cognitive consequences, such as deficits with thinking/learning process, poor judgment, easily distracted, amnesia, and disorientation/confusion.
• Emotional/behavioral consequences, such as anxiety, depression, agitation, overreactive behaviors, disinhibition, impulsivity, and mood swings (National Institute on Disability & Rehabilitation Research, 2010).

Rehabilitation

After the brain injured patient is medically stable, he or she is often transferred to an inpatient rehabilitation unit for comprehensive multidisciplinary brain injury rehabilitation. Patients receive intensive therapy from a team of physiatrists, therapists (physical, occupational, and speech), nurses, social workers, and neuropsychologists. Patients and their caregivers may need to learn or relearn activities of daily living to meet the ultimate goal of discharge to the community.

Specialized brain injury rehabilitation units make a difference in the lives of hundreds of brain injured individuals every year. Only 16 hospitals in the United States possess a Department of Education designation as TBI Model System facilities. TBI Model System facilities promote national research and evidence-based care for brain injured individuals (National Institute on Disability & Rehabilitation Research, 2010). Very few of these designated facilities incorporate an unique locked neurobehavioral unit (NBU) that provides a safe, low-stimulation environment for brain injury patients. NBU patient admission criteria include severe confusion/disorientation, ambulatory/wandering, severe anxiety/agitation, and inappropriate or combative behavior.

Rehabilitation nurses help brain injury patients and their families adapt soon after their disabling injury. The nurses employ a holistic rehabilitative and restorative practice approach by managing medical issues, working with other members of the rehabilitation team, setting collaborative discharge goals, and educating patient, family, and caregivers. The brain injury rehabilitation staff members who work in the locked NBU are trained to interact and provide care for this special population in this unique environment.

Patient Management

Managing physical and behavioral issues of brain injury patients in acute inpatient rehabilitation are a challenge to rehabilitation staff members, particularly the rehabilitation nurses who provide patient care around the clock. Brain injury patients in acute rehabilitation have increased cognitive arousal and are beginning to participate in the physical therapy program. As a result of cognitive impairment, there is a careful balance between increased mobility and safety of the patient that needs to be achieved under the watchful eye of staff (Trudel, Scherer, & Elias, 2011). Caregivers of brain injured patients must be knowledgeable of medications and their use, how to construct behavioral plans, and how to maintain a safe, therapeutic patient environment.

Medication Management

Continued medication education and competence among unit nursing staff is imperative in rehabilitation. Patients in the acute rehabilitation setting are often still recovering from traumatic injuries, or may have any number of comorbidities. Staff needs to be aware of potential interactions and adverse effects of medications. Brain injury patients are frequently treated with neurostimulants, sedatives, antidepressants, anticonvulsants, serotonin inhibitors, beta-blockers, antipsychotics, and dopamine agonists (Chew & Zafonte, 2009). Many patients also have preexisting medical conditions that require them to take additional daily medications, such as antihypertensive or diabetic medications.

Medications are frequently used to manage behavior of brain injured individuals and the effects of medications on each patient may vary. Medications are carefully monitored and adjusted for full therapeutic effect. Alternative behavioral modification interventions are used in conjunction with medications for optimizing patient interactions. Nursing staff need to communicate with the physiatrist so that medication interactions are minimized, optimal behavior is achieved, and sleep cycle is established without compromising participation in the rehabilitation program (Beaulieu et al., 2008).

Environment

Brain injured individuals with cognitive impairment require 24-hour supervision to maintain safety. The NBU has staffing ratios to meet the supervision needs of the patient. Ambulatory patients are encouraged to walk the unit. The locked environment in the NBU allows the patient to ambulate without increased elopement issues that occur on standard units, thus in some cases decreasing or eliminating the need for patient care sitters and/or restrictive devices. Each patient is carefully evaluated and in some cases sitters or restrictive devices cannot be avoided because brain injury patients are at increased risk for falls, elopement, wandering, and decreased safety awareness.

According to Nott, Chapparo, Heard and Baguley (2010), brain injury patients are often more agitated in the afternoons when structured activities are less, cognitive fatigue exists, and increased stimuli are present during hours of visitation. An environment with decreased stimulation promotes adequate activity and rest periods. Patients may receive therapy in their rooms or within the NBU corridor versus going to the inpatient gym to decrease stimulation and fatigue. Patients also have rest breaks between therapies and may have limited light or television in their rooms to promote rest. Visiting hours in the NBU are limited, the number of visitors allowed on the unit at one time is limited, and the age of the visitor is limited. This is in an effort not to over stimulate patients and cause agitation issues.

Behavioral Plans

Behavior change is a common issue among many of the brain injury patients admitted to the rehabilitation unit and the NBU. The most common issues are mood swings, impulsivity, poor temper control, agitation, and impaired decision-making. Mood swings and confusion may hamper patients' judgment or realization of their need for rehabilitative therapies and they may refuse or become frustrated with treatments sessions. Impaired decision-making and impulsivity may compromise the safety of a brain injury patient who is confused and wants to go home. The patients may attempt to ambulate off the nursing unit and not know where they are or where they are going (Wood & Alderman, 2011).

Patient agitation is disruptive to the therapeutic environment and may place patients and staff members at increased risk of injury. Patient agitation levels are evaluated on admission and throughout the stay to help explore causes of agitation, and develop interventions to decrease adverse behaviors. Members of the interdisciplinary rehabilitation team develop individualized behavioral plans to set limits, establish goals, reinforce positive patient behavior, and help the patient reach his or her rehabilitative goals (Parker-Singler, 2011).

Behavioral plans include formal set of desired individual patient behaviors, such as refraining from inappropriate conduct or adequate participation in rehabilitative therapy activities. The plan may also include procedures to be followed in patient care for a consistent approach by staff. Behavioral plans contain interventions to decrease triggers for adverse patient behavior, methods of reward and punishment, and evaluation of the effectiveness of the interventions so they may be replicated or changed if necessary. Implementing behavior plans helps teach the patient appropriate social behavior to transition him or her back into the community (Wood & Alderman, 2011).

Restrictive Devices

A number of restrictive devices exist, including wrist or ankle restraints, belts or straps, mitts, vests, and enclosed beds. If a patient poses a significant danger to himself or others, restrictive devices may be used as a last resort. The least restrictive device is used at all times because restrictive devices frequently worsen agitation in brain injured patients and every restrictive device carries the risk of patient injury (Novack, 2011).

Every attempt is made to discontinue invasive lines when patients admit to rehabilitation. If the line must be maintained, the staff first attempts to hide the necessary line under clothing, bed linen, or by wrapping with gauze dressings. When this is not possible or successful, the least restrictive device may be used to eliminate patient interference with treatment, such as pulling out tracheotomy tubes, feeding tubes, or intravenous lines. Staff assesses and communicates the appropriateness/effectiveness of the restrictive device every day with the interdisciplinary care team. The team works toward discontinuation of the device as soon as possible to eliminate increased agitation or potential injury related to the device (Beaulieu et al., 2008).

A common intervention seen on the NBU is the use of enclosed bed. Enclosed beds allow for unlimited patient movement and access to nurse call systems in the bed. Enclosed beds are sometimes viewed by the brain injury patient as a safe environment with limited extraneous stimulation. However, in some patients the bed may be a source of increased agitation. Continual patient assessment is imperative to determine the most effective intervention for agitated or restless behavior (Novack, 2011). Low beds are another type of bed that are commonly used in the NBU. The low beds are six inches from the floor, contain rails with padding, and a bed alarm.

When a patient is cleared as safe to ambulate, he or she is allowed to ambulate freely on the NBU. If a patient lacks physical ability to ambulate independently safely and is at risk for falling and sustaining further injury, safety alternatives are implemented. Safety alternatives may include seat belts, chair and bed alarms, padded floor mats, and placing seated patients in a common area that is in view of the nurses’ station.

Non-Violent Crisis Intervention

The interdisciplinary brain injury rehabilitation staff should be trained and certified in a program containing non-violent crisis intervention (NVCI) techniques. NVCI encompasses verbal and physical crisis intervention techniques taught to the interdisciplinary brain injury staff by certified Crisis Prevention Institute instructors. When patients display escalating aggressive verbal or physical behavior, staff intervenes with NVCI techniques to de-escalate the situation and prevent potential risk of harm to patient or others while balancing care needs (Crisis Prevention Institute, 2011). Staff members working in the NBU are certified in NVCI and participate in monthly mock behavioral escalation drills to maintain skills.

When there is a patient behavioral crisis emergency the incident is overhead paged as a Code Gray for emergency team response. Emergency team responders are NVCI certified staff members. The staff carefully and safely de-escalates the situation with appropriate therapeutic NVCI techniques, establishes or reviews the patients’ behavioral management plan, and review any precipitating factors that caused the behavior so it may be prevented in the future. Behavioral management and NVCI techniques should prevent escalation of aggressive behaviors to a level that would require using a restraining device or a pharmaceutical agent (Beaulieu et al., 2008).

Staff Attitudes

Brain injury nurses must anticipate, de-escalate, and cope effectively with aggression while minimizing outbursts. Nurses working in the NBU are as unique as the population they care for. Staff must demonstrate calm supportive characteristics and understand the importance of controlling their own behavior and not take the acting-out behavior of patients personally. Specialized staff training in NVCI, teach staff how to employ techniques, such as active listening, verbal and paraverbal techniques, therapeutic rapport, and personal safety techniques (Crisis Prevention Institute, 2011).

Nurses working in this environment are a team who are focused on patient needs and not tasks. NBU staff must not be fearful, remain calm, and not overreact to behavioral crisis situations. Staff must possess certain personality traits and interpersonal skills, such as situational adaptability, genuineness, nonjudgmental and empathic response to appropriately manage and prevent aggression and violence (Pryor, 2007).

Conclusion

Rehabilitation nurses who work in the NBU are knowledgeable of the special needs of the brain injury population. This unique knowledge decreases the fear and anxiety the nurse experiences when caring for aggressive brain injured individuals. Staff may not be able to control patient behaviors, but can control his or her own response to the behaviors that result. The low stimulation NBU environment maximizes safety and close staff observation. Professional attitude and appropriate therapeutic response from staff maximizes patient potential and results in optimal rehabilitative outcomes.

Key Practice Points

• “Brain injury is one of the most common causes of death and disability in adults age 45 or younger and specialized brain injury rehabilitation units make a difference in the lives of hundreds of these brain injured individuals every year.”
• “Brain injury rehabilitation nursing units are specialized areas that may contain locked, low-stimulation neurobehavioral units (NBU) keep the special physical, cognitive, behavioral, and emotional needs of this population in mind.”
• “Rehabilitation nurses who work with brain injured patients face special challenges that require continuing education and training to maintain the balance between increased mobility and safety of the brain injury patient in a rehabilitative setting.”
• “Caregivers of brain injured patients must be knowledgeable of medications and their use, how to construct behavioral plans, and how to maintain a safe, therapeutic patient environment.”

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Biography

• Christine Becker, BSN MBA RN, is a Clinical Nurse Specialist in Carolinas HealthCare System, Charlotte, NC, and Nursing Doctoral Learner with the University of Phoenix. Address correspondence to [e-mail].