The plan of care with disorders of consciousness
The disorders of consciousness program provides specific types of care and monitoring of persons who are in low level states of consciousness resulting from brain injury.
The program aims to help the person achieve an optimal physical state and to monitor and evaluate their progress during this period of time. This allows for better decision-making regarding future treatments and program placement.
Areas of care
Medical stabilization and health needs
The goal of medical stabilization is to resolve any medical problems that the person may have. Common problems often include previous infections, an open airway or presence of a tracheostomy tube, seizures, skin sores, and/or broken bones. If needed, the doctor will prescribe medicines to help fight infections as well as control seizures.
Breathing support
The doctor will also pay special attention to the person’s breathing status. If a person has a tracheostomy tube in their throat or is using oxygen, attempts will be made to eventually discontinue them if possible.
Skin care
If a skin sore is present, a nurse specially educated in skin and wound care will be consulted to treat the sore and help it to heal. Proper skin care will be provided by scheduled turning of the person in bed as well as performing weight shifts in a wheelchair.
If a person has skin sores, special wound care, positioning techniques and/or mattresses will be used to aid in the healing process. Nursing and/or therapy staff will check the person’s skin several times throughout the day.
Special mattresses or padding and positioning techniques will be used to prevent any further sores as well as help maintain proper body alignment and general comfort.
Bowel and bladder management
Problems controlling the bowel and bladder are also common after a brain injury. The person may have bowel or bladder accidents since they are not alert enough to know when to go to the bathroom. Part of the therapy will be to make a plan to establish a bowel and bladder program.
Certain medicines may be ordered to help the person have a bowel movement. Catheters may also be used to help empty the bladder if necessary.
Improving alertness
There are certain medications that may also be given to try to improve levels of alertness. If the doctor thinks a person could benefit from these medicines, they will discuss them with you. Ask your doctor if you have any questions about the medicine your loved one is taking.
Nutrition
Determining an optimal nutritional plan is very important in the recovery process. Sometimes feeding through a tube in the stomach (a PEG tube, G-tube, or J- tube) is done until the person is alert enough to safely swallow food. This doesn’t mean that the person cannot swallow, but it does mean that they may not be able to swallow safely.
Swallowing
Swallowing can happen automatically and the person may not be able to really control the food and fluids safely. A person may be swallowing and attempting to eat or drink but not be able to follow other types of commands. The speech therapist checks the person’s ability to swallow and will determine when it is safe to introduce food and fluids.
When it is safe to introduce food, different diet textures may be used such as thickened liquids to promote safe swallowing. This is important because in the early stages of recovery a person may choke on foods or swallow them into the lungs, called aspiration, instead of the stomach.
If aspiration occurs, pneumonia may result. The speech therapist and dietician work together to make the best plan to help the person maintain adequate weight and have proper nutrition. Certain blood tests may be ordered to further monitor the person’s nutritional status.
Positioning and preventative care
In addition to proper positioning, the therapy staff may apply casts or splints to the person’s arms and/or legs. Sometimes casts are needed to heal a broken bone. These types of casts are put on by an orthopedic doctor. The therapists will use casting and splints as a way to maintain proper position of joints and to decrease increased tone.
Improving range of motion
They can also be used to improve limited range of motion caused by muscle shortening and tight muscles. When the casting process is finished, bivalve splints or positioning splints may be used to keep the position made by the original casting. If no casting is needed, splints may be made to prevent muscle tightness from occurring.
Range of motion exercises
Other positioning issues will also be addressed. The therapy staff will perform range of motion exercises to the limbs. This involves moving the limbs and stretching them to help them remain flexible and promote circulation.
Optimal body positioning
The person will also start getting out of bed with help when they are medically stable. The staff will establish a schedule and decide how long the person can comfortably tolerate being up in a chair and/or out of the room. A careful balance between rest and passive exercise will be prescribed. The therapy staff will also determine the most optimal body positions for the person during times of rest and when out of bed.
Cognition and communication
Cognition and communication are also important areas that will be reviewed. Because the person is in a lower state of consciousness and cannot communicate, it is important to check daily for any improvements in the level of alertness. Staff will ask the person to follow commands to open their eyes or to squeeze your hand. Staff will also look at whether or not the person tries to follow movement with their eyes.