ACUTE AND INTERMEDIATE PHASE NURSING IN TBI: SENSORY-PERCEPTUAL, COMMUNICATION, AND COGNITION DEFICITS

Sensory-Perceptual Deficits

  1. Problems/Causes include deficits as a result of the injury in vision, communication, and/or perception of self, body image, illness, spatial relationships, agnosia, and apraxia

  2. Nursing Diagnoses include:
    • Perception of illness deficits, such as denial of hemiplegia or other motor or sensory deficits and anosognosia, the inability to recognize the denial or unawareness of a deficit
    • Body image disturbance, the patient's concept of the sum of his/her body parts in relationship to the whole, including unilateral neglect, the ignoring of the hemiplegic side
    • Sensory/perceptual alterations, such as:
      • Hemianopia (loss of vision in half of the visual field) and defects in localizing objects in space, estimating size, judging distances, remembering arrangement of objects, finding one's way to or back from places, telling time, and right-hand discrimination
      • Agnosia, the inability to recognize familiar objects with the senses
    • Self-care deficit, such as apraxia, the inability to carry out a learned, voluntary act in the absence of paralysis

  3. Assessments include:
    • Fails to use, shows a lack of concern for, lacks awareness of or denies the part of the body involved in hemiplegia or other motor or sensory deficits
    • Draws an object and omits the side of the object that corresponds to the affected side of the body
    • Has difficulty walking through a doorway, exhibits impaired recall of objects in a familiar environment, has difficulty reading and computation, and is unable to identify left or right
    • Unable to identify common objects by sight or with the eyes closed or to respond appropriately to common sounds
    • Exhibits clumsiness or an inability to carry out ADLs correctly or to complete a task involving a sequence of components

  4. Nursing Interventions include:
    • Accepting the patient's perception of, stimulating the affected side or body part, teaching the patient to position and care for the affected side or body part, and positioning the affected side or part in the patient's visual field
    • Encouraging the patient to handle and use the affected side or body part and teaching visual scanning and other compensatory measures
    • Providing verbal cues and instructions to the affected side or body part
    • Having the patient use other, intact senses to identify stimuli or objects, teaching relearning via the drill method, protecting the patient from injury, and interpreting the patient's behavior for the family
    • Encouraging participation in ADLs, correcting mistakes or misuse of equipment, and reteaching forgotten skills

Communication Deficits

  1. Problems and Nursing Diagnoses - Aphasia in 1 of 3 forms:
    • Nonfluent aphasia, the inability to express thoughts verbally or in writing, can vary from mild to severe
    • Fluent aphasia, the ability to hear, but not fully comprehend speech, resulting in speech by the patient that contains many errors and may be lengthy
    • Global aphasia, a combination of expressive and receptive aphasia in which little of the communication system is left intact

  2. Assessments
    • Needs to search for words, chooses incorrect words
    • Can communicate only by pointing, pantomime, etc.

  3. Nursing Interventions include:
    • Stimulating conversation, giving patient time to search for words, disregarding incorrect words, and generally supporting the patient's efforts to speak
    • Accepting alternate forms of communication and showing the patient pictures to permit communication
    • Standing close so patient is aware of lip movements
    • Speaking slowly and distinctly in a normal speaking voice, using vocabulary or gestures the patient can understand
    • Anticipating the patient's needs

Cognitive Deficits

  1. Problems/Nursing Diagnoses include:
    • Shortened attention span and concentration, due to diminished alertness, effort, and selection of stimuli received
    • Impaired judgment, due to decreased comprehension and an inability to determine the consequences of actions
    • Impaired memory, both verbal and visual memory
    • Initiation and sequencing problems

  2. Assessments
    • Inability to focus long enough to permit understanding and appropriate response, and easily distracted by external environmental factors
    • Inability to take action in a safe and appropriate manner
    • Inability to retain information for 1 minute - 1 hour (short-term memory) or for 1 hour or longer (long-term memory)
    • Inability to start a task and complete it from start to finish

  3. Nursing Interventions
    • Attention: Reduce/minimize distractions, simply tasks and procedures, allow ample time for task completion, refocus attention as needed, avoid fatigue, provide frequent verbal, visual, or tactile cues, and encourage simple leisure activities
    • Judgment: Allow patient to make simple decisions, involve patient in other decision making processes, and provide patient choices, ample time, and frequent feedback
    • Memory: Encourage use of memory aids, provide clocks, calendars, radios and TVs, structure daily exercises, post schedule/routine in a highly visible place, and repeat and record new information as needed for later review
    • Initiate/sequence: Post daily schedule in a highly visible place, break tasks into smaller steps, provide cues for each step, allow patient to complete each step, and provide supervision and support

Based on information in Hickey JV. The Clinical Practice of Neurological and Neurosurgical Nursing, 4th ed., Philadelphia: Lippincott, 1997 and in Chin PA, et al. Rehabilitation Nursing Practice, N.Y.: McGraw-Hill, 1998, except for information where other papers are cited.