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Clinical Consultation: Nonpharmacologic Management of Agitated Behaviors After Traumatic Brain Injury (CE)
A.O. is a 23-year-old male who suffered a traumatic brain injury (TBI) and third-degree burns to his buttocks after a motor vehicle collision. After the first night on the rehabilitation unit, the nurses asked the medical team for medication to manage agitation because he was up all night, calling and trying to get out of bed. What interventions could rehabilitation nurses implement to decrease this patient’s agitation before turning to medication?
A recent study found that 70% of brain injury patients admitted for rehabilitation experienced some form of agitation (Beaulieu et al., 2008). Often rehabilitation professionals will use medications to manage agitated behaviors, especially in situations that place the survivor or staff at risk for injury. Medications do not address the underlying cause of the agitation and can negatively impact overall function and recovery (Hoffman, Cheng, Zafonte, & Kline, 2008).
Rehabilitation nurses play a key role in identifying triggers for agitation and ways to manage the environment to prevent unwanted behavior. The impaired cognition that results from TBI can make it difficult for the survivor to interpret his or her environment. Orientation of confused survivors can be performed through verbal and environmental cues such as calendars, clocks, and signs. A phone call to a family member may help the survivor if he or she is confused and untrusting. A consistent schedule and treatment team will help. If the agitation is related to boredom, keep the survivor involved in activities that are therapeutic. Therapeutic activities such as games, reading, movies, or supervised ambulation can be developed by the team and implemented by aides or volunteers. Staff should continuously assess whether the interventions implemented are age appropriate and effective. Interventions can become overstimulating, which can worsen agitation. The Agency for Healthcare Research and Quality guideline “Traumatic Brain Injury: Diagnosis, Acute Management and Rehabilitation” recommends behavioral management by a trained professional but does not specify interventions (Chestnut et al., 1999).
In survivors who are easily overwhelmed in stimulating situations, a quiet environment works well. Assessing whether the survivor will do best in a private room, needs a limit on the number of visitors, or needs a room away from hallway noise is important. Other calming interventions that have been studied to calm agitation include playing soft music or the use of gentle hand massage (Remington, 2002).
The incidence of sleep disturbances following TBI is as high as 70% (Makley et al., 2008). Poor sleep can result in problems with attention, concentration, new learning, and processing speed. Agitation can result from lack of sleep. Implementing interventions to improve sleep can reduce agitated behaviors. Turning off televisions and radios will provide a less stimulating environment. Shutting off lights or closing blinds will make the room dark and distinguish it as a time to rest. Avoiding caffeine or heavy meals before bedtime will prevent the survivor from having trouble falling asleep. Naps during the day and taking neurostimulating medication after ¨3 pm should be avoided.
Physical impairments following TBI can also cause agitation; the most common is pain, which is present in 1/3 to 1/2 of patients up to 5 years postinjury (Dobscha et al., 2009). Pain following TBI is multifactorial. Spasticity, heterotopic ossification, posttraumatic headaches, neuropathic pain, or pain from multiple fractures or injuries can all contribute to agitation. Applying heat or ice, massaging, or using nonnarcotic medication can help relieve pain and decrease agitation while avoiding interventions that may decrease cognition.
Incontinence following TBI has been documented at 60% (Masel & Dewitt, 2010). The inability to communicate the need to use the bathroom or the inability to accurately perceive the sensation of a full bladder or rectum can lead to agitation. A well-established program to anticipate the need for toileting can also decrease agitation.
A.O. was seen that morning and found to have had six loose stools overnight. When the patient was assessed by the advanced practice nurse, the perianal skin was found to be raw and painful to touch. Working with the nursing staff, a temporary rectal bag and topical ointments were implemented to protect his skin. The dietician changed the enteral feeding formula. Lactobacillus and a routine schedule of pain medication to anticipate his pain was added. The physical therapist was contacted and obtained a more appropriate wheelchair cushion. By addressing the pain issues, the survivor’s agitation diminished and he did not need any sedating medication. Rehabilitation nurses working with brain injury survivors can collaborate with the interdisciplinary treatment team to devise behavioral management interventions to manage and prevent agitation and avoid the use of medication that may impair cognition and recovery.
About the Author
Sylvia A. Duraski, MS APN-BC CRRN CBIST, is a nurse practitioner at the Brain Injury Medicine and Rehabilitation Program at the Rehabilitation Institute of Chicago in Chicago, IL. Address correspondence to her at email@example.com.
Beaulieu, C., Wertheimer, J. C., Pickett, L., Spierre, L., Schnorbus, T., Healy, W., et al. (2008). Behavior management on an acute brain injury unit: Evaluating the effectiveness of an interdisciplinary training program. Journal of Head Trauma Rehabilitation, 23(5), 304–311.
Chestnut, R. M., Carney, N., Maynard, H., Patterson, P., Mann, C., & Helfand, M. (1999). Rehabilitation for Traumatic Brain Injury (AHRQ Publication No. 99–E006). Rockville, MD: Agency for Healthcare Quality and Research.
Dobscha, S. K., Clark, M. E., Morasco, B. J., Freeman, M., Campbell, R., & Helfand, M. (2009). Systematic review of the literature on pain in patients with polytrauma including traumatic brain injury. Pain Medicine, 10(7), 1200–1217.
Hoffman, A. N., Cheng, J. P., Zafonte, R. D., & Kline, A. E. (2008). Administration of haloperidol and risperidone after neurobehavioral testing hinders the recovery of traumatic brain injury-induced deficits. Life Sciences, 83(17–18), 602–607.
Makley, M. J., English, J. B., Drubach, D. A., Kreutz, A. J., Celnik, P. A., & Tarwater, P. M. (2008). Prevalence of sleep disturbance in closed head injury patients in a rehabilitation unit. Neurorehabilitation and Neural Repair, 22(4), 341–347.
Masel, B. E., & Dewitt, D. S. (2010). Traumatic brain injury: A disease process, not an event. Journal of Neurotrauma, 27(8), 1529–1540.
Remington, R. (2002). Calming music and hand massage with agitated elderly. Nursing Research, 51(5), 317–323.
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