Discharge

Issues surrounding the discharge of the brain-injured person from an acute care hospital. Rehabilitation

Rehabilitation is a comprehensive program designed to reduce and/or overcome the deficits a patient may have following an injury. The goal is to return the patient to the highest level of mental and physical functioning possible.

The rehabilitation process begins while the patient is still in a coma.

This early intervention increases the possibility of maximum recovery--- medically, physically, cognitively and psychologically.

For example: The physical therapist will work with the comatose patient helping to preserve muscle tone and mobility. The speech therapist will work on the swallow function, which may be impaired. Rehabilitation nurses will test for response from the patient.

The respiratory therapist also plays an important part in the early stages of rehabilitation.

There are a number of different ways that the respiratory therapist is involved in the rehabilitation of the brain injured patient. More often then not the brain injured patient will have been maintained on life support for a good deal of time and this causes some other difficulties that must be managed after the patient is weaned from the mechanical ventilator:

1) Training must be provided to the patient/family in maintaining the patient's tracheostomy tube (which most severely brain injured patient's acquire due to the length of time that he/she is on mechanical ventilation) including learning how to suction the patient and changing the dressing and cleaning the tube.

2) The respiratory therapist will often provide pulmonary hygiene to keep the patient free from pulmonary problems such as pneumonia or atelectasis (collapse of the alveoli - air sacs - in the lungs). Because the patient is often less active these pulmonary complications often appear in the brain injured patient and the respiratory therapist assists by providing breathing treatments (aerosolized medication), bronchopulmonary hygiene (clapping or tapping on the back to promote the movement of secretions in the lungs) and suctioning of the patient.

3) Assistance in swallowing retraining.

4) Diaphragmatic retraining. If the diaphragm (the major muscle involved in breathing) is paralyzed or weakened the respiratory therapist can instruct the patient on exercises to improve the function of the muscle.

These are some of the areas in which the respiratory therapist assists in returning the TBI patient to his/her previous ADL's (activities of daily living).

As the patient begins to emerge from the coma, rehabilitation will begin to involve the patient's cooperation.

Before he/she is "conscious", he/she may be encouraged to sit, or move in the bed. As the patient progresses, so will the rehabilitation.

Rehabilitation should not be confused with recovery.

The deficits that occur with brain injury are typically permanent. However, through rehabilitation, improvement is possible.

The rehabilitation process may last several years.

Occasionally the patient will reach a "plateau" or "leveling off" in improvement. It is important to continue rehabilitation as the plateau may be only a temporary slowdown. It was once believed that the "recovery" process was generally completed during the first twelve months, with very little improvement occurring after twelve months. It is now believed that brain injured individuals may improve over a period of several years.

There are several different types of rehabilitation programs and options.

The physiatrist will develop a program specifically suited to the individual. This program usually involves a team approach; utilizing medical personnel in several different fields to address the deficits the patient may have.

The goal of rehabilitation is to return the brain injured individual to a functional level as close to his/her pre-accident self as possible.