Severe brain injury rehabilitation. What's going to happen after critical care.

Treatment advances and technology will continue to decrease mortality in SBI in the future. A clearer line between lingering death and reasonable potential for recovery will only slowly reveal itself, and prediction will never be an exact science. Concerns about resource utilization and costs will continue to escalate. Critical care, acute care, and rehabilitation nurses will continue to live in this painful haze with the patients and their families. Nevertheless, critical care nurses can help by assisting families to understand the possible outcomes of SBI, the clinical state the patient is experiencing, how diagnosis and prognosis are related and how they are different, the indicators used to establish prognosis early on and then later in the course, and how prognosis is related to treatment decisions. Likewise, the critical care nurses can help the family begin to come to terms with the level of sophistication (or lack of precision, as the case may be) of prognostication, the agonizing time length factor involved, and the demanding prerequisites for level of consciousness assessment in the low functioning clinical states.

Pragmatics: right brain communication.

Neuroscience nurses as well as other health care providers are called upon to assess and implement intervention strategies to assist clients and family members and significant others to communicate in the presence of communication deficits. Language, high level language skills and speech are frequently addressed in presentations and in the literature but pragmatics which includes prosody, attitude, emotions and gestural behaviors is rarely addressed. Pragmatic competence mediated by the right hemisphere, is an equally important and essential component of human communication. An understanding of pragmatics permits the neuroscience nurse to identify and evaluate pragmatic deficits so interventions to facilitate communication can be undertaken. Specifically prosody, that is melody, pause, intonation, stresses and accents, affective tone, subtle grades of meaning and varied emphasis; its components; and aprosodia (lack of prosody) will be discussed. Kinesics, that is limb, body and facial movements, and referred to as pantomime and gestures, will be examined also as will facial expression. Suggestions for pragmatic assessment and therapeutic nursing interventions will be given.

A self-care assessment tool (SCAT) for persons with a spinal cord injury: an expanded abstract.

The purpose of this study was to develop a reliable and valid tool that assesses the cognitive and functional skills needed for self-care in persons with spinal cord injury (SCI). The Self-Care Assessment Tool (SCAT) assesses cognitive and functional skills in eight self-care areas: bathing/grooming, nutritional management, medications, mobility/transfers/safety, skin management, bladder management, bowel management and dressing. The tool was carefully developed and has demonstrated content validity. Using two samples of veterans seen in the SCI clinics of two Southern Veterans Affairs Medical Centers, n = 13 and n = 15, interrater reliabilities computed by Pearson product moment correlations for the cognitive, functional and total scores ranged from .69 to .94. Test-retest reliabilities using Pearson product moment correlations for the cognitive, functional and total scores of two groups (n = 14 and n = 15) ranged from -.06 to .86. Regarding predictive validity, R2 was found to be .61 to .90 for the cognitive, functional and total scores. Although continued reliability and validity studies are needed, the SCAT has potential to measure patient rehabilitation outcomes, to evaluate nursing care approaches and to serve as a quality assurance indicator for nursing care.

Self-care competence among persons with spinal cord injury.

The authors of this article report the results of a secondary data analysis which examined the self-care competence of persons with spinal cord injury (SCI) and the retention of cognitive and functional skills following discharge from acute rehabilitation as well as additional learning of self-care following discharge. The sample consisted of 48 persons with SCI from two Veterans Affairs Medical Centers and a state university affiliated rehabilitation program. The data collection tool was the Self-Care Assessment Tool (SCAT) which measures cognitive and functional skills in eight self-care areas: bathing/grooming, nutritional management, taking medications, mobility/transfer/safety, skin management, bladder management, bowel management, and dressing. The overall self-care competence of the participants was high (mean = 78.25) as was their competence in the eight self-care areas. In general, participants retained both the cognitive information and functional skills learned in the acute rehabilitation setting and also continued to learn after discharge in both cognitive information and functional skills.

The neurophysiological basis of learning, Part 2: Concept formation/abstraction, reasoning and executive functions--implications for SCI nurses.

Understanding the neurophysiological basis of learning enables nurses working with spinal cord injured persons to astutely assess potential for learning. This is particularly relevant when head injury or drug effects are influencing neurological systems relevant to learning. The neuroanatomical and neurophysiological bases of learning are related to attention, memory, concept formation/abstraction, reasoning, and executive systems. Concept formation/abstraction, reasoning and executive systems are discussed as they relate to learning in this article. This information is incorporated into expanded assessment. More in-depth nursing assessment related to cognitive systems necessary for learning enables nurses to identify intact and deficit cognitive systems and quantify deficits. Astute assessment is fundamental to planning effective teaching and learning strategies for spinal cord injured persons especially when learning deficits exist, e.g., in head injured persons who have sustained a spinal cord injury. Implications for client and family education derive from an understanding of the normal neurophysiological basis of learning and normal and abnormal assessment findings.

The neurophysiological basis of learning: attention and memory implications for SCI nurses.

Understanding the neurophysiological basis of learning enables nurses working with individuals with spinal cord injury to astutely assess potential for learning. This is particularly relevant when head injury or drug effects influence neurological systems relevant to learning. The neuroanatomical and neurophysiological bases of learning are related to attention, memory, concept formation/abstraction, reasoning, and executive systems. Attention and memory are discussed as they relate to learning in this article. This information is incorporated into an expanded assessment (Ciminaro, Calhoun, & Adams, 1977; Gazzaniga 1979; Lezak, 1983: Mesulam, 1985). More in-depth nursing assessment related to cognitive systems necessary for learning enables nurses to identify intact and impaired cognitive systems and to quantify deficits. Astute assessment is fundamental to planning effective teaching and learning strategies for spinal cord injured persons especially when learning deficits exist, e.g., in head injured persons who have sustained a spinal cord injury. Implications for client and family education derive from an understanding of the normal neurophysiological basis of learning and normal and abnormal assessment findings. Learning is dependent on several cognitive systems--attention systems, memory systems, concept formation/abstraction and reasoning systems, and the "executive" system. Attention and memory systems are discussed in this article, the remainder will be discussed in the next issue. The neuroanatomy and neurophysiology, clinical findings associated with normal and abnormal function, and nursing implications for the nurse working with individuals with spinal cord injury will be explored.

Self-care assessment tool for spinal cord injured persons.

The purpose of this study was to develop a reliable and valid tool that assesses the cognitive and functional skills needed for self-care in persons with spinal cord injury (SCI). The Self-Care Assessment Tool (SCAT) assesses cognitive and functional skills in eight self-care areas: bathing/grooming, nutritional management, taking medications, mobility/transfers/safety, skin management, bladder management, bowel management and dressing. The tool was carefully developed and has demonstrated content validity. Interrater reliabilities for the cognitive, functional and total scores ranged from .69 to .94 (n = 10). Test-retest reliabilities for the cognitive, functional and total scores ranged from -.06 to .86 (n = 14, 16). Regarding predictive validity, R2 ranged from .61 to .90 for the cognitive, functional and total scores (n = 18). Although continued reliability and validity studies are needed, the SCAT has potential to measure patient rehabilitation outcomes, to evaluate nursing care approaches and to serve as a quality assurance indicator for nursing care.

Managing communication disorders in stroke.

Dysphasias, dyspraxias, and dysarthrias are communication disorders that may be experienced following a stroke. Nursing assessment of language and speech is based on an understanding of normal language and speech systems. Location of the stroke and clinical assessment findings uncovered through the history and physical examination allow identification of language and speech deficits. Language is examined by assessing spontaneous speech, verbal comprehension, reading, writing, and ability to name and repeat. Speech is examined by testing motor function and reflexes of cranial nerves VII, IX, X, and XII. The identification of intact language and speech functions and language and speech deficits enables the nurse to plan and implement interventions based on the assessment findings in four areas--environmental manipulation, supportive behaviors, behaviors designed to enhance communication, and teaching of the person and family.

Cognitive systems: nursing assessment and management in the critical care environment.

In-depth knowledge of cognitive systems allows the critical care nurse to incorporate that information into an expanded assessment. This in-depth nursing assessment enables the nurse to identify intact and deficient cognitive systems and quantify the deficits. Astute assessment is fundamental to planning appropriate interventions and permits more specific deficit-related interventions by the critical care nurse.

Normal aging in the nervous system: implications for SCI nurses.

The normal microscopic and macroscopic changes that occur with aging and the neurophysiological effects of these neuroanatomical changes are described. Among the microscopic changes are dendritic and neuronal losses, thinning of axons and myelin sheaths; a decrease in the number of receptors and amount of neurotransmitter available together with the appearance of lipofuscin, granulovacuolar organelles, neurofibrillary tangles and senile plaques. Macroscopic changes include decreases in the weight and volume of the brain, thinning of the cortical mantle and white matter tracts, widening of sulci and fissures, and meningeal thickening. Neurophysiologically aging persons evidence decreased recent memory, a decreased ability to process information and an increased conduction time. These factors result in increased learning time, response time and, hence, recovery time. The major nursing implications of these neurophysiological changes for spinal cord injured persons relate to safety when mobilizing and engaging in self care and providing increased learning time.

More than they bargained for. Adverse drug effects.

All individuals interviewed wanted to pursue meaningful activities regardless of their age. Use of medication may facilitate positive adaptation to chronic illness by allowing the pursuit of meaningful activities. When side effects occurred, activities were altered by means of substitution, temporary discontinuance, or modified participation, but most individuals struggled to maintain participation to feel involved. An individual's ability to cope may be interrupted due to adverse effects of medication. Also, hospitalization caused by adverse side effects disrupted meaningful activities and created a need to readapt to an illness. Medication for chronic illness increased the person's ability to seek and use social support. The physical limitations of illness were the cause of loneliness and isolation.

Socialization of R.N. to B.S.N.

The Nurse's Professional Orientation Scale and Schwirian's Six-Dimension Scale of Nursing Performance (Six-D Scale) were used in a five-year, longitudinal study of the professional socialization of the Registered Nurse/Bachelor of Nursing Science (RN/BSN) (n = 30) and generic baccalaureate students (n = 193) in a nursing program in the Southeast United States. Program exit socialization scores between RN/BSN and generic graduates were not significantly different. Using an ANCOVA, significantly higher socialization scores were found for the generic graduates. The scores for the RN/BSN graduates were significantly higher than the generic students at graduation on the teaching/collaboration, planning/evaluation and interpersonal communication subscales of the Six-D scale. When program entry Six-D subscales score were controlled, only the professional development subscale differentiated between RN/BSN and generic graduates. The program impact on the RN/BSN student/graduate as well as the means by which this process can be studied are questioned.

Syncope: neuroscience nursing assessment based on an understanding of underlying pathophysiological mechanisms.

To assist neuroscience nurses in their assessment of the client experiencing syncope, the authors propose use of models derived from the three underlying pathophysiological mechanisms of syncope to guide data collection and documentation. This approach is also useful in educating the client and family, as well as nurses and students about the phenomenon of syncope.

Memory impairments: forgetfulness versus amnesia.

Two varieties of memory disorders can be distinguished--those characterized by the phenomenon of forgetfulness and those characterized by the presence of an amnesic state. Although these two conditions may appear similar, they have different anatomical correlates and functional significance. States of forgetfulness and amnesia arise from different etiologies, have different prognoses and require different therapeutic regimes. The purpose of this article is to distinguish these two varieties of memory disorders and contrast them as to anatomical features, functional differences, etiologies, prognoses and therapeutic management regimes. This should assist the neuroscience nurse to better understand relevant nursing assessment features and plan appropriate therapeutic nursing interventions for the client. Teaching protocols for families and significant others as well as clients with memory impairments should also be enhanced.

The neuroanatomical and neurophysiological basis of learning.

The physiological basis of learning is memory. The established facts about memory, the memory systems, and learning are presented along with relevant theories currently proposed. Additionally, current physiological theory about cognition is examined. Specifically, the functions of the memory systems in cognition and the function of the frontal lobes in goal orientation and elaboration of thought are addressed. Implications for neuroscience nursing practice are drawn.