Neurorehabilitation

Neurorehabilitation is a person-centered program designed to help individuals recover from injuries or diseases of the nervous system brain, spinal cord, or peripheral nerves. It combines medical management with specialized therapies to restore function, reduce disability, and enhance quality of life

Core Goals of Neurorehabilitation

• Restore motor skills, coordination, balance, and mobility
• Improve cognitive abilities (memory, attention, problem-solving)
• Re-establish communication and safe swallowing function
• Support emotional well-being and adaptive coping strategies
• Maximize independence in activities of daily living and community reintegration

Multidisciplinary Team

1) Stroke Rehabilitation

An injury to the nervous system can occur at any age. The injury can happen at birth, following an acute illness, or from a traumatic or an ischemic event.

Stroke occurs when there is ischemia to a part of the brain or hemorrhage into the brain that results in death of brain cells.

Although stroke is considered as the leading cause of long-term disability, an estimated 1 in 10 stroke victims recovers completely. Nearly half may experience moderate to severe impairments that could require special care.

Definition

Rehabilitation is the process of maximizing the patient’s capabilities and resources to promote optimal functioning related to physical, mental, and social well-being.

Goals

• To lessen physical and cognitive impairments.
• To increase functional independence.
• To lessen the burden of care provided by significant others.
• To reintegrate the patient into family and community.
• To restore the patient’s health related to quality of life.
• To prevent complications.
• To achieve maximal self-sufficiency.
• To modify social and vocational environment.

Principles

• Stroke rehabilitation is patient- or patient-centered and should meet the diverse and changing needs of stroke survivors.
• Stroke survivor’s rehabilitation potential should be assessed by experts and should get timely and appropriate access to expertise care.
• Stroke rehabilitation is a specialized area. Expertise, competency, and continuing education should be used.
• This should include high-quality, accurate, and timely information, and information management into decision making.
• Stroke rehabilitation should be research and evidence based.
• This requires new and innovative ways of delivering services based on existing resources.

Indications

Patients with the following conditions:

• Hemiplegia resulting in spasticity and aphasias.
• Neurological fatigue syndrome.
• Lacunar stroke.
• Pure sensory stroke.

Assessment

A baseline comprehensive assessment is performed on admission.
Assess the following:

• Rehabilitation potential of the patient.
• Physical status of all body systems.
• Presence of complications caused by stroke or other chronic conditions.
• Cognitive status of the individual.
• Family resources and support.
• Expectations of the patient and family regarding rehabilitation.

Various tools can be used as follows:

• Functional Independence Measure (FIM) scale
• It is used to examine the degree of dependence in performing 23 items in various activities such as mobility, locomotion, and communication.
• The items include 13 motor and 5 cognitive measures.
• A 7-point scale is used to estimate the severity of disability and need for assistance.
• An FIM score of 18 points represents the need for total assistance compared with 126 points representing complete independence.
• Barthel Index.
• To evaluate the level of independence in ADLs.
• The National Institutes of Health Stroke Scales (NIHSS).
• The NIHSS is a 15-item neurological examination stroke scale used to evaluate the impact of acute cerebral infarction on the levels of consciousness, language neglect, visual field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss.
• A trained observer rates the patient’s ability to answer questions and perform activities.
• Ratings for each item are scored with 3-5 grades with 0 as normal.

Interventions

• Balance training
• Begin with the patient sitting up in bed or dangling the lower extremities over the edge of the bed.
• Evaluate tolerance by observing for dizziness or syncope due to vasomotor instability.
• Then transfer from bed to chair or wheelchair; place the chair beside the bed to help the patient to lead stronger arm and leg.
• Supervise the transfer or provide minimal assistance by guiding the patient’s strong hand to wheelchair arm; stand in front of the patient blocking his/her knees with the nurses to prevent buckling.
• Bobath method can be used to help to gain control over spasticity by inhibiting abnormal reflex patterns. for example, transfer using weak or paralyzed side and stronger side to facilitate more bilateral function.
• Constraint-induced movement therapy (CIMT): Patient is encouraged to use weakened extremity by restricting movement of normal extremity.
• Supportive or assistive equipment may be used.
• Incorporate physical therapy activities into daily routine for practice and enhanced result.

Nutritional Therapy

• Assist in determining the appropriate daily caloric intake based on weight and activity level.
• Assess the ability to swallow with dietician; plan the diet type, texture, caloric count, and fluids to meet the nutritional needs.
• Evaluate the ability for self-feeding and recommend assistive devices to allow independent eating.

Interventions

• Encourage to use unaffected upper extremity to eat.
• Employ assistive devices such as rocker knives, plate guards, and nonslip pads for dishes.
• Remove unnecessary items from tray or table to reduce spills.
• Provide a nondistracting environment to decrease sensory overload.

Evaluate in terms of maintenance of weight, adequate hydration, and patient satisfaction.

Bowel Function

• This is implemented for problems with bowel control, constipation, or incontinence.

Interventions

• Recommend a high-fiber diet and adequate fluid intake.
• Encourage the following:
• Fluids: 2500-3000 mL daily, unless contraindicated.
• Prune juice daily (120 mL).
• Cooked fruits three times a day.
• Cooked vegetables three times a day.
• Whole grain cereal or bread three to five times a day.
• For incontinence:
• Place the patient on bedpan or bedside commode or take the patient to bathroom daily at a regular time to re-establish bowel regularity.
• Regular practice of using bedpan or bedside commode 30 minutes after breakfast should be initiated because eating stimulates gastrocolic reflex and peristalsis.
• Adjust time according to individual bowel habits.
• Sitting on commode or toilet promotes elimination through both gravity and increased abdominal pressure.
• Administer stool softeners or suppositories as ordered to stimulate anorectal reflex.
• Use bisacodyl suppository when other measures are ineffective.

Bladder Function

• Often the patient may have functional incontinence which is associated with communication difficulties, mobility problems, and dressing and undressing difficulties.

Interventions

• Assess bladder distension by palpation.
• Offer bedpan/urinal/commode every 2 hours during daytime and every 3-4 hours during nighttime.
• Focus the patient on the need to urinate voluntarily or when instructed.
• Assist with clothing and mobility.
• Schedule majority of fluid intake between 7 am and 7 pm.
• Encourage usual position for urinating.
• Other short-term interventions include:
• Indwelling catheters.
• Intermittent catheterization.

Sensory-Perceptual Function

For patients with stroke on right side of brain:

• Directions for activities are best given verbally for comprehension.
• Break down the task into simple steps for easy understanding.
• Remove clutters and obstacles; use good lighting.
• Assist or remind to dress the weak or paralyzed side first for patients with unilateral neglect.

For patients with stroke on left side of brain:

• Use nonverbal cues and instructions for better comprehension.

Affect

• Distract the patient who suddenly becomes emotional.
• Explain to the patient and family regarding the emotional outburst.
• Maintain a calm environment.
• Avoid shaming or scolding the patient during emotional outburst.

Coping

• Support communication between the patient and the family.
• Discuss the lifestyle changes resulting from stroke deficits.
• Discuss changing roles and responsibilities within family.
• Be an active listener to allow expression of fear, frustration, and anxiety.
• Include the patient and family in short and long-term goal planning and patient care.
• Support family conferences.
• Encourage family therapy.
• Encourage to join in stroke support groups.

Sexual Function

• Initiate the topic with the patient and spouse with significant others.
• Educate on;
• Optional positioning.
• Patient and partner counseling.

Communication

• Provide frequent, meaningful communication.
• Allow time for the patient to comprehend and answer.
• Use simple short sentences.
• Use visual cues.
• Structure conversation to permit simple answers by the patient.
• Praise the patient honestly for improvements with speech.

Community Integration

• Provide a review of patients’ health, social care, and secondary stroke prevention needs, typically within 6 weeks of leaving hospital, after 6 months, and then annually to enable access to further advice, information, and rehabilitation when needed.
• Give written information about the patient’s diagnosis and management plan.
• Train the family/caregivers on the practical aspects of home care for stroke patients.
• Persons with very severe stroke may be given active end of life care by skilled personnel.

Evaluation

• Patient (and) caregivers verbalized awareness of home care management of stroke.
• They cope adequately according to the level of disability of the patient.
• They demonstrate satisfactory skills in caring for stroke patients.

2) Spinal Cord Injury Rehabilitation

Damage to nervous system can occur at any age. Following spinal cord injury, temporary neurological deficit to permanent total paralysis can occur. Successful rehabilitation should begin in ICU.
Spinal cord injury rehabilitation is a complex field that addresses the medical, functional, and psychosocial needs of patients with spinal cord injury.

Definition

Spinal cord injury rehabilitation is a comprehensive term including a holistic approach in meeting functional, emotional, medical, vocational, educational, environmental, and spiritual needs of a patient who had spinal cord injury.

Goals

• To minimize the ultimate neurological deficit.
• To develop the full potential of spared abilities.
• To prevent and treat the complications that occur in the acute and chronic phases.
• To maximize mobility.
• To develop self-care activities.

Principles

• The process of rehabilitation does not cause neurological recovery, rather, it takes advantage of existing function or recovered function by strengthening nonparalyzed muscles.
• It uses holistic approach.
• It encourages continuity of care and lifetime access to a specialized care.
• It facilitates community integration and education regarding spinal cord injury.

Indications

Patients with the following conditions:

• Spinal and neurogenic shock.
• Central cord syndrome.
• Autonomic dysreflexia.
• Neurogenic bladder.

Contraindications

• Conditions which interfere with rehabilitative process or those which may cause risk during exercise training.

Rehabilitation Potential Among Injuries in Specific Levels of Spinal Cord

• C2 or C3: Completely dependent for all care.
• C4: Usually needs a ventilator and is dependent for all care.
• C5: May feed themselves using assistive devices, may need a type of respiratory support but may be able to breathe without a ventilator.
• C6: May be able to push themselves on wheelchair indoors; perform daily living tasks such as eating, grooming, and dressing.
• C7: May be able to drive a car with special adaptations or can propel a wheelchair.
• C8: Same as C7.
• T1-T6: May be able to become independent with self-care and use of a wheelchair.
• T7-T12: May improve sitting balance and be able to participate in athletic activities with the use of a wheelchair.
• L1-L5: May be able to walk short distances with assistive devices.

Assessment

A baseline comprehensive assessment is performed on admission.
Assess the following:

• Rehabilitation potential of the patient.
• Physical status of all body systems.
• Presence of complications caused by stroke or other chronic conditions.
• Cognitive status of the individual.
• Family resources and support.
• Expectations of the patient and family regarding rehabilitation.
• Prior psychological response style to life stressors.
• Premorbid psychological status.
• Behavioral and psychological response to spinal cord injury.
• Current mental status, neuropsychological status, and intelligence.
• Personality factors.
• Ethnic, cultural, and religious factors.
• Family and social support networks.
• Financial status and resources.
• Housing and living arrangements.
• Patient and family expectations of treatment.
• Recreational interests.
• Work history and vocational status.
• Educational background.
• Barriers to rehabilitation.
• Behavioral strengths and weaknesses.
• Sexual concerns.
• Legal issues.
• Substance use and abuse.

Tools such as American Spinal Injury Association Score (ASIA scale) can be used for assessment.

Implementation

The components of spinal cord injury rehabilitation are as follows.

• Respiratory Rehabilitation
• Patients with high cervical cord injury may have greater mobility with phrenic nerve stimulators and electronic diaphragmatic pacemakers; these are not appropriate for all ventilator dependents, but for those with intact phrenic nerve.
• Teach about home ventilator care if on ventilator.
• Teach assisted coughing and regular use of spirometer and deep breathing exercises when the patient is not on the ventilator.
• Good pulmonary toileting with a routine for coughing, breathing exercises, mobility, chest physiotherapy. positioning, and use of abdominal binder enhances elastic recoil of diaphragm.

Neurogenic Bladder

• A neurogenic bladder is any type of bladder dysfunction related to abnormal or absent bladder innervations.
• Neurogenic bladder may be classified as uninhibited, reflex autonomous, motor paralysis, or sensory paralysis.
• Method of urinary drainage depends on type of dysfunction, preference of the patient, and availability of family caregiver, physician, and nursing staff.
• Before selecting a program, consider upper extremity function, caregiver burden, and lifestyle choices.

Interventions

For reflexic bladder with detrusor and sphincter dystynergia:

• Provide low-pressure storage, low-pressure voiding, and adequate emptying.
• Administer anticholinergics as per order to suppress bladder contraction.
• Administer alpha adrenergic blocker to decrease outflow resistance at bladder neck and antispasmodics to reduce spasm of pelvic floor muscles.
• Drainage options may include intermittent catheterization, external catheter, or indwelling catheter.

For reflexic bladder with detrusor hyperreflexia:

• Anticholinergics, intravesical capsaicin, and botulinum A toxin may be administered as per order.

For a reflexic bladder:

• Intermittent catheterization or indwelling catheter can be used.
• Initially catheterization is done every 4 hours.
• Then, bladder volume is assessed; if there is less than 200 mL of urine, the time interval may be increased.
• If there is more than 500 mL of urine, time interval is shortened as overdistended bladder can cause ischemia of bladder wall, bacterial invasion, and infection.

Neurogenic Bowel

• Encourage a high-fiber diet and adequate fluid intake.
• Plan bowel evacuation 30-40 minutes following the first meal of the day to stimulate gastrocolic reflex.
• Suppositories, small-volume enema, or digital stimulation may be needed.
• In patients with upper motor neuron lesion:
• Digital stimulation necessary to relax external sphincter to promote defecation.
• Stool softeners to regulate stool consistency.
• Oral laxatives only if absolutely necessary and not on routine basis.
• In patients with lower motor neuron lesion:
• Valsalva maneuver and manual stimulation are useful for patients who have injury below T12.
• Incontinence may result from too much stool softener or fecal impaction.
• Record bowel movements carefully including amount, time, and consistency.

Maintaining Skin Integrity

• Do comprehensive visual and tactile examination of skin twice daily with special attention to ischia, trochanters, heels, and sacrum.
• Carefully position and reposition every 2 hours; increase the time between turns if there is no redness at the bony prominences at the time of turning.
• Use pressure-relieving cushions in wheelchairs.
• Carefully move during turns and transfer.
• Avoid stretching and folding of soft tissues, friction, and abrasion.
• Assess nutritional status regularly as weight loss or gain can contribute to skin breakdown.
• Encourage protein intake.
• Avoid thermal injury by hot foods, liquids, radiators, and heating pad.
• Anticipatory guidance about potential risk is essential.

Physical Mobility

• A detailed assessment is needed to identify positioning and equipment need.
• Assess mobility to determine level of independence when performing ADLS.
• Use splints and braces (molded ankle, foot orthoses, MAFOs, and ankle-foot orthoses) to assist with mobility and self-care activities.
• Functional electric stimulation may be used to stimulate specific muscle group to create contraction and relaxation needed for assisted ambulation.
• iBOT, an innovative high-technology power mobility system, can be used. This requires the patient to have one arm to operate the iBOT. The system has four wheels and uses sensors and gyroscopes to navigate stairs while balancing on two wheels.

Spasticity

• Begin with muscle stretching exercises and then progress to nonpharmacological interventions and then to medications.

Sexuality

• Maintain open discussion.
• Rehabilitation should be handled by a person trained in sexual counseling.
• Teach about alternative methods of obtaining sexual gratification.
• Care should be taken not to dislodge the indwelling catheter.

For men:

• Reflex sexual function is possible if the patient has upper motor neuron lesion.
• Medications such as T. sildenafil and vacuum suction devices may be used.

For women:

• Those with upper motor neuron lesions may retain capacity for reflex lubrication.

Grief and Depression

• Goal of recovery is related more to adjustment rather than to acceptance.
• Allow mourning.
• Reassure the patient and stress on the expertise of entire healthcare team in denial stage.
• In anger stage: Assist the patient in achievement of control over environment by allowing his/her input in plan of care; do not respond to anger or become involved in a power struggle with the patient.
• Provide counseling to family members.
• In depression stage: Be patient and persistent, and maintain a sense of humor.

Driving

• If not available as a part of the program, a referral to driving program may be done.

Rehabilitation Engineering, Vocational Rehabilitation, and Technology

• Professionals in these fields should be available for both inpatient and outpatient departments.

Various technologies are as follows:

• Functional electrical stimulation (FES) with applications that enable;
• Strengthening of upper and lower limb musculature.
• Hand grasp and functional pinch.
• Ambulation.
• Urination via stimulation of anterior sacral nerve roots.
• Ventilator-free breathing via stimulation of phrenic nerves or the diaphragm.
• Body weight support treadmill systems to facilitate gait training.
• SMART wheel to examine manual wheelchair use during propulsion.
• Pressure mapping system to identify an optimal seating system or mattress.

Education
Topics that can be included are as follows:

• Access to benefits and other support systems, such as education, vocational rehabilitation, medical insurance, social security/disability, and workers’ compensation.
• Autonomic dysreflexia.
• Bladder management.
• Bowel management.
• Effects of spinal cord injury on cardiovascular system an risk factors for cardiovascular disease.
• Consumer advocacy organizations.
• Diabetes prevention.
• Edema management.
• Emergency preparedness.
• Health and wellness.
• Home and community safety.
• Follow-up medical care, including the need for and how to access care.
• Independent living.
• Leisure education.
• Life care management.
• Medical nutrition and weight management.
• Musculoskeletal issues.
• Pain management.
• Personal assistance services.
• Psychosocial issues.
• Pulmonary care.
• Skin care and prevention and treatment of pressure ulcers.
• Spasticity management.
• Spinal cord injury research, including access to current research.
• Substance use, abuse, and dependency.
• Self-advocacy and consumer competency.

3) Traumatic Brain Injury Rehabilitation

Brain injury rehabilitation necessitates attention to a wide range of changes that include physical recovery which further includes cognitive, social, emotional, and behavioral complications of the injury and their effects on recovery and family unit.

Definition

Rehabilitation is the process of using all means to minimize the impact of the disabling conditions and to assist patients to achieve their desired level of autonomy and participation in society.

Goals

• To enhance the patient’s ability to return to his or her highest level of functioning and to his or her home, and the community.
• To address all concerns before discharge for a smooth transmission to home or rehabilitation.
• To reduce the caregiver burden of care provided by significant others.
• To promote independence with adaptation to deficits.

Principles

• Rehabilitation should be started as soon as possible after the injury.
• Holistic and interdisciplinary approach should be followed when providing the services.
• Therapies should focus on both the microdeficits and macrodeficits problems within a laboratory/treatment setting. ADLs should also be considered.
• The design and implementation should proceed from a comprehensive, systematic, interdisciplinary evaluation process.

Indications

Patients with the following conditions:

• Blunt trauma.
• Penetrating injuries.
• Contusion, concussion.
• Hematomas.
• Diffuse brain injury such as subarachnoid hemorrhage.
• Diffuse axonal injury.

Assessment

Comprehensive assessment is performed on admission.

Assess the following:

• Rehabilitation potential of the patient.
• Physical status of all body systems.
• Presence of complications caused by stroke or other chronic conditions.
• Cognitive status of the patient.
• Family resources and support.
• Expectations of the patient and family regarding rehabilitation.

The clinical assessment includes the following:

• Past medical history.
• Functional history.
• Review of all systems.
• Cognitive level: Orientation, memory, judgment, and impulsiveness.
• Motor evaluation: Upper and lower extremities strength, balance, and gait.
• Functional mobility.
• Activity level, mobility, and transfers.
• Pain flow sheet with pain score, location, and duration.
• FIM flow sheet.
• Medication.
• Bladder function.
• Adaptive equipment, assistive devices, and orthotics.
• Skin and wound inspection.
• Social interactions.

The following tool may be used to assess the patient during rehabilitation:

Rancho Los Amigos Scale of Cognitive Functioning.

• It is a behavioral rating scale to assess and treat patients with head injury.
• This scale ranges from 1 (no response) to 8 (purposeful/appropriate) up to 10 (post acute, stable, and can handle multiple tasks).
• In acute phase, Rancho scale is used to categorize a patient’s status as a benchmark and for comparison to measure cognitive improvement.
• At the time of discharge, the patient’s Rancho level may determine placement and the level of care required.
• Patients admitted for rehabilitation may have a score as low as 2-3.
  

Implementation
The components of TBI rehabilitation are as follows.

Musculoskeletal Function

Orthopedic Injuries

• These are common with TBI. Interventions include the following
• Limited periods of traction.
• Open reduction, internal fixation, serial casting, splints, and various orthotics.

Pressure Ulcers

• Assess the response to range of motion exercises.
• Observe skin for redness, edema, and physiological responses.
• Follow prescribed and documented turning schedule. Avoid positions that increase muscle tone.
• At the earliest sign of breakdown, consult with wound therapist.
• Use pressure-relieving mattress, special beds, and dressings.
• If not effective, enzymatic, mechanical, and surgical debridement optimizes recovery.

Spasticity or Spastic Hypertonia

• Cerebral origin spasticity characteristically causes greater extensor tone in lower extremities and lesser tendency to spasms.
• Spasticity has positive and negative results; patients may use increased muscle tone of spasticity to assist with weight bearing, for transfers, or for taking a few steps.
• Increased muscle tone may improve muscle bulk or help to prevent deep vein thrombosis. It may also increase muscle fatigue, reduce dexterity, and interfere with sleep and ambulation by producing a plantar flexed foot that makes ambulation impossible.
• The interventions include the following:
• Therapeutic exercises or massage.
• Range of motion exercise, a muscle-strengthening exercise program once or twice daily.
• Cold/heat applications.
• Aquatic therapy.
• Continence management.
• Appropriate positioning.
• Frequent turning.
• Consultation with physical and occupational therapists to evaluate for orthotics, splinting, braces, transelectrical nerve stimulation (TENS), or casts with serial casting (to increase flexion or extension of extremity-inhibiting spasticity).
• Botulinum toxin A injection, to discover uncovered muscle weakness when spasticity has been removed (this injection blocks the release of acetylcholine which causes muscle contraction).
• Intrathecal baclofen, which is a muscle relaxant and antispastic.

Self-Care Deficit

• Organize the environment in a structured way so as to meet both physical and cognitive needs of the patient.

Prevention of Injury

• Remove the source of agitation.
• Ensure absence of noxious stimuli.
• Identify seizure activity, withdrawal from substance abuse, and other potential causes.
• Provide a protective environment with padded floor and walls using Craig bed to enhance freedom of movement.
• Use physical restraints with caution and in minimum amount for safety.
• Have a family member or sitter to stay to have a calming effect.
• Plan the action to minimize stimuli in anticipation of an episode of agitation.
• Provide Geri chair, Q Foam International Chair, or Planet Chairs for better response.

Cognitive Rehabilitation

• Cognitive rehabilitation is a treatment for cognitive impairments related to brain injury that is supported by well-designed research.
• A neuropsychological assessment is required in order to assess cognitive function and develop an appropriate treatment plan.
• Cognitive rehabilitation consists of diverse interventions that must be tailored to the individual needs of the patient.
• Cognitive rehabilitation can be effective regardless of the length of time since the injury and the injury severity level.
• Cognitive rehabilitation leads to improvements in cognitive and psychosocial functioning.

The various areas of cognitive rehabilitation are described next:

• Attention and Concentration
• Reduce the distractions. For example, work in a quiet room.
• Concentrate on one task at a time.
• Start practicing attention skills on simple, but practical activities (e.g., adding numbers) in a quiet room. Gradually make the tasks harder (read a short story/balance a checkbook) or work in a more noisy environment.
• Take breaks when getting tired.

• Problems with Processing and Understanding Information
• Pay full attention to what the patient is trying to say. Decrease distractions.
• Allow ample time to comprehend the information before moving on.
• If needed, read and re-read the information; ask the patient to take notes and summarize in his/her own words.
• Ask to repeat himself/herself, to say something in a different way, or to speak slower when needed.
• Repeat statements to make sure that he/she understood it correctly.

• Language and Communication
• Use kind words and a gentle tone of voice. Be careful not to “talk down.”
• When talking with the injured, ask often if he or she understood what you are saying.
• Do not be too fast or say too much at once.
• Show signal (like raising a finger) that will allow the patient to realize that he or she has forgotten a topic. Practice this ahead of time. If signals do not work, try saying, “We were talking about….”
• Limit conversations to one patient at a time.

• Problems Learning and Remembering New Information
• Put together a structured routine of daily tasks and activities.
• Be organized and formulate a set location for keeping things.
• Learn to use memory aids such as memory notebooks. calendars, daily schedules, daily task lists, computer reminder programs, and cue cards.
• Spend time and attention reviewing and practice new information often.
• Have adequate rest and try to reduce anxiety as much as possible.
• Discuss with the doctor about how medications may affect the memory.

• Planning and Organization Problems
• Create a list of things that need to be done and when.
• Prioritize them in order of what should be done first; think about the end goal when doing this and work backward.
• Break down activities into smaller steps.

• Problems with Reasoning, Problem Solving, and Judgment
• This can be done by a speech therapist or psychologist who is experienced in cognitive rehabilitation. Organized approach for daily problem solving can be taught.
• Suggest patients to use step-by-step problem-solving strategy in writing: define the problem, brainstorm possible solutions, list the pros and cons of each solution, pick a solution to try, evaluate the success of the solution, and try another solution if the first one does not work.

• Inappropriate, Embarrassing, or Impulsive Behavior
• Think ahead about situations that might bring about poor judgment.
• Give realistic, supportive feedback as you observe inappropriate behavior.
• Provide clear expectations for desirable behavior before events.
• Plan and rehearse social interactions, so they will be predictable and consistent.
• Establish verbal and nonverbal cues to signal the patient to “stop and think.” For example, you could hold up your hand to signal “stop” shake your head “no,” or say a special word both of you have agreed on. Practice this ahead of time.
• If undesired behavior occurs, stop whatever activity the patient is doing. For example, if the patient is at the mall, return home immediately.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
8. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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