Medical, nursing and therapeutic needs of people with a PDoC by Julie Latchem-Hastings

Spasticity

2020-03-12 22:55:38 UTC

Unreliable Communication

2020-03-13 09:15:53 UTC

Unable to communicate their needs, therefore needs need to be assumed/attended in best interests.

Need for good quality positioning, pressure relief and postural management

2020-03-13 09:37:17 UTC

Need for nutritional management

2020-03-13 09:38:15 UTC

Family of patient need psychological input for acceptance, adjustment and emotional support

2020-03-13 09:39:16 UTC

May need orthoptic/opthalmology review for potential visual problems

2020-03-13 09:40:17 UTC

Patients with or without tracheostomy are at risk of retained secretions and may need suction and/or respiratory physio input

2020-03-13 09:40:52 UTC

Need for behavioural assessment e.g. CRS-r/WHIM/SMART from appropriate team members

2020-03-13 09:41:44 UTC

Orthotics/Splinting

2020-03-13 11:33:19 UTC

Appropriate custom seating. Standing program - levels of arousal and awareness at their highest in standing.

2020-03-13 11:34:10 UTC

Saliva management

2020-03-13 11:55:30 UTC

ACPs to understand pt background, likes and dislikes to enable them to make decisions for them

2020-03-13 11:57:30 UTC

Personal care

2020-03-13 11:59:22 UTC

Full assistance with washing and incontinence needs

Stimulation

2020-03-13 14:20:22 UTC

Visual, Auditory, Proprioceptive, Sensory, Tactile

Mental Capacity

2020-03-13 17:47:54 UTC

People in PDoC lack capacity to make decisions and so ALL decisions should be made in their best interest following a legal framework

Artificial nutrition and hydration

2020-03-13 17:51:55 UTC

Consider if artificial nutrition and hydration is in a patient's best interest

Continence management

2020-03-13 17:55:09 UTC

Optimise continence management to minimise risk to skin integrity and infections

Postural management

2020-03-13 17:57:43 UTC

Need for 24 hour postural management to include specialist seating and bed positioning. The need for standing should be assessed on an individual basis and not be a routine part of therapeutic input

Comorbidities

2020-03-13 17:59:59 UTC

Pre-existing conditions need to be effectively managed to optimise possible awareness

Pain

2020-03-13 18:01:49 UTC

Often overlooked in this patient group but spasticity and contractures can cause significant pain especially in the MCS plus population

Medications

2020-03-13 18:10:13 UTC

People in PDoC are usually put on a lot of medication in the acute phase. This needs rationalising and minimising to reduce harmful side effects

oral hygiene

2020-03-14 18:36:16 UTC

Routine/ daily timetable Opportunities for meaningful activity. Involve MDT rehab, time with family member and rest periods

2020-03-14 18:37:20 UTC

Tracheostomy management/weaning

2020-03-15 12:40:34 UTC

Co-ordinated team work to ensure optimum respiratory management, including management of oral secretions and MDT input to wean tracheostomy when possible

Medication management

2020-03-15 12:42:39 UTC

Close monitoring for medications that may cause a sedative effect which may impair responses. This needs skilled input as anti spasticity medication may be required but can often be sedating
Consideration of the use of neurostimulants

2020-03-16 06:50:02 UTC

Sleep wake cycle is often disrupted and MDT input is required to normalise this (e.g. structured timetable with regular times sitting out and accessing the outdoors, minimise interventions overnight as much as possible, potentially medication such as Melatonin).

Multi-trauma

2020-03-16 10:11:13 UTC

May have fractures/lacerations etc that need planned management.

Craniectomy management

2020-03-16 10:12:47 UTC

Craniectomy helmets/planning surgery for replacing bone flap.

Skin management

2020-03-16 12:08:12 UTC

immobility and prolonged postures leave out patients at high risk of skin breakdown. Regular monitoring, specialist equipment, 24 hour posture management plans and treatment of at risk areas is required.

Hypersensitivity

2020-03-16 13:10:23 UTC

consider analgesics & pregablin/gabapentin,
Desensitisation ,
Facial oral tract therapy to enable adequate oral care
Wean trache/ Ng

Prevention of secondary comlications

2020-03-16 17:51:33 UTC

Maintaining soft tissue length, ROM, best positioning for respiratory function, skin integrity, social interaction

2020-03-16 21:01:40 UTC

Maintenance of respiratory function - physio adjuncts e.g. cough assist, Clearway, MI:E

A

2020-03-17 11:42:56 UTC

Aware

2020-03-17 11:42:57 UTC

Awareness of over stimulation, sleep/wake cycle, rest time and daily routine.

2020-03-17 11:42:57 UTC

Catheter care - urethral / suprapubic

2020-03-17 14:21:53 UTC

hygiene + possible bladder washout / monitor / treat infection
or management using incontinence pads

Bowel management - establish programme may involve invasive procedures

2020-03-17 14:24:37 UTC

2020-03-17 14:52:18 UTC

Consideration/ax of whether underlying factors (e.g. eyesight, hearing) may be masking awareness

Complex communication needs. Can take a great deal of assessment to establish a reliable means of communication.

2020-03-17 16:09:25 UTC

MDT management of secretions / swallowing difficulties.

2020-03-17 16:10:12 UTC

bowel/bladder management

2020-03-17 18:12:00 UTC

communication needs
skin integrity management
pain
sleep/wake routine

Medications vs arousal

2020-03-18 10:36:12 UTC

Often those in PDOC are on a range of medications - to address a lot of the other topics mentioned here. Some of these could have a detrimental effect on their alertness and more - this needs to be fine tuned as a priority and monitored by the MDT to ensure the best outcome...

Mobilily

2020-03-18 17:29:08 UTC

Patient are bed bound, require a qualified team to provide the right equipment and to assist them to ensure they are able to spend time on a wheelchair.

Continence

2020-03-18 17:29:29 UTC

Patients all most all the time come with an indwelling catheter, TWOC for reducing care.

Medical

2020-03-18 17:32:15 UTC

Use of neuro stimulants to increase the patient alertness and to have a better sleep-awake cycle.

P

2020-03-18 20:38:38 UTC

Ph

2020-03-18 20:38:39 UTC

Sensory overload/overstimulation

2020-03-18 20:38:40 UTC

Need for appropriate environment. Need to control sensory stimulation.

Postural management - maintanence of body shape. Prevention of deformity/maladaptive biomechanical changes.

Continence

Swallowing difficulties/secretion management/chest care/sialorrhea

Spasticity management - consideration of the most appropriate treatment apprroach - consideration needs to be given to the overall systemic impact of oral antispasticity medications particularly on arousal levels.

Communication impairments

Skin care/pressure management

Somatosensory impairments

May have visual/hearing impairments

Nutrition and feeding considerations

P

2020-03-18 21:08:58 UTC

Pos

2020-03-18 21:08:59 UTC

Pos

2020-03-18 21:09:00 UTC

A

2020-03-18 21:09:02 UTC

A

2020-03-18 21:09:03 UTC

Abn

2020-03-18 21:09:04 UTC

Abnorn

2020-03-18 21:09:05 UTC

Abnormal posturing

2020-03-18 21:09:06 UTC

Sometimes due to pain or infection, may require specialist equipment to support posture and seating.

P

2020-03-18 21:59:10 UTC

Present

2020-03-18 21:59:11 UTC

Presentat

2020-03-18 21:59:11 UTC

Presentation/Impairments/Needs

2020-03-18 21:59:12 UTC

People with PDoC can have impairments in vision, perception, cognition, mood, mobility, sensation, praxis, continence, communication, language, movement , breathing, eating, sleeping, which impact on their ability to participate in their valued occupations. They may require some to maximum assistance with activties (physical, cognitive, social, spiritual) and need support with decision/choice making.

It’s important that, where available, stimulatory interventions are used to create as natural a context as possible, so that the pt has the best chance of demonstrating their potential and awareness

2020-03-19 08:18:09 UTC

Respect

2020-03-19 08:19:37 UTC

Family support - psychological support for family members/children. Their lives have been changed for ever, not just the patient's; they need support and knowledge be be able to manage the situation and make the right decisions.

2020-03-19 10:06:49 UTC

T

2020-03-19 12:57:41 UTC

Considered needs

2020-03-19 12:57:57 UTC

Leisure activities. These patients are human whether they have an initial reaction or understanding, it is still their need to experience leisure activities.

T

2020-03-19 12:58:04 UTC

Issues

2020-03-19 13:00:28 UTC

Contractures. Due to less mobility they are faced with these issues. They are more at risk for further injuries and makes them even sensitive to the environment

Treatment escalation – this should be discussed at an early stage giving considerations to likely success of treatment interventions and any advance planning in place

2020-03-19 13:01:49 UTC

Neew

2020-03-19 13:03:22 UTC

N

2020-03-19 13:04:22 UTC

Spastcity and tone management

2020-03-19 15:10:25 UTC

Psycological needs

2020-03-19 15:11:53 UTC

Impairments of Insight

2020-03-19 15:12:18 UTC

Risk of overstimulation

2020-03-19 15:13:14 UTC

Fatigue

2020-03-19 15:13:24 UTC

Need time - need patience and extra time to respond as responses can be very delayed

2020-03-20 09:12:32 UTC

poor attention

2020-03-20 09:14:21 UTC

variety of significant cognitive/perceptual deficits such as poor intiation, dyspraxia, poor attention, poor memory, inattention etc

2020-03-20 09:14:51 UTC

Visual impairment - to varying degree, patients often can have altered movement of eyes causing double vision which may impact on responses. Can be cortically blind.

2020-03-20 09:16:44 UTC

Airway Clearance Techniques

2020-03-25 15:32:43 UTC

Ensuring that respiratory function remains optimal assessment and treatment.

2020-03-26 15:37:28 UTC

Cognitive difficulties
Communication difficulties
Swallowing and secretion management difficulties
Visual impairment
Motor impairment
Issues with tone
Issues with pain
Airway management difficulties

Vision

2020-04-25 13:58:54 UTC

Whilst some level of physical adjustment to focus may be estimated by an optician, the level to which a person with PDoC might be able to perceive, interpret, or respond to visual stimuli is difficult to ascertain. Patients may be unable to track moving objects, and the different hemispheres of the brain might not be working together to process the physical image seen through
the eye.

Assessment of nutritional requirements via PEG feeding according to individual need

2020-05-10 15:02:12 UTC

Consideration for additional protein requirements depending on skin integrity

2020-05-10 15:03:23 UTC

Additional vitamin supplementation if feed volume and energy requirements are low

2020-05-10 15:04:00 UTC

Families and friends

2020-05-14 08:49:03 UTC

verbal stimulations from significant others

Difficulty in concentration

2020-05-14 08:51:36 UTC

Need therapy in bite size chinks. Use of visual timers for each task. Use of alternative communication aids

2020-05-14 10:27:23 UTC

Airway Clearance Techniques

Feel lost when they may be back to full consciousness condition

2021-04-01 02:14:32 UTC

2021-04-01 06:24:24 UTC

in VS -- grinding the teeth
teeth need to be protected

Changing nutritional needs

2022-05-06 14:03:47 UTC

Energy needs gradually decline with a reduction of muscle mass, requiring lower calorie enteral nutrition to achieve an appropriate body weight, but need to ensure adequate protein and micronutrients for optimum health

Holistic whole-person Care

2022-05-11 16:43:11 UTC

Many patients have spiritual or cultural needs which should be honoured and respected as a part of their continued "personhood".

Postural management

2022-06-10 07:52:19 UTC

Require to consider a 24 hour postural management plan to be implemented by all within the MDT to optimise positioning to minimise risk of contracture, to support the management of chest and prevent pressure areas.

Communication diary to record any meaningful communication when emerging from PDOC - also a care diary from the start of their care and continuing on through rehabiliation.

2022-07-17 21:41:32 UTC

2022-10-06 08:30:42 UTC

They may have reduced motor function due to injury or neurological damage therefore one of their needs might be sedation or to be bedbound. This may create secondary complications like muscle wastage, muscle shortening, contractures, pressure sores, dehydration, malnourishment, infections, respiratory intervention, negative effects on mental health.

24 hour postural care plan - avoid deformities, contractures, pressure sores, discomfort and pain

2022-10-06 08:31:14 UTC

communication plan/documentation

2022-10-06 08:31:31 UTC

chest care - cough assist, manual techniques, suction - people who are less or immobile are more prone to chest infections and problems, but often won't be able to produce an efficient cough independently

2022-10-06 08:32:38 UTC

2022-10-06 08:33:36 UTC

Skin care. Repositioning often to reduce risk of pressure sores. Stretching.

inability to mobilise, therfor having a reduction in muscle mass, and will need physical therapy to prevent contractures and respiratory interventions to prevent chest infections

2022-10-06 09:24:18 UTC

post experienceing a specific disorder of consciousness patients may experience psychological distress and require interventions to help them with this.

2022-10-06 09:25:58 UTC

At risk of contractures, respiratory deterioration, dental problems, skin breakdown, nutrition complications (NG/peg), problems with decision making and need for BIM decisions, difficult for their families.

2023-06-30 07:59:27 UTC

Gynaecological/menstrual management in some patients in addition to bladder and bowel management

2024-03-06 21:19:28 UTC

dignity, control over their life, their environment - this right has been delegated to their carers in their current situation..

2024-03-10 04:21:51 UTC

2024-07-22 07:30:44 UTC

Language, I think patients in PDOC situations should be spoken in their language can provide reassurance to family members and those individuals, they feel valued and included.

Professionals may sometimes forget to introduce themselves and the purpose of their sessions, maintain their dignity and actively engage them when interacting with them rather than treating them as passive participants.

2024-12-17 17:24:43 UTC

Communication & Swallowing

2025-01-02 10:22:47 UTC

Reduced secretion management, reduced swallow frequency, reduced laryngeal level secretion. Tracheostomy management - complex. Anticipation of care needs. Stimulation and environmental management. Communication partner training (stimulation management). Person centred care.