Jim's Story
A brief history
Aged 31, Jim was assaulted outside his home. Admitted to the intensive care unit at his local hospital with a Glasgow Coma Scale of 6, a CT scan revealed basal and temporal skull fractures with diffuse brain injury and no focal lesions. A tracheotomy was also performed.
Entirely dependent for all activities of daily living, with nourishment provided through a PEG feed, Jim was transferred to a rehabilitation hospital where on admission he was totally disorientated in time, place and person. The duration of this Post Traumatic Amnesia exceeded 7 days.
Jim was both verbally and physically aggressive in response to staff intervention and the rehabilitation hospital was consequently unable to consistently care for his basic personal needs. For example he would become physically aggressive when he was assisted to wash or go to the toilet. A thorough assessment of his needs was not possible at this time.
Assessment
Three years later, aged 34, Jim was transferred to Kemsley, National Brain Injury Centre at St Andrew’s Healthcare. During the initial assessment period, some physical difficulties were identified. These included left sided hemiparesis, poor trunk control and impaired dexterity bilaterally. While 2 care workers were needed to assist Jim with transfers, his physical aggression demanded an additional team member to ensure safety levels were maintained. He was also reliant on a wheelchair for mobility which was pushed by staff.
Jim presented with moderate receptive and expressive language skills although he did maintain functional expression of his basic needs. Though not medically necessary, Jim was PEG fed as he would not tolerate any food and became aggressive if eating was proposed. He was dependant upon staff for all activities of daily living. These included getting up in the morning, mobilising, using the toilet and getting dressed. As he did not request assistance with any activities, Jim was therefore doubly incontinent.
Challenging behaviour
Thorough assessment concluded the main barrier to Jim’s rehabilitation was his frequent, and severe, challenging behaviour. This included physical aggression, hitting and attempting to hit staff, spitting and throwing objects. He also demonstrated frequent verbal aggression, such as swearing at staff and co-patients, making threats of violence and making personal insults towards others. Other challenges included poor co-operation and sexually inappropriate behaviours, all causing a barrier to further rehabilitation and more independent living. In summary, any interactions with other people generally led to aggression from Jim and he was not able to access the community at all due to his high risk behaviour.
Treatment
Jim’s challenges posed a complex case as he was faced with cognitive, physical and behavioural difficulties. In order to provide rehabilitation in the most efficient manner, a structured holistic, neurobehavioural approach was applied to all aspects of care and development. Following a full functional analysis, his behaviour was targeted through a variety of individually tailored techniques. This enabled other aspects of his rehabilitation to be addressed with a holistic approach by the full inter-disciplinary team.
Rehabilitation
Following 18 months of rehabilitation, Jim no longer presented with any physical aggression and he was fully co-operative with his treatment. He was eating and his food did not need to be modified. Jim was also fully continent and able to walk for short distances unaided. Activities of daily living were vastly improved with Jim participating and enjoying a range of activities including shopping, cooking basic meals, doing laundry and cleaning his own room. He was also able to attend a sheltered work placement.
After 24 months at Kemsley, although not completely independent in all areas of living, Jim has been able to progress to a small group home in the community where he is able to regularly access the community. His quality of life is now greatly improved.