Case Study Analysis: Traumatic Brain Injury and Stroke Management

This case study assignment focuses on the assessment and management of two distinct neurological conditions: traumatic brain injury (TBI) and stroke. The first part of the assignment presents a scenario involving a 70-year-old patient, Mr. James, who sustained a TBI following a fall. The assessment includes gathering comprehensive patient history, vital signs, and a thorough neurological evaluation, emphasizing the use of the Glasgow Coma Scale to determine the severity of the injury. The second part delves into stroke, differentiating between ischemic stroke and the treatment approaches to restore blood flow to the affected areas. The assignment outlines the immediate and long-term goals for stroke management, including medication and occupational therapy interventions. The case study also addresses the role of occupational therapy in stroke rehabilitation, highlighting techniques to improve motor skills and independence in daily activities. The assignment follows APA 6 guidelines for referencing and formatting.

Question 1
Traumatic brain injury occurs when a person's head is injured in a manner which may have
knocked, jolted or cause penetrative harm to the head and also to the brain (Peeters et.al, 2015).
In old people it mostly due to accidental falls as when people advance in age their body gait
changes causing the center of gravity to shift hence the risk of falls. Their joint and muscle
functions are also greatly reduced. In most cases when these people fall, their brains get stroked
against the skull causing bleeding, swelling and even bruising to the brain. These influences
proper functioning of the brain and therefore can affect activities is daily living. According to
Faul and Coronado (2015), the most common signs and symptoms of brain injury are memory
loss, bleeding from the nose and ears, loss of speech and even nausea. The most important
information to be gathered from Mr. James is more information on any form of headache he may
be experiencing. Confusions, ringing ears, fatigue, and changes in sleep patterns are important
information in knowing the extent of brain injury. Many at times this information is obtained
from a close relative or the person accompanying the client as the patient may be confused or
unconscious at the time of admission (Andrews et.al, 2015).
Moreover, trouble in concentration, memory, thinking, and attention are very important in a
patient with head injury. Many at times, some patients may present with physical symptoms such
as convulsions, seizures, loss of coordination and weakness especially in the extremities and also
abnormal pupil dilatation and contraction. Some may present with active bleeding on the skull or
any deformity showing fractures bones which may have affected the brain (Stephens et.al, 2018).
Complete vital signs are also important as brain injury can cause an alteration in the normal vital
sign range for example increased pulse rate due to excessive bleeding. Brain injury signs and
symptoms are due to injury to the specific part of the brain. The brain is divided into different

parts each performing different functions. For example, the cerebrum is divided into lobes each
playing an important role. The frontal lobe is responsible for memory, language, problem-
solving, sexual behaviors and emotional expression. Injury to this lobe causes an alteration in the
functioning of this part of the brain. Injury to the occipital lobe causes abnormal pupil
functioning and eye movements. Therefore, the signs and symptoms the patient present with
clearly indicate the part of the brain which has been damaged and this helps in proper
management of the patient and to predict the prognosis of the patient (Crane, et.al, 2016).
Individuals with brain injuries present with different signs and symptoms, therefore, a
comprehensive assessment is required to enable proper treatment and rehabilitation program for
the patient. The main aim of the assessment is to determine whether brain injury occurred or not
and if it occurred to what extent or severity. The main important tools that can be used are
Glasgow coma scale, level of consciousness, post-traumatic amnesia, neurologic signs, bleeding
disorders and use of anticoagulants, seizures, drug and alcohol intoxication, headache and
vomiting and finally the history of cranial neurosurgical interventions. According to Yue et.al
(2017), Glasgow coma scale provides an indication of the level of consciousness of an individual
with a traumatic head injury. It is commonly used in the acute phase of suspected brain injury
and allows for serial measurements. It has a total score of between three and fifteen. Fifteen
indicate that the patient's injury is minimal while three shows that the patient is worst. To obtain
the total score using the Glasgow coma scale, three parameters are used. They include the best
motor response, best verbal response, and best eye response. The total sum of the scores
indicates the patient's level of consciousness. In assessing eye-opening, the patient's name is
called and if the patient opens the eyes spontaneously then a score of 4 is given. If the patient
opened the eye on verbal command, then a score of 3 is given. If the patient does not open eyes

on command, a painful stimulus is introduced and if the patient responds by eye-opening then a
score of 2 is given. If the painful stimulus is used and the patient does not open any of the eyes
then a score of 1 is given.
Best verbal response is assessed by asking the patient some questions. If the patient responds
coherently to time, person and place where he or she is then the patient are oriented and a score
of 5 is given. If the patient answers the questions on time, person and place coherently but there
are some confusion and disorientation then a score of 4 is given. A score of 3 is given if the
patient uses inappropriate words. This is when the patient speaks some word randomly but not a
conversational exchange. Words spoken do not make sensible sentences. If the patient produces
a sound such as moaning or granting but no words, then a score of 2 is given. Finally, a score of
1 is given if the patient has no verbal response at all. Assessment of motor response is achieved
by asking the patient to do simple things such as to extend their arm. If they obey the command
and extend their arm, then a score of 6 is given. A score of 5 is given if a painful stimulus is
applied and the patient tries to localize the pain. For example, when supraorbital pressure is
applied, the patient moves their hand beyond the chin. If the patient shows withdrawal from pain
for example when supraorbital pressure is applied she or is not able to lift the hand up beyond the
chin but when nail bed is pinched, then he pulls away then a score of 4 is given. When the patient
responds to pain by flexion, for example, flexing the knee when pain is applied on the leg a score
of 3 is given. If he responds by extension a score of 2 is given and finally a score of 1 if there is
no motor response at all. A sum of all scores is done and the result indicates the patient’s level of
consciousness. Any drop in Glasgow coma scale is an alarm as it may indicate an intracranial
bleeding or further brain damage and therefore immediate intervention is needed. Increase in
scare shows good prognosis (Emami et.al, 2017).

Assessment of the level of consciousness is achieved by obtaining any history of altered or loss
of consciousness after the accidental injury. In most cases, long durations of altered or loss of
consciousness indicate severe brain injury and proper interventions should be taken into
consideration (Choonthar et.al, 2016). Post-traumatic amnesia assesses memory of events after
injury. Increased memory loss indicates an increased risk of intracranial complications (Hart
et.al, 2016). Neurological signs are achieved by assessing the general neurological assessment
such as sensory and motor reflexes. Bleeding disorders and anticoagulant use is important as
people with bleeding disorders are at an increased risk of intracranial complications whenever
they have a head injury. Intracranial bleeding can lead to sudden death if not intervened early.
Seizures occurring in a person with a head injury do not indicate intracranial hematoma on its
own as it might be caused by other factors such as drugs but other confirmatory tests can be done
such as CT scan can be done to confirm the head injury.
Question 2(a)
Stroke occurs when there is a tissue that has been irreversibly damaged due to ischemia or lack
of blood flow to the tissue. When tissues do not receive blood, they undergo necrosis and die and
therefore they no longer perform the function they used to. The tissues surrounding the ischemic
areas also called the ischemic penumbra are hypoperfused and are at risk of permanent injury. If

perfusion is restored at these areas, then they may be rendered functional again hence reducing
damage. Therefore, the main treatment and management focus on restoring blood flow to the
ischemic penumbra regions. Stroke can be caused by a blocked artery or bursting of a blood
vessel. Arteries can be blocked by; an air embolus, tissue fragments or blood clots.
(i) Problem (ii) Short-
term
goals
(iii) Treatment
media/activiti
es/tasks
(iv) Long-
term goal
Decreased blood flow
to the ischemic
penumbra regions.
Increase blood flow
to the ischemic
penumbra regions by
the end of 30
minutes and able to
handle a light pen
with his right hand.
The first immediate
treatment to restore
blood flow to the
ischemic penumbra
region is by
administration of tissue
plasminogen activator
through intravenous
administration. This
should be administered
within four and half
hours of the last known
normal time and it
greatly reduces the
occurrence of disability
after ischemic stroke
Restore the function
of the brain that was
hypo perfused to
normal functioning.
The patient shall
demonstrate
improved writing
abilities by the end
of six months.

(Ferrigno et.al, 2018).
Large arterial
occlusion
To increase blood
flow to the ischemic
penumbra region
within 30 minutes
and able to handle
light things with his
right hand.
Patients with large
arterial occlusions tend
to have minimal
response to the use of
tissue plasminogen
activator. For such
patients, intra-arterial
thrombolysis can be
performed. This is
usually done by use of
coil retrievers and
mechanical disruption
with aspiration. Recently
stent retrievers are used.
This has shown greater
improvement in
perfusion after large
vessels occlusion. This
should be achieved
within 6 hours of the last
known normal time
(Berkhermer et.al 2015).
The patient shall
demonstrate an
increased functional
level of being able
to write properly

Decreased function on
the right hand.
The patient shall
demonstrate the
ability to hold a pen
using his right hand
at the end of six
months.
According to de
Jong.et.al (2018),
occupational therapy has
been found to be helpful
to people suffering from
a stroke. One way that
an occupational therapy
could help the patient
recover from stroke is by
improving their ability
to do day to day
activities independently.
They can perform such
activities like bathing,
grooming, driving,
cooking and even
dressing. Occupational
therapy mainly depends
on the type of stroke, in
the case of Noel; he can
be helped by training
him to perform more
activities using his left
The patient shall
demonstrate the
ability to write with
his right hand and
do much using the
left hand.

hand since the right hand
is affected. Also
exercising the right hand
by starting with light
duties improves activity
rather than just relaxing.
Occlusion of the blood
vessels reducing
perfusion.
Improve the
perfusion of the
affected areas before
clot removal is done.
Use of medications such
as antiplatelet,
anticoagulants and
antihypertensive are
important in the
treatment of stroke
patients. They help in
dissolving blood clots
and prevent further
increase of blood clot
causing further
occlusion. This helps
improve perfusion on
the affected areas
especially before surgery
to remove the clot is
done (Mas et.al, 2017).
Complete
reperfusion of the
ischemic penumbra
and restored
function

Question 2(b)
Occupational therapy takes quite a long time to be effective in an individual with stroke. It also
depends largely on the extent of stroke effect and the willingness and passion of the patient.
(i) Problem (ii) Short-
term
goals
(iii) Treatment/activity/
task
(iv) Long-
term
goals
Reduced strength
and flexibility of
the right hand.
The patient shall
demonstrate the
ability to grasp a
knife with the
right hand by the
end of two
months.
According to Peterson, Hunt,
and White (2018), hand therapy
balls can be used to improve the
strength and flexibility of the
hand after a stroke. Routine use
of this equipment helps to
prevent joint stiffness and reduce
muscle pain. This will help gain
the grasping function faster by
strengthening hands and fingers.
The patient shall
demonstrate the
ability to hold a
knife and peel
potatoes by the
end of four
months.
Poor motor skills The patient shall
demonstrate
improved motor
skills by the end
of one month.
According to McKenney,
Broach and Mullen (2018), the
use of therapy or putty-clay
helps to improve motor skills
and also improve muscle
strength. Through using this
method, the patient can attain the
The patient shall
demonstrate the
ability to grasp
objects by the end
of four months.

grip effect robustly hence able to
hold thing using the fingers. It
also offers resistance training
and has been found to be a stress
reliever.
Reduced finger
strength
The patient shall
demonstrate the
ability to hold
objects by the end
of one month.
According to Sahagun and Mai
(2018), finger exercises helps to
regain fine motor skills, maintain
the dexterity and strength of the
fingers after a stroke. One of the
most commonly used exercisers
is the Epitomie fitness finger
master and has sets of pistons
which can be manipulated to
help strengthen fingers, forearms
and also the hands. It is very
reliable as it is small and can be
carried anywhere one goes.
The patient shall
demonstrate the
ability to hold
objects such as
tomatoes and be
able to peel or cut
them by the end
of four months.
Impaired
functioning of the
left cerebral
hemisphere.
The patient shall
demonstrate
improve activity
on the right hand
by the end of one
The use of mirror therapy box is
helpful in reducing pain and
improving motor skills and to
treat hand paralysis after a
stroke. It works by a process
The patient shall
demonstrate full
or almost full
functioning or
activity of the

month. known as neuroplasticity by
tricking the brain to recognize
itself after a stroke. The mirror
tricks the brain by using the
reflection of an unaffected,
working limb two project the
image to unaffected, working
limbs. Performing this exercise
with the unaffected limb in the
mirror box, it appears to the
brain as two unaffected limbs
and hence important in the
development of previously
damaged neural pathways.
Routine repetition produces
good results (Thieme et.al,
2018).
right hand at the
end of four
months.
The problem in
flexion and
extension of the
fingers.
The patient shall
demonstrate the
ability to flex and
extend fingers to
some degree by
the end of one
Use of therapeutic gloves and
splints are important in
improving hand and functional
mobility after a person has had
stroke. It helps in the grasp and
release exercises as it can flex
The patient shall
demonstrate the
ability to grasp
and release
objects using the
right hand by the

month. and extend the thumb and other
fingers. This does so by the help
of a spring on the device and
continuous training is important
to achieve better outcomes
(Gustafsson, Patterson, Marshall,
Bennett, & Bower, 2016).
end of four
months.