The Best Intervention Plans to Help the Patient Regain Back Functional Independence - Case Study Example

Nursing Process Introduction The case study involves a follow-up visit by a 76-year-old Africa-American following a mechanical fall. She had a large bruise on her left posterior thigh and no open areas on her sacral area, heels, and b-buttocks. She complained of pain during movements which prompted the medical doctor to order for a left-arm and shoulder x-ray. After undergoing various tests, results showed that she had sustained a left scalp laceration with a hematoma. Neurology tests indicated she had an altered encephalopathy. EEG, CT and MRI brain scans were negative for the acute process. A CT spine scan revealed she had a minor fracture. Her left shoulder had no disorders as result of the mechanical fall. Correspondingly, her ammonia levels were within normal range. She was later recommended for pain management and rehabilitation. Following her hospitalization, she suffered from functional decline. According to the assessment, she had cervical DJD, left pubic rami fracture, a hematoma on her left frontal scalp and a fracture of her left humerus. Furthermore, she had no known drug allergies. Moreover, the patient had an insufficient voluntary control over her bladder and bowel movements. Also, she had panic attacks which as evidenced by an intake of psychotropic medication. The patient required assistance ranging from extensive, limited to total in performing ADLs. It was acclaimed that the patient had to undergo physical and occupational therapy to enable her to gain back muscular strength (Falvey et al., 2016; Pergolotti et al., 2016). Patient Health and History When a patient is admitted to a healthcare facility, it is essential for a nurse to assess the health status (Rothman et al., 2012). In this case, a head-to-toe assessment was used to evaluate the patient’s physical features, emotional factors and mental status condition (Rothman et al., 2012). She had a rounded skull indicating it was symmetrical and normocephalic. Her hair was neither brittle nor dry. However, the patient had blood clot and laceration on her left frontal scalp indicating the presence of a hematoma. The patient's eyebrows, eyelashes, and eyelids were symmetrical. Additionally, the patient did not show any signs of discharge or discoloration from the eyes. A penlight was used to inspect the cornea, sclera, and pupils all of which had no abnormalities. The patient's nose was symmetrical, straight and had a uniform color. Similarly, no discharge or lesions were noticed. Correspondingly, she did not show any signs of bleeding gums, and she had a pink buccal mucosa with moist and smooth lips. According to her physical examination results, they showed that the patient had an aware and oriented intermittent confusion. Her vital signs were likewise stable with a blood pressure of 138/60, a pulse rate of 74 and body temperature of 98.9 Degrees Fahrenheit. Moreover, the amount of oxygenated hemoglobin in her blood was 96% and her respirations held at 18.Her lungs were clear to auscultation bilaterally with no signs of rales, rhonchi or wheezing. Furthermore, she had an obese abdomen which was soft and tender. Nevertheless, her belly musings were positive. Her extremities indicated she had limited range of motion on her left shoulder most likely due to the pain. Moreover, her other extremities did not have any abnormalities as there was no sign of nail clubbing, edema or cyanosis. Illness History and Hospitalization Encephalopathy is a general term used to describe an illness that affects normal brain functioning. There are a variety of encephalopathy defects which can be temporary or permanent. Encephalopathy can develop as a result of head trauma or occur during birth and growth (Mez et al., 2017). In the case of the patient, she most likely suffered from a hypoxic-ischemic encephalopathy. Tests showed she had an A/O intermittent confusion which is encephalopathy’s main symptom (Arciniegas, 2010). Additionally, one can develop neurological complications such as having muscle weakness in some regions of the body as in the case of a patient (Arciniegas, 2010). Poor perfusion can also lead to various brain defects. Perfusion is the process through which a tissue’s capillary bed receives blood from the body’s lymphatic or circulatory system (Ekbal et al., 2013). In the case of the patient, she had reduced perfusion indicated the brain could not access enough oxygenated blood leading to the encephalopathy. Additionally, other body tissues did not have access to oxygenated blood resulting in increased body weakness (Ekbal et al., 2013. Therefore, this might have brought about the mechanical fall incident encountered by the patient as noted from the left upper extremity weakness thus leading to the fractures of her humerus and pubic rami. The patient similarly noted of an augmented pain during movement which most likely resulted from a cervical DJD. The cervical vertebra plays an essential role during motion at the C4-C5 and C6-C7 (Mekata et al., 2013). Maximum inflammation occurs at these sections as one gets older thus affecting locomotive abilities. The degenerative joint disease affected the patient’s joints leading to an inflammation that caused the irritation and pain (Gregory and Fellner, 2014). After hospitalization, the patient suffered from functional decline. From the tests results, she has a hematoma on her left front scalp, fracture of the left humerus, cervical DJD, fracture on her left pubic ramus and is oriented with confusions. The patient is therefore at risk of experiencing pains, falling, skin breakdown, constipation, weight loss, pressure ulcers, urinary tract infections and a decline in her range of motion. Following this, the patient will require assistance during toileting, dressing, locomotion, bathing transfers, bed mobility, and hygiene. Pathophysiology of Illness A functional decline is a form of disability affecting one in every seven individuals in the USA (Colon-Emeric et al., 2013). It has brought about increased healthcare costs and reduced quality of life. It is allied with the weakening in movement capabilities and a diminished capability to carrying out ADL (activities of daily living). According to statistics, more than 50% of older adults suffer from functional decline after hospitalization (Boltz et al., 2012). However, functional decline can result from other factors such as cervical DJD, encephalopathy, and fractures. According to Gregory and Fellner (2014), more than 20 million Americans suffer from the cervical degenerative joint disease, a form of arthritis. However, there exist hundreds of other types of arthritis. In most cases, the probability of suffering from degenerative joint disorder increases with age. It is, therefore, the reason why a high number of older adults suffer from the disease.There are two types of DJD, secondary and primary. As for secondary degenerative joint disorder, it is brought about by an injury or after surgery while primary degenerative joint disorder has no known causes. The degenerative joint disease affects the joints located in the knees, hips, feet, hands, and spine (Gregory and Fellner, 2014). The joint is an essential part of the human anatomy for it is here that various skeletal bones meet. In between the joints, cartilage makes it easier for the two connected bones to slide against each other without inflammation or irritation (Gregory and Fellner, 2014). As human beings age, the cartilage becomes more stiff and weak leading to wear and tear. Therefore, in the long run, the bones will start rubbing against each other leading to pain. Gregory and Fellner (2014) state the typical symptoms of DJD are joint stiffness after inactivity, bone spurs and pain. The main DJD risk factors are genetics, obesity, injuries and aging (Gregory and Fellner, 2014). Hypoxic-ischemic encephalopathy occurs when the brain gets insufficient oxygenated blood due to lower perfusion (Arciniegas, 2010). The shortages can result from the reduced gaseous exchange in lungs, low hemoglobin levels, interference by other toxic gases such as carbon dioxide and carbon monoxide and pulmonary dysfunction (Arciniegas, 2010).The brain will also lack essential nutrients and not have the ability to discharge of any waste products coming from its cells metabolism (Arciniegas, 2010). The outcome of this is that; the brain will suffer from low cellular energy levels, cerebral edema, the release of excess neurotransmitters and a hindrance of macro and microscopic cerebral blood flow autoregulation (Arciniegas, 2010). Hypoxic-ischemic encephalopathy will disrupt the entire brain function which indicates the whole body will become affected. According to Arciniegas (2010), the leading effects of this include seizures, loss of memory and focus, behavioral, emotional and cognitive dysfunctions resulting into a functional decline. Older adults have much higher incidences of fractures as compared to younger adults and children. According to Whiteing (2008), a break or loss of continuity in the bone structure constitutes a fracture. Fractures resulting from traumas such as road accidents or mechanical falls. However, osteomalacia, osteoporosis or Paget’s disease can similarly induce fractures due to the weakening of the bone structure (Whiteing, 2008). An open fracture indicates that one can access it due to the presence of an open wound (Whiteing, 2008). A closed fracture cannot be easily accessed for the skin is still intact. The fracture pattern is determined by the injury mechanism, the location, complexity, and type of break determine the fracture types. The various types of fracture patterns include transverse, spiral and oblique, impacted, comminuted, greenstick, torus, avulsion, crush and fracture-dislocation (Whiteing, 2008). Diagnostic Testing The patient was subjected to an estimated glomerular filtration rate test. An eGFR number is calculated after performing the creatinine blood test. Creatinine is a waste product found in blood. An eGFR test allows a healthcare practitioner to determine how a patient’s kidneys are working. An average eGFR should be above 60, and in case it falls below this, it indicates kidney abnormalities. According to the patient, her eGFR number was 138 placing it under the 90 and above bracket indicating its normal. Additionally, the patient took a blood sugar test to measure the amount of blood glucose. Glucose is an essential element in a person’s body for it is the primary source of energy. Low or higher than normal levels of glucose in the blood will affect the proper functioning of all body and brain cells.According to the expected glucose test results brackets, > 200mg/dl indicates that one is suffering from diabetes mellitus. 140-200 mg/dl will suggest one has an impaired tolerance of glucose in the body. 70-139 mg/dl means a patient has normal but postprandial levels of blood sugar. Correspondingly, 70-99 mg/dl shows that one has an average fasting blood sugar rate. According to the patient’s blood sugar test, the results indicated she had 97 mg/dl which falls under the average and fasting blood sugar bracket. The basic tool used by a lot of physicians in determining the health status of an individual is the blood test. A blood test will provide the doctor with a thorough understanding of the various waste products and nutrients in a patient's blood, the disease markers and the functioning of various body organs such as the liver and kidney. The physician will outline a lipid profile that accounts for the various elements found in the blood and a complete blood count. According to the patient’s blood test results, her liver enzyme levels were within range for they stood at 13.8 IU/L. The albumin levels were 3.4 mg/dl. The alkaline phosphates results indicated they were within a normal range of 55 IU/L. The aspartate aminotransferase (AST) was also within normal range of 20.3 IU/L. The sodium, potassium, chloride, carbon dioxide, calcium, albumin were within ranges of 134 mg/dl, 3.9 mg/dl, 102 mg/d, 22 mg/dl, 8.5 mg/dl, and 3.4 mg/dl respectively. The white cells are a significant component of the body’s immune system. In case one is sick, the WBC count is much higher as seen in the case of the patient at 6.2 X10\E^E\3/uL. Red blood cells play an essential role in delivering oxygen to the body. A low RBC count indicates one is anemic or is suffering from kidney complications. Likewise, a high RBC count suggests one is suffering from dehydration, kidney complications or heart-related defects. The patient has a healthy RBC count of 3.72 X10\E^E\6/uL. The mean corpuscular hemoglobin is 29.0 while the mean corpuscular value is 91 fL which falls within the normal ranges. Platelets play an essential role in wound healing and reducing excessive bleeding. The patient’s platelet count falls within the normal range of 150-400 X10\E^E\3/uL as it stands at 234.The neutrophils, lymphocytes, monocytes, eosinophil, and basophils from part of the white blood cells. Through these cells, they can allow a physician to identify infections and allergies in patients. The patient’s results about these cells indicate they fall within normal range. Current Medications The patient was asked to purchase bisacodyl tablets and 400mg/5ml of milk of magnesium suspension over the counter to ease constipation. The patient was to take bisacodyl medication on a pro-re-nata basis. As for the magnesium hydroxide she had to ensure first that she did not experience bowel movements for three days before taking. Furthermore, the patient received 10mg of adult suppositories for relieving occasional constipation and would be taken on a pro-re-nata basis. Similarly, the patient received 5-325 mg of Norco tablets which contain hydrocodone, an opiate pain medication. An oral administration would see the patient take one pill after every 6 hours. The doctor prescribed 25mg of Seroquel tablets which she would take one pill at 5 pm using oral administration. Seroquel is used in the treatment of various mood disorders and is known as an antipsychotic drug. The main side effect of the drug is frequent hallucinations. The physician prescribed 1,000 units of vitamin D3 tablets which she would take one pill daily at 9:00 am.Vitamin D3 plays an essential role in helping the body in phosphorus and calcium absorption which aid in the keeping and building of healthy skeletal bones. The patient took two tablets of Tylenol. The medication is a level 1-3 pain reliever and helps in reducing fevers, muscle aches, and headaches. Nursing Assessment The patient’s initial admission to the hospital resulted from a mechanical fall. During the initial assessment, it indicated that she not only suffered from a left scalp laceration with a hematoma but had other complications. The neurological tests showed she had an altered encephalopathy. However, the MRI, CT scans and EEG showed that her brain was negative for the acute process. Moreover, her ammonia levels noted she did not have any kidney related problems. Nevertheless, following hospitalization, the patient’s condition worsened as seen from the frequent need of assistance in carrying out her activities of daily living. Activities of daily living (ADLs) comprise of the fundamental capabilities that an individual requires to manage their physical requirements on a regular basis (Mlinac and Feng, 2016). These include transferring, toileting, bathing, eating, dressing, locomotion, and hygiene. The mastering of these functional skills occurs early in life indicating that one who does not suffer from any related cognitive disorders can carry them out (Mlinac and Feng, 2016). In most cases, the instrumental activities of daily living (IADLs) differ from the ADLs (Mlinac and Feng, 2016). IADLs comprises of more complex events a human being has to carry out on a daily basis such as managing their medication intake, preparation of meals, using the telephone, and tracking financial spending. In most cases, one may lack the IADLs early in life due to cognitive-related abnormalities (Mlinac and Feng, 2016). For a person to have full ADLs functioning, one must have complete physical functioning (Mlinac and Feng, 2016). The patient, in this case, cannot perform ADLs an indication that she does not have the necessary capabilities in sequencing her actions and manipulating them to achieve any daily desired goals. The physician can use physical therapy to help the patient resume back functional independence (Falvey et al., 2016). The doctor must first identify the various functional and physical limitations that the patient requires assistance in manipulating. Through identifying such, the therapist will have the ability to come up with an effective treatment plan. The primary goal of physical therapy is to allow for an increased functional activity, balance and patient’s gait (Falvey et al., 2016). Occupational therapy correspondingly can ensure the patient attains functional independence (Pergolotti et al., 2016). It is through using a variety of problem solving, coping and supervision strategies in helping the patient to achieve social participation (Pergolotti et al., 2016).The patient, however, must adhere to the prescribed medication and a standardized treatment procedure. In the case of the patient, the therapist will have one-hour interventions for the next three months. A therapist will have the ability to determine any remaining skills which might require more interventional procedures as time progresses. Some of the approaches the therapist can employ include the encouragement of independence by offering praises in case the patient succeeds in completing a specific ADLs. Analysis and Planning Lack of physical activity contributes to functional decline, especially in older adults due to the development of lean muscular tissues. Physical activity benefits have extensively been studied ranging from reduced cardiovascular disorders, depression, stress, diabetic control and high musculoskeletal tone and mass. The use of physical therapy aids the patient to engage in various physical activities thus decreasing muscular weakness which leads to a reduced functional decline. (Falvey et al., 2016). One of the physical therapy interventions, in this case, can is weight training. It will allow the patient to exercise large muscles used in mobility. The ability to ambulate and stand depends on the strength of quadriceps muscles. In the long-run, an individual will have the ability to perform social activities such as dancing. In the case of occupational therapy, the therapist can use range-of-motion exercises and pressure and positioning devices. As a result of the pain emanating from the fractured humerus, pubic ramus, and frontal scalp, the patient, lacks locomotion abilities. These exercises will ensure the patient overcomes the pain and is capable of resuming her motion capabilities (Pergolotti et al., 2016). Clinical Judgment The inability to perform ADLs is the primary adverse outcome of functional decline (Mlinac and Feng, 2016). As seen from the case of the 76-year-old African-American female patient, she requires assistance in performing ADLs leading to a reduced quality of life (Colon-Emeric et al., 2013). If left alone without care, she will experience a deterioration of health and lose her life. It is thus essential for her to engage in ADLs to ensure she reduces the likelihood more health defects (Mlinac and Feng, 2016). Without eating, she will not have the ability to provide enough energy for the body which will render her weak. Likewise, hygiene is essential in case she wants to have improved well-being whereas locomotion will allow her in performing various personal and social activities. Physical and occupational therapy will ensure that the patient regains back functional independence (Falvey et al., 2016; Pergolotti et al., 2016). It is an indication she will see improved locomotion, hygiene, bathing, bed mobility, transfers and gain back the ability of self-care and productivity (Pergolotti et al., 2016). Intervention In order to ensure the patient resumes back her full functional independence, therapeutic interventions will become employed based on physical and occupational therapy (Falvey et al., 2016; Pergolotti et al., 2016). The expected full recovery date for the patient is 06/12/2018. However, for the next three months, one-hour interventions will become employed to ensure the patient is clean, well groomed, does not have any signs of skin breakdown, bleeding, falls and pain. It will see an administration of the pain medication as per the prescribed instructions. The pain medication prescribed for the patient includes the Tylenol tablets. The patient must take two pills after four hours, and she must ensure that she does not skip the dosage. Monitoring of this medication intake will ensure the management of pain becomes observed. The patient will have to perform various ADLs without assistance. In case she completes an assigned task, praises will be made. The main aim for this is to ensure the patient is sufficiently motivated to continue performing duties and elevate her performance from the simple to the challenging activities. More importantly, the patient must participate in various social activities. Through this, it can play a crucial role in helping her control the panic attacks. It is important to check her fluid intake, lab weight, pressure ulcer and any skin damage. Her immune system is weak, and if the skin damage and pressure ulcer are left unclean, it will lead to further complications. In case the patient shows any signs of non-healing, odor, changes in body temperature or increased drainage, it is vital to report such conditions to the primary care physician. Finally, monitoring of any signs and symptoms of skin breakdown and constipation is necessary, and if noticed, the primary care physician must be notified. Pressure and positioning devices will help the patient in reducing any bed sores and pressure ulcers. Some of the poisoning devices include the blankets, rolls, and pillows. Client Teaching The primary driving force behind most of the decision-making abilities of people depends on their culture. Culture encompasses the different beliefs, behaviors, attitudes, and characteristics of a specific ethnic group. In this case, the patient is an African-American female indicating she has various reservations when it comes to health-related matters. Throughout history, African-Americans have encountered massive instances of health disparities. Different cultures have multiple attitudes when it comes to therapy. Some tend to take therapy as being a treatment for people deemed as being crazy. In most instances, African-Americans find alternatives to a therapy session and seek help from close family members, religious leaders among other social community members. When conducting a therapy session, the patient should reveal vital information which will help with the treatment process. Nevertheless, most African-Americans find this impossible for they would not want to disclose some private information to someone they have not yet earned their trust (Hansen et al., 2016). Therefore, a massive number of this ethnic group tends to view therapy sessions as an invasion of their privacy. In times of need, most members of this race will choose to turn to their religious leaders for assistance For any intervention plan to work out, the patient and physician must develop a relationship based on trust (Hansen, Hodgson and Gitlin, 2016). Nevertheless, mistrust between the two parties occurs at times as a result of racism, ageism or poor past experiences with healthcare providers. Most of the older African-Americans have developed misgiving insolences with the country’s healthcare system due to previous incidents such as the Tuskegee syphilis experiment (Hansen, Hodgson and Gitlin, 2016).It is a study that was conducted by the Public Health Service in 1932 in collaboration with Tuskegee Institute. The study had 600 participants from the African-American community (Hansen, Hodgson and Gitlin, 2016). The study bypassed all the ethical consideration when it comes to carrying out research. The researchers did not provide the right medical assistance for treating the participants’ illness but instead used them as “lab rats.” They only received free meals, medical exams and burial assurance (Hansen, Hodgson and Gitlin, 2016). Additionally, the USA health system has continually discriminated this ethnic group thus leading to much-heightened mistrust margins between a patient and the physician. Before engaging in the therapy session, it is essential that the healthcare provider creates room for trust to develop with the client (Hansen et al., 2016). The trust paradigm is vital in healthcare especially when a patient is reliant on the doctor’s competence to treat their health condition. The practitioner should provide the patient with relevant information on why it is essential to take the therapy sessions. More importantly, the nurse should ensure he/she outlines the adverse outcome of deciding to take therapy sessions. Through this, one will build a rapport with a client. Similarly, the doctor should be open to any questions asked by the patient and answer them without concealing any meaningful information that might aid the patient in coming up with various decisions. The patient will most likely open-up and disclose information if they feel that they have gained the physician’s trust. Additionally, it is crucial that the patient provides information on various aids and intervention activities that will be undertaken to ensure her functional independence is back to its normal levels. The different teaching strategies can involve how to take the medication. Some of the tablets must not be chewed; therefore, it is vital that the patient is aware of such information. An explanation of the various monitoring intervention is essential. The main reason for this is that some of the monitoring will involve invading the privacy of a patient. It is necessary to thoroughly teach the patient about why some of these actions are crucial towards their overall health and well-being. In this case, the patient should have an awareness of why it is essential to have a weight and fluid intake follow-up. Additionally, the nurse will have to monitor the bowel movement of the patient to check for any signs and symptoms of constipation. When a patient is fully aware of the importance of the intervention activities and the involvement of the nurse in accomplishing them, it will ensure that the patient adheres to all the necessary actions set up towards allowing her to recovery. Lack of patient awareness regarding the various intervention activities might result in reduced outcomes even after the set recovery period. Reflection Nutrition plays an essential role towards healthy aging. Through this, it will allow one to develop a robust immune system, and maintain the recommended muscular mass. For older adults, they must ensure they have an increased intake of vitamin B2, C, D, folate, and beta-carotene (Bernstein and Munoz, 2012). However, there is an increased rate of malnutrition in the older adult population which has seen an increased rate of decline in their functional independence. A high number of older adults tend to suffer from decreased bone and muscle mass, immune dysfunction, and low cognitive abilities. The result of these factors is that it will lead to much higher rates of hospitalization which is a risk factor for functional decline. In order to reduce functional decline resulting from re-admission, it is vital for the older adults to take a well-balanced diet. It will make it possible for them to have healthy skeletal and muscular mass required in performing ADLs and IADLs (Bernstein and Munoz, 2012; Mlinac and Feng, 2016). Most of the older adult generation has retired indicating they do not have a source of income. A considerable number of this population depends on family members and various social benefits availed to them by the state and the federal government. Therefore, it makes it hard for the members of this population to access the right foods which will ensure they have an intake of the recommended nutrients. Following this, it is an indication that the older adult generation is bound to see an increased functional decline resulting from hospitalization (Colon-Emeric et al., 2013). It is essential for the importance of nutrition to become part of the various therapy sessions. In most of the physical and occupational therapy sessions, they do not mention the significance of taking a well-balanced diet. Therapists should ensure that as they implement the various intervention strategies on their patients on how to regain back muscular strength and self-care abilities, they should also recommend them to ensure they observe proper diets (Bernstein and Munoz, 2012). Conclusion Functional decline is affecting a considerable number of the older adult generation (Colon-Emeric et al., 2013). The result of this is that this generation will end up being dependent on other individuals to help them in taking care of their daily needs. In most cases, function decline affects the ability of a person to take care of their ADLs (Mlinac and Feng, 2016). These essential activities contribute primarily to the overall well-being of a person. From the older adult generation, hospitalization is the primary contributing factor to functional decline (Colon-Emeric et al., 2013). However, other various chronic illnesses such as cardiovascular disorders, obesity, and arthritis can for a decrease in the functional capabilities. Likewise, the functional decline can similarly lead to the development of chronic illnesses such as type 1 and 2 diabetes. As evidenced by the case study involving a 76-year-old African-American female, her initial admission to the ER was due to a mechanical fall. It led to her suffering from a cervical DJD, left pubic rami fracture, hematoma on the left frontal scalp and a fracture of her left humerus. However, upon hospitalization, she suffered from functional decline. The patient required extensive aid in hygiene, transfers, locomotion and bed mobility. Limited and total assistance was needed for eating and bathing respectively. The best intervention plans to help the patient regain back functional independence involved the use of physical and occupational therapy (Falvey et al., 2016; Pergolotti et al., 2016). Physical therapy would help the patient build her muscular and skeletal strength while occupational therapy would assist her in regaining back the ability to perform self-care and leisure activities. Nevertheless, it is essential for a health care provider to completely understand various barriers that might hinder successful implementation of the respective intervention strategies. Following her African-American ethnic background, mistrust and lack of belief in therapy session would have impeded the entire process (Hansen et al., 2016). Nonetheless, the practitioner implemented a client teaching program that ensured she was fully aware of the various procedures for the interventions. More importantly, the teaching program made it possible for the patient to receive additional information about medication administration. Nevertheless, despite physical and occupational therapy playing a vital role in reducing functional decline, it is essential to have a nutritional awareness program (Falvey et al., 2016; Pergolotti et al., 2016; Bernstein and Munoz, 2012). It will outline the importance of observing a balanced diet and reducing functional decline (Bernstein and Munoz, 2012) However, although the inclusion of nutrition awareness into the intervention, the lack of finances will hinder successful implementation of a balanced diet by the older adult population. References Arciniegas, D. B. (2010). Hypoxic-ischemic brain injury: addressing the disconnect between pathophysiology and public policy. 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