The Restorative Care Program is a collaborative effort between nursing, rehabilitation, and patient families designed to maximize the restoration of function, prevent deterioration and minimize disability. Providers act as a team to increase mobility, maximize nutritional intake, provide sensory stimulation, and promote receptive and expressive communication skills. This team approach allows families to participate in the recovery of their loved ones and engages staff at all levels of expertise.

Specially trained certified nurse assistants provide constant observation and behavior modification to the head injured patient. The term “sitter” has been replaced by the term “coach” to emphasize the unique role that these providers play. Coach training focuses on safety, redirection and teaching.

Goals: 

a.  May affect the reticular activating system (RAS) and increase arousal and attention to the level necessary to perceive incoming stimuli

b.  May prevent environmental (sensory) deprivation, which has been shown to retard recovery and the development of central nervous function and further depress impaired brain functioning

c.  Allows for frequent monitoring of patient’s responsiveness 

d.  May improve the quantity and quality of responses toward purposeful activity 

e.  May provide opportunities for the patient to respond to the environment in an

adaptive way 

f.  May heighten the patient’s responses to sensory stimuli and eventually

channel them into meaningful activity

Guidelines

a. When determined appropriate, sensory stimulation is usually done by the family and members of the IDT in coordination with the Speech Pathologist.

b. The patient should be seen frequently, 3-4 times daily.

c. Do no harm. Before starting any stimulation, check resting vital signs (heart rate, blood pressure and respiratory rate).

d. Avoid or minimize stimulation programs with a comatose patients who have a ventriculostomy when increased intracranial pressure (ICP) and/or cerebral perfusion pressure (CPP) are still issues. Monitor ICP and CPP during and after treatment if necessary.

e. Control the environment to eliminate as many distractions as possible. The environment should be simple and uncluttered, with a limited number of people around the patient; the television should be off and the door closed.

f. Make sure the patient is as comfortable as possible before starting: tubes, restraints, etc. may interfere with stimulation.

g. Organize the stimuli; present them in an orderly manner. Present only 1 or 2 modalities of senses at a time.

h. Describe the purpose and procedure of each activity in a clear, concise manner.

i. Orient the patient to person, time, place and reason for being in the hospital frequently throughout session.

j. Allow patient extra time to respond (because of slow informational processing). 1 or 2 minutes between the administration of different stimuli are useful as an initial guide until response time has been established.

k. Keep sessions relatively brief- patients can usually only tolerate 15-30 minutes.

l. Conduct sessions frequently, 3-4 times daily. Alternate periods of stimulation with periods of rest.

m. Select meaningful stimuli, such as the voice of family or friends, favorite music etc. Stimuli that have emotional significance to the patient are usually more likely to elicit responses.

n. Attempt to stimulate all of the senses, and vary the stimuli in nature and intensity to maximize the possibility of increasing arousal.

o. Direct treatment toward increasing the frequency and rate of response, the period of time that the patient can maintain alertness, the variety of responses and the quality of attention to the environment.

p. Avoid overstimulation by alternating brief periods of stimulation and rest.

q. Note: all nursing activities are forms of multi-sensory stimulation. It is important to explain all tasks at hand and request the patient’s participation. (I.e. “I am going to raise you up in bed. Can you bend your knees to help me?”)

Responses to Sensory Stimulation:

a. Reflexive Responses:

• Increased eye blinking/eye opening

• Increased of decreased breathing rate

• Increased or decreased blood pressure

• Change in skin color

• Increased or decreased muscle tone (flexion or extension changes)

• Total body movement or tremor

• Grimacing, grinding teeth, chewing-like movement

• Startle to loud noise

b. Localized Responses:

• Turning head or eyes away or towards tactile or auditory stimuli on or near the face

• Attempting to move extremity touched by the tactile stimuli

• Attempting to make movement upon request (i.e. Squeeze my hand or close your eyes)

• Vocalization

Suggested Stimuli:

a. Auditory: 

Auditory stimuli should be provided without the presence of background noise. Verbal stimuli should be presented with a normal but firm voice. Note where the stimuli are presented (on the right, left or in midline). Avoid stimulation that evokes a startled response. This type of stimulation is counterproductive. The following are examples of auditory stimuli:

• Calling name 

• Voice (normal tone) 

• Social conversational speech 

• Tapes of family members, familiar music or voices 

• One step commands 

• Yes/no questions 

• Pen on bedrail 

• Cough 

• Keys 

• Door closing 

• Music at scheduled intervals 

• Xylophone 

• Squeaky toy 

• Rattle 

• Bell 

• Tambourine

 

b. Visual: 

The patient should be positioned upright if possible (in the bed or wheelchair). Attempt visual tracking after focusing is established, i.e. getting a patient to follow a stimulus with his/her eyes as it moves. Tracking usually begins in the center or midline. Examples of visual stimuli are: 

• Faces 

• Family pictures 

• Changes in position and location 

• Mobile at bedside 

• Posters 

• Flashlight 

• Shiny objects 

• Bright colored objects 

• Familiar objects within the environment (clock, bed etc.) 

• Mirror

c. Touch/Tactile: 

This includes rubbing the skin with various textures or temperatures, applying vibration, and using a firm or moving touch. Bath time can be an ideal time for tactile stimulation. Care should be taken with vibration as it can increase flexor or extensor tone. The face, especially the lips and mouth, are the most sensitive areas. The following are examples of specific stimuli:

• Textures (cotton, nerf ball, fur, sandpaper, velcro, brush, terry cloth, soap, lotion, shaving cream)

• Temperature (ice, water bottle, metal utensils, warm or cold face cloth) 

• Varying degrees of pressure (feather, tickling, fan, deep rubbing,

vibrator) 

• Noxious (pin prick, rub sternum with knuckle)

d. Smell/Olfactory: 

Olfactory stimuli can be presented by holding a saturated cotton ball next to the patient’s nose for 2-5 seconds. Irritants such as ammonia and strong perfumes should be avoided. Olfactory stimuli may be less effective if the olfactory nerve has been damaged, or if there is a tracheostomy tube which may reduce the patient’s sense of smell. Examples of stimuli are:

• Fruit Extracts (lemon, strawberry) 

• Perfume 

• Scratch n’ sniff items 

• Spices

• Alcohol 

• Listerine 

• Foods (lemons, onions, coffee grinds, chocolate, peanut butter etc) 

• Shampoo 

 

e. Movement/Positioning/Proprioceptive- Kinesthetic: 

Heart rate, ICP and blood pressure should be monitored during stimulation. Examples of this are:

• Various positions (check level of responsiveness in each) 

• Range of motion 

• Sitting 

• Elevate head or foot of bed

• Elevate arms or legs on pillows 

• Uncomfortable positions 

• Hoyer lift and all transfers 

• Rolling in a sheet in bed

 

f. Taste/Gustatory:

Oral Stimulation should be provided during routing oral care, unless the patient demonstrates a bite reflex.

• Use a sponge tipped or lemon glycerin swab or a soft toothbrush to diminish hypersensitivity and abnormal oral/facial reflexes

• Use a flavored cleansing agent, such as mint or lemon, to increase oral stimulation during oral care

• Provide stimulation to the lips and area around the mouth 

• Do not attempt to feed patients in a coma

 

e. Vestibular: 

Vestibular stimuli are contraindicated in patients with tracheostomy, elevated ICP or seizure. This stimulus is provided by changing body position while monitoring heart rate, ICP and blood pressure. Position changes that are meaningful and familiar should be used. The following are examples:

• Rolling 

• Swinging 

• Tilting the bed 

• Moving the patient in bed or on the mat 

• Rocking slowly

 

Revised 2002 by Jeanne Roder, MS SLP CCC Adapted from the Miami Project