Brain Injury and dementia/Alz Flashcards
Glasgow coma scale
used for initial evaluation and continuing assessment to determine someone’s level of consciousness after a head injury
15 total points
15 is best score (fully conscious)
3 is worst (deep coma or death)
<8 severe
9-12 moderate
>13 minor
Glasgow - Eye response (E)
1 - no eye opening
2 - eyes open to pain
3 - eyes open to speech
4 - eyes open spontaneously
Glasgow - Verbal response (V)
1 - none
2 - incomprehensible sounds (moaning)
3 - inappropriate words
4 - confused (coherent, but some disorientation)
5 - oriented (self, place, time, situation)
Glasgow - motor response (M)
1 - none
2 - extension to pain (decerebrate response)
3 - flexion in response to pain (decorticate response)
4 - withdraws from pain
5 - localizes to pain (purposeful movements)
6 - obeys commands
Rancho Los Amigos
levels of cognitive functioning - 10 levels
Level I
no response
total assistance
Level II
generalized response
total assistance
reflex to painful stimuli
non purposeful movement
Level III
localized response
total assistance
some purposeful movement - withdrawal, turning away, following objects
some consistency
Level IV
confused/agitated
maximal assistance
alert and in high state of activity, purposeful attempts to remove tubes etc
aggressive/flight behavior
Level V
confused, inappropriate, non agitated
max assistance
may wonder randomly, not oriented, brief attention, severely impaired memory and confusion, inappropriate use of objects
unable to learn new information
socially inappropriate, no censor
Level VI
confused, appropriate
moderate assistance
inconsistently oriented
attend to highly familiar tasks with redirection
assistive memory aid with max A
emerging awareness
follow simple directions
more socially appropriate
Level VII
automatic, appropriate
min A for ADLs
consistently oriented
*min A for new learning; demo carryover of learning
monitor accuracy of doing things familiar/routine
min A for safety
unaware of others feelings/abilities
Levels VIII, IX, X
purposeful, appropriate
stand by assistance
complete familiar tasks with distraction
recall past and recent events
over/under estimates abilities
awareness/think of consequences with min A
depressed, irritable, self centered
IX - self monitor and estimate abilities
X - modified independent
allen cognitive levels
used for populations with psychiatric disorders, acquired brain injury, and/or dementia
the person performs 3 leather lacing stitches progressing in complexity
ACL 1
awareness and automatic actions
cognition is profoundly impaired
fleeting attention
total assistance, 24/7
intervention: sensory stim
ACL 2
limited awareness: postural, gross body movements
max A
very impaired cognition
righting reactions
prevent them from transferring on their own/wandering
aimless walking and grabbing
create calm, sensory rich environment
ACL 3
manual and repetitive actions - spontaneous in response to tactile cues
max attn span 30 min
mod A
unpredictable, remove unsafe items
do repetitive actions with tactile cues and demonstration
distinguishing objects, using them
ACL 4
pt may live alone with assistance
familiar activities, goal directed
min A, visual cues
make a sandwich
walk to familiar places, make a small purchase
sequencing, completing a goal, personalizing, rote learning
ACL 5
new learning occurs
cognition is mildly impaired
SBA
better attention
exploratory, trial and error, general learning
impulsivity, poor judgment, unable to anticipate errors
discriminating between parts of an activity, self-directed learning, considering social standards, consulting with others/collaboration
ACL 6
planning new activities
conceptual
independent
anticipate, plan, reflect
occasionally seek guidance
stage 1 Alz
very mild –> mild cognitive decline
others might not know, but you begin to notice and worry
intervention: engage in wellness behavior and exercise to decrease anxiety and promote success
post its, calendars, appointment books
stage 2 Alz
mild –> moderate decline
begin to withdraw from social situations, more anxiety, hostility, paranoia
intervention: structure, routine, environmental supports, reality orientation (photos)
stretching, walking, balancing, volunteering (simple)
stage 3 Alz
moderately severe decline
“go away! who are you!”
agitated, paranoia, delusions, sleep disturbance, wandering behavior, not oriented
intervention: safety comes first (remove sharp objects, add lighting, ID bracelet) over learned tasks with 2-3 steps
caregiver instruction
stage 4 Alz
severe decline
patients cannot communicate, incomprehensible, most likely bed ridden, need nursing care
intervention: positioning in bed, instructing caregivers with transfers and skin, promote comfort, controlled sensory stimulation
