exam 3: moderate TBI Flashcards
this describes what type of TBI:
- second most severe type
- middle GCS level
- mod-high medical needs
- some LOC
- post-trauma amnesia for at least 1 day and less than 7 days
- marked confusion by Rancho Level
moderate TBI
a mild TBI is also known as:
– 3 distinct characteristics:
concussion
- possibly no LOC
- <1 day of PTA
- no injury on neuroimaging
moderate TBI:
- GCS score:
- PTA days?
- loss of consciousness for how long?
- 9-12
- 1-7 days (O-log score <25 for at least 1 day and less than 7)
- 30 min to 24 hours
Rancho levels for moderate TBI:
- level IV
- level V
- level VI
- confused-agitated
- confused-inappropriate
- confused-appropriate
what Rancho level is this describing?
- hyperaroused
- behavior is bizarre and not purposeful
- unable to cooperate
- incoherent or inappropriate words or stories (confabulate)
- no selective attention
- lacks recall
- limited ability to learn
level IV - confused-agitated
what Rancho level is this describing?
- respond to simple commands
- random response to complex commands
- attention to environment but not task
- verbalizations are confabulatory or inappropriate
- memory is impaired
- inappropriate use of objects
- can perform old learned tasks, but difficulty learning new ones
level V - confused-inappropriate
what Rancho level is this describing?
- goal directed behavior but needs external input
- carry-over from relearned tasks
- follows simple directions
- past memories show up in more depth
- wrong answer to questions, but appropriate in answers
level VI - confused-appropriate
when taking history of a moderate TBI patient, should you completely rely on them for accurate information?
Should you still consult with the RN for behavior strategies at this stage?
no, often confused and confabulate due to limitations in arousal, consciousness and behavior
- yes, even though medical status is not as dynamic in this stage
5 categories of attention:
1. _______ attention - process and respond to specific info.
2. _____ attention - perform an activity continuously over a period of time
3. _______ attention - focuses on one thing, perform activity with distracting stimuli
4. _______ attention - shifts focus of attention between multiple stimuli
5. ______ attention - respond to multiple stimuli simultaneously
- focused
- sustained
- selective
- alternating
- divided
Do TBI patients typically have the capacity for attention?
- if so, what outcome measure would be best?
not usually
MARS
higher thought functions that represent advanced cognitive functions which are dependent on the presence of basic cognitive functions
executive functions
the ability to understand either oneself or an external situation
insight
the ability to form an opinion or reach a decision after comparing options
judgment
cognition drives behavior:
– paying attention requires ____ ____ –> leads to _____ _____ –> leads to _____ and _____
cognitive demand ; cognitive fatigue ; agitation and irritability
decreased executive function presents as
misbehavior
patient is diagnosed with a moderate TBI and has significant affect/behavioral changes upon meeting them. which outcome measure is most appropriate to use?
agitated behavior scale
which outcome measure is this?
- measures behavioral aspects of agitation during the acute phase of recovery from a TBI
- measures aggression, disinhibition and lability
- can also be used with dementia
agitated behavioral scale (ABS)
ABS scoring:
- ___ items scored
- min score ___
- max score ___
- _____ scores are better
- ____ = WNL, ____ = severe agitation
- 14
- 14
- 56
- lower
- </=21 ; >/= 36
what is all included in your neuro screen of a moderate TBI patient?
–> what two are included only if appropriate?
- PROM (tone)
- motor exam
- sensory exam
- reflexes (identify improved CNS control)
- postural stability
- gait
what are the 6 outcome measures that look at gait, balance, and transfers for a general neurologic injury?
- 6 MWT
- 10 MWT
- Berg balance scale
- functional gait assessment (FGA/DGI)
- activities-specific balance confidence scale
- 5x sit to stand test
what 3 outcome measures are recommended for TBI in the inpatient setting?
FAM+FIM
Barthel index
Disability Rating Scale
what 3 outcome measures are recommended for TBI in the outpatient setting?
high level mobility assessment
community balance and mobility scale
quality of life after brain injury
14 item scale designed to measure balance of the geriatric adult or neuro patient in a clinical setting to assess for fall risk and takes 15-20 minutes to administer
- Has static and dynamic balance tests
Berg balance scale
Berg balance scale scoring:
- higher score =
- score of _____ = independent
- score _____ = fall risk
- is this the best outcome measure for a TBI pt? why or why not?
- higher function
- 45-56
- < 45
- no, ceiling effect possible
measures confidence in performing various activities without losing balance or experiencing unsteadiness
- self report measure
Activities specific balance confidence scale (ABC)
what is the disadvantage of the ABC scale?
subjective to patient
self-efficacy plays a role
consists of 12 items added to the FIM to enhance its utility for the brain injury population
FAM (functional assessment measure)
assesses ability of an individual with a neuromuscular or msk disorder to care for him/herself
- inpatient rehab measure
- not specific to TBI or stroke
barthel index
Barthel index scoring:
- high scores =
- scoring based on _____
- more independence
- amount of assistance required
the Barthel index is similar to the _____ but it includes ____
FIM
evaluation of independence
observer rated measure of general functional changes over the course of recovery for individuals with moderate to severe TBI
Disability Rating Scale (DRS)
the DRS evaluates 8 areas of functioning in 4 categories. what are the 4?
- consciousness
- cognitive ability
- dependence on others
- employability
DRS scoring:
- rated on scale of 0 to either ___ or ____
- high score =
- max score =
- min score =
- 3 or 5
- higher level of disability
- 29-extreme vegetative state
- 0-person without disability
designed to assess high level motor performance in TBI patients
- must be able to ambulate independently 20 meters w/o AD
- used in outpatient setting
High level mobility assessment tool (HiMAT)
what type of activities are performed in the HiMAT?
13 items - running, skipping, hopping, jumping, stairs at max safe speed
HiMAT scoring:
- higher scores =
- total scores range ____
- normative values (18-25 y.o) –> males: ____ females: _____
- greater performance
- 0-54
- males: 50-54
females: 44-54
used to detect high level balance and mobility deficits based on tasks that are commonly encountered in community environments
community balance and mobility scale
community balance and mobility scale is similar to HiMAT but …
not specific to TBI
community balance and mobility scale scoring:
- score of 0 =
- score of 5 =
- max score of
- high score =
- complete inability to perform the task
- most successful completion of the item possible
- 96
- high function
what is the main PTs role in the subacute phase for moderate TBI interventions?
- motor relearning or return to mobility (compensation vs restoration)
what rancho level should the PT focus on:
- managing behavior agitation in subacute phase
Rancho level IV –> reorientation is primary focus
what rancho level should the PT focus on:
- managing orientation/cognition in subacute phase
rancho level V and VI
intervention considerations for a moderate TBI pt:
- practice should be ______
- self ____ and executive _____
- ___ ____ performance
- _____ conditioning
- distributed with frequent rest periods
- efficacy ; function
- dual task
- aerobic
what are 3 options for more alert patients w/ moderate TBI to help with return to mobility?
standing frame
body weight support system
sabina lift
what are considerations for providing behavior managment?
- work on familiar activities in closed environment
- use your ANS to regulate theirs (calm, open, low stimulation)
- do not escalate with them
- promote your safety and theirs first
- develop behavior modification plan (rancho V and VI)
what are considerations for providing cognition/executive function interventions?
** this is focus of SLP and OT interventions, but we need to reinforce them
- promote safety and appropriate behavior
- start simple
- incorporate cognitive thought into mobility (mental walkthroughs, self reflection)
considerations for providing caregiver training for a moderate TBI patient if they need:
- physical assist
- supervision for cognition
- body mechanics and equipment
- safety strategies, redirection techniques, stimulation schedules, behavioral management, de-escalation techniques
when developing your plan of care and focusing on community reintegration after discharge, what are some things you need to do/consider?
- help pt set their own schedule
- interdisciplinary emphasis on return to work, school and pragmatic situations
- emphasize self-responsibility
- encourage independent and cooperative work
- emphasize need for exercise
what outcome measure could you use for a TBI patient after community integration?
quality of life after brain injury questionnaire
quality of life after brain injury questionnaire scoring:
- ______ self rated items
- 0 =
- 100 =
37 self rated items
0 = worst possible QOL
100 = best possible QOL
