Rancho Levels TBI Flashcards
NO RESPONSE/TOTAL ASSISTANCE
-no response to external stimuli
- no awareness of himself or herself
-total assistance required
-messages from brainstem do not connect with higher levels of the brain
-in a coma
-eyes closed
-no following of commands, communication, or response to pain
LEVEL I
GENERALIZED RESPONSE/TOTAL ASSISTANCE
-Respond inconsistently and non-purposefully to external stimuli
-Responses are often the same regardless of the stimulus applied
-opening of eyes but no conscious response
-periods of wakefulness
-some return of sleep-wake cycle
-attention severely impaired
-no verbal communication
-awake but unable to follow commands
-unable to localize or attend to voice
-minimal response, delayed, inconsistent
-breathes heavier and tenses up in response to pain
-no verbal or non-verbal response to a question, may exhibit reflexive chewing
-fatigue
LEVEL II
LOCALIZED RESPONSE/TOTAL ASSISTANCE
-Respond inconsistently and specifically to external stimuli
-Responses are directly related to the stimulus
-Tend to be more responsive to familiar people (friends and family) than to strangers
-awake for longer periods of time
-responses are localized and specific
-stares in the direction of sound or voice
-looks at pictures
-grabs tube or catheter
-pulls away from pain
-no verbal communication–> Responses are inconsistent or delayed
-starting to recognize objects
-decreased arousal
** allow up to 10 seconds for a response before repeating
LEVEL III
CONFUSED/AGITATED/MAX ASSIST
-In a hyperactive state with bizarre and non-purposeful behavior
-Demonstrate agitated behavior that originates more from internal confusion than the external environment
-yelling, foul language, hitting, yelling, restless, short attention span
-confabulation- makes up stories to fill memory
-can complete tasks with structure
-lability
-unable to attend and recall new info
-Max assist with familiar tasks
TREATMENT:
-keeping loved ones safe and reducing agitation and restlessness
-may need an attendant or specialized bed
-adequate rest periods
-do activities they enjoy
-keep stimulation low, prevent cross-talk
-limit amount of visitors
GOALS:
-brushing teeth
-writing name
-sorting objects by color
-simple activities they enjoy doing
LEVEL IV
CONFUSED/INAPPROPRIATE/
NONAGITATED/MAX ASSIST
-increased consistency with following and responding to simple commands
-purposeful and random responses to complex commands
-confusion and confabulation common
-behavior and verbalization can be inappropriate
-lack of task initiation
-can perform task or action if modeled first
-memory severely impaired–> post-traumatic confusional state
-need step-by-step assistance to perform simple tasks
-max supervision required for safety
-may wander
-decreased awareness and understanding of injury
-limited problem-solving ability
-poor attention to tasks and does not recognize errors
-can show agitation to unpleasant external stimuli
LEVEL V
CONFUSED/APPROPRIATE/MOD ASSIST
***EMERGED FROM PTA –> Orientation to date and location is better
-executive functioning still impaired
-Able to follow simple commands consistently
-Able to retain learning for familiar tasks they performed pre-injury (brushing teeth, washing face) but are unable to retain learning for new tasks
-Demonstrate an increased awareness of self, situation, and their environment
-are unaware of any specific impairments and safety concerns
-Responses may be incorrect secondary to memory impairments but appropriate to the situation
-still difficulty with problem-solving
-can start to name deficits of injury
-use of memory planner to remind self of important info
-lack of insight about how deficits impact pre-injury activities
-emotional lability
-mod assistance for recall
-decreased flexibility of thought
FOCAL INJURIES
-left or right-sided weakness
-comprehension deficits
-word-finding problems
TREAT:
-consistency and predictability is key
LEVEL VI
AUTOMATIC, APPROPRIATE/MIN ASSIST
-Oriented in familiar settings
-consistent day-to-day memory
- wake-fullness, awareness, perception, attention, and memory improved
-still difficult to remember specific details
-Able to perform a daily routine automatically with absent to minimal confusion (can initiate going to therapy sessions independently)
-Demonstrate carry-over for new tasks and learning in addition to familiar tasks
-Can be superficially aware of diagnosis but unaware of specific impairments
-Continue to demonstrate a lack of insight, decreased judgment, and safety awareness
-Beginning to show interest in social and recreational activities in structured settings
-Require at least minimal supervision for learning and safety purposes
-decreased competence in performing tasks in distracting or stressful situations
-may have rigid and inflexible thinking
-overestimates abilities
-concrete thinking
-slow processing speed
-poor attention to details
-minimal awareness of errors
THINK ABOUT FOCAL DEFICITS
-physical or communication
-executive function
LEVEL VII
PURPOSEFUL, APPROPRIATE/SBA
-consistently oriented to person, place, time
-may be ready to think about returning to work or school
-assistance or reminders to use compensatory strategies (SBA)
-cog deficits remain: attn, memory, reasoning, problem-solving
-awareness and acknowledgment of behaviors increases
-can perform routine activities in a non-distracting environment
-improvement in organization and exec functioning skills
-difficulty with social interaction skills, but can recognize when social interactions go astray
-increased insight and self-evaluation
-starts to see how specific impairments interact with tasks
-use assistive memory devices to recall daily schedule
-can acknowledge the emotional states of others –> min assist to respond appropriately
-increase in consolidation of past and future events
-can be depressed, irritable, frustrated, argumentative
LEVEL VIII
PURPOSEFUL, APPROPRIATE/SBA ON REQUEST
LEVEL IX
-need SBA to adjust to a new task
-accurately estimates abilities
-better understanding of the consequences of decisions and actions
-awareness of fatigue
-needs rest breaks
-increased frustration related to limitations
-Uses assistive memory devices to recall daily schedule, “to do” lists and record critical information for later use with assistance when requested
-Initiates and carries out steps to complete familiar personal, household, work and leisure tasks independently and unfamiliar personal, household, work and leisure tasks with assistance when requested
-is aware of and acknowledges impairments and how they can interfere with task completion
-requires SBA to adjust to task demands
-depression, fatigue, and low frustration tolerance may still persist
-can acknowledge others’ needs and feelings and appropriateness of social interactions with SBA
PURPOSEFUL, APPROPRIATE/MODIFIED INDEPENDENT
- independent with everything within their physical capabilities
- independently uses compensatory strategies as needed
- most likely able to return to work, school, and volunteer opportunities
- Able to handle multiple tasks simultaneously in all environments but may require periodic breaks
*Able to independently procure, create, and maintain own assistive memory devices
*may require additional time or rest breaks to complete familiar tasks or compensatory strategies
-Able to independently think about consequences of decisions or actions but may require more than usual amount of time and/or compensatory strategies to select the appropriate decision or action
-can INDEPENDENTLY adjust to task demands
-can automatically and independently respond to the feelings and needs of others
-during periods of stress: may increase levels of frustration and irritability
-periodic depression may be present
LEVEL X
Do all ppl progress through all levels?
no
Can you stay at one level forever?
yes
-patients may also regress temporarily
What is the coma recovery scale?
CRS-R a standardized neurobehavioral assessment measure designed for use in patients with disorders of consciousness. The scale is intended to be used to establish diagnosis, monitor behavioral recovery, predict outcome, and assess treatment effectiveness.
CRS-R: coma
RLA I
-no response
-complete loss of arousal
-no sleep/wake cycle
CRS-R
vegetative state/unresponsive wake-fullness syndrome
RLA II:
-generalized response
-return of sleep/wake cycle
-no behaviors indicating awareness of self or environment
