TBI Flashcards
What is Level 1 Rancho?
No response: total assistance
Complete absence of observable changes in behavior when presented visual, auditory, tactile, proprioceptive, vestibular, or painful stimuli
What would your treatment look like for Rancho level 1?
Pain response: sternal rub, pinch fingernail, foot stimulus
PROM: assess first then teach family how to do it
Pressure relief: make sure nurses don’t put pillows under knees
Use coma stim form to work on things they respond too
Use strong stimuli to see if you get a response: rubbing arm with sandpaper, bad tastes, bad smells, etc
At risk for pulmonary issues: may be doing suctioning or other pulmonary work
T/F: coma stim is an evaluative objective measure?
True
What is Rancho level II?
Generalized response: total assistance
Demonstrates generalized reflex response to painful stimuli
Responds to repeated auditory stimuli
Responds to external stimuli with physiological changes generalized, gross body movement and/or not purposeful vocalization
Responses inconsistent and delayed
Responses may be significantly delayed
T/F: with rancho level II we should give them time to respond to short instructions
True
What are treatment ideas for rancho level II?
Do things with touch: “Make a sound when I touch your arm with something rough” or “When I touch your fingers I want you to move them”
Must expose them to stimuli, if not they might not get better.
Need to get brain moving again
Small tiny movements of recovery
What is Rancho level III?
Localized response: total assistance
Demonstrates withdrawal or vocalization to painful stimuli
Turns toward or away from auditory stimulus
Blinks when strong light crosses visual field
Follows moving object passed within visual field
Responses: discomfort by pulling tubes or restraints; inconsistent to simple commands, come persons but not to others
What are treatment ideas for Rancho Level III?
Make sure you introduce yourself, tell them where they are and what happened
Turn on their favorite music, get their favorite picture and have them follow you around the room with their eyes.
Positioning is key, keep head in neutral
Get family and nursing on same page with communicating: finger lifts
At this stage reflexes cause movement so educate them on it and see if the movement is consistent and if it isn’t it’s just a reflex
What is Rancho level IV?
Confused/agitated: max assist
Alert and in heightened state of activity
Purposeful attempts to remove restraints/tubes or crawl out of bed
May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another’s request
Very brief and usually non purposeful moments of sustained alternatives and divided attention
Absent short term memory
May cry out or scream to stimulus
May exhibit aggressive or flight behavior
Unable to cooperate with treatment efforts
Verbalizations are frequently incoherent and/or inappropriate
Consistent routine important
What are treatment considerations for Rancho level IV?
Since absent short term memory we may need to be repetitive or redirect them
See if they can recall things you worked on the other day.
May need to compromise their treatment plan to get them to cooperate.
Get creative to get them to participate
They may get angry with you, may not like noise, may not like standing next to a certain person
What do people with TBI act out at level IV stage?
Frontal lobe not intact (Sandy emphasized this)
Other possibilities: lack of short term memory, frustrated, want control, only way they know how to communicate
What is Level V Rancho?
Confused, inappropriate non agitated: max assist
Alert, not agitated (unless external stimulus or lack of structure)
Brief periods, non purposeful sustained attention
Severely impaired recent memory, confusion of past/present
Absent goal directed, problem solving, self monitoring behavior
Performs previously learned tasks: structured and cues
Unable to learn new information- simple commands
Social behavior
Confabulation
What are treatment considerations for level V rancho?
Work on goals and problem solving
Work on their memory and recall: “can you go get puzzle we did yesterday?”
People float between level IV and V so they may have outbursts
What is rancho level VI?
Confused, appropriate: mod assist
Inconsistently oriented to person, time and place
Attend to highly familiar tasks no distractors x30 min (mod redirection)
Vague recognition of some staff
Uses assistive memory aide with max assist
Emerging awareness of appropriate response to self, family and basic need
Carry over for relearned familiar tasks, limited new learning
Unaware of disability, impairments and safety
What are treatment considerations for rancho level VI?
Still have trouble orienting to person so may need to gain trust
May need to work in quieter areas since they need to work w/o distractors
For new activities may need to practice more or go slower
What is rancho level VII?
Automatic, appropriate: minimal assist for daily living skills
Consistently oriented to person and place: highly familiar environment, moderate assistance for orientation to time
Attend to highly familiar tasks: non distraction environment for at least 30 min with minimal assist to complete tasks
Initiates and carries out steps to complete familiar personal and household routine: shallow recall of what he/she has been doing
Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with min assist
Min supervision for safety in routine home and community activities
Unrealistic planning for future
Unable to think about consequences of a decision or action
Overestimates abilities
Unaware of others needs and feelings
Oppositional/uncooperative
Unable to recognize inappropriate social interaction behavior
What are treatment considerations for rancho level VII?
Since they are consistent with orientation to person and place: “meet me at elevator at 9 for therapy”
Since they are able to complete each step of ADLs: I want you to be done with breakfast, and dressed by the time I get here at 9
Hard stage because of unrealistic plans
:It’s about me stage”
What is rancho level VIII?
Purposeful, appropriate: standby assist
Consistently oriented to person, place and time
Attends to and completes familiar tasks with distractions
Recall and integrate past and recent events
Independent with assistive memory devices for recall, “to do” lists and record critical information SBA
Complete household, community, work, and leisure routines with SBA
Can modify the plan when needed with min assist
Over/underestimate abilities
Depressed or irritable
What is treatment for level VIII?
High level activities
May regress at this stage because they are close to going home and don’t feel ready
What is Rancho level IX?
Purposeful, appropriate: standby assist on request
Independently shifts back and forth between tasks and completes them accurately
Uses assistive memory devices to recall daily schedule, “to do” lists, and record critical info
Initiates and carries out steps for household, work, and leisure tasks independently
Aware of and acknowledges impairments and disabilities when they interfere with task completion
Takes appropriate corrective action but requires stand by assist to anticipate a problem before it occurs and take action to avoid it
Thinks about decisions and consequences
Depression may continue/may be easily irritable/low frustration tolerance
Self monitors appropriateness of social interaction with SBA
What are treatment ideas for rancho level IX?
High level complex activities: recipes, go to grocery store, what did OT want you to do, balance on bosu, kitchen activities
What is Rancho level X?
Purposeful, appropriate: modified independent
Handles multiple tasks simultaneously in all environments: independently initiates and carries out steps for completion of familiar and unfamiliar personal, household, community, work and leisure tasks
May require more than usual amount of time and/or compensatory strategies to complete tasks
Anticipates impact of impairments and disabilities
Thinks independently about decisions/consequences
Estimates abilities for tasks
Recognizes other’s feelings and thoughts
What are parts of acute care rehab for TBI?
ICU and acute care: ortho rehab (hip or other joint precautions), neuro rehab, coma stimulation, cardiopulmonary, general bed mobility and transfers
What are rehab options after hospital?
Rehab unit
Brain injury facility: meadowbrook rehab, moss rehab, Kessler rehab, timber ridge
Skilled nursing
Outpatient
What are reach dysfunctions in TBI?
Timing problems
Impaired inter limb coordination
Proximal weakness
What are psychosocial functioning in TBI?
Work employment: 85% loss after 6 months post injury, 70% loss after 1 year injury
Social and leisure activities: social contacts dropped by 25-35%, leisure activities dropped by 25%
What is definition of prevocational training?
Approach to recovery
Undergo a period of preparation
Occurs prior to seeking competitive employment
Involves: landscaping, animal care, yard and home maintenance projects, group and individual projects, social interaction, janitorial, office work/clerical, recycling program
What are “other” challenges post TBI?
Schizophrenia/paranoia Substance abuse Behaviors/inappropriateness Psychological/mental disorders Psych disorders/dual diagnosis
Post TBI patients revealed high rates of…?
Major depression Bipolar affective disorder Generalized anxiety disorder Borderline and avoidant personality disorders Good/evil debate Voices
What are psychological/mental disorders found in post TBI patients?
Illness with psychological or behavioral manifestations and/or impairments in functioning
Varied symptoms and inability to function/perform at an adequate level in society: anxiety, mood swings, confusion, paranoia, impaired self control, inappropriate behavior regarding sexual activity
What are some psych disorders/dual diagnosis?
Borderline personality disorders Depression/emotional labile Bipolar disorders Social recluse Poor judgement: prison, attention seeking behaviors
What are behavior management and behavior intervention for challenges post TBI?
Management: teacher role- consistent, systematic, trusting relationship
Intervention: antecedents, behaviors, consequences, recognize and respond to precursors, de-escalation strategies (rational detachment, integrated experience), verbal intervention tips (remain calm, avoid power struggles, isolate situation)
What is role of PT in TBI?
Whole person (all aspects of personal well being) Realistic and functional goals Community re-entry Behavior modification/treatment plan: conjunction with team including psychologist
What are some examples of “out of the box” treatment strategies?
Tim’s paper
Tyler motivated by food: grapes, clips on bball net, shaving cream
Sensory integration: ball, sheet swing
Step aerobics/coordinated movements
Rice/beans for object location
Sensory integration
Neuro re-ed
Sitting on wobble board
Post-it notes: write sayings on them and make them go find specific ones
Videos/computer: slide show of pictures with yes/no questions
What are considerations for sports related injuries?
Conservative approach to return to play
Seek medical attention when signs/symptoms present
