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
