TBI

Question 1

Describe Level 1 of the Rancho Los Amigos Scale

Answer 1

“NO Response”

Will not respond to sounds, sights, touch, or movement

Question 2

Describe Level 2 of the Rancho Los Amigos Scale

Answer 2

“Generalized Response”
Begins to respond to sound sight and touch
Responds slowly, inconsistently, or after a delay
Responses=Chewing, sweating, breathing faster, moaning, moving, and increased blood pressure

Question 3

Describe level 3 of the Rancho Los Amigos Scale

Answer 3

“Localized Response”
Awake intermittently throughout the day
Reactions match stimulus more accurately (withdrawing from pain, or turning to sound)
Begin to recognize family and friends
Follow simple directions “Look at me”
Responds inconsistently to yes and no questions

Question 4

Describe level 4 of Rancho Los Amigos Scale

Answer 4

"Confused and Agitated" 
Confused and Frightened
Overreact to stimuli due to confusion
Highly focused on basic needs
May not understand when people are trying to help
Difficulty following directions
Can do simple routines with help
Attention span limited to seconds at a time

Question 5

Describe level 5 of Rancho Los Amigos Scale

Answer 5

"Confused and Inappropriate"
Attend for a few minutes at a time
No orientation to date and location
Needs step by step directions for self care tasks
Confabulates due to poor memory
Easily stressed and overloaded
Perseverates on thoughts and actions

Question 6

Describe level 6 of Rancho Los Amigos Scale

Answer 6

"Confused and Appropriate"
Remembers main points, but forgets details
Follow consistent schedule with assist
Knows month and year
Attends for ~30 mins
Completes ADLs with minimal assist
Impulsive with speech
Aware of physical issues, but  not cognitive.

Question 7

Describe level 7 of Rancho Los Amigos Scale

Answer 7

“Automatic and Appropriate”
Follows a set schedule
Completes ADLs independently
Lacks problem solving skills in new situations
Problems with planning, initiating and completing
Inflexible or rigid in thinking

Question 8

Describe level 8 of Rancho Los Amigos Scale

Answer 8

“Purposeful and Appropriate”
Realizes there is a cognitive problem and begins to compensate
Ready for driving and job training evaluations
Poor judgement in novel situations.

Question 9

What is good bed positioning in the Acute phase of a TBI?

Answer 9

Side lying, or semi-prone to normalize tone and provide sensory input

Question 10

What is a Severe score on the Glascow Coma Scale?

Answer 10

Below 8

Question 11

What is a moderate score on Glascow Coma Scale?

Answer 11

9-12

Question 12

What is a minor score on Glascow Coma Scale?

Answer 12

Greater than 12

Question 13

What are the three categories for the Glascow Coma Scale?

Answer 13

1. Eye response
2. Verbal Response
3. Motor Response

Question 14

If a person is showing a decorticate posture in response to pain, responding with moans, and opening their eyes only to pain… What is there score on the GCS?

Answer 14

Motor: 3
Verbal: 3
Eyes: 2
8- Moderate TBI

Question 15

If a person is opening their eyes to speech, responding to words inappropriately, and withdrawing from a painful stimulus, what is their score on the GCS?

Answer 15

Motor: 5
Verbal: 3
Eyes: 3
11- Moderate TBI

Question 16

What are the four eye responses and their corresponding scores on the GCS?

Answer 16

1= No response
2= Eyes open to pain
3=Eyes open to speech
4=Full control of eyes

Question 17

What are the 5 verbal responses with corresponding scores on the GCS?

Answer 17

1- no response
2-Moaning
3-Random words
4-Inappropriate and confused verbal response
5-Oriented to conversation

Question 18

What are the 6 motor responses with corresponding scores on the GCS?

Answer 18

1- No response
2-Decerebate posture in response to pain
3-Decorticate posture in response to pain
4-Withdraws from pain
5-Tries to remove painful stimulus
6-Obeys verbal commands