TBI Flashcards
GCS - best eye response
4
- No eye opening
- Eye open to pain
- Eye open to verbal command
- Eyes open spontaneously
GCS - best verbal response
(5)
- No repsonse
- Incomprehensible sounds
- Inappropriate words
- Confused
- Oriented
GCS - best motor
(6)
- No motor reponse
- Extension to pain
- Flexion to pain
- Withdrawal from pain
- Localizing pain
- Obeys commands
GCS grading
> 13, mild
9-12 moderate
8 or less, severe
Rancho 1
No repsonse: total assist
Complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular, or painful stim
Rancho 2
Generalized repsonse: total assist
Demonstrates generalized reflex to painful stim,
Responds to repeated auditory stim w/ increased or dec activity
Responds to external stim w/ PHYSIO changes generalized gross body movements, not purposeful vocaliziation
Response may be same regardless of type/location of stim
Repsonse may be sig delayed
Rancho level 3
Localized repsonse: total assist
Withdrawal/focalization to painful stim
Turns toward/away from audio stim
Blinks when strong light crosses visual field
Smooth pursuit
Responds to discomfort by pulling tubes/restraints
Responds inconsistently to simple commands
Responds directly related to type of stim
May respond to some persons but not others
Rancho levels 1-3
Just emerging from coma, physically very dep, sleep a lot
Level 4
Confused/agitated: max assist
Alert and in highented state of activity
Purposeful attempts to remove restraints/tubes/crawl OOB
Motor activities w/out any apparent purpose or upon another request
Absent short term memory
Aggressive or flight behavior, mood swings
Verbalizations incoherent/inappropriate to activity/enviro
Rancho level 5
Confused, inappropriate, non agitated- max assist
Not orientedto PPT
Frequent brief periods, non purposeful sustained attention
Impaired recent memory, confusion of past and present
Absent goal directed, problem solving, self monitoring behavior
Unable to learn new info
Respond appropriately to simple commands fairly consistently w/ external structure and cutes
Need external structures and cues to be appropriate w/ conversation
Rancho level 6
Confused, appropriate: mod assist
Unaware of impairments, disability, safety risk
Inconsisten orientated to PPT
Able to attend to highly familiar tasks in non distracting enviro 30 mins
Remote memory has more depth than recent
Vague recognition of some staff
Assistive memory aid w/ max A
Emerging awareness of appropriate response to self, family, basic needs
Carry over for learning familiar tasks
Max A for learning new w/ little to no carryover
Rancho level 7
Automatic, appropriate: min A for daily living skills
Unrealistic planning for future, unable to think about consequences, overestimates abilities, unaware of others needs/feelings
Oppositional uncooperative
Unable to recognize inappropriate social interaction behaviors
Min A for new learning, carry over
Initiates ADLS, but shallow recall of what he was doing
Rancho level 8
Purposeful and appropriate SBA
I attends to/completes familiar tasks for 1 hour in distracting enviro
Able to recall and integrate recent and past events
Recall daily schedule/to do
Can modify plan w/ min A
Thinks about consequences. Of decision w/ min A
Depressed, irritable, low frustration tol/ easily angered, argumentative, self centered,
Able to recognize/acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action w/ min A
Ranch level 9
Purposeful appropriate: SBA on request
Consequences, accurately estimates abilities but SBA to adjust task demands
Acknowledges others needs/feelings, responds appropriately w/ SBA
Self monitory appropriateness of social interactions w/ SBA
Rancho level 10
Purposeful, appropriate, mod I
Multiple tasks simultaneously but may require breaks
Able to indep create/maintain own assisted memory device
Level 1 goal
Elicit generalized repsonse to any sensory input
Level 1 sensory stim
Always give clear explanation May affect reticular activating system 1 sense at a time Don’t allow for accommodation, Short, frequent sessions
Types of stim
Gustatory Olfactory Auditory Visual Tactile Vestibular Noxious
Level 2 pts react
Inconsistently and non purposefully to stim in a nonspecific manner
Level 2 to priorities
- Continue bed positioning as needed. Introduce wheelchair positioning program.
- Communication of positioning changes with interdisciplinary team/goals
- ROM: Maintain joint mobility and muscle flexibility. Inhibitory casts or splints if needed.
- Closely monitor for changes in status
Level 2 tx goals
- Elicit localized repsonse
- Increase non reflexive repsonses
- Begin to introduce appropriate postural set for functional activities, as tolerated
Level 2 application of stim
Sit pt up
Use stim that most consistently elicits a desired response
Level 2 light touch
Midline perioral area facilitates UE flexion
To dermatome of t10 facilitates LE flexion
Level 3 response
Specifically but inconsistently
Level 3 tx priorities
- Maintain joint mobility and flexibility
- Comm of postural and mobility goals
- Structure tx to encourage functional activities
Level 3 goals
Increase repsonse consistency
Channel repsonses into functional activities
Level 3 posture
Provide correct postural set to give pt optimal chance to repsond motorically
Level 4
Alert and in heightened state of activity, purposeful attempt to remove restraints or tubes/crawl out of bed
May perform motor activities
Aggressive or flight behavior
Level 4 tx goals
- Consistent ID comm, manage and avoid escalation of inappropriate behavior
- Decrease intensity, duration, frequency of agitated repsonses.
Increase attention, orientation, and repsonse to specific stim
Level 4 tx strategy
Non threatening and calming
Elim noxious stim
Never approach/startle
Use automatic repsonses/movements incorporated into therapy
Level 4 consistency
Physical exercise or recreation activities to channel restless behavior
Safe area to move
Set boundaries for safe release
Family instructions for level 4
Don’t force pt to do things
Give breaks and change activities frequently
Keep room quiet and calm
Limit visitors to 2-3 at a time
One to one supervision
Highest level 24 hour supervision
Bracelet
whoever has the key or bracelet is responsible for the patient the entire time that they have it. Must be passed on to the next staff member with patient
Eyes on
everyone in immediate area keeps an eye out for this patient.
– No single person responsible
– May have specific rooms
Restraints
any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the patient’s ability to move his or her arms, legs, body, or head freely
Last resort, requires ongoing documentation and justification
Level 5 tx goals
- Dec confusion, improve orientation
- Decrease inappropriate behavior
- Increase approp behavior
- Increase attention
- Improve memory
- Improve functional ability
Level 6 tx goal
- Improve orientation and deficit awareness
- Improve selective attention
- Increase initiation
- Improve planning and sequencing
abilities - Increase functional ability
Level 6 tx strategy
• Begin to add variation into daily routines
• Participate in a verbal logic and problem-
solving group
• Use safety drills for fire, earthquake, child
emergencies
• Give the patient small responsibilities • Gradually increase steps to your
instructions
Level 7 tx goal
- Increase memory
- Increase safety judgment and problem-
solving abilities - Improve learning
Level 8 goals
- Determine ability to return to school or job
- Improve reasoning, tolerance to high
stress, and high-level problem solving 3. Improve ability to function in unfamiliar
settings and situations
Level 8 strategies
• Focus on community mobility and
navigation
• Referral to transitional living center
• Referral to pre-vocational or vocational
program
• Referral to community re-entry program
Level 9 and 10 tx goal
- Focus on appropriate social behavior
- Community reintegration in school, job,
recreation - Independent/supervised living
MDC: Minimal Detectable Change
Statistical estimate of the minimum amount of
change in a score required to ensure that the change isn’t the result of a measurement error
MCID: Minimal Clinically Important
Difference
Published value that indicates the minimum
amount of change required for your patient to feel a difference in the variable you are measuring.
dual-task effect
DTE
relative change in performance
associated with dual-tasking
Dual task TUG cut off in community elderly for increased fall risk
TUG(Cognitive): >15 seconds
If gait speed improves, but the cognitive task
worsens
this is only a trade-off in attention, not a true
improvement in dual-task gait performance
