TBI ranchos los amigos scale

Question 1

I

Answer 1

• coma, no response

Question 2

II

Answer 2

• generalized response
• inconsistent, whole body movement, vocal, non-purposeful

Question 3

III

Answer 3

• local response
• purposeful - can follow simple commands: ex squeeze hand, close eyes
• inconsistent
• can track objects

Question 4

treatment for I,II,III

Answer 4

• positioning: head neutral, prevent ulcer, sit (if stable)
• gentle prom, joint and skin integrity
• resp care: postural drainage, percussion, vibration
• family education - what to expect/how to be more involved

Question 5

IV

Answer 5

• confused and agitated
• confabulate, agressive, doesnt cooperate, verbalization is incoherent
• cannot form new memories: no long or short term mem
• no selective attention
• NOT oriented to date, time, location

Question 6

treatment for IV,V,VI

Answer 6

• closed environment
• SAME therapist
• establish a routine
• reintroduce self, and family should reintroduce self daily
• orient pt to place and time: calendar, clock
• use chart and graph to measure progress because no memory
• calm behavior - DO NOT confront
• no yes/no questions - give choices so feel like theyre in command

Question 7

V

Answer 7

• confused inappropriate
• can socialize for short period of time with struture
• respond consistently to simple commands
• respond inconsistently to complex commands
• memory impaired, cant learn new tasks
• inapropriate use of obkects

Question 8

VI

Answer 8

• confused appropriate
• can be goal oriented now with external input
• follow simple instruction consistently
• memory: carryover of previous skills present (self-care)

Question 9

VII

Answer 9

• automatic appropriate
• oriented to hospital and home
• can do daily routine automatic/robot-like
• can initiate social or recreational activity with structure

Question 10

VIII

Answer 10

• purposeful appropriate
• carryover of new skills present
• impaired judgement in emergency situation, abstract reasoning and reduced stress tolerance

Question 11

manage levels VII, VIII

Answer 11

• re-entry to work and community
• problem solving, social interaction
• trial period of independent living
• adaptation at work or school to return to normal life