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OTA 220 - Advanced OT Skills > TBI > Flashcards

TBI Flashcards

1
Q

Modified Ashworth Scale

A

Widely used assessment of muscle tone, scale of 0–4.
0 = no increase in tone
1 = slight increase, manifested by catch/release, or by min resistance at end ROM
1+ = slight increase, manifested by catch, followed by min resistance thru remainder (< half) ROM
2 = more marked increase thru most of ROM, but affected part(s) are easily moved
3 = considerable increase, passive movement difficult
4 = affected part(s) rigid in flex/extension

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2
Q

Richmond Agitation Sedation Scale (RASS)

A

Scale used to determine pt’s level of consciousness, on scale from +4 to -5

\+4 = combative/danger to staff
\+3 = very agitated/aggressive/removes tubes
\+2 = agitated/non-purposeful mvmnt, fights vent
\+1 = restless/anxious, non-aggressive mvmt
0 = alert and calm/spontaneously pays attn to caregiver
-1 = drowsy/not fully alert, but wakes to voice; eye open/contact >10 sec
-2 = light sedation/brief awakening; eyes open/contact <10 sec
-3 = moderate sedation/mvmt, eye open to voice; no eye contact
-4 = deep sedation/no resp to voice, but to physical stimulation
-5 = unarousable/no response to voice or physical stim
  • **RASS >/equal -3, proceed to CAM-ICU assessment
  • **RASS -4/-5, STOP and RECHECK later
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3
Q

Confusion Assessment Method for the ICU (CAM-ICU)

A

Used to evaluate delirium. USE EVERY SHIFT (8-12 hrs). Follow through Features (steps) to determine pt’s delirium level, resulting in delirium present/absent.

FEATURE 1/ALTERATION IN MENTAL STATUS: Is mental status different than baseline? OR Has pt had flux in mental status in past 24 hr (can ref Glasgow Coma Scale or RASS)? If yes to either, then:

FEATURE 2/INATTENTION: Use letters attention test. “I’m going to read you a series of 10 letters, whenever you hear “A,” squeeze my hand.” S A V E A H A A R T (count each fail). If number of fails >2, then:

FEATURE 3/Altered LOC: RASS anything OTHER THAN 0 (alert/calm), OR SAS is anything OTHER THAN 4 (calm). If yes to either, then:

FEATURE 4/Disorganized Thinking: Ask pt YES/NO questions. “Will a stone float?” “Are there fish in the sea?” “Does 1 pound weigh more than 2 pounds?” AND/OR Ask pt to follow commands: “Hold up this many fingers.” “Now do the same with the other hand.” ADD all errors. If errors >1, then:

***If both Features 1-2 are present AND 3 OR 4 are present, CAM-ICU is POSITIVE/delirium present.

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4
Q

Rancho Levels of Cognitive Function-ing (RLA Levels)

A

Level of cognitive function based on response/attention/learning, from Level I to Level VIII.

LEVEL I = No Response, Total Assistance required
LEVEL II = Generalized Response, Total A; same response to everything
LEVEL III = Localized Response, Total A; more specific/inconsistent responses
LEVEL IV = Confused, Agitated, Max A; frightened, overreact, unable to concentrate more than few seconds
LEVEL V = Confused, Inappropriate, Nonagitated; Max A; pays attn only few minutes; not OX4; poor memory; overwhelmed
LEVEL VI = Confused, Appropriate; Mod A; attn for 30 min; better OX4, but think they can go home
LEVEL VII = Automatic, Appropriate; Min A; self-care independently; follow schedule; can learn but have unrealistic expectations/unable to initiate
LEVEL VIII = Purposeful, Appropriate; Standby A; aware of problems, begin to compensate; focus up to 1 hour; potential to return to work/driving

  • **LEVELS I-III = TOTAL ASSIST
  • **LEVELS IV-VI = CONFUSED (hard to learn)
  • **LEVELS VII-VIII = AUTOMATIC (new learning)
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5
Q

Most important to consider this when using CAM-ICU:

A

The patient’s baseline mental status.

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6
Q

RASS -4, what would you do?

A
  • Do not expect pt to participate in tx

* Do not proceed with CAM-ICU assessment

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7
Q

RLA Level II; intervention to reactivate neural pathways prior to injury?

A

Guide the patient to wipe their mouth. Use functional sensory stimulation that is within their ability at the time.

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8
Q

RLA Level I-III, how to use con-trolled sensory input to increase neurological signals?

A

Introduce ISOLATED sensory input. Level I-III are too low cog. function for too much stimulation.

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9
Q

Pt emerging from vegetative to minimally conscious state; what is most appropriate to incorporate into tx?

A

Ask the patient situational orientation questions. See if they know where/who they are? What time of day? Who you are?

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10
Q

RLA Level II pt response to OT tx:

A

Limited responses, often the same regardless of the stimulus presented. (ie: always says “Yes.”)

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11
Q

Pt unable to make small adjustments in distal/proximal ends of extremities in order to make smooth movements

A

Ataxia

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12
Q

Appropriate education to provide staff in care of RLA Level II?

A
  • Fluctuations in tone as result of changes in position.
  • Fluctuations in tone as result of volitional mvmnt.
  • Fluctuations in tone as result of changes in environmental factors.
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13
Q

RLA Level III pt developing spasticity in BUE; educate family on:

A

Spasticity as an involuntary increase in muscle resistance that is dependent on velocity (use simpler terms).

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14
Q

RLA Level III pt has loss of PROM and hard end feel in elbow; you should:

A

Notify the MD because this is most likely the result of heterotopic ossification (bone build up in joint). Easy to determine with x-ray.

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15
Q

RLA Level I

A

No Response; Total Assist needed.

• May be unresponsive to sounds, sights, touch, mvmnt

  • Keep room calm/quiet.
  • Keep comments/qs short, simple.
  • Explain what is about to be done using calm tone.
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16
Q

RLA Level II

A

Generalized Response; Total Assist needed.

  • May begin to respond to sounds, sights, touch or mvmnt.
  • May respond slowly, inconsistently, delayed
  • May respond IN SAME WAY to what they hear/see/feel. Responses may include chewing, sweating, moaning, incr BP.

(Same approach as Level I):
• Keep room calm/quiet.
• Keep comments/qs short, simple.
• Explain what is about to be done using calm tone.

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17
Q

RLA Level III

A

Localized Response; Total Assist needed.

  • May be awake on/off
  • May move more; react with more specificity/inconsistently.
  • May react slowly, begin to recognize family/friends
  • May follow simple instructions; answer yes/no qs
  • Limit visitors to 2-3 ppl
  • Allow extra time to respond; may be incorrect
  • Allow rest periods; remind person of OX4
  • Bring favorite belongings/photos
  • Engage in familiar activities (music, combing hair, etc.)
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18
Q

RLA Level IV

A

Confused, Agitated; Max Assist needed.

  • May be very confused and frightened
  • May not understand feelings/what’s happening
  • May overreact to stimuli (may need restraint)
  • May not understand why they’re being helped
  • May not pay attn longer than a few seconds
  • May begin recognizing familiar people/activities
  • Allow as much mvment as is safe
  • Allow pt to choose activities; follow their lead (do not force)
  • Give breaks and change activities esp if agitated
  • Keep room quiet/calm; limit visitors 2-3 ppl
  • Find calming activities
  • Bring in memorabilia
  • Remind where they are; that they are safe; take person through environment to familiarize
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19
Q

RLA Level V

A

Confused, Inappropriate, Nonagitated; Max Assist needed

  • May be able to pay attn only a few mins
  • Difficulty making sense of surroundings, OX4
  • Need step-by-step instructions to start/complete tasks
  • Become overwhelmed/restless; poor memory (but recall older events clearer)
  • Fill in memory gaps
  • Focus on basic needs
  • Repeat qs/comments; do not assume they remember; keep it simple
  • Tell person OX4 at arrival and departure from room
  • Help person organize/stay on task
  • Limit visitors 2-3 ppl
  • Frequent rest periods when having trouble attending
  • Help connect current goings on with family/friends; reminisce
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20
Q

RLA Level VI

A

Confused, Appropriate; Mod Assist needed.

  • May be confused due to memory/thinking issues
  • Follows schedule with help; needs constant routine
  • May know month/year
  • May pay attn about 30 mins, without distraction
  • Self-care with help
  • Speak quickly, unaware of consequences
  • More aware of problems/hospitalization, but think they’d be fine at home
  • Repeat things; remind of current happenings
  • Encourage them to repeat info
  • Provide cues to start/continue activities
  • Use familiar visual/written info to help memory (calendar)
  • Encourage participating in all therapies
  • Encourage daily journal entries
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21
Q

RLA Level VII

A

Automatic, Appropriate; Min Assist needed.

  • May follow set schedule
  • Routine self-care without help
  • Frustrated with new situations
  • Trouble planning, starting, finishing
  • Can learn but unrealistic in expectations
  • Treat as an adult, with guidance in decisions
  • Validate feelings
  • Do not tease or use slang/jokes
  • Check with drs on restrictions to driving/working/etc.
  • Help participate in family activities
  • Reassure pt that problems are caused by TBI
  • Encourage pt they will benefit from continued tx, even if they feel they are normal
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22
Q

RLA Level VIII

A

Purposeful, Appropriate; Standby Assist needed (safety)

  • May realize they have thinking/memory issues
  • May begin to compensate for problems/be flexible
  • May be ready for driving/job training evals
  • May learn new things but at slower rate
  • Focus up to 1 hour
  • May still become overwhelmed/show poor judgment
  • Discourage drinking/drug use
  • Encourage note taking
  • Encourage self-care, ADLs as independently as possible
  • Discuss coping with anger/feelings
  • Consult with Social Work/Psych for living with TBI
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23
Q

Somnolent

A

Unrousable; no response. RASS of -5 is considered somnolent.

24
Q

How to treat RASS +1 or +2?

A

Manage the patient’s restlessness. Give them something to do. Sit EOB, but do not allow feet to touch floor (avoid them wanting to walk).

25
Q

How to treat RASS -2 or -3?

A

To combat mod sedation, give them vestibular stimulation. Sit EOB to encourage alertness (being vertical can “wake” someone up).

26
Q

RASS score that is ideal starting point to work with a Pt

A

0 = Alert and calm is best. Also workable in +1 to +3, although the Pt becomes more agitated/aggressive.

27
Q

Self-Feeding Issues with TBI

A

Oral Apraxia: inability to perform intended action or exe-cute an act on command with mouth/lips.

Ideational Apraxia: difficulty understanding demands required of self-feeding activity and will be unable to recognize utensils as tools for eating.

Ideomotor Apraxia: Loss of motor planning for self-feeding. May not be able to access motor pattern to bring food to mouth.

Hemianopia: Visual field cut, or visual neglect, preventing client from seeing half the plate of food.

Dysphagia: difficulty completing the four stages of chew-ing and swallowing (caused by cranial nerve/brainstem damage). Can also affect speaking.

28
Q

Graphesthesia

A

Ability to interpret letters written on the hand without visual input. May be impaired with TBI.

29
Q

Retrograde Amnesia vs. Anterograde Amnesia

A

Retrograde: Loss of memories for events before the time of specific injury.

Anterograde: Inability to create new memories after an injury (TBI). Can last days, weeks, or months.

30
Q

Concrete Thinking

A

Ability to process information only on the most literal lev-el. May not foresee consequences of actions; need to be given very specific and detailed instructions for activities for their safety.

31
Q

Visual Skill Deficits Common in TBI

A

Accommodative Dysfunction: causes blurred vision.

Convergence Insufficiency: inability to maintain single vision while fixating on an object.

Lateral or Medial Strabismus: both eyes do not line up in the same direction (crossed eyes).

Nystagmus: involuntary rhythmic side-to-side, up and down or circular motion of the eyes.

Hemianopia: visual field cut/visual neglect (of a side).

Impairment of Scanning and Pursuits: knowing what info to look for, and ability to follow a moving target.

Saccades: fast, jerky movements of the eyes as they change from one position of gaze to another, as in read-ing.

Ptosis: drooping of eyelid

Lagophthalmos: incomplete eyelid closure.

32
Q

“Agnosia” Perceptual Skills affected by TBI

A

Visual Agnosia: inability to recognize familiar objects/ppl.

Prosopagnosia: Inability to connect faces with names.

Anosognosia: failure to recognize deficits or limitations (can lead to unilateral neglect).

33
Q

“Aphasia” Perceptual Skills affected by TBI

A

Aphasia: disturbance of comprehension or formation of language, usually caused by damage to left hemisphere. (Can be Wernicke and Transcortical Sensory types.)

Broca’s/Transcortical Aphasia: “nonfluent” aphasias, characterized by relatively preserved prehension but effortful or explosive speech with phonemic paraphasias (ie: “bork” for fork).

Conduction Aphasia: intact comprehension, fluent speech, but impaired repetition.

Anomic Aphasia: Trouble naming objects when speak-ing/writing.

34
Q

Executive vs. Receptive Dysprosody

A

Dysprosody = impaired production/comprehension of tonal inflections or emotional tone of speech.

Executive: inability to inflect voice to convey emotion.

Receptive: inability to perceive the emotional content of other people’s spoken language.

35
Q

Affective Changes when TBI damage is Left Hemisphere

A
  • Tend to exhibit increased depression/emotional lability
  • Can cause severe depression and heightened affect (excitement, agitation, tearfulness)
  • Can create decreased or flat affect
  • May appear depressed even though they feel fine
36
Q

Affective Changes when TBI damage is Right Hemisphere

A

• Frequently causes a strange sense of euphoria or lack of emotional response to the severity of injury.

37
Q

Interventions in Behavior Management Program Include:

A
  • One-on-one coaching
  • Intervention with psychotropic meds (for sleep and minimizing agitation)
  • Individually designed behavior management guidelines and interventions
  • Environmental modifications to minimize undesirable behavior (ie net bed, alarm system)
  • Create calm environment free of distractions (to reduce agitation)
  • Behavior Mgmt Program should be administered 24/hr, 7/day
38
Q

Aim of Intervention at RLA Levels I-III

A

To increase patient’s level of response and overall aware-ness of self and environment.
• Well structured stimulation, broken into simple steps/commands
• Allot time for response/slower processing
• Can be Sensory Stimulation, Bed Positioning, Cast-ing/Splinting, Wheelchair Positioning, Management of Dysphasia, or Emotional/Behavioral Mgmt.
• Begin family/caregiver education; involve them as familiarity/routine are key

39
Q

What to watch for when incorporating Kinesthetic Input into intervention?

A 
Observe for any changes during the activity, such as:
• visual tracking
• turning of head
• physical responses
• vocalizations
• ability to follow verbal commands
40
Q

Proper Wheelchair Positioning for Lower Level RLA

A
  • Facilitates head/trunk control
  • Helps prevent skin breakdown and joint contractures
  • Facilitates normal muscle tone
  • Inhibits primitive reflexes
  • Increases sitting tolerance
  • Enhances respiration and swallowing functions
  • Promotes function
41
Q

Proper Bed Positioning for Lower Level RLA

A
  • Prevents pressure sores
  • Facilitates normal muscle tone
  • Prevents loss of pelvis and trunk ROM and mobility
  • Facilitates normal positions/prevents abnormal postures
42
Q

Intervention at Intermediate/Higher RLA (IV-VIII)

A
  • Client alert but often confused and agitated, inappropriate responses
  • May be able to follow simple 2-to-3 step commands
  • Easily distracted
  • Can complete most of OT eval, but require several breaks due to distractability/agitation
  • Same evals as lower levels (physical status, dysphagia, physocial/behavioral, vision, sensation, perception), but requires more extensive eval of ADLs (may include driving, work readiness, reintegration)
43
Q

Physical Status Eval of RLA IV-VIII

A
  • Joint ROM
  • Muscle strength
  • Sensation
  • Proprioception
  • Kinesthesia
  • Fine/Gross motor control
  • Total body control (dynamic stand/sit balance)

**Limits to phys status usually due to abnormal tone, spasticity, weakness, heterotopic ossification, fractures, soft tissue contractures, and peripheral nerve compression.

44
Q

Dysphagia Eval of RLA IV-VIII

A
  • May include both clinical (bedside) eval and videofluoroscopy (to view anatomy of oral, pharyngeal and esophageal stages)
  • Aspiration assessed by client’s eating (gulping large portions?)
  • Pocketing food/drooling observed (impaired oral motor)
  • Can provide info on cognitive status (use of utensils, neglect, aphasia?)
  • Must include assessment of positioning
45
Q

Cognitive Eval of RLA IV-VIII

A
  • Cog skills assessed within functional tasks (ADLs, meal prep, money mgmt., community skills)
  • Assess for following directions
  • Assess for sequencing
  • Assess for attention to task
  • Assess safety awareness/judgment
  • May also include conditions of the environment during the assessment
46
Q

Vision Eval of RLA IV-VIII

A
  • Must undergo vision screening
  • Early detection of visual deficits yields more reliable info about client’s health, as they influence results of other testing
  • Vision intervention program created by optometrist and implemented by OT
  • Includes eval of visual attention, near/distant acuity, ocular movement (ie saccades), convergence, accommodation, ocular alignment, depth perception (stereopsis), and visual field function
  • Observe behaviors showing problems such as tilting head, covering an eye, or bumping into things
47
Q

Perceptual Function Eval of RLA IV-VIII

A
  • Evaluated AFTER having understanding of patient’s cognitive, sensory, motor, and language status
  • Visual perception: right-left discrim, form constancy, position in space, topographical orientation, naming of objects
  • Perceptual speech/language: aphasia and anomia
  • Perceptual motor function: ideational praxis, body schema perception (ie: unilateral neglect)
48
Q

ADL Assessment of RLA IV-VIII

A

Assess pt at these levels in all basic ADLs (grooming, oral hygiene, bathing, toileting, dressing, func mobility, emergency response).
• Advanced levels can include IADLs (meal prep, money mgmt., safety, work readiness)
• Also develop leisure skills (can prevent falling back to abusing drugs/alcohol)

49
Q

Driving Assessment of RLA IV-VIII

A

Two types may be performed:

1) Clinical assessment: eval of visual, cog, perceptual, physical status as related to driving)
2) On-road assessment.

Both are necessary as one might fail but do well on another using compensatory strategies.

50
Q

Neuromuscular Reeducation

A

Multifaceted spasticity reduction program, which improves ROM, head/trunk control, and functional use of UEs.

51
Q

Two Primary Approaches of Intervention for RLA IV-VIII

A

1) Rehabilitative Model: based on neuroplasticity, brain can repair itself/reorg neural pathways to relearn lost functions. Often used at the Acute stage.
2) Compensatory Model: repair of damaged brain tissue has occurred to its fullest, person is left unable to perform lost functions without assistance. Tools used are AT, env modification, and compensatory strategies to perform ADLs. Often used after plateau in progress.

52
Q

Neuromuscular Impairments for RLA IV-VIII

A
  • Spasticity
  • Rigidity
  • Soft tissue contractures
  • Primitive reflexes
  • Diminished/lost postural reactions
  • Muscular weakness
  • Impaired sensation
Intervention must:
• Facilitate control of muscle groups
• Progress proximally to distally
• Encourage symmetric posture
• Facilitate integration of both sides of body
• Encourage bilateral weight bearing
• Introduce normal sensory experience
Can use:
• Neurodevelopmental Treatment (NDT)
• Proprioceptive Neuromuscular Facilitation (PNF)
• Myofascial release
• Physical agent modalities (PAMs)
53
Q

Cognitive Intervention for RLA IV-VIII

A
  • Enhance cog skills through functional ADLs/IADLs
  • Concrete thinking is common; use simple steps/wording
  • Generalization of skills still difficult
  • Use everyday life activities
  • Even higher cog skills can still have trouble with organization, planning, sequencing, short-term memory
54
Q

Vision Intervention for RLA IV-VIII

A

May include:
• Use of corrective lenses (after subacute phase in case it improves without)
• Occlusion (patching one eye)
• Prism lenses (for diplopia)
• Vision exercises
• Environmental adaptations
• Corrective surgery (after one year to allow potential recovery)
• Binasal Occluders (encourage misaligned eye to fixate centrally)

55
Q

Environmental vs. Interactive Behavioral Management Strategies

A

Environmental Interventions: alter objects or environmental features to facilitate appropriate behavior, inhibit un-wanted behavior, and maintain individual safety. Avoid extraneous stimuli.

Interactive Interventions: how staff/caregivers interact with client. Entire team should use same tactics for consistency. Speak calmly, simple explanations. Reduce frustration. Keep door open and awareness of client in relation to self.

56
Q

Functional Mobility training categories

A
  • Bed mobility
  • Transfer training
  • Wheelchair mobility
  • Functional ambulation during ADLs
  • Community mobility

OTA 220 - Advanced OT Skills (10 decks)

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