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OTA 220 - Advanced OT Skills > TBI > Flashcards

Flashcards in TBI Deck (56)
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1

Modified Ashworth Scale

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

2

Richmond Agitation Sedation Scale (RASS)

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

3

Confusion Assessment Method for the ICU (CAM-ICU)

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.

4

Rancho Levels of Cognitive Function-ing (RLA Levels)

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)

5

Most important to consider this when using CAM-ICU:

The patient’s baseline mental status.

6

RASS -4, what would you do?

• Do not expect pt to participate in tx
• Do not proceed with CAM-ICU assessment

7

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

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

8

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

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

9

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

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

10

RLA Level II pt response to OT tx:

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

11

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

Ataxia

12

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

• 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.

13

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

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

14

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

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

15

RLA Level I

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.

16

RLA Level II

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.

17

RLA Level III

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.)

18

RLA Level IV

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

19

RLA Level V

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

20

RLA Level VI

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

21

RLA Level VII

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

22

RLA Level VIII

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

23

Somnolent

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

24

How to treat RASS +1 or +2?

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

How to treat RASS -2 or -3?

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

26

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

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

27

Self-Feeding Issues with TBI

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

Graphesthesia

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

29

Retrograde Amnesia vs. Anterograde Amnesia

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

Concrete Thinking

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.