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Flashcards in TBI Deck (56)
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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


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


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.


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 IV-VI = CONFUSED (hard to learn)
***LEVELS VII-VIII = AUTOMATIC (new learning)


Most important to consider this when using CAM-ICU:

The patient’s baseline mental status.


RASS -4, what would you do?

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


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.


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.


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?


RLA Level II pt response to OT tx:

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


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



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.


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).


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.


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.


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.



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.)


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


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


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



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



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



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


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).


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).


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.


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.



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


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.


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.