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Flashcards in TBI Deck (18):
1

Describe Level 1 of the Rancho Los Amigos Scale

"NO Response"
Will not respond to sounds, sights, touch, or movement

2

Describe Level 2 of the Rancho Los Amigos Scale

"Generalized Response"
Begins to respond to sound sight and touch
Responds slowly, inconsistently, or after a delay
Responses=Chewing, sweating, breathing faster, moaning, moving, and increased blood pressure

3

Describe level 3 of the Rancho Los Amigos Scale

"Localized Response"
Awake intermittently throughout the day
Reactions match stimulus more accurately (withdrawing from pain, or turning to sound)
Begin to recognize family and friends
Follow simple directions "Look at me"
Responds inconsistently to yes and no questions

4

Describe level 4 of Rancho Los Amigos Scale

"Confused and Agitated"
Confused and Frightened
Overreact to stimuli due to confusion
Highly focused on basic needs
May not understand when people are trying to help
Difficulty following directions
Can do simple routines with help
Attention span limited to seconds at a time

5

Describe level 5 of Rancho Los Amigos Scale

"Confused and Inappropriate"
Attend for a few minutes at a time
No orientation to date and location
Needs step by step directions for self care tasks
Confabulates due to poor memory
Easily stressed and overloaded
Perseverates on thoughts and actions

6

Describe level 6 of Rancho Los Amigos Scale

"Confused and Appropriate"
Remembers main points, but forgets details
Follow consistent schedule with assist
Knows month and year
Attends for ~30 mins
Completes ADLs with minimal assist
Impulsive with speech
Aware of physical issues, but not cognitive.

7

Describe level 7 of Rancho Los Amigos Scale

"Automatic and Appropriate"
Follows a set schedule
Completes ADLs independently
Lacks problem solving skills in new situations
Problems with planning, initiating and completing
Inflexible or rigid in thinking

8

Describe level 8 of Rancho Los Amigos Scale

"Purposeful and Appropriate"
Realizes there is a cognitive problem and begins to compensate
Ready for driving and job training evaluations
Poor judgement in novel situations.

9

What is good bed positioning in the Acute phase of a TBI?

Side lying, or semi-prone to normalize tone and provide sensory input

10

What is a Severe score on the Glascow Coma Scale?

Below 8

11

What is a moderate score on Glascow Coma Scale?

9-12

12

What is a minor score on Glascow Coma Scale?

Greater than 12

13

What are the three categories for the Glascow Coma Scale?

1. Eye response
2. Verbal Response
3. Motor Response

14

If a person is showing a decorticate posture in response to pain, responding with moans, and opening their eyes only to pain... What is there score on the GCS?

Motor: 3
Verbal: 3
Eyes: 2
8- Moderate TBI

15

If a person is opening their eyes to speech, responding to words inappropriately, and withdrawing from a painful stimulus, what is their score on the GCS?

Motor: 5
Verbal: 3
Eyes: 3
11- Moderate TBI

16

What are the four eye responses and their corresponding scores on the GCS?

1= No response
2= Eyes open to pain
3=Eyes open to speech
4=Full control of eyes

17

What are the 5 verbal responses with corresponding scores on the GCS?

1- no response
2-Moaning
3-Random words
4-Inappropriate and confused verbal response
5-Oriented to conversation

18

What are the 6 motor responses with corresponding scores on the GCS?

1- No response
2-Decerebate posture in response to pain
3-Decorticate posture in response to pain
4-Withdraws from pain
5-Tries to remove painful stimulus
6-Obeys verbal commands