TBI - Rancho I-VI Flashcards
(99 cards)
1
Q
What are the goals of TBI rehabilitation?
A
1) record and track recovery
2) optimize recovery
3) provide optimal environment to maximize rehab
4) provide support and education to family
5) design therapy to maximize neuroplastic changes and guide recovery
6) guide discharge
2
Q
Describe the typical course of rehabilitation
A
ICU –> acute care –> long term care or outpatient –> possible re-entry or exercise programs
3
Q
When should you start rehabilitation for a TBI?
A
- dependent on patient and 2 markers
1) normalization of ICP (<20mmHg)
2) hemodynamic stability
4
Q
What are the neuromuscular impairments from a TBI?
A
1) impaired motor control
2) impaired coordination
3) hemiparesis
4) hypertonicity
5) somatosensory impairment
6) impaired postural control
5
Q
What are the behavioral impairments from a TBI?
A
1) easily frustrated
2) agitation
3) mental inflexibility
4) impulsivity
5) disinhibition
6) emotional lability
7) irritability
6
Q
What are the possible cognitive impairments from a TBI?
A
1) arousal/disorder of consciousness
2) attention
3) concentration
4) memory
5) learning
6) executive functions
7
Q
What are the 3 stages of arousal/disorder of consciousness?
A
1) coma
2) UWS
3) MCS
8
Q
What are the 5 executive functions affected with cognitive impairments?
A
1) planning
2) cognitive flexibility
3) initiation and self generation
4) response inhibition
5) serial ordering and sequencing
9
Q
What is post traumatic amnesia?
A
patient is unable to form new memories
10
Q
What must the patient be able to identify to be out of PTA? how many days in a row must he correctly do this?
A
- specifics of date, time, place, and situation consistently
- 2-3 days in a row
11
Q
What are other non-categorized impairments from TBI?
A
- communication and language (not usually aphasia)
- cranial nerve involvement
- visual deficits
- perception deficits
- dysphagia
12
Q
What medications are used for tone?
A
baclofen, diazepam, dantrolene
13
Q
What medications are usually prescribed for seizure control in TBI?
A
anti- epilpetics: depakote, keppra, dilantin, cerebyx
14
Q
What medications are usually prescribed for attention impairments from TBI?
A
neurostimulants and dopamine
15
Q
What medications are usually prescribed for arousal impairments from TBI?
A
- amantadine (4-16wks after dx)
- methylphenidate
- other neurostimulants
16
Q
What medications are usually prescribed for depression following TBI?
A
nontricyclic meds are most effective
17
Q
What are some typical activity limitations following TBI?
A
ambulation, basic mobility, ADLs
18
Q
What are some typical participation limitations following TBI?
A
return to employment, family role, community/social role
19
Q
What levels on ranchos are considered low level patients?
A
1 - 3
20
Q
What can be seen in the early stages of recovery based on the cognitive recovery pyramid?
A
wakefullness –> awareness, arousal, attention, purpose –> perception and recognition of info –> speed of info processing
21
Q
What are some things to acknowledge/look for when doing an acute care chart review?
A
- ventilator
- ICP monitoring
- WB restrictions
- ROM restrictions
- cardiac precautions
- open wounds or surgical sites
- external fixators
- dysautonomia
- presence of other tubing
22
Q
What are the rehab goals for ranchos levels 1-3?
A
- constantly assessing level of consciousness and tracking progress
- increase arousal
- improve tolerance to upright
- reduce risk of secondary impairments
- improve or retain ROM
- educate
23
Q
What can be determined based on levels of consciousness in an acute care patient?
A
prognosis, treatment, education
24
Q
What impacts a patients ability to respond to stimuli and commands?
A
- limited motor functions
- communication impairments
- sedating medications
- impaired sensation
- impaired cognition
25
What requirements place someone in Coma Ranchos level I?
- unresponsive to ANY stimuli
- arousal system not functioning
- eyes closed, often ventilator dependent
- no auditory, visual, cognitive, or communication function
26
What requirements place someone in Unresponsive Wakefulness Rancho level II?
- awake but NOT aware
- basic brainstem functions only
- minimal communication with cortex (spontaneous eye opening and restoration of sleep wake cycles)
27
What must you differentiate ranchos level II from?
locked in syndrome
28
What movement responses may be seen in Rancho Level II?
- may startle to visual or auditory stimuli
- not able to follow commands or communicate
- reflexive smiling/crying/yawning
- - withdraw/posture to noxious stimuli
29
What requirements place someone in a minimally conscious state Rancho level III?
- awake and partially aware
- inconsistent cognitively mediated behaviors; different from reflexes
- needs to complete certain tasks routinely
30
What tasks must a rancho level III be able to do 1 or more of sustainably?
- follow simple commands
- gesture or verbal yes/no
- intelligible verbalization
- movement or emotional behavior that occur in relation to relevant stimuli
31
What would signal emergence from a minimally conscience state (level III)?
one or both reliable and consistently:
1) accurate yes/no responses to 6/6 situational questions on 2 consecutive exams
2) functional use of at least 2 different objects
32
Why would being able to functionally use objects signal emergence from MCS ? (how it relates to brain function?)
motor strip of the frontal lobe is able to send the signal from the brain --> communicate with basal ganglia --> brainstem --> CST --> muscles
33
What is the gold standard for assessing levels of consciousness?
coma recovery scale revised
34
What items are included coma recovery scale revised?
auditory, visual, motor, oromotor, communication, arousal
35
What is the coma recovery scale used to determine?
coma, VS, MCS, or emergence
36
What does the disorders of consciousness scale test for?
social knowledge, taste/swallowing, olfactory, proprioception, tactile sensation, auditory and visual function
37
What is the sensory modality rehab techniques (SMART) for?
treatment tool for patients in VS or MCS with a sensory component and behavioral observation
38
What does the western neurosensory stimulation profile used to assess?
arousal/attention, expressive communication, response to auditory visual tactile and olfactory stimulation
39
What is the goal of multi-modal sensory stimulation programs?
To increase arousal and attention
40
What is multi-modal sensory stumulation?
engage cortical function by including lots of stimulation in different ways. Make sure to balance stimulation and rest and monitor pt response
41
What is Familiar Auditory Stimulation Training (FAST)?
5 min storytelling by relatives that involve autobiographical events
- has show improvement in CRS and increased activation of language areas
42
What are the benefits of music therapy in MCS?
- behavioral improvement
- improved BP in MCS
- greater activation of auditory network and physical response
43
Is multi-modal more effective in MCS or VS/UWS?
MCS
44
What are the benefits of early mobilizations?
- shorter length of stay
- increase chance of D/c to home
- decreased secondary complications
- improved outcomes
45
What are the contraindications for early mobilization?
- unstable spine
- increasing ICP
46
What are the precautions for early mobilization?
- WBing restrictions
- skin/joint integrity
- autonomic instability
- CV status
47
What are examples of positions for early mobility?
- sitting on side of the bed
- sitting in wheelchair
- tilt table
- standing frame
48
What is the goal of early mobility?
- increase alertness with stimulation in different positions/environment
- improve level of consciousness
- improve GI motility, ROM, CV response
49
What secondary impairments should we be aiming to prevent with early mobility?
contractures, pressure sores, pneumonia, DVT
50
What are the proper parameters for wheelchair positioning?
- need manual wheelchair
- weight shift every 30 min for 2 min
51
What are the proper positioning and parameters for bed?
- hip/knees should be slightly flexed
- turn every 2 hours
52
What are the benefits of serial casting?
- help improve PROM
- used in various neuro conditions including pediatrics
53
What does the evidence state about serial casting?
- it has a positive effect on PROM but not on spasticity or functional abilities
54
What are the 4 layers of family education and support?
1) maintain open communication
2) involve them in POC and decisions
3) educate on current evidence when appropriate
4) provide realistic and consistent messages
55
What approach does the coma recovery scale revised take in terms of arranging tasks?
- a top down approach
- cognitively mediated processes to reflexive
56
True or False: The coma recovery scale can be used to determine emergence
true
57
What are some environmental factors to consider when assessing with the coma recovery scale?
- distraction free environment
- Patient positioning (best in a wheelchair so they stay awake)
- be cautiously optimistic when dealing with all staff and family members
- timing, patients tend to score better in the morning
58
What are the main considerations when assessing LOC with the coma recovery scale?
- only ask for motor behaviors within patients ability level and wait for a response
- reassess frequently
- look for consistency
59
What is the behavior correlated with Ranchos Level IV?
Confused-agitated
60
What kind of behavior would you expect to see in a ranchos IV patient?
non-purposeful behavior that is bizarre relevant to the environment
61
How is memory affected in ranchos level IV patients?
short term and long term are both impaired
62
What is a ranchos level IV patient driven by?
Confusion
63
True or False: you need multiple people to manage a ranchos level IV patient
false
64
What are the two main behavioral and cognitive concerns when examining a ranchos IV patient?
- ability to sustain attention
- distractability
65
What are some of the main challenges presented in a ranchos level IV patient?
- amnesia
- confusion
- decreased attention
- distracted
- uncooperative
- agitation
- aggressive
- impaired insight into deficits
66
What is the ideal environment for avoiding any agitation with a patient?
- closed
- freedom of movement
- low distraction
- dim light
- one family member at a time
67
How should consistency be included to avoid agitation from patients?
- address inappropriate behaviors in a consistent manner
- follow a consistent schedule
- expect no carry over of non-automatic tasks
- re-orient frequently
68
How should activity selection be used to decrease agitation in patients?
- change activities frequently
- choose functional tasks near patient level
- allow rest time and shorter treatment sessions
- do not force patient to do things!!
69
How can we model calm behavior to promote skillful patient interaction and decrease agitation?
- be in control of our motions
- use a calm slow tone
- get on patient level
70
How can we model our communication to promote skillful patient interaction and decrease agitation?
- be clear and concise
- be mindful of our nonverbal communication
- start with simple questions/commands
71
What items can be used for patient safety when agitated?
- helmet
- locked unit
- posey mitt
72
What are the general safety guidelines for PTs when dealing with an agitated patient?
- look out for signs of increasing agitation
- get help when needed
- maintain access route out of room
- be aware of clothing/jewelry
73
what is the behavior modification program built on?
- positive reinforcement and re-direction
74
What is always considered first choice for medical management?
behavioral interventions
75
What is always considered last for medical management?
restraints
76
When should you use medications for medical management?
At times required to maintain safety of patient, family, or staff
77
When should you use ativan for a patient?
in times of severe agitation
78
What SOM can be used during a ranchos level IV patient to measure aggression/agitation?
Agitated Behavior Scale
79
What is the most important thing to remember when setting rehab goals for a ranchos level IV?
- new learning is NOT possible at this level
- formerly learned skills can be practiced and regained at this level
80
What are some examples of appropriate goals for a ranchos IV patient?
- improve endurance
- improve activity tolerance
- improve attention to task
- family education and support
- prevent agitation
- help patient learn to control behavior
81
Identify 3 strategies for managing agitation
- stay calm
- get patient moving
- vary exercises frequently
82
What characteristic name fits with a ranchos Level V?
Confused-Inappropriate
83
What are some characteristics of ranchos level V?
- can follow simple commands
- extremely distractible
- inappropriate and confabulatory speech
- severely impaired memory
- can't learn new info
- poor safety awareness
84
How would a patient in ranchos level V react to a complex task and environment?
- the patients response would be non-purposeful and random
- a structured environment would allow socialization on an automatic level for short periods
85
What characteristic name fits with a ranchos Level VI?
Confused-appropriate
86
What are some main characteristics of a patient in ranchos level VI?
- goal directed behavior
- recognizes basic needs
- shows carryover of re-learned tasks
- follows simple commands consistently
- able to follow a structured schedule
- poor insight into deficits
87
What memory problems would you expect to see in a patient in Ranchos Level VI?
- long term memory better than short
ex: Date may be wrong but person is giving a recent date
88
What are the treatment goals for patients in ranchos level V and VI?
- increase safety and independence with mobility and ADLs
- improve postural control, balance, and gait
- improve strength
- improve endurance
- education
89
What testing may be introduced during ranches level V and VI?
- formalized testing to determine more focal injury deficits
90
T/F: A patient in ranchos Levels V & VI are still confused and unable to learn new tasks
True
91
Why does a person in ranchos level V and VI need strict supervision during treatment?
They have poor insight into their deficits and poor safety awareness
92
What should you consider when choosing a treatment environment for ranchos level V & VI?
- work in meaningful environments
- reduce distractions
- start with short sessions and add breaks
- limit task complexity
- saliency
- create a routine
93
Give 3 examples of intervention examples for ranchos Level V & VI
- ball toss while standing
- STS transfer while reaching for colored targets
- adding cognitive load to exercises such as walking or stairs
94
What are the 5 communication strategies for treating a ranchos level V & VI?
1. repeat info as needed
2. use a memory planner
3. avoid too many questions
4. explain what is going to happen between activities
5. allow time for processing and response
95
Which SOM would you use to measure attention and cognition in a ranchos level V & VI patient?
Moss Attention Rating Scale
96
What levels is the moss attention rating scale valid for?
Ranchos LOCF IV or higher
97
What are two secondary SOMs that can be used to measure attention and cognition in a ranchos level V and VI patient?
- orientation log
- galveston orientation and amnesia test
98
What is the orientation log used for?
- logging improvement in memory
99
What SOM is used to measure balance in a ranchos level V & VI?
Berg Balance Scale
