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Assessment of TBI Higher

Level Evaluation and

Intervention for TBI People

with Rancho Level 4-

Objectives of this

presentation

 (^) Continued understanding of the impact of brain injury on the motor, cognitive, and psychosocial aspects of normal functioning  (^) Gain understanding in how cognitive and behaviorial deficits can affect a person’s recovery post brain injury.  (^) Gain understanding of how therapists can adapt treatment to effectively assist rehabilitation of the patient using the Rancho Scale  (^) Discriminate various levels of the Glasgow Coma Scale, the Rancho Scale, and the Disability Rating Scale for use in assessment and development of intervention plans  (^) Gain understanding of the continued support needed by people with TBI and the important role of the family during and after the rehabilitation process

After Acute Care Comes…

 (^) Worse case scenario  (^) Slow to recover  (^) Long-term care  (^) Phone Call  (^) Transition note  (^) includes progression of intervention and goals  (^) Instructions for Restorative Aide (include your phone #)  (^) Instructions for caregiver training  (^) Best case scenario  (^) In-patient rehab  (^) Generally at least level 3-4 with relatively quick recovery  (^) D/C note that includes progress to date and ideas for continued intervention and goals  (^) Phone new therapists

Additional Motor Issues

Addressed in Inpatient Rehab

 Same motor theories apply.  (^) Lack of movement-facilitation theories.  (^) Has movement-motor learning theories  (^) Sustained abnormal tone will cause mm length issues and capsular mobility deficits.  (^) Correct mm length/capsular deficits as they progress through orthopedic techniques such as splinting, casting, joint mobilization, modalities, soft tissue mobilization and ADL prescription/adaptation.

Intrathecal Baclofen Pump System

http://www.clevelandclinic.org/health/health- info/docs/0300/0369.asp?index=4590&src=newsp  (^) Muscle Relaxant  (^) Baclofen works by blocking the release of excitatory neurotransmitters in the spinal cord. Ideally, baclofen restores the balance of excitatory and inhibitory input to reduce muscle hyperactivity. In this way, it also allows more normal motor movements.

http://www.clevelandclinic.org/health/health- info/docs/0300/0369.asp? index=4590&src=newsp  “Baclofen can be taken orally or delivered intrathecally (as an injection in the spine). Oral baclofen causes side effects that may limit its usefulness, especially when prescribed for children. Of the oral baclofen delivered throughout the body, only a small portion goes to the spinal fluid where it is needed to work.’  “With an intrathecal delivery system, baclofen is delivered right to the target site in the spinal cord. Because the intrathecal system continuously delivers baclofen in small doses directly into the spinal fluid, there are fewer and less severe side effects than that seen with the oral medication.”  (^) Retrieved March 26, 2007.

Rancho Level IV-

Confused/Agitated

 (^) Alert and in a heightened state of activity  (^) Purposeful attempts to remove restraints and tubes. At danger for falling out of bed.  (^) May perform motor activities such as sitting, reaching and walking but not on request.  (^) Very brief sustained and divided attention  (^) Very decreased, if any, short term memory  (^) May overreact to stimuli by crying or screaming  (^) May exhibit aggressive or flight behavior  (^) Mood swings from euphoria to hostile without cause  (^) Verbalizations are incoherent or inappropriate  (^) Unable to cooperate with treatment

Intervention Strategies at RLA IV

• (^) Provide a calm, soothing, relaxed atmosphere.
• (^) Use short, simple directions and repeat them frequently.
• (^) Simplify your vocabulary and slow down your rate of speech.
• (^) Don't expect the person to remember recent events or instructions.
• (^) Tell the person things that you want known. Avoid questioning the person, since this is likely to heighten irritability.
• (^) Provide orientation information frequently (date, hospital, city, and cause of hospitalization) and correct the person gently.
• (^) Don't argue with the person or criticize them for forgetfulness.

Rancho Level V (continued)

 Behavior is not goal directed and is not self- monitored  (^) Unable to learn new information  Response to simple commands without external structure are random and non-purposeful  (^) Able to converse on a social, automatic level for brief periods of time.  Unable to understand joking, sarcasm, etc.  (^) Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided

Intervention Focus at RLA 4-

 Sensori-motor/Cognitive  Reduce agitation  (^) Through motor activity  (^) Initiate ADL training  (^) Structured schedule  Environmental modifications  (^) 24 hour supervision, if needed

Tools used at RLA 4-

 Agitated Behavior Scale (ABS)  Scored for entire day  Items scored (14)  (^) Attention span  (^) Rapid, loud, or excessive talking  (^) Self-abusiveness, etc.  (^) Score of 1-4 for each item  (^) 1= absent, 4=present to an extreme degree  (^) Scores range from 14-  (^) Useful in determining factors that increase agitation and proper use of medication, if needed

Agitated Behavior Scale Rating Form Agitated Behavior Scale Patient (^) ________________________________ Observ. Environ.

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Rater/Disc. ________________________________ Period of Observation: From_____am/pm at Date___// To_____am/pm on Date___// At the end of the observation period indicate whether the behavior described in each item was present and, if so, to what degree: slight, moderate or extreme. Use the following numerical values and criteria for your ratings.

Agitated Behavior Scale Items ___ 1. Short attention span, easy distractibility, inability to concentrate. ___ 2. Impulsive, impatient, low tolerance for pain or frustration. ___ 3. Uncooperative, resistant to care, demanding. ___ 4. Violent and or threatening violence toward people or property. ___ 5. Explosive and/or unpredictable anger. ___ 6. Rocking, rubbing, moaning or other self-stimulating behavior. ___ 7. Pulling at tubes, restraints, etc. ___ 8. Wandering from treatment areas. ___ 9. Restlessness, pacing, excessive movement. ___ 10. Repetitive behaviors, motor and/or verbal. ___ 11. Rapid, loud or excessive talking. ___ 12. Sudden changes of mood. ___ 13. Easily initiated or excessive crying and/or laughter. ___ 14. Self-abusiveness, physical and/or verbal. ___ Total Score

Tools Used at RLA Level

Staff Training

 MANDT, PART-2OOO, CAPE  Useful in identifying possible trigger behaviors and methods for staff to protect themselves  Increases awareness of staff’s self- reaction—both physical and psychological  Addresses methods to safely “take down” a patient as a last resort only.