SCI - TBI II - Ranchos Los Amigos Coma Scale

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shmvii
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220548
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SCI - TBI II - Ranchos Los Amigos Coma Scale
Updated:
2013-05-21 16:28:19
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TBI II
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spring 2014
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  1. does the RLACS prognosticate?
    no
  2. does the RLACS assess physical functioning?
    nope, except in how it is impacted by cognitive fxn
  3. general descriptors of the stages of RLACS
    • I: no response
    • II: generalized response
    • III: localized response
    • IV: confused/agitated
    • V: confused/inappropriate
    • VI: confused-appropriate
    • VII: automatic appropriate
    • VIII: purposeful, appropriate, needs stand-by assistance
    • IX: needs assistance on request
    • X: modified indep
  4. RLACS with "complete absensce of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular, or painful stim"
    I
  5. characteristics of RLACS level II
    • give a generalized response (increase or decrease of activity) to stim
    • responds to stim w physiologic changes (gross body mvmnt, vocalization, sweating, reddening...)
    • responses are the same regardless of the type and location of stim
    • response may be significantly delayed
  6. what makes TBI so special
    it's a combo of cognitive and physical issues, so you have a double whammy of problems and have to figure out how to train the pt who has impaired learning apparatus
  7. TBI RLACS level III
    • shows appropriate response  to stim (blinks in bright light, turns away from noise, visual tracking, pulls at tubes or restraints)
    • responds inconsistantly to simple commands
    • may respond to some folks (friends and fam) but not others
  8. RLACS IV
    • alert, heightened state of activity, irritated
    • acts w/o purpose
    • no STM
    • cry/scream out of proportion to stim
    • big mood swings
    • can't cooperate w tx eforts
    • incohernt a/o inappropriate verbalizations
    • confabulation
    • Bookbaum thinks it's a matter of overstim
  9. RLACS V
    • alert, not agitated (but can regress to IV)
    • wander randomly, vague intention of going home
    • not oriented to person, place, time
    • IV had very brief, now you get frequent brief periods of non-purposeful sustained attention
    • memory is disabled - past and present get mixed
    • limited or agbsent goal directed, problem solving, self monitorying behavior
    • inappropriate use of objects w/o external direction (liek apraxia)

    more stuff, in other slides
  10. RLACS V - w task performance?
    • may be able to do previously learned tasks w help and cues
    • can't learn ner info
    • can respond to simple commands fairly consistantly w external structures and cues - but it's automatic, not reliable
  11. RLACS V w social
    • responses to commands w/o external structure are random, non-purposeful in rel to command
    • can converse on automatic level when given cues
    • verbilizations about present events become inappropriate and confabulatory wehn external structures and cues not provided
  12. RLACS I, II, III were total assist, IV and V were max assist, now we're in mod assist at VI. Tell me about this presentation!
    • A+Ox3 inconsistantly
    • uses memory aids and books
    • can do familiar tasks in a calm env for  min w mod redirection
    • LTM > STM
    • vague recognition of some staff
    • emerging awareness of appropriate response to self, fam, basic needs
    • ca do a bit of problem solving for task completion
  13. at which stage of RLACS is there carryover of new learning?
    VII
  14. RLACS VII
    • can learn, can carry out steps of ADL, has KR, and can modify plans w min assist
    • superficial awareness of TBI, but can't id the impairments, disabilities, new limitatinos, consequences of actions ... decreased risk awareness!
    • unaware of others' needs and feelings / can't recognize inappropriate social behavior
  15. RLACS IX
    • can multi-task
    • can not anticipate difficulties, but can id them when they're happening
    • in PT: work on planning, seeing steps and challenges ahead of time
    • can think about consequences of decxisions nd actions w assistance
  16. RLACS VIII
    • lots of stuff - basically - lucid, able to do a lto fo things but still needs min/stand by assist
    • can recognize other's feelings
    • still can't correctly estimate own abilities
    • aware of impairments but can't take corrective action
  17. attitude in RLACS IX
    • depression, irritable, frustratable, 
    • but, can self-monitor w assistance
  18. RLACS X
    • can multitask even better than at IX, but still needs periodic breaks (me too! nah, none for a hunter dpt candidate, nope!)
    • still needs mem devices, but can make and maintain their own
    • can estimate own abilities and adjust to them
    • still have some depression, and more susceptible to bad moods when sick, tired, or stressed (like most humans?)

    read thru these again!
  19. there are 3 cognitive levels, based on RLACS. what's "low" on this scale/
    I, II, III - responses range from limited, inconsistent, and nonpurposeful to som ability to respond to simple commands, tho many repetitions may be required to produce adequate respone
  20. the second cognitive categor, "mid level"
    IV, V, VI - confused, sometimes agitated, inappropriate, agtgressive behaviours, porgressing to more consistent, purposeful, goal oriented behavior
  21. 3rd cognitive category "high"
    VII, VIII, IX - some mem defcits still present. more appropriate responses, some level of functinal indep, dfficulty w abstract reasoning, multitasking, overstim
  22. 3 categories of physical impairment
    • severely impaired: (D) for all or most ADL
    • mod: amb w assist, AD, or WC
    • min: (I) amb w high level of balance and coordination deficits
  23. basic method for assisting a TBI pt progress to higher level of cognitive/physical fxn?
    systematic and gradated stim and activity
  24. PT for low level cog (LOC I-III)
    • prevent secondary issues (bed sores, contractures...)
    • resumption of upright pos
    • use activities that require more cog skills, like sitting and standing - these may push cog awareness
    • sensory stim - all sorts
  25. PT for mid level cog TBI (LOC IV- VI)
    • (this is when they're going from min responsiveness to confusion and agitation)
    • the industry says to work more on cog that physical at this stage, but he says pushing phys may help cog
    • work in a quiet structured env
    • have clear goals and directions
    • use multiple short tx sessions w structured recovery time
  26. primary cog impairments in mid level (IV-VI), and what to do
    • STM
    • highly distractible
    • limited ability to perform goal directed behaviour

    • structure env and activities to reinforce success
    • compensatory strategies (mem book, rewards, cuing, modalities, progressive difficulty)
    • train self monitoring
  27. 4 basic interventions for mid level cog / LOC 4-6
    • repetition
    • consistency
    • scheduling
    • progress by varying task steps, cues, feedback
  28. high level cog (VII-IX - or VIII, depending where you look) -- what are the deficits?
    • abstract cognitive deficits
    • difficulty generalizing to novel situations
    • difficulty reacting to suble cues
    • lack of insight
  29. high level cog (VII-IX - or VIII, depending where you look) - intervention strategies?
    • reduce structure
    • encourage self-monitoring
    • increase distractions w motor tasks (stroop!)
    • problem solving in community settings

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