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RANCHO SCALE

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RANCHO SCALE Powered By Docstoc
					        Counseling in the
 hospitals—working with
patients and families with
      neurological issues

Dana Farias, M.S., CCC
Senior Speech Pathologist
Neuro-Cognitive Clinical Specialist
Department of Physical Medicine and Rehabilitation
UC Davis Medical Center
Part-Time Faculty
Department of Speech Pathology & Audiology
California State University Sacramento
SPHP 219 students….
   Any slide with asterisks will be fair game on
    the next exam

   **** means that this info could crop up on
    Test 3 
Patient population
   UC Davis Medical Center – Level 1 trauma
   Head injury
   Stroke
   Others
Head Injury

   Mild
   Moderate
   Severe
Cognitive Assessment***
   Orientation
   Attention
   Memory
   Comprehension
   Naming
   Problem Solving/Judgment
JP
   35 y/o male
   MVA
   GCS = 7 in field
   Admit to OSH 9/29/10
   OSH Head CT WNL
   Transferred to UCDMC for f/u care
Clinical presentation
   Very low level of alertness with brief periods
    of wakefulness (5 -10 minutes a couple times
    per day)
   Not following directions
   Repeat Head CT completed
   Negative findings
10/01/10
10/01/10
10/01/10
Clinical presentation 2 days
later
   Continues to present with low level of
    alertness
   Not following commands
   Minimal response to external stimuli
   Repeat Head CT
   Negative findings
10/03/10
10/03/10
10/03/10
Clinical presentation 4 days
later
   Now beginning to remain awake for slightly
    longer durations
   Remains confused with poor comprehension
   Overall little progress but not regressing
   Repeat Head CT
   Negative findings
10/07/10
10/07/10
Speech Pathology Consult
received 8 days later (10/15/10)
   Evaluation completed (Cognistat)
   Patient’s father at bedside
   Patient remained awake for entire duration of
    evaluation (approximately 30 minutes)
   Report from father indicates this is the
    longest period of time patient has remained
    awake and responsive since admit
Results of testing

   Orientation – moderate to severely impaired
    (states age as 30)
   Attention – moderately impaired
   Comprehension - moderately impaired
    (follows only single step consistently)
   Memory – Severely impaired (unable to recall
    4 words from forced choice, unable to give
    accurate biographical data)
Results of testing
   Reasoning /problem solving – severely
    impaired (delayed response time up to 30
    seconds with inappropriate responses)
   Naming – moderately impaired (paraphasic
    errors such as “squadash” for “octopus”)
   Affect – flat, mild agitation
Recommendations
   Family – How to share results with patient
    and patient’s father and recommendations for
    rehab
   Staff – Suggested that an MRI of the brain
    may want to be obtained given patient’s
    presentation over 2 weeks after accident
MRI 10/15/10
MRI 10/15/10
IMPRESSION:

DIFFUSE AXONAL INJURY IN THE RIGHT FRONTAL LOBE REGION AND
SPLENIUM.
The next day
   Re-evaluation – patient’s mother and
    patient’s friend are at bedside. Patient’s
    friend is a trained medical professional and
    interested in the results.
   Sharing MRI findings and the notion of DAI
   Request made to return later that evening to
    discuss findings with patient’s spouse (who
    has been home with 3 children)
TBI literature and prognosis
   Time frames
   TBI binder
   POC for acute stay, rehab, return home and
    work potential
RANCHO SCALE

   I. No response to stimulation
   II. Generalized response to stimulation
   III. Localized response to stimulation
   IV. Confused and agitated behavior
   V. Confused, inappropriate, and non-agitated behavior
   VI. Confused and appropriate behavior
   VII. Automatic and appropriate behavior
   VIII. Purposeful and appropriate behavior
   IX. Purposeful and appropriate behavior
   X. Purposeful and appropriate behavior
Brain Injury Glossary

Abstract Concept - A concept or idea not related to any specific instance or
object and which potentially can be applied to many different situations or
objects. Persons with cognitive deficits often have difficulty understanding
abstract concepts.
Abstract Thinking - Being able to apply abstract concepts to new situations
and surroundings.
Abulia - Absence or inability to exercise will-power or to make decisions. Also,
slow reaction, lack of spontaneity, and brief spoken responses. Usually
associated with damage to a cerebellar vessel.
Acalculia - The inability to perform simple problems of arithmetic.
Acute Care - The phase of managing health problems which is conducted in a
hospital on patients needing medical attention.
Acute Rehabilitation Program - Primary emphasis is on the early phase of
rehabilitation which usually begins as soon as the patient is medically stable.
The program is designed to be comprehensive and based in a medical facility
with a typical length of stay of 1-3 months. Treatment is provided by an
identifiable team in a designated unit. See Program/Service Types.
Adaptive/Assistive Equipment - A special device which assists in the
performance of self-care, work or play/leisure activities or physical exercise.
Affect - The observable emotional condition of an individual at any given time.
Agnosia - Failure to recognize familiar objects although the sensory mechanism
is intact. May occur for any sensory modality.
Brain Injury Resources
National Brain Injury Organizations, Education and Advocacy
Brain Injury Association of America
The Brain Injury Association of America (BIAA) is a nonprofit organization that aims to improve the lives of individuals with
brain injury and their circles of support by focusing on prevention, research, education, and advocacy.
Brain Injury Information: 1-800-444-6443
Address: 8201 Greensboro Drive, Suite 611, McLean, VA 22102
Phone: 703-761-0750 Fax: 703-761-0755
http://www.biausa.org/
While you are waiting
Website dedicated to supporting individuals who have family members who are in coma, providing educational material on
the following topics: Intracranial Pressure, Coma, The Rancho Los Amigos Scale, Neurosurgery, Brain Anatomy, Brain
Functions and Pathology, and a complete Glossary of terms you may encounter. Links are available for online support
groups and legal assistance.
http://waiting.com/
Traumatic Brain Injury Survival Guide
This online book on brain injury can be viewed on line or downloaded for a $5.00 contribution.
Written by Dr. Glen Johnson, Clinical Neuropsychologist and Clinical Director of the
Neuro-Recovery Head Injury Program: 5123 North Royal Drive, Traverse City, MI 49684
Tel: 231-935-0388
http://www.tbiguide.com/
Stroke
   Ischemic vs. Hemorrhagic vs. TIA
   Left-sided and aphasia
   Right-sided
   Swallowing issues
CVA
   7yo-RHD
   Right-sided weakness and language difficulty
   HX: Standing in line with classmates and
    slumped over against wall
   CT OSH was WNL
   MRI: acute infarction of L internal capsule
   Transient Cerebral Arthropathy of Childhood
    (focal stenosis or segmental narrowing)
Findings and prognosis
   Severe expressive aphasia
   Intact comprehension
   Prognosis given etiology and site of lesion?
UC Davis Medical Center Stroke Program
Effects of Right Sided Stroke

Left sided weakness known as left hemiplegia. Patients could have difficulty moving
the left side of their body.
Decreased sensation on the left side. Patients could have some numbness/tingling or
complete loss of sensation on the left.
Impaired analytical thinking such as understanding how parts are put together to
make a whole. For example, it makes it difficult to know how all the parts of a car can be
assembled to make a car run or parts of a wheel chair adjusted in order to stand up.
Difficulty with spatial and perceptual abilities. This would make judging distances
difficult such as planning to step up some stairs or reaching for a cup of hot coffee. It
would also make crossing the street dangerous since judging the speed and distance of
oncoming cars could be impaired.
Patients can become impulsive. Unaware of their impairments, patients attempt to
perform the same tasks as they did before the stroke. This behavioral style can be very
dangerous. Patients could attempt to stand without assistance or even drive a car.
 Left sided neglect from visual field impairments. This would make it difficult to see
things on the left such as the phone or a wall.
Decreased short term memory. Patients can remember events occurring many years
ago however could have difficulty recalling events which happened that day.
Swallowing issues
   Aspiration and its consequences
   Non-oral feeding options
   Long-term outlook
Things to remember***
   Its always best to be honest and straight-forward
    from the start
   Use visual aids and leave handouts
   Although the literature/statistics may suggest a
    certain outcome, you never really know for certain
    (especially in the early stages)
   It’s best to defer a more definitive prognosis until a
    few months following the “event”
   If you don’t know something say so and direct the
    family or patient to the appropriate resource