Frazier Rehab Institute 220 Abraham Flexner Way Luisville, KY 40202 502-582-7476
T learn that smene yu care abut has sustained a brain injury is never easy. Many peple experience wrrisme and cnfusing thughts while the uncertainty abut the patient s recvery adds t the level f stress and despair. In recgnizing hw difficult brain injury is fr patients, families and friends, Frazier has develped a a cmprehensive brain injury treatment prgram. It is staffed with highly skilled prfessinals and has been rganized t treat each patient accrding admitted accrding t his/her t individual his/her individual needs. needs. This Handbk has been prepared fr the family and friends f persns with brain injury. It has been designed t prvide yu with basic infrmatin abut brain injury, t briefly utline the Brain Injury Prgram at Frazier and explain hw yu can assist in the recvery f yur family member and/r friend. The Brain Injury Prgram at Frazier The persn with brain injury is admitted t the Brain Injury Prgram by a physiatrist, a physician wh specializes in rehab medicine. Once admitted, a specified treatment team f prfessinals is assembled accrding t the rehabilitatin needs f each patient. Members f the treatment team may include: Name Patient s Name Family Member Family Spkespersn Physiatrist r Rehab Physician Psychlgist Psychlgical Assciate Case Manager Nurse Occupatinal Therapist Occupatinal Therapy Assistant Physical Therapist Physical Therapist s Assistant D ietitian Pulmnary Rehab Clinicians Therapeutic Recreatin Specialist Speech-Language Pathlgist Schl Tutr/Crdinatr 1
Treatment Guide 2
Family Spkespersn The treatment team includes a patient s family r significant thers because yu have valuable infrmatin that is helpful during treatment planning and, yu can supprt the patient in very special ways during the recvery prcess. The treatment team will ask that ne persn in the family be identified as the family spkespersn. This is the persn t whm the treatment staff will cmmunicate all relevant infrmatin abut treatment gals, patient prgress and plans fr discharge. Weekly cmmunicatin between the family s spkespersn and case manager is essential. We ask that the spkespersn then cmmunicate relevant infrmatin t ther family members. Getting Started at Frazier Once the patient has been admitted t his/her rm at Frazier, a rehab nurse will begin the evaluatin prcess t determine the patient s level f functining. Others n the treatment team will begin their evaluatin that same day r the day fllwing depending upn the time f day the patient is admitted. Part f the evaluatin prcess will include interviews with yu. This helps the treatment team learn abut the patient s backgrund, likes and dislikes, and significant events in the past. The team will als want t knw what changes the family and patient have nticed since the nset f the injury r illness. Prviding this infrmatin is ne imprtant way the patient and family can participate in the rehab prcess. If yu think f relevant infrmatin after these interviews, make a nte and share that infrmatin with the apprpriate team member at a later time. During the initial evaluatin, the treatment team will begin t identify the patient s Functinal Prblems. These functinal prblems are caused by the brain injury and culd include inability t maintain attentin, memry impairment, and impaired self-care r mbility skills. It is these functinal prblems that clarify the reasn that rehabilitatin is needed fr the patient. Once functinal prblems are identified, the team will establish a Treatment Gal fr each prblem. The functinal prblems and the treatment gals are the basic cmpnents in the Treatment Plan. Once each week, the treatment team will meet t update and revise the functinal prblems list and lng-term treatment gals. In additin, the team will identify the Weekly Treatment Pririties upn which the team will fcus during the next seven days. When apprpriate, the family will be asked t help the patient and ther team members reach these weekly gals. The treatment team will carefully evaluate the patient s level f functining accrding t the Ranch Ls Amigs Cgnitive Recvery Scale, which defines ten levels f recvery frm brain injury. Shrtly after admissin, yu may hear the staff say that the patient is functining at a Ranch Level between 1 and 10. During a patient s admissin, the Ranch Level may change significantly and ften. Sme survivrs mve slwly thrugh the Ranch Levels and speed f recvery des nt suggest pr ultimate utcme. A summary f the Ranch Scale can be fund later in this bklet. As yu read further, yu will find additinal infrmatin that will help yu during recvery. We encurage yu t write dwn yur questins as yu prceed s yu can ask them when meeting with members f the brain injury team. Yu may find it helpful t read this material mre than nce. 3
Therapy sessins are scheduled at specific times fr each patient. There are ccasinal therapeutic reasns t change a patient s schedule and as a result f timely team cmmunicatin these beneficial schedule changes will ccur. Please be aware that the patient s therapy schedule may change fr nn-clinical reasns, such as, changes in a therapist schedule r ur admissin/discharge patterns. A daily master schedule is available by 8:30 a.m. at the nurses statin. Team Apprach. Case Management: Case managers crdinate discharge planning with the patient, family and treatment team. They schedule family teaching days and team/ family meetings t educate family members abut brain injury and t prepare them fr discharge. The case manager cmmunicates with yur insurance cmpany and can direct families where t get insurance questins answered. The case manager prvides infrmatin abut and makes referrals t cmmunity resurces. The case manager serves as the family s liaisn t the treatment team t ensure that yur questins and cncerns are addressed as they arise. Psychlgy: Psychlgy services are prvided by psychlgists and psychlgical assciates wh specialize in diagnsing and treating the behaviral, scial and emtinal prblems that result frm neurlgical illness and injury. They prvide cnsultatin t the treatment team, educatinal and supprt services t families and patients. Cmprehensive neurpsychlgical evaluatins are available thrugh Frazier that assess a variety f thinking, memry, sensry, intellectual, academic and vcatinal skills as well as emtinal functining. Occupatinal Therapy: Occupatinal therapists and ccupatinal therapy assistants help patients imprve the skills needed t perfrm self-care, participate in leisure activities and return t wrk. Occupatinal therapists will fcus n increasing strength, balance, sensatin and crdinatin. They will als address cgnitin (thinking) and prblem slving abilities. Patients may be encuraged t use adaptive equipment r adaptive techniques in rder t becme mre independent in daily activities. Physiatry: A physician wh specializes in rehabilitatin medicine is called a physiatrist. Yur physiatrist crdinates the medical and rehab care, utside cnsultants and referrals fr cntinued services. Upn cmpletin f the brain injury prgram, sme medical rehab services will cntinue t be prvided by yur physiatrist. Yu will need t see yur primary care physician within a cuple f weeks f discharge frm the inpatient stay at Frazier. If yu dn t have a primary care physician, yur physiatrist will help refer yu t ne. Physical Therapy: Physical therapists and physical therapist s assistants wrk with patients t imprve mbility, strength, crdinatin, balance, endurance, flexibility and safety within their envirnment. The gal is t achieve the highest level f functin fr each individual bth in and utside the hme envirnment. If patients are unable t achieve independence with walking skills, physical therapists recmmend and encurage the use f braces, assistive devices r custm wheel chairs t maximize each patient s level f independence. Therapeutic Recreatin: Therapeutic recreatinal specialists help patients imprve their abilities t participate in leisure activities and teach patients hw t adapt t recreatinal skills and attitudes after disability. The recreatinal therapists plan many activities, indr and utdr, s patients can practice being as independent as pssible in their wn recreatinal r leisure activities. 4
Registered Dietitian: Dietitians are part f the multidisciplinary team ensuring adequate nutritin fr all patients. An individualized nutritin plan f care is develped and educatin prvided as needed. Rehabilitatin Nurse: The rehabilitatin nurse clsely mnitrs, crdinates and delivers nursing interventins designed t restre and maintain maximal health and independent functining. These interventins vary depending n the individual s physical and mental status, vital signs, level f alertness, nutritinal status, bwel and bladder status, sleep/wake cycles, skin integrity, pain levels, medicatin, and treatment regimen. The rehab nurse is an active member f the interdisciplinary team. The RN and nursing assistant reinfrce skills learned in therapy. Speech-Language Pathlgy: Speech-language pathlgists address cmmunicatin skills, which invlve listening, speaking, reading, writing, and cgnitive (thinking) skills. Speech-language pathlgists als diagnse and treat swallwing prblems. Brain Injury Services After Inpatient Hspitalizatin In mst instances, patients are ready t be discharged frm the inpatient prgram befre many f the prblems assciated with the brain injury have reslved. Frazier Rehab Institute ffers several therapy alternatives after discharge t meet the needs f the patients with a brain injury. The treatment team will recmmend the ptin that is best suited t the patient s needs. NeurRehab Prgram This prgram prepares the patient fr a successful return t cmmunity life. Lcated in ne f ur utpatient facilities, this service has a cmplete interdisciplinary team that specializes in neurlgic rehab. Thrugh individualized case management, the specific and unique needs f each patient are addressed. The team may cach patients at jbsites, schl r in their hme. The prgram als ffers family educatin. The emphasis fr this part f ur cntinuum is achieving practical, real life gals. The persn with brain injury is ready fr the Neurrehab Prgram - when they demnstrate a readiness fr return t unsupervised independence within the hme, schl, wrk setting r ther prductive rles within the cmmunity. Falls, Preventin Brain injury patients are at high risk fr falls. This is due t pssible cnfusin and physical weakness. Falls can lead t serius physical injuries such as cuts, bruises, brken bnes, anther brain injury, and even death. T prevent falls, an alarm may be placed n the bed r wheelchair that will sund when the patient tries t get ut f bed r the wheelchair. Anther safety ptin t prevent falls, is an enclsed bed. Family members shuld nt get patients up. Always call fr assistance by using the call light. A patient shuld nt be left sitting at the side f the bed as many falls ccur while sitting n the side f the bed. The patient will be assessed fr falls risk thrughut the stay. Visitatin at Frazier The treatment team has fund that the mst prductive scial visits ccur during the evening hurs after therapies have been cmpleted. Therefre, we request that extended family members and friends schedule their visits after 4:30 p.m. Mnday thrugh Friday. Primary caregivers are encuraged t be present fr family teaching thrughut the day as ften as pssible. Weekend therapy may nt be as tightly scheduled as n week days s visiting during the day n Saturday and Sunday may be mre pssible. 5
Scial visits shuld be limited t brief perids f time with n mre than ne r tw family members r friends present in the patient s rm at a time. Questins cncerning the patient s readiness fr visitrs, particularly thse wh might verstimulate the patient are best discussed with the patient s dctr r therapists. The staff als requests that yu respect the rights f ther patients t a private, quiet and peaceful hspital envirnment. The length and frequency f visits that are mst helpful t any given patient varies. Smetimes patients becme verstimulated, verly emtinal r even lse mtivatin when family and friends are present. This is nt uncmmn and shuld be viewed as a nrmal part f the recvery prcess. Accrdingly, the treatment team may ask yu t limit yur visits during this stage f recvery. Similarly, the team may encurage yu t increase yur visits when this benefits the patient. The Family as Team Members The Brain Injury Prgram Staff views family as imprtant members f the rehab team because yu have infrmatin abut the patient that is imprtant t cnsider when develping a cmprehensive treatment plan. Als, because f yur pre-injury relatinship with the patient, yu can lve and supprt yur family member in ways that n ther treatment team member can. Dependency Patients with brain injury ften try t get family and friends t assist them in varius ways, e.g., reading a menu, making a decisin abut clthes r a TV shw, r retelling a stry. This ccurs when the patient finds that perfrming these relatively simple tasks is very difficult. Yu and ther family members may want t cmply with these requests ut f kindness and because it is t difficult t stand back and watch a lved ne struggle and smetimes fail. Hwever, allwing a patient t try, t struggle, and at times, t fail is ften the basis fr learning r relearning a skill. Please be pen t staff as they ffer suggestins abut hw best t assist yur lved ne, i.e., maintain the right distance that encurages a sense f persnal cnfidence and independence. Encuragement We have fund that in sme cases, the encuragement given by family members, even when dne gently and lvingly, may be experienced by the patient as pressure t perfrm. Additinally, this can be embarrassing particularly when the patient is aware f his/her inadequacies when perfrming even the simplest f tasks. In these situatins, the family and staff will talk tgether t try t establish a sund therapeutic plan. The staff will ffer yu many suggestins abut hw best t interact with yur lved ne. Please d nt take any cmments r suggestins frm staff as a persnal criticism. They are meant t be helpful. 6
Family Teaching Participating in Family Teaching is ne f the mst imprtant ways family members and caregivers can help the patient. Family teaching includes cming t Frazier fr the day and ging thrugh ccupatinal, physical and speech therapies in the mrning and afternn. During these sessins, therapists will wrk with yu and the patient t set the treatment plan that is the mst functinal fr the patient and t help yu understand the skills that remain intact and the skills that need t be imprved. Yu will have pprtunity t try techniques the therapists are using t imprve the functinal skills. The team is wrking with yu and the patient t transitin safely t hme and t the next steps in the recvery and rehab prcess. The family will als have pprtunity t gain knwledge and skills thrugh training with the nurses. Yu may be asked t participate in sme basic nursing care, such as bwel and bladder care, feeding tube management, ral care, trachetmy care, and wund care. The purpse f asking yu t d this is nt t have yu substitute fr care prvided by ur nursing staff, but t prepare yu t prvide care fr the patient at hme. Dctrs, psychlgists, case managers and ther team members will als be available fr teaching, supprt, and answering questins as needed. In mst cases, the mre frequently family attends family teaching the better. Primary caregivers are encuraged t cme as ften as pssible and spend the day learning. If full days are nt pssible, yu are encuraged t cme fr half days. Let the team knw what days and times yu are able t attend. It is crucial fr the patient s safety and well being that family is present t learn hw t best care fr the patient as they prepare fr discharge. Recvery frm brain injury happens ver an extended perid f time. Generally yu can expect significant changes fr the patient at least in the early stages f recvery and attending family teaching will help yu t be prepared fr changes yu may encunter at hme. Anther frm f family teaching ccurs by attending Brain Injury educatin classes. Frazier ffers a twice weekly Brain Injury educatin class n Mnday and Friday frm 10:30-11:30 in the 7 th flr team and family cnference rm. A series f tpics related t brain injury is cvered ver a tw week perid. The tpics are relevant t family members f brain injury survivrs. Questins are welcmed leading t discussins that enhance the learning. Family members are encuraged t g thrugh the entire tw week series beginning the Mnday r Friday after the admissin t Frazier. This series is pen t any number f family members and may be repeated. Patients wh have prgressed t a level f recvery that wuld allw them t benefit frm classrm style educatin and discussin are scheduled t attend the classes. Taking Care f Yurself Yu knw, caring fr a family member with a brain injury presents emtinal and physical challenges fr yu and yur family. Nrmally, family members experience grief, anxiety, sadness, and anger t name but a few emtins. These may cntribute t disturbances f sleep, appetite and energy levels. Dealing with brain injury is nt easy. These are difficult times. Clearly, family s health and well-being are critical t the patient s recvery. If yu burn ut r becme sick, yu will have little t ffer the patient r ther family members. Unfrtunately, the staff sees t many family members sacrificing their health by trying t Stand Watch at the hspital many hurs each day. 7
If yu are caught in this dilemma, staff will encurage yu t view the situatin mre bjectively. Yu may find it helpful t meet with a psychlgist, a trained prfessinal n the treatment team, wh has specific knwledge abut yur lved ne. He/she can ffer guidance, supprt and relevant infrmatin. Cnfidential appintments can be made with the psychlgist directly r thrugh anther team member. In summary, taking gd care f yurself is ne f the mst helpful things yu can d fr yur injured family member. Questins and Cncerns Yu will have many questins and cncerns abut yur lved ne during hspitalizatin. Regular attendance in all Family Teaching activities and attending the Mnday and Friday mrning educatin classes, will answer many f yur questins and address many f yur cncerns. There are tw ther ways t deal with yur questins and cncerns. The first is t cntact specific members f the treatment team. Fr example, the nurse can be helpful in addressing questins abut daily care, physical functining, visitatin and special precautins fr care. The Case Manager can address issues related t discharge planning, cmmunity resurces and medical insurance. Secndly, specific cncerns abut prgress and treatment recmmendatins can be addressed during weekly runds and during a team and family meeting with all team members present. Yu may request such a meeting by cntacting yur Case Manager. Many variables are cnsidered when deciding upn a discharge date. The mst apprpriate setting fr cntinued rehab is a primary cnsideratin. Sme ther factrs include the prgress the patient is making in treatment, availability f family, the need fr further services, limitatins f individual insurance plicies/cverage, and equipment needs. If persistent ne-n-ne nursing care and/r cnstant medical mnitring is needed, a transfer t anther facility may ccur. Suicidal behavir requires a transfer t a mre apprpriate setting, and disruptive behavir that interferes with prviding rehab services r creates patient safety issues may require discharge frm Frazier. Since discharge needs vary frm patient t patient, each case is addressed individually. The case manager will crdinate the discharge plan and discuss the develpment f discharge plans weekly with the family spkespersn. The entire treatment team will participate in this planning. Our gal is t prepare fr a well rganized transitin t hme. As a general rule f thumb a patient will need t demnstrate prgress n a weekly basis in rder t remain in the rehab hspital. Insurance cmpanies require that the treatment team reprt weekly n the patient s prgress r lack f prgress. The criteria that insurance cmpanies use t determine cverage and length f time they will pay fr services varies frm cmpany t cmpany. Any questins r cncerns abut cntinued cverage shuld be directed t yur Case Manager. 8
Discharge planning may als be discussed when yu meet with the rest f the treatment team during the Team & Family meeting. Transitin frm Rehab t Schl Fllwing a brain injury, yur child may have special needs in relatin t schl. Often changes in the schl prgram will be necessary fr yur child t prgress academically. A team effrt is required fr a smth transitin. Yu as parent/guardian will be a vital member f the team. Currently, there are tw Federal laws that set the standard fr services within each state. Keep in mind hwever, that there are variatins in educatinal services frm state t state. The Individuals with Disabilities Educatin Act (IDEA): Public Law 101-476 makes certain that federal funds are available. This law sets guidelines fr delivering services t children frm ages 3 21 years wh are in need f special educatin services. There are fur steps t this prcess: 1. Identify the need fr special services. A dctr, parent r agency can make the referral. 2. Evaluatin t determine the child s learning strengths and weaknesses. A parent/guardian must give permissin fr this step. 3. Individual Educatin Plan Gals and bjectives are created by a team f prfessinals including the parents/guardian. All services will be delivered in a setting that is least restrictive fr the child. 4. Review -The plan (IEP) is t be reviewed at least annually but mre frequent reviews are usually recmmended fr a child with brain injury. The secnd federal law is listed under sectin 504 f the Rehabilitatin Act. A 504 plan is less frmal but prvides a list f accmmdatins t help the child succeed in the schl setting. In the event that yur child attends a private schl, the rehab team will wrk with the schl and prvide essential infrmatin fr the reentry prcess. Private schls are nt subject t Federal Law requirements fr special educatin. Fr children under the age f 3, the rehab team will cntact the federal prgram called First Steps. First Steps is an early interventin prgram fr children with develpmental delay r a particular medical cnditin that is knwn t cause a develpmental delay. Services are crdinated thrugh the Cabinet fr Health Services in each state. Yu are encuraged t speak t the academic re-integratin crdinatr and ask questins abut the schl re-entry prcess. Yu as parents/guardians are the mst valuable nging surce f infrmatin. The key t successful reintegratin f yur child back int the schl system is cmmunicatin and educatin abut brain injury fr all parties invlved. 9
Areas f the Brain 10
Areas f the Brain Frntal Lbe Lcatin Functin The frntal lbe is lcated in the area arund yur frehead. Emtinal cntrl Reasning & judgment Vluntary mvement Mtivatin & Initiatin Scial behavir Creativity Expressive language Prblem slving Planning & Decisin making Parietal Lbe Lcatin Functin The parietal lbes are lcated behind the frntal lbes, abve the tempral lbes, and at the tp back f the brain. Related t the tactile senses: Tuch Pain Taste Pressure Temperature Spatial relatinships Tempral Lbe Lcatin Functin The tempral lbes are lcated n bth sides f the brain and just abve the ears. Hearing Memry Meaning Language cmprehensin Learning Interpreting auditry stimuli Prcessing auditry stimuli. 11
Occipital Lbe Lcatin Functin The ccipital lbe is fund in the back f the brain. Related t the brain's ability t recgnize bjects Visual perceptin Visual input Reading Cerebellum Lcatin Functin The cerebellum is lcated at the base f the brain, underneath the ccipital lbe. Balance Equilibrium Crdinatin f vluntary mvement Brain Stem Lcatin Functin The brain stem is lcated at the bttm f the brain and cnnects the brain t the spinal crd. Related t life-sustaining actins: Breathing Heart rate Temperature Level f alertness 12
Ranch Ls Amigs Cgnitive Recvery Scale 13
RANCHO LOS AMIGOS COGNITIVE RECOVERY SCALE The Ranch Ls Amigs Cgnitive Recvery Scale (RLA) is ne f several scales develped t identify stages r levels f brain injury recvery. This scale begins with Level 1 and prgresses thrugh Level 10. The treatment team will use this scale as a guide when develping each patient s treatment plan. The team s treatment strategy will change if the patient prgresses frm ne Ranch Level t the next. Each persn with a brain injury will mve thrugh the Ranch Levels at varius speeds. Patients will be discharged frm the hspital prir t prgressing thrugh all f these levels. Therapy services ften cntinue after discharge. Mst patients d nt require a lt f stimulatin during mid range Ranch Levels (4,5,6). Instead they usually get mre than enugh stimulatin fr the whle day by attending therapies. Brief, quiet visits are mst helpful. Stimulatin can be anything that excites the patient, such as TV, radi, lights, talking, seeing several peple at nce, being in a hallway r nisy place. The patient may nt utwardly shw ver stimulatin and their expressin may be blank but still be ver stimulated n the inside. They may, fr example, sweat r breathe rapidly when ver stimulated. Recvery Levels Level I (1). N respnse: (t any stimulus): Ttal Assistance the patient appears t be in a deep sleep r cma and des nt respnd when presented with visual, auditry, tactile, prpriceptive, vestibular r painful stimuli. Level II (2). Generalized respnse: Ttal Assistance the patient mves arund, but mvement des nt seem t have a purpse r cnsistency. This reactin may be due t deep pain. Patient may pen their eyes but d nt seem t be fcused n anything in particular. Level III (3). Lcalized respnse: Ttal Assistance the patient begins t mve their eyes and lk at specific peple and bjects. They turn tward r away frm lud vices r nise. The patient at level 3 may fllw a simple cmmand such as, squeeze my hand. Respnses are incnsistent and directly related t the type f stimulus. Level IV (4). Cnfused and agitated: Maximal Assistance the patient is very cnfused and agitated abut where he r she is and what is happening in the surrundings. At the slightest prvcatin, the patient may becme very restless, aggressive, r abusive (verbally and/r physically). The patient may enter int incherent cnversatin in reactin t inner cnfusin, fear r disrientatin. Mtr activities that culd be detrimental are attempted. Safety and deficit awareness are imprtant issues. Level V (5). Cnfused, inapprpriate, nn-agitated: Maximal Assistance the patient is cnfused and des nt make sense in cnversatins, but may be able t fllw simple directins. Stressful situatins may prvke sme upset, but agitatin is n lnger a majr prblem. Patients may experience sme frustratin as elements f memry return. Fllws tasks fr 2-3 minutes but is easily distracted by envirnment. Level V1 (6). Cnfused, apprpriate: Mderate Assistance the patient s speech makes sense, and he r she is able t d simple things such as dressing, eating, and teeth brushing. Althugh patients knw hw t perfrm a specific activity, they need help discerning when t start and stp. Learning new things may als be difficult. The patient's memry and attentin are increasing and he r she is able t attend t a task fr 30 minutes. Level VII (7). Autmatic apprpriate: Minimal Assistance fr daily living skills the patient can perfrm all self-care activities and are usually cherent. They have difficulty remembering recent events and 14
discussins. If physically able, can carry ut rutine activities. Ratinal judgments, calculatins, and slving multi-step prblems present difficulties, yet patients may nt seem t realize this. Needs supervisin fr safety. Level VIII (8). Purpseful, Apprpriate: Stand-By Assistance: The patient is independent fr familiar tasks in a distracting envirnment fr ne hur. He r she acknwledges impairments but has difficulty self-mnitring. Emtinal issues such as depressin, irritability and lw frustratin tlerance may be bserved. Level IX (9). Purpseful, Apprpriate: Stand-By Assistance n Request: The patient is able t shift between tasks fr tw hurs. Requires sme assistance t adjust t life demands. Emtinal and behaviral issues may be f cncern. Level X (10). Purpseful, Apprpriate: Mdified Independent: The patient is gal directed, handling multiple tasks and independently using assistive strategies. Prne t breaks in attentin and may require additinal time t cmplete tasks. Descriptin and family strategies fr each RLA Level Level I - N Respnse: Ttal Assistance Cmplete absence f bservable change in behavir when presented visual, auditry, tactile, prpriceptive, vestibular r painful stimuli. Level II - Generalized Respnse: Ttal Assistance Demnstrates generalized reflex respnse t painful stimuli. Respnds t repeated auditry stimuli with increased r decreased activity. Respnds t external stimuli with physilgical changes generalized, grss bdy mvement and/r nt purpseful vcalizatin. Respnses nted abve may be same regardless f type and lcatin f stimulatin. Respnses may be significantly delayed. Level III - Lcalized Respnse: Ttal Assistance Demnstrates withdrawal r vcalizatin t painful stimuli. Turns tward r away frm auditry stimuli. Blinks when strng light crsses visual field. Fllws mving bject passed within visual field. Respnds t discmfrt by pulling tubes r restraints. Respnds incnsistently t simple cmmands. Respnses directly related t type f stimulus. May respnd t sme persns (especially family and friends) but nt t thers. 15
Family Strategies fr Level I-III Family members shuld nt interpret the agitatin and cnfusin as regressin, but rather as prgress. The individual is nt aware f what he/she is ding and is likely t remember little f this perid f time. When relating t a persn at a lw Ranch level, family and friends shuld: Use calm, reassuring tnes, and in a nrmal tne f vice Tell the persn what yu are ging t d befre yu d it. Fr example, I m ging t mve yur leg. Speak in shrt phrases, keeping cmments and questins shrt and simple. Fr example, instead f saying, Can yu turn yur head t me? say, Lk at me. Allw the persn extra time t respnd. Smetimes respnses are incnsistent, incrrect r d nt ccur. Have ne persn speak at a time. Tell the persn wh yu are, where they are, why they are in the hspital, and what day it is. Speak in cncrete terms. Discuss things that are happening near the persn. Bring in favrite belngings and pictures f family members and clse friends. Bring in familiar activities, such as favrite music, talking abut family and friends, reading favrite magazines r bks ut lud, watching favrite TV shws r vides t stimulate senses and memry. Gently massage ltin n the persn s arms, legs, back and stmach. This nt nly increases the persn s tactile awareness but als helps prevent skin breakdwn. Tuch the persn n the face, arm, r leg with varius textures like a washclth, fuzzy ty, flannel, plastic, rubber, etc. fr sensry stimulatin. Use a variety f saps, fragrances and ltins t stimulate smell. Keep a ntebk nearby fr family and visitrs t sign. Instruct them t lg in any nticeable respnses t stimuli. Limit the number f visitrs t 2-3 at a time. Keep the rm calm and quiet. Maintain rest perids. Always assume the persn with brain injury can understand what is being said. Never discuss subjects that may be upsetting in frnt f the persn. 16
Level IV - Cnfused/Agitated: Maximal Assistance Alert and in heightened state f activity. Purpseful attempts t remve restraints r tubes r crawl ut f bed. May perfrm mtr activities such as sitting, reaching and walking but withut purpse r upn anther's request. Very brief and usually nn-purpseful mments f sustained alternatives and divided attentin. Absent shrt-term memry. May cry ut r scream ut f prprtin t stimulus even after its remval. May exhibit aggressive r flight behavir. Md may swing frm euphric t hstile with n apparent relatinship t envirnmental events. Unable t cperate with treatment effrts. Verbalizatins are frequently incherent and/r inapprpriate t activity r envirnment. Family Strategies fr Level IV Ranch Level IV is characterized by: Emergence f Agitatin and Cnfusin Family members shuld nt interpret the agitatin and cnfusin as regressin, but rather as prgress. The individual is nt aware f what he/she is ding and is likely t remember little f this perid f time. When relating t a persn at Ranch Level IV, family and friends shuld: Tell the persn where they are and reassure them that they are safe. Bring in family pictures and ther persnal items. These may make the persn feel mre cmfrtable as well as stimulate memry. Allw the persn as much mvement as is safely pssible; Take persn fr rides in a wheel chair, if permitted. Nt frce the persn int activities; listen t them and fllw their lead, as is safely pssible Prvide frequent rest breaks t minimize episdes f increased restlessness and agitatin. Keep the rm quiet and calm; if the persn is agitated, turn ff the TV and radi. Limit visitrs t 2-3 at a time. 17
Level V - Cnfused, Inapprpriate Nn-Agitated: Maximal Assistance Alert, nt agitated but may wander randmly r with a vague intentin f ging hme. May becme agitated in respnse t external stimulatin, and/r lack f envirnmental structure. Nt yet riented t persn, place r time. Frequent brief perids, nn-purpseful sustained attentin. Fllws tasks fr 2-3 minutes befre being easily distracted Severely impaired recent memry, with cnfusin f past and present in reactin t nging activity. Absent gal directed, prblem slving, self-mnitring behavir. Often demnstrates inapprpriate use f bjects withut external directin. May be able t perfrm previusly learned tasks when structured and cues prvided. Able t respnd apprpriately t simple cmmands fairly cnsistently. Able t cnverse n a scial, autmatic level fr brief perids f time. Verbalizatins abut present events may becme inapprpriate and cnfabulatry. Family Strategies fr Level V Ranch Level V is characterized by Cntinued Cnfusin with Inapprpriate but Nn-Agitated Behavir. Cnversatins can be cnfused, unusual, insistent, humrus r bizarre. When relating t a persn at Ranch Level V, family and friend shuld: Avid a tendency t reward r play int inapprpriate behavir. Use redirectin and distractin t stp inapprpriate behavir. Due t cgnitive limitatins, reasning at this stage is nt successful, but redirectin is ften easy and effective, since the patient is s easily distracted. Nt assume that the persn will remember what yu tell them. Persns at Ranch Level V ften require frequent repetitin Keep cmments and questins shrt and simple. Remind the persn f day, date, name and lcatin f the hspital as well as why they are in the hspital. Help the persn get rganized fr tasks and activities. Bring in familiar pictures and persnal bjects frm hme. Limit visitrs t 2-3 at a time. Give patient frequent rest perids. 18
Level VI - Cnfused, Apprpriate: Mderate Assistance Incnsistently riented t persn, time and place. Able t attend t highly familiar tasks in nn-distracting envirnment fr 30 minutes with mderate redirectin. Remte memry has mre depth and detail than recent memry. Vague recgnitin f sme staff. Able t use assistive memry aide with maximum assistance. Emerging awareness f apprpriate respnse t self, family and basic needs. Mderate assist t prblem slve barriers t task cmpletin. Supervised fr ld learning (e.g. self care). Shws carry ver fr relearned familiar tasks (e.g. self care). Maximum assistance fr new learning with little r nr carry ver. Unaware f impairments, disabilities and safety risks. Cnsistently fllws simple directins. Verbal expressins are apprpriate in highly familiar and structured situatins. Family Strategies fr Level VI Ranch Level VI is characterized by Cntinuing Cnfusin but Emergence f Apprpriate Behavir. When relating t a persn at Ranch Level VI, family and friends shuld: Expect the persn t be unaware f their deficits and the need fr increased supervisin and rehabilitatin. They may insist nthing is wrng with them and that they can g hme and resume their usual activities. Realize that redirectin is nt effective and arguments can be frequent and prlnged. Encurage the persn t participate in and cntinue t stay in rehabilitatin services. Understand that the persn may react t their head injury in a nn-emtinal manner and may appear nt t care that they are injured. Family shuld knw that this behavir is related t their stage f recvery. Realize frequent repetitin may be necessary. Discuss and jurnal activities that have happened during the day, t help the persn imprve his/her memry. Help with starting and cntinuing activities. 19