Serving Clients with TBI

1
Serving Clients with TBI -

• Consideration of Rancho Los Amigos Scales and
  Potential for Vocational Services

2
Distinctive Characteristics of TBI Disability

• brain injury almost always disrupts intellect
  and emotion, limiting available resources for
  coping.
• TBI,..often abruptly diminishes the social and
  vocational roles of individuals who have achieved
  a stable adaptation.
• TBI without accompanying physical deficits may
  evolve into a silent affliction conferring unique
  problems on the injured individual.

3
Rancho Los Amigos Scale -

• Rancho levels progress rapidly, but progress,
  from level to level, cannot be predicted
• patients may demonstrate characteristics of more
  than one level
• patients may remain at any level for an extended
  period
• as months pass, progress will slow and
• level at which the patient plateaus cannot be
  predicted.

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Level I - No reaction

• appears to be sleeping
• offers no response to environmental stimuli
  (i.e., voices, sounds, light, or touch) and
• comatose state can last seconds, minutes, hours,
  days, weeks, or months.

5
Level II - Generalized reaction

• awake, but not aware, and eyes may open, but not
  focus
• reacts with garbled words and broad body
  movement, inconsistently and without purpose, but
  with significant delay and
• simple, reflexive reaction offered regardless of
  type or location of stimuli.

6
Level III Localized reaction

• responses and reactions more purposeful and
  specific, but still inconsistent and vary
  according to different stimuli
• may, in delayed manner, follow simple commands
• may offer better response to familiar persons
  while offering no reaction to others and
• may have vague body awareness.

7
Level IV Confused and agitated

• very active and in heightened state of
  excitement, but unaware of present events and in
  confused disorientation
• tires easily and unable to cooperate with
  treatment or participate in self-care
• attention span usually very brief and
  non-purposeful and short-term memory absent and
• may perform automatic motor activities such as
  sitting, reaching, and walking as part of
  agitated state (not necessarily with apparent
  purpose or upon anothers request).

8
Level V Confused andinappropriate

• less agitated, demonstrating greater alertness,
  and can manage self-care activities with
  assistance
• Reacts fairly consistently, for two to three
  minutes, to simple commands and previously
  learned tasks with external structures and cues
  and
• able to converse on social, automatic level for
  brief periods of time when provided external
  structure and cues but

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Level V Confused andinappropriate (cont.) -

• lacks orientation to person, place, or time
• recent memory severely impaired, unable to learn
  new information, and relation of past and present
  to ongoing activity often confused
• will not try to do things independently and
  absent goal directed, problem-solving, and
  self-monitoring behavior and
• in danger of wandering off, often with vague
  intention of going home.

10
Level VI Confused andappropriate

• motivated and shows goal-directed behaviors
• general activities of daily living can be
  completed with supervision
• highly familiar tasks, in non-distracting
  environment, can be attended to for 30 minutes
  with moderate redirection
• may be able to use assistive memory aide with
  maximum assistance, and
• memory of the past has improved greatly but
  memory of recent events still damaged but

11
Level VI Confused andappropriate (cont.)

• still inconsistently oriented to person, time,
  and place and may not generalize to new
  situations or people
• maximum assistance required for new learning, but
  frequent repetition is necessary and little or no
  carry over should be expected
• still needs external structure and depends on
  others to lead way and
• unaware of personal impairments, disabilities,
  and safety risks.

12
Level VII Automatic and appropriate

• knows self and acts appropriately in hospital and
  home
• can dress, wash, and feed self without help and
  able to monitor accuracy and completeness of each
  step in routine personal and activities of daily
  living and
• in a non-distractive environment, for at least 30
  minutes, initiates and carries out steps to
  complete highly familiar personal and household
  routines but

13
Level VII Automatic and appropriate
(cont.)

• like a robot, consistently oriented, within
  highly familiar environments, to person and
  place, while moderate assistance may be required
  for orientation to time and
• expresses superficial awareness of condition but
  may be unaware of specific impairments and
  disabilities and the limits they place on his or
  her abilities and

14
Level VII Automatic and appropriate (cont.)

• may overestimate abilities, due to damage done to
  judgment and problem-solving skills, may not
  accurately consider the consequences of a
  decision or action, and cannot make realistic
  plans for the future and
• unaware of others needs and feelings,
  oppositional and uncooperative, and unable to
  recognize inappropriate social interaction
  behavior.

15
Level VIII Purposeful and appropriate (standby
assistance)

• consistently oriented to person, place, and time
  
• independently attends to and completes familiar
  tasks for one hour in distracting environments
  and able to recall and integrate past and recent
  events and
• uses assistive memory devices to recall daily
  schedule, keep to do lists, and record critical
  information for later use with standby
  assistance and

16
Level VIII Purposeful and appropriate (standby
assistance, cont.)

• initiates and carries out steps to complete
  familiar personal, household, community, work,
  and leisure routines with standby assistance and
  can modify plan when needed with minimal
  assistance and
• requires no assistance once new tasks and
  activities are learned, but is aware of and
  acknowledges impairments and disabilities when
  they interfere with task completion and require
  standby assistance to take appropriate corrective
  action but

17
Level VIII Purposeful and appropriate (standby
assistance, cont.)

• overestimates or underestimates abilities
  (although able to think about consequences of a
  decision or action with minimal assistance)
• may have difficulty with abstract reasoning,
  judgment, and learning, especially when under
  stress, subject to unexpected events, or in
  unusual or emergency situations and
• able to recognize and acknowledge inappropriate
  social interaction while occurring and takes
  corrective action with minimal assistance.

18
Level IX Purposeful and appropriate (standby
assistance on request)

• initiates and carries out steps to complete
  familiar personal, household, work, and leisure
  tasks independently
• independently shifts back and forth between tasks
  and completes them accurately for at least two
  consecutive hours and
• uses assistive memory devices to recall daily
  schedule, keeps to do lists, and records
  critical information for later use with
  assistance when required and

19
Level IX Purposeful and appropriate (standby
assistance on request, cont.)

• may request assistance regarding unfamiliar
  personal, household, work, and leisure tasks
• aware of and acknowledges impairments and
  disabilities when they interfere with task
  completion and takes appropriate corrective
  action, but may require standby assistance to
  anticipate a problem before it occurs and take
  action to avoid it and
• able to think about consequences of decisions or
  avoid actions with assistance when requested but

20
Level IX Purposeful and appropriate (standby
assistance on request, cont.)

• accurately estimates abilities but may require
  standby assistance to adjust to task demands
• depression may continue, he or she may be easily
  irritable, and low frustration tolerance may be
  evident and
• able to self-monitor appropriateness of social
  interaction with standby assistance.

21
Level X Purposeful and appropriate (modified
independent)

• alert, oriented, independent, and functions well
  in society
• recalls and integrates past events and remembers
  how the past aligns with the future
• accurately estimates abilities, learns new
  activities and continues without supervision
• can resolve simple and complex questions, is
  independent in home and living skills, and may be
  allowed to drive and
• recognizes needs and feelings of others and
  responds in appropriate manner and

22
Level X Purposeful and appropriate (modified
independent, cont.)

• handles familiar and unfamiliar personal,
  household, community, work, and leisure tasks
• anticipates impact of disabilities on ability to
  complete daily living tasks and takes action to
  avoid problems before they occur
• able to independently procure, create, and
  maintain own assistive memory devices
• independently think about consequences of
  decisions or actions
• these may require more than the usual amount of
  time and/or compensatory strategies and

23
Level X Purposeful and appropriate (modified
independent, cont.)

• may experience occasional periods of depression,
  and irritability and low frustration tolerance
  may persist when he or she feels sick, fatigued
  and/or under emotional distress and
• social interaction behavior consistently
  appropriate.