1Glasgow coma scale - eye opening
out of 4
spontaneous -4
to speech - 3
to pain - 2
nil- 1
2Glasgow coma scale - verbal response
out of 5
oriented - 5
confused convo - 4
inappropriate words -3
incomprehendable sounds -2
nil -1
3galsgow coma scale - motor response
out of 6
obeys commands - 6
localizes P! - 5
withdrawls - 4
abnormal flex - 3
extensor response -2
nil - 1
4what is the max and min amount of score for galsgow
3-15
5<8 on GCS
severe TBI or coma
69-12 on GCS
moderate TBI or coma
713-15 on GCS
mild TBI or coma
8Modified ashworth score of 0
no increase in mm tone
9modified ashworth scale (MAS) of 1
- slight increase in mm tone
- marked by a catch and release or min resistance at end range of motion while in flexion
10- slight increase in mm tone
- marked by a catch and release or min resistance at end range of motion while in flexion/extension
modified ashworth scale (MAS) of 1
11MAS of 1+
- slight increase in mm tone
- catch and then min resistance through 1/2 ROM
12- slight increase in mm tone
- catch and then min resistance through 1/2 ROM
MAS of 1+
13MAS of 2
- more marked increase in mm tone throughout most of ROM
- affected parts still easily movable
14- more marked increase in mm tone throughout most of ROM
- affected parts still easily movable
MAS of 2
15MAS of 3
- considerable increase in mm tone
- PROM difficult
16- considerable increase in mm tone
- PROM difficult
MAS of 3
17MAS of 4
affected parts are rigid in flexion or extension
18affected parts are rigid in flexion or extension
MAS of 4
20RLAS 2
generalized response
- reacts inconsistently & non purposefully
- responses are limited and the same no matter the stumulus
21pt reacts inconsistently and nonpurposefully. Resposnes are limtied and the same no matter the stimulus
RLAS?
2: generalized response
22RLAS 3
3: localized response
- reacts specifically, but inconsistently to stimuli
- responses related to stimulis are present
- simple commands (close eyes, squeeze hands) inconsistent or delayed manner
23Pt reacts specifically to a stimuli, but inconsistently to stimuli. Pt is able to respond to simple commands inconsistently or in a delayed manner
RLAS?
RLAS 3: localized response
24RLAS 4Pt
4: confused-agitated
- heightened state of activity
- bizarre and nonpurposeful
- no discrimination of ppl or objects
- unable to cooporate
- incoherrent verbalizations
- selective attention is nonexistent
- lacks short term recall
25Pt is in a heightened state of activity with bizarre and non-purposeful behaviors. The are unable to discimitate ppl or objects and are unable to cooporate. They lack short term recall and have no selective attention.
RLAS?
RLAS of 4: confused-agitated
26RLAS 5
5: Confused - inappropriate : max assist
- responds to simple commands consistently
- responses are nonpurposeful, random or fragmented
- gross attention to enviroment but highly distractable
- unable to focus on a task
- converse on a social level
- severly impaired memory
- inappropriate use of objects
Different from level IV in that individual does not demonstrate agitation to internal stimuli. However, they can show agitation to unpleasant external stimuli.
27Pt Shows increase in consistency with following and responding to simple commands. Responses are non-purposeful and random to more complex commands.
Behavior and verbalization is often inappropriate, and individual appears confused and often confabulates. If action or tasks is demonstrated individual can perform but does not initiate tasks on own. Memory is severely impaired and learning new information is difficult
RLAS?
RLAS 5: confused - inappropraite : max assist
28RLAS 6
6: confused - appropriate : Mod assist
- Able to follow simple commands consistently
- Able to retain learning for familiar tasks they performed pre-injury (brushing teeth, washing face) however unable to retain learning for new tasks
- Demonstrates increased awareness of self, situation, and environment but unaware of specific impairments and safety concerns
- Responses may be incorrect secondary to memory impairments but appropriate to the situation
29Pt is able to follow simple commands consistently, retain learning for familiar tasks they performed pre-injury (brushing teeth, washing face) however unable to retain learning for new tasks. They demonstrate increased awareness of self, situation, and environment but unaware of specific impairments and safety concerns. Responses may be incorrect secondary to memory impairments but appropriate to the situation
RLAS?
6: confused - appropriate : Mod assist
30RLAS 7
7: automatic- Appropriate : min assist for ADLS
- appropriate and oriented
- robotic like, but able to go throuh routines
- min - no confusion
- shallow recall of activites
31Pr presents: oriented in familiar settings. Able to perform Daily routine automatically with minimal to absent confusion. They Demonstrates carry over for new tasks and learning in addition to familiar tasks. Pt is Superficially aware of one’s diagnosis but unaware of specific impairments. Continues to demonstrate lack of insight, decreased judgment and safety awareness. Beginning to show interest in social and recreational activities in structured settings. Requires at least minimal supervision for learning and safety purposes.
RLAS 7: automatic- Appropriate : min assist for ADLS
32RLAS 8
RLAS 8: purposeful-Appropriate
- recalls and integrates past and recent events
- aware and responsive to enviroment
- no supervision once activies are learned
- Consistently oriented to person, place and time
33Pt is Consistently oriented to person, place and time. THey recall and integrate past and recent events. They require no supervision of activties that are learned and are aware and responsive of their enviroment
RLAS 8: purposeful - Consistently oriented to person, place and time
34max score for mini mental state exam
30
35range for mild cognitive impairement for mini mental state exam
21-24
36range for moderate on mini mental state exam
16-20
37range for severe on mini mental state exam
<15
38<15 on mini mental state exam
severe cognitive impairment
3916-20 on mini mental state exam
moderate cognitive impairment
4021-24 on mini mental exam
mild cognitive impairment
41is higher or lower better on mini mental state exam
higher = better
max score = 30
<15 = severe cognitive impairment