Rancho los Amigos Lvls of Cog Fnx

what does the Ranchos los Amigos measure consist of?

10 lvls (originally 8) useful for describing & communicating cog/behav status

Can be helpful for tx planning

Helps to describe pattern of recovery: Individuals can plateau at any level

what level has no response to stimuli? (visual, auditory, tactile, proprioceptive, vestibular, painful)

Level 1: no response- total assistance (coma)

what level demos general responses, inconsistent, not purposeful, not specific?

Responses can be delayed significantly & are often same regardless of type or location of stimuli

Responses may be physiologic, gross body mvmts, &/or vocalizations

Level 2: generalized response- total assistance

what level where responses are specific, but inconsistent?

Response is directly related to the stimuli

Responds inconsistently to commands; better to some individuals than others (family/friends)

demos withdrawal or vocalization to painful stimuli

might follow object in visual field, responds to discomfort by pulling at lines/tubes, Turn to/away from auditory stimulus

Level 3: Localized response- total assistance

what level is pt in state of heightened activity?

demos purposeful attempts to remove lines/tubes, crawl out of bed, get out of a chair

Often performs motor behaviors w/o apparent purpose or request

Absent short & long term memory

Difficulty cooperating w/ tx: Aggressive or flight behaviors, Incoherent & inappropriate verbalizations to situation, Significant mood swings w/o relationship to enviro context

level IV: confused/agitated- Max A

what level is pt alert, but disoriented, & highly distractible?

May become agitated in response to external stimulation, &/or lack of enviro structure.

Often demos inappropriate use of objects w/o external direction

Simple command following w/ structure & cues: May perform previously learned tasks w/ structure & cues; w/o structure, responses are random & non-purposeful

Memory/learning: Very poor recent memory, confusion of past & present; Unable to learn new info; Absent goal directed, problem solving, self-monitoring behavior

Communication: Social, automatic level for brief periods w/ structure & cues; w/o structure & cues→ inappropriate, confabulatory

Level V: confused, inappropriate, non-agitated- Max A

What lvl where pt is inconsistently oriented to person, time, & place?

Emerging awareness of appropriate responses to self, family, basic needs BUT unaware of impairments, disabilities, & safety risks

Poor problem solving for task completion Mod A

Communication: Consistently follows simple directions, Appropriate verbal expression in very familiar & structured settings

Memory/Attention/Learning: Vague recognition of some staff, Use memory aid w/ Max A

Remote memory > recent memory: Attend to highly familiar tasks in non-distracting enviro w/ Mod redirection

Supervision for old learning, but MAX A for new learning. Little to no carryover for new learning, but carryover w/ familiar, relearned tasks

Level vi: Confused, appropriate – Mod A

What lvl where pt consistently oriented to person & place, w/in highly familiar enviro. Mod A for orientation to time

Communication/Interaction: Unaware of others’ needs/feelings & unable to recognize own inappropriate social behavior, Oppositional & uncooperative

Memory/Learning/Attention: Min S for new learning & demos carryover of new learning. Attend to highly familiar tasks in non-distracting enviro w/ Min A to complete tasks

Safety: Overestimates abilities→ Min supervision for safety in routine activities. Unable to think about consequences or realistically plan for future. Superficial awareness of condition, but unaware of specific impairments & impact of them

Can carry out familiar personal/household routines but requires Min A for accuracy, completeness, or plan modification & demos limited recall of what they been doing

Level vii: automatic appropriate – Min A for daily living skills

what ranchero level is pt consistently oriented to person, place, & time?

Communication/Interaction: Depressed, irritable, argumentative, self-centered, poor frustration tolerance, uncharacteristically independent/dependent. Acknowledges others’ needs/feelings & responds appropriately w/ Min A. Can recognize & acknowledge inappropriate social behavior & correct w/ Min A

Safety: Over- or underestimates abilities. Thinks of consequences w/ Min A. Awareness & acknowledgement of impairment impact on fnx, requires min A to initiate corrective action

Memory/Attention/Learning: Independently attends to & completes familiar tasks for 1 hr in distracting enviro. Uses memory devices w/ stand-by A. Can recall & integrate past & recent events. No A once new learning has occurred for tasks/activities

Can carry out familiar routines w/ stand-by A & modify if needed w/ min A

Level Viii: purposeful, appropriate – stand-by A

What lvl where pt communication/Interaction: MAY demo depression, ease of irritability, low frustration tolerance. Demo social self monitoring w/ stand-by A. Acknowledges others’ needs/feelings & demo appropriate response w/ stand-by A.

Safety: Awareness & acknowledgement of impact of impairment on fnx & initiates corrective action as needed BUT requires stand-by A to anticipate problems & take action to avoid. Can think of consequences w/ A when requested. Understands abilities but requires stand-by A to adjust to task demands

Memory/Attention/Learning: Uses memory devices w/ A only when requested. Can independently shift between tasks & complete them accurately for up to 2 hrs

Can carry out familiar routines independently & unfamiliar tasks w/ A when requested

Level ix: purposeful, appropriate – Stand by A on request

What lvl pt when can independently carry out familiar & unfamiliar tasks but may require increased time or compensatory strats?

Communication/Interaction: Consistently appropriate social behavior. Periodic depression MAY occur; irritability & low frustration tolerance only when sick, fatigued, stressed. Recognizes needs/feelings of others & automatically responds appropriately

Safety: Accurately estimates abilities & can adjust to demand of task. Can think of consequences but may require increased time or compensations to select appropriate choice/action. Can anticipate impact of impairment on fnx & takes action to avoid problems but may require increased time or compensatory strats

Memory/Attention/Learning: Can multi-task in all enviro but may require rest breaks. Can create & maintain memory devices

Level X: purposeful, appropriate - Mod I

what level is this pt: Upon initial eval, you note that pt demos withdrawal to painful stimuli & inconsistently closes their eyes to command. This command following is better when command comes from pt’s mother.

lvl 3

what lvl is this pt: Tina participated in her ADL routine this morning w/ OT. She was initially uncooperative, but w/ some coaxing, was agreeable to get started. She required min A to complete the ADL routine in her hospital room (w/ door closed & min distractions) that she has been working on for a few weeks now.

lvl 7

what lvl is this pt: Ashlee has been assigned a 1:1 aide. She is constantly trying to get out of bed & pull out her PEG tube. When she is in her wc, she is constantly attempting to roam the halls & yells as she moves around the unit in her wc.

lvl 4

what lvl is this pt: Sally would like to go to the caf & buy herself ice cream. She remembers that she has been to caf before, but can’t remember where it is, so she asks for help w/ directions. She starts to make her way there, but when she gets to stairs, she realizes she needs to take steps. (She needs her crutch to do steps & does not have it w/ her.) She is not sure what to do, so she asks her PT for help. Her PT prompts her of the consequence of attempting the steps w/o crutch. Sally determines she better go back to get the crutch before moving forward.

lvl 9

what lvl is this pt: Tom was just brought down to PT gym by rehab aide. He is in his wc waiting his PT & he is looking all around gym & keeps grabbing items off a nearby shelf & placing them in his wc. When PT arrives, he does not remember her but tells her he thinks they went to HS together. His PT wants to start the session & asks Tom to stand up from his wc using a very specific & structured set of cues so that he is successful.

lvl 5