Occupational therapy programs tables of content


COMA EVALUATION PROCEDURES



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COMA EVALUATION PROCEDURES
Fill in all blanks.

Chart review: Self-explanatory.

Pertinent medical/social history: Include other diagnoses, complications, occupational/leisure activities/family support. Note any occupational therapy treatment the patient has received in the past for the same diagnosis. Note marital status and number of dependents. Request family to complete Biographical Data Sheet (Exhibit 7-6) on the patient.

Mechanisms of injury: Describe the type of impact or blow and note the side of head to determine whether injuries are coup (injuries at the site of impact) or contracoup (injuries distant to the site of impact).

Precautions: Note any monitoring lines, life-support systems, need for head of bed to be elevated, and any other pertinent patient information that might jeopardize the safety of the patient or be detrimental to the therapist during treatment if not documented. e.g., isolation requirements, seizure disorders, allergies, and use of restraints.
MEDICAL STATUS


Record Glascow Coma Scale data from chart. Note scores on admission and present scores. Note the most current ICP reading from the chart and record the date of the reading.

Circle how the ICP is being monitored.

Circle whether the patient is in a drug-induced coma.

Circle which drug is being used if a coma is being induced.


BED TYPE/POSITIONING


Note the patient’s positioning in bed when initially seen for assessment before therapist provides a stimulus. I.e., fetal position, upper extremities flexed, legs extended, arms or legs adducted, or head extended or flexed.
REFLEXES
Record presence of reflex with (+), absence of reflex with (-). Reflexes are an involuntary, stereotyped response to a specific stimulus. In an adult with brain damage, these primitive reflexes can dominate and negate attempts at normal movement. A patient’s physical improvement is dependent on normalization of posturing tone, reintegration of primitive reflexes, and the subsequent redevelopment or rediscovery of normal automatic movement reactions.

Innate primary reactions–Reflexive primitive movements that involve total flexion and extension synergies of the proximal body parts. In the traumatic brain-injured patient, these are indicative of severe brain damage. If reflexes are absent on re-evaluation, it is a sign of improvement.

Rooting


Stimulus: Stroke outward on the corner of the patient’s mouth

Response: The lower lip, tongue, and head move toward the stimulus.

Sucking

Stimulus: Place a finger on the patient’s lips (wear gloves or substitute a cotton-tipped



swab for finger).

Response: Sucking motion of the lips.

Facial grimacing: Note whether present either spontaneously or in response to any stimulation (note the stimuli in comments section) provided by therapist/other discipline.

Teeth clinching/grinding: Note whether present either spontaneously or in response to any stimulation (note the stimuli in comments section) provided by therapist/other discipline. When any of these reflexes are present, they can interfere with normal eating patterns

Grasp reflex

Stimulus: Apply pressure in the palm of the hand from the ulnar side.



Response: Finger flexion with a strong grip that persists and resists removal of the stimulus object.

A grasp reflex may be viewed by the family as voluntary motion. The grasp reflex impairs

normal reaching, grasping, and releasing activities.

Other reactions

Spinal level–Phasic reflexes of total flexion or extension.

Flexor withdrawal

Test position: The patient is supine or sitting with head in midposition and legs are

extended.

Stimulus: A quick tactile stimulus is applied to the sole of one foot. A stimulus

therapists often use is to scrape the thumbnail from the heel to the ball of the

patient’s foot.

Response: Uncontrolled extension of the stimulated leg.

Crossed extension

Test position: The patient is supine with head in midposition; one leg is in

extension and the other leg is fully flexed.

Stimulus: Passively flex the extended leg.

Response: Extension of the opposite leg with hip adduction and internal rotation.

Cautions: It is unsafe to test for this reflex while the patient is sitting. With a strong

positive response, the patient could slide forward out of the chair.
The presence of a positive response to crossed extension influences creeping, as the extended leg cannot be flexed. It may also combine with a positive supporting reaction while the patient is standing and reinforce extension in the affected limb, making ambulation difficult.

Brain stem level–Tonic or static reflexes that involve sustained changes in postural muscle tone affecting the whole body or more than one part of the body. By changing the position of the head relative to the body or the position of the head in space, the proprioceptors located in the neck or in the vestibular apparatus are stimulated. The resultant changes in muscle tone are maintained as long as the stimulus is applied. These responses buildup gradually, and the stimulus for each of the following reflexes should be held to allow time for the response in cases of less severe involvement when the response may occur more slowly after several seconds’ delay.

Asymmetrical tonic neck

Test position: The patient is supine or sitting with arms and legs extended.

Stimulus: Passively or actively turn the head 90 degrees to one side.

Response: Extension of limbs on the face side and flexion of limbs on the skull

side. If the reflex response is weak, there may be no motion of the extremities,

but a change in tone can be noted in the extremities. Repeat the stimulus to the

other side.

A positive response to this reflex prevents rolling supine to prone because

shoulder retraction of the flexed upper extremity prevents the arm from coming

across the body, and the extended arm keeps the patient from rolling over as

well. If the reflex is strong, it also negatively influences sitting and standing

balance. A patient in the quadruped position may collapse when the head is

turned from neutral.

Use caution when administering reflex testing in regard to monitors and

equipment, e.g., monitoring, arterial lines, intravenous lines, catheters, or

cardiac monitors.

Posturing

Check whether the patient displays any type of posturing (+= present; -= absent). Check whether posturing is decerebrate (thought to be caused by damage to the upper midbrain and lower pons, sparing the vestibular nuclei) or decorticate (thought to be caused by damage to the internal capsule or cerebral hemispheres, interrupting the corticospinal pathways) in nature.

MOTOR RESPONSE TO SENSORY STIMULATION
Refer to the Sensory Awareness Evaluation and Flow Sheet Form (Exhibit 1-4) if completed and summarize the results if possible. If this evaluation has not been completed, state the stimuli given to the patient during this assessment and the patient’s response.
VOCALIZATIONS/VERBALIZATIONS IN RESPONSE TO SENSORY STIMULATION

Describe the patient’s vocal/verbal response to sensory stimuli provided in motor response stimulation.


UPPER EXTREMITY EVALUATION

1. AROM/PROM: Provide general information regarding ROM. State in functional terms as appropriate. If specific measurements are taken refer to the specific form. Range of Motion Record–Upper Extremity (Exhibit 7-2).

Muscle Tone

Procedure: Apply quick stretch to a muscle group in an attempt to elicit stretch reflex. Try to move joint through complete range beyond stretch reflex. Work proximally to distally. Note position of the patient.

Grading


Within normal limits

Has AROM and PROM

No stretch reflex elicited.

No resistance to passive motion.

No disturbance of speed of passive motion throughout complete range.

Flaccid


Patient lacks AROM.

Has full PROM.

No stretch reflex elicited.

No resistance to passive motion.

No disturbance of speed of passive motion through complete range.

Mild–Any of the following conditions:

Palpable stretch reflex elicited.

Slight resistance to passive motion beyond point of stretch reflex.

No disturbance in speed of passive motion beyond point of stretch reflex.

Moderate–Any of the following conditions:

Visible stretch reflex elicited.

Resistance to passive motion beyond point of stretch reflex.

Disturbance in speed of passive motion beyond point of stretch reflex.

Severe–Any of the following conditions:

Strong, visible stretch reflex elicited that halts passive motion.

Marked increase in resistance to continued passive motion beyond point of stretch reflex; requires slow steady pressure to complete full range.

Resting position of joint likely to be in direction of pull of spastic muscle.
COGNITION


Check when patient responds consistently (correct response each time) or inconsistently (correct response at least 25% of time) to the following commands and questions:

Question 1–4: Self-explanatory.

Question 5: Ask the patient to touch nose, ear, mouth, L/R arm, hand.

Question 6: Ask the patient what his or her name is. If no response, ask whether the name is something other than what the patient goes by; e.g., “Is your name Joe?” (Patient’s name is Tom), so that the patient can nod yes or no. If the patient nods no, ask accurate name: e.g., “Is your name Tom?” If the patient does not respond, state his or her name and observe for facial recognition.

Question 7: Ask questions such as: Are you in the hospital? Is this your nurse? Is this your son, daughter, wife, etc.? Have you eaten breakfast yet?

Questions 8 and 9: Hand the patient a wet washcloth. If the patient does not respond, ask him or her to wash face. Give visual prompt or manual prompt as necessary. Can also hand the patient a comb or brush, toothbrush, cup, spoon, glasses, pencil, etc. (If the patient has no voluntary control of extremities, this portion of the test cannot be administered. Complete the evaluation by writing “unable to administer at this time” and write the date).


PREFEEDING


Present status of food and liquid intake: Circle appropriate status.

Oral intake: Circle present method of oral intake.

Present respiratory status: Circle present status.

History of aspiration: Review chart and discuss with nursing staff to determine whether there is any history of:

Tracheostomy: If yes, note size and type; if a tracheostomy cuff is present, note how the cuff is to be kept.

Cough: If a spontaneous or voluntary cough is not observed, test this reflex by observing a respiratory therapist’s insertion of the suction catheter into the pharynx.

Gag reflex: Normal reflex is shown by contraction of the constrictor muscle of the pharynx. To evaluate, tough the mucous lining of the posterior pharynx, tonsil area, or rood of tongue to elicit contraction of the pharynx and sometimes a complex movement of retching (tongue humps, evidence of discomfort). Test right and left, avoiding the carotid arteries. Do not evaluate patients who are prone to seizures.

Other impairments: Describe any other oral motor impairments or behaviors that would make feeding difficult.

Tonic bite: Teeth clamp shut in response to a stimulus placed between gums. To evaluate, place a padded tongue blade or rubber seizure stick on the patient’s tongue, gums, and tooth surfaces. A tonic bite reflex is present if mouth clamps shut.

Tongue thrust: Tongue arches, protrudes outside oral cavity, and retracts. It may be a repetitive motion. To evaluate, observe patient’s tongue motions.

Agitation, impulsivity, level of alertness: Self-explanatory.
ORTHOTICS/ADAPTIVE EQUIPMENT
List on initial evaluation all splints and adaptive equipment you have provided or intend to provide to the patient. Note any already provided by other services (e.g., orthopedics, nursing, or physical therapy).
TREATMENT PLAN


Complete the Comprehensive Treatment Plan (Exhibit 7-17) after the evaluation.

Complete the evaluation and sign and date the document.



DEPARTMENT OF OCCUPATIONAL THERAPY REPORT

COMA EVALUATION

Patient ________________________________________________ Age/Sex_____________________

Date of Referral____________________________________Referring Physician____________________________

Reason for Referral____________________________________________________________________________

Diagnosis____________________________________________________ Date of Onset____________________

Surgeries____________________________________________________________________________________

Pertinent Medical/Social History__________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Patient/Family Comments_______________________________________________________________________

____________________________________________________________________________________________

Mechanisms of Injury_____________________________________Coup___________Contracoup_____________

Precautions__________________________________________________________________________________

___________________________________________________________________________________________


I. MEDICAL STATUS

Glascow Coma Scale






Adm

Present

Intracranial Pressure (ICP): Date

Eye Opening







Safe ICP range during OT treatment is:

Motor Response







ICP is/is not currently being monitored by: Richmond Bolt

Verbal Response







Ventriculostomy

Total Score







Camino Bolt

Patient is/is not currently in drug-induced coma/paralysis to monitor intracranial pressure.

Drug used: N/A Pavulon Pentobarbital Morphone Other:______________________


II BED TYPE/POSITIONING_________________________________________________________________
III REFLEXES  Score: + =Present - =Absent




Right

Left

Comments

Innate Primary Reactions










Rooting










Sucking










Grasp Reflex










Facial Grimacing










Teeth Clinching/Grinding










Other:


































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