CIWA
What vital signs must be completed with a CIWA scoring?
Blood pressure and heart rate
What does TBI stand for?
Traumatic Brain Injury
What does the Rancho scale measure?
Levels of cognitive functioning/phases of recovery from a brain injury
What should be on the patient's door if they require controlled stimulation?
A sign that states what level of RANCHO/controlled stimulation the patient requires and how to help control their environment accordingly
Where can you quickly access the CIWA protocol?
UCHealth Northern Colorado dashboard in EPIC
What keyword do you search in ULearn to access a module about caring for a TBI patient?
TBI
How many levels are there in the RANCHO scale?
10
What level of stimulation program would the patient be on if they need 1 step simple directions, No TV or phone, limited visitors, normal lighting in room?
Level I, II, and III
How often should a CIWA score be performed?
Every 4 hours if score is less than 5, every 2 hours if score is 5-15, every 1 hour if score is 16 or greater.
What symptoms may you see in a TBI patient?
Mild symptoms may include:
Fatigue, headaches, visual problems, memory loss/amnesia, poor attention/ concentration, sleep disturbances, dizziness/ loss of balance, irritability, depression, nausea/vomiting, sensitivity to light and sound, mood changes, confusion, slowness of thought
Moderate /Severe Range symptoms may include:
Agitation, poor attention, difficulty concentrating, distractibility, poor memory, slowness of thought, confusion, impulsiveness, perseveration, little or no awareness of inappropriate behaviors, difficulty starting tasks, limited problem solving, poor time management, deficits with reading, spelling and writing, difficulty in understanding or producing speech correctly, slurred speech, swallowing deficits, changes in vision, ringing in ears or changes in hearing, seizures, pain, sleep disturbances, uncontrolled bowel and bladder function, and personality changes
What level on the RANCHO scale is a patient most likely at if they are confused and agitated?
Level IV (4)
What are 2 common things to keep consistent with any patient on any level of controlled stimulation?
Keep them on a schedule
Keep consistent staff
Other than holding out their arms, how can you assess a patient's tremor when performing CIWA?
Ask them to stick their tongue out
What information is especially important to communicate in shift to shift report about a TBI patient?
What escalates and de-escalates the patient, what behaviors does the patient exhibit when agitated, level on RANCHO scale that the patient is rated on
What type of behavior may a patient at a level IV (4) display?
Very confused and/or agitated. Unusual behaviors may occur such as hitting, screaming or using abusive language.
May have difficulty using familiar objects.
Do not understand what he/she feels or what is happening around them
Highly focused on basic needs for example, relieving pain, eating, going to bed, going to the bathroom or going home.
They may not understand that people are trying to help them.
Difficulty following directions
Trouble remembering daily events/routines
Poor attention to tasks/self-care
Impaired problem solving
What level on controlled Stimulation does a patient have no TV restriction, can have their door open, and can handle feedback on their emotions and behaviors?
Level VII (7)
Name 4 of the 10 assessment topics you must do in order to get a CIWA score
nausea/vomiting, Tactile disturbances, Tremor, Auditory Disturbances, Paroxysmal Sweats, Visual Disturbances, Anxiety, Headache/fullness in head, Agitation, Orientation/Clouding of Sensation
How do you approach and interact with a patient at a RANCHO Level III, IV, and V?
Calm and quiet. Move around room slowly, do not argue with the patient, redirect/distract the patient, position yourself between the patient and the door so you can exit quickly.
What can the staff do to help a patient at a RANCHO IV (4)?
Bring in family pictures and personal items to make them feel comfortable
Reassure the person they are safe
Avoid trying to reason or bargain
Speak in a calm tone, in simple terms and allow extra time for response. Keep questions to allow for yes and no answers.
Allow the person as much movement as is safely possible
May need to change activities frequently or give rest breaks frequently if they become restless or agitated. Allow them to lead the activities.
Keep the room clutter free.
Keep the room calm and quiet (silence cell phones, no TV)
Limit visitors to 1-2 people at a time
What should you consider if a patient presents with continued agitation on a level I, II, and III program?
Patient should be progressed to a level IV program