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Severe Traumatic Brain Injuries: Levels of

A severe traumatic brain injury (TBI) usually causes a state of
unconsciousness. The Glasgow Coma Scale (GCS) is an easy to use tool for
assessing neurological function and brain injury in comatose patients
particularly in acute stages of traumatic injury or illness. The scale is based on
observing the patient's best response to the three components as follows: eye opening, verbal
response and motor response. (Iacono & Lyons, 2005). The Ranchos Scale helps to
determine an individuals improvement through recovery (Brain-Recovery,

Ranchos Scale:
Level 1: No Response:
Individual in a coma and appears to be asleep. He or she will not
respond to sights, noises, tactile stimulation, or various movements.
Level 2: Generalized Response:
Individual in semi-comatose state. Begins to respond to noises, sights,
tactile stimulation or various movements. Slow and inconsistent
response occurs. Individual responds or copies what is heard by
chewing, breathing faster, moaning, grunting, perspiration, or moving
of body parts.
How to Assist Loved One During Levels 1 and 2 of
Talk to individual about familiar people, places and
activities in a regular, reassuring calm voice. Do not talk
about the individuals condition.
Even when in a coma, the individual may be able to hear
what people are talking about so be aware of what is said.
Stimulate individuals senses.
Touch individual gently while talking to him or her.
Introduce yourself each time you enter room.
Encourage eye contact when eyes are open.
Level 3: Localized Response:
The individual appears more alert. Reacts to what is seen, heard or
felt. May turn eyes or turn head to sound. Individual may cry out when
he or she is uncomfortable or feels irritation. Individual may follow

simple commands such as close your mouth. May recognize familiar

How to Assist Loved one During Level 3 Recovery
Try to repeat level 1 and 2 activities.
Always call the individual by his or her first name and
introduce yourself.
Use short and simple sentences during social interaction
and turn off distracting background noises to encourage
Encourage nodding of the head for a response to yes or no
questions and allow enough time for a response.
Provide basic day-to-day information to individual.
Provide visual cues oriented to day of week and time of
day by pointing to calendar or clock.
Place familiar decorations, pictures, sentimental items
around room.
Establish a schedule for the individual.
Praise individual when progress is made.
Allow individual appropriate rest breaks.
Level 4: Confused and Agitated:
The individual may be confused, disoriented, and frightened. May
remove all splints, lines, hit, kick, and try to crawl out of bed or get out
of wheelchair. The individual may say somethings that are not
appropriate, scream or yell due to confusion. May also have a very
short attention span and memory will be limited to long-term memory
of past events that have occurred. Individual may be focused on basic
needs such as showering, using the restroom, or getting dressed.
How to Assist Loved One During Level 4 Recovery
Reassure the individual that they are safe; stay calm and
orderly in the individuals environment. Avoid too many
visitors at this time.
Keep social interaction and conversation simple and
messages concise.
Regularly remind individual of where he or she is, what
time of day it is, and the current date.
Keep individual updated on what is going on.
Help individual recall past life events.

Assist individual with simple daily activities.

Allow individual to make simple decisions.
When or if individual becomes irritated stop what is
happening, change subject, and call for assistance when
Avoid becoming frustrated with the individual and
remember to remain patient and reassuring.
Provide positive reinforcement or praise frequently.

Level 5: Confused and Inappropriate:

Individual is more alert and can follow simple instruction. Complex
instruction may lead to frustration. Limited attention span is present.
Long term memory will be easier to recall compared to short term
memory of recent events. Individual may become confused during
learning, organizing and problem solving. Daily activities will become
easier to individual; however, initiating activity may require
instructions to get started. Individual will be unaware of safety
awareness and physical limitations.
How to Assist Loved one During Level 5 Recovery
A memory book or photo album may help the individual
with memory and recall of past life events. Keeping a daily
journal may be helpful for the individual to recall day-today events and activities.
Repeat old self-care skills and continue to practice them
while slowly introducing new self-care skills.
Use simple, concise, sentences and instructions to organize
thought and activity.
Encourage individual to make choices for him or herself.
Limit number of visitors and extra noise.
Encourage participation in simple social activities.
Level 6: Confused and Appropriate:
Behaviors become more functional. Memory and orientation to day and
time increase. Attention to tasks increases and can focus on one task
for around 30 minutes. Easier for individual to learn new tasks. May

have difficulty forming sentences and may say something without

thinking it through.

to Assist Loved one During Level 6 Recovery

Motivate individual to complete tasks independently.
Continue to keep conversations simple and short.
Continue with the use of memory aids and daily routines.
Provide support through problem solving activities.
Stay updated on doctor/staff protocol including special
instructions or restrictions.
Motivate individual to participate in rehabilitation.

Level 7: Automatic and Appropriate:

Most daily activities will be done automatically after set schedule has
been established. Judgement and safety awareness is limited. Complex
tasks, such as driving, are not recommended. Takes time to learn or
relearn tasks, so patience is crucial. Work counseling or school may be
introduced if it is the appropriate time.
How to Assist Loved one During Level 7 Recovery
When at home, the environment should be safe and not
have any hazardous objects within the individuals
24 hour supervision may be necessary.
Practice simple household tasks, slowly adding more tasks
as individual progresses.
Social interaction will become less stressful.
Continue to encourage and motivate participation in
rehabilitation program.
Level 8: Purposeful and Appropriate:
Individual has purpose in day-to-day living. Individual can recall events
that have happened in the past and know what is happening in the
present. Learning new skills becomes easier and carryover of new
information is present. Individual is able to be independent at home
and throughout the community. Individual will not have the same
abilities compared to pre-injury, but will be able to successfully
function with day-to-day activities.

How to Assist Loved one During Level 8 Recovery

Encourage individual to write important events down to
improve memory and daily function.
Give support through decision making.
Talk and get involved with community regarding resources
Promote rehabilitation in order to continue with health and
wellness at home.
Support and positive feedback can make a huge difference
(Brain-Recovery, 2004-2012).

Goals of Occupational Treatment of TBIs:

Prevention of secondary injuries and conditions such as contractures

and pressure sores.
Increase normal movement and normal posture
Increase active and passive range of motion, strength, endurance,
Provide necessary sensory integration stimuli
Improve cognitive deficits and visual perceptual deficits
Achieve independence with functional mobility and transfers
Traditionally, occupational therapy practitioners focus on deficits in
performance of activities of daily living (ADL) and instrumental
activities of daily living (IADL); however, a more holistic approach is
warranted (Cotton, 2012). A holistic approach views the individual as a
whole verses viewing the individual as separate units. Occupational
therapy practitioners should also include the individuals interests and
activities that are meaningful and interesting to them. (Cotton, 2012).
Abigail Shamp, OTAS

Brain-Recovery. (2004-2012). Brain Injury: Stages of Recovery. The Ohio

State University Wexner Medical Center.
Cotton, G. S. (2012). Occupational Identity Disruption After Traumatic Brain
Injury: An Approach to Occupational Therapy Evaluation and Treatment.
Occupational Therapy In Health Care, 26(4), 270-282.

Iacono, L., & Lyons, K. (2005). Making GCS as easy as 1, 2, 3, 4, 5, 6. Journal

Of Trauma Nursing, 12(3), 77-81.

Gave this handout to my OTR supervisor and she said that she will be
sharing it with the PTs, other OTs and the ST at the Blackduck Choice Therapy
Clinic. She stated that it was cool, awesome, thank you, this will be very
helpful for us. This handout will educate and be beneficial to the staff at
Blackduck because they have not had much experience with having patients
that have severe TBIs/comas.