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KEMENTERIAN STANDAR Disahkan oleh :

Direktur
KESEHATAN OPERASIONAL
REPUBLIK PROSEDUR
INDONESIA
TERAPI WICARA PADA
AFASIA DEWASA

Poltekkes Kesehatan Surakarta Satino,SKM,MScN


Jurusan Terapi Wiccara
NIP. 196101021989031001
Jl. Letjen Sutoyo Mojosongo
Surakarta 57127
No Dokumen : Tanggal Halaman :
Revisi Ke : No Revisi : Tanggal :

1. PEGERTIAN Afasia merupakan gangguan bahasa perolehan yang dIsebabkan oleh


cidera otak dan ditandai dengan gangguan pemahaman serta
gangguan pengutaraan bahasa lisan maupun tertulis

2. TUJUAN Mengoptimalkan komunikasi antara pasien afasia perkembanagn


dengan lingkungannya

1. UU RI No 36 Tahun 2009 Tentang Kesehatan.


3. KEBIJAKAN 2. UU RI No 8 Tahun 2016 Tentang Penyandang Disabilitas
3. UU RI No 36 Tahun 2014 Tentang Tenaga Kesehatan
4. UU RI No 44 Tahun 2014 Tentang Rumah Sakit
5. Keputusan Kepala Pusat Pendidikan Tenaga Kesehatan No. HK.
00.06.144. 7791 Tentang Standar alat bantu mengajar dan belajar
DIII Terapi Wicara tahun 2001
6. Peraturan Menteri Kesehatan Nomor 46 Tahun 2013 tentang
Registrasi Tenaga Kesehatan
7. Permenkes RI No 24 tahun 2013 Tentang Penyelenggaraan
Pekerjaan dan Praktik Terapis Wicara
8. Peraturan Menteri Kesehatan Nomor 67 Tahun 2013 tentang
Pendayagunaan Tenaga Kesehatan Warga Negara Asing.
9. Kurikulum Nasional Pendidikan : Keputusan Kepala Badan
Pengembangan dan Pemberdayaan Sumberdaya Manusia Nomor
HK.02.05/I/III/2/06104/2011 tentang Kurikulum Program
Pendidikan Diploma III Terapi Wicara
10. Kurikulum Nasional Pendidikan Diploma IV Terapi Wicara di Indonesia Pusat
Pendidikan dan Pelatihan Kesehatan BPP SDM Kesehatan Kementerian
Kesehatan R.I, SK No. HK. 02.05/I/III2/97725.2/2012 Taanggal 10 Desember
2012
11. Kepmenkes RI No : 547/Menkes/SK/VI/2008 ttg Stardar Profesi
Terapi Wicara
12. Per Menpan No: PER/48/M.PAN/4/2005 ttg Jabatan Fungsional
Terapis Wicara
13. Peraturan Menteri Kesehatan RI No 81 Tahun 2014 tentang
Standar Pelayanan Terapi Wicara di Fasilitas Kesehatan

4. PROSEDUR 1. Persiapan :
a. Terapis Wicara melakukan pemeriksaan dengan cara
observasi, wawancara, membaca / menganalisa data dokter
ahli dan melakukukan beberapa assesment menggunakan
formulir assesment
b. Menegakkan Diagnosa dan Prognosa Terapi Wicara
c. Menyusun rencana program dan persiapan alat-alat : spatel
lidah, sarung tangan, dan sikat lidah.
d. Terapis menjelaskan hal-hal yang akan dilakukan

2. Pelaksanaan Terapi
a. Stimulasi Multimodal :
1) Terapis memberikan kalimat yang disajikan secara lisan
maupun tulisan
2) Pasien diminta untuk meniru, mengulang, menuliskan
dan kemudian mengucapkan kata/kalimat yang
diberikan terapis
3) Pasien diminta untuk menyebutkan nama suatu gambar

Dalam metode stimulasi multimodal, modalitas yang gangguan lebih


ringan diutamakan terlebih dahulu daripada modalitas yang
gangguannya lebih berat.
b. Metode Preventif
1) Terapis menganjurkan pasien untuk menggunakan kata
seru dan kalimat lengkap untuk mencegah terjadinya
gaya telegram.
2) Terapis melatih pasien untuk meniru kata-kata seperti,
‘oh’ , ‘tidak’ , ‘sekarang’ , ‘baik’ , kemudian
dikombinasikan dengan kata kerja lain seperti, ‘saya
mau makan’.

c. Metode Intonasi Melodi


Metode ini terdiri dari 4 tingkat :
1) Pada tingkat pertama pasien diajarkan untuk mengambil
alih lagu-lagu yang didukung oleh ketukan irama dan
aksen lagu
2) Pada tingkat dua pasien diajarkan menyanyikan kalimat-
kalimat pada melodi
3) Pada tingkat ketiga , masih menggunakan lagu tetapi
dilatih dengan kalimat-kalimat yang lebih panjang
4) Pada tingkat ke empat adalah tahap antara menyanyi
dan bicara normal.
d. Metode Intervensi Semantik Divergen
1) Terapis memilih kata-kata yang dimuai dengan suatu
huruf tertentu atau menggunakan suatu kata dalam
berbagai kalimat.
2) Terapis memberikan suatu stimulus kepada pasien, dan
pasien harus merespon dengan lebih dari satu respon
3) Respon pasien antara lain menyebutkan kemungkinan
pemakaian suatu benda atau menyebutkan nama benda-
benda dalam suatu kategori tertentu

5. FORM 1. Form pemeriksaan riwayat kasus


2. Form Oral Facial Examination
3. Form Kemampuan Evaluasi Bahasa
1. Ahli Saraf
2. Psikolog
6. UNIT TERKAIT 3. Fisioterapi
4. Okupasi Terapi
5. Dll

Disetujui oleh : Terapis Wicara,

Ka Jurusan Terapi Wicara,

(Wiwik Setyaningsih, SKM, MKes) (Gunawan, SMTW, SPd, MM)


NIP 197001051998032001 NIP 196403191995031003

CHAPTER 13 Assessment of Neurocognitive Disorders


Form 13-1

Evaluation of Aphasia
Name : Age : Date :
Primary Care Physician :
Medical Diagnosis :
Date of Incident :
Condition Prior to Incident :
Date of CT Scan/MRI : Findings :
Relevant Medical History :

Medications :
Examiner’s Name :

Instructions: Administer selected sections or all sections as appropriate for the client. Specific instructions
are provided under each subheading.

Conversational Speech
Use pictures or converse with the client to stimulate speech, noting specific difficulties the client exhibits.

Agrammatism
Anomia
Circumlocution
Disfluency
Effortful speech
Jargon
Paraphasia
Perseveration
Telegraphic speech
Other
(continues)

Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.
Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
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CHAPTER 13 Assessment of Neurocognitive Disorders
Recognition of Common Nouns
Name each picture on the left-hand page one at a time and have the client
point to the picture requested. If the client is unable to point, observe eye
gaze. Record responses in the first colum of the checklist on the right-hand
side.

Naming Common Nouns


Use the same pictures and ask the client to name each item. Record
responses on the checklist in the middle column of the right-hand side.

Recognition of Common Functions


Use the same pictures and ask the client to identify the correct item for the
following questions. Record responses in the third column of the checklist
on the right-hand side.

What do you eat with?


What do you use to see at night?
What do you use to write something?
What do you use to talk to someone who is not in the room with you?
What do you use to hit a nail?
What do you use to cut paper?
What do you use to unlock the door?
What do you sit on?
What do you use on your hair?
What do you drink out of ?
What do you use to play a game with?
What do you use to tell time?

Checklist for Common Nouns and Functions


Recognition Naming Recognition
of Word Word Word
fork ____________ ____________ ____________
key ____________ ____________ ____________
ball ____________ ____________ ____________
flashlight ____________ ____________ ____________
chair ____________ ____________ ____________
hammer ____________ ____________ ____________
scissors ____________ ____________ ____________
watch ____________ ____________ ____________
pencil ____________ ____________ ____________
comb ____________ ____________ ____________
cup ____________ ____________ ____________
telephone ____________ ____________ ____________

Resources for Assessing Communicative Disorders


Yes-No Questions
Ask the following questions to evaluate appropriateness of yes and no responses. Score a plus (+) or minus
(-) for correct or incorrect responses.
________ Are you sitting on a chair? _______________________________________________
________ Are we in Paris, France? ________________________________________________
________ Is a book an animal? ___________________________________________________
________ Is a dog an animal? ____________________________________________________
________ Are you wearing a swimsuit? _____________________________________________
________ Am I an adult? ________________________________________________________
________ Do you butter toast with a comb? _________________________________________
________ Do frogs swim? _______________________________________________________
________ Do cars fly? __________________________________________________________
________ Do trains carry people? _________________________________________________

Following Commands
Ask the client to carry out each of the following commands. Make sure your client waits until you have
finished the entire command before responding.
One-Part Command
______ Touch your nose.
______ Raise your hand.
______ Look at the door.
Two-Part Command
______ Touch your head, then your mouth.
______ Clap your hands, then touch your knees.
______ Nod your head twice, then close your eyes.
______ Touch your chair, then clap twice.

(continues)
CHAPTER 13 Assessment of Neurocognitive Disorders
Form 13-1. continued
Three-Part Command
______ Nod your head, clap your hands, then make a fist.
______ Look at the door, look at me, then close your eyes.
______ Touch your chin, then your nose, then raise your hand.

Repeating Phrases
Read each phrase and ask the client to repeat it. Syllabic complexity of each phrase increases as you read
down the list (the number of syllables for each phrase is indicated in parentheses). Note the syllable length
at which the client exhibits difficulty.
______ (1) Cap
______ (1) Boat
______ (2) Laughing
______ (2) Not now
______ (3) Piano
______ (3) Forty-two
______ (4) Geography
______ (4) It’s time to go.
______ (5) Magnifying glass
______ (5) The car was dirty.
______ (6) Personal computer
______ (6) Put everything away.
______ (7) Revolutionary War
______ (7) She is not very happy.
______ (8) Mechanical engineering
______ (8) The letter arrived yesterday.
______ (9) Recreational motorcycle
______ (9) Put it in the microwave oven.

Resources for Assessing Communicative Disorders


Form 13-1. continued
Logic Questions
Ask the following questions to evaluate logic and problem-solving skills. Suggested answers are provided,
but other responses may also be appropriate.
____ Why do you store ice in the freezer? (so it won’t melt)
____ Why do you brush your teeth? (so you don’t get cavities, to clean them, etc.)
____ Why don’t people swim outdoors in the winter? (it’s too cold)
____ Why don’t people eat house plants? (they aren’t edible, they are for decoration, etc.)
____ What would you do if your car ran out of gas? (call someone for help, walk to a gas station, etc.)
____ What would you do if you couldn’t find a friend’s phone number? (look it up in a phone book, ask
someone else, call information, etc.)
____ How could you learn about current news if you didn’t have a newspaper? (listen to the radio, watch
television, etc.)
____ How could you get downtown if you didn’t have a car? (take a bus, walk, etc.)

Sequencing
Ask the client to describe the steps necessary to complete the following tasks. Make a note of difficulties
with thought organization or sequencing.
______ Make a sandwich
______ Wash a car

CHAPTER 13 Assessment of Neurocognitive Disorders


Form 13-1. continued
______ Prepare a frozen dinner
______ Change a light bulb
______ Write and send a letter

Definition of Terms
Ask the client to define each of the terms below. Note behaviors such as paraphasias and circumlocutions.
______ Car
______ Tree
______ Window
______ Bathe
______ Shopping
______ Cloudy
______ Solo
______ Tricky
______ Northern
______ Controversial
______ Fleeting
______ Content
______ Opinion
(continues)
482 PART III Resources for Assessing
Communicative Disorders
Form 13-1. continued

638
11 29 49
173 207 151
297 2,046 7,921
one six four
nine seven three
thirteen twenty-two
seventeen
thirty-three forty-one ninety-one
one hundred and twenty-seven
two hundred and twelve
two thousand and forty-four

(continues)NEUROCOGNITIVE
DISORDERS
CHAPTER 13 Assessment of Neurocognitive Disorders
Form 13-1. continued
Number Recognition
Ask the client to identify each number on the left-hand page. Circle correct responses and mark a slash (/)
through incorrect responses.
836
49 29 11
151 207 173
7,921 2,046 297
Numeric Word Recognition
Ask the client to read each number on the left-hand page. Circle correct responses and mark a slash (/)
through incorrect responses.
four six one
three seven nine
seventeen twenty-two thirteen
ninety-one forty-one thirty-three
one hundred and twenty-seven
two hundred and twelve
two thousand and forty-four
(continues)
Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.
Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

484 PART III Resources for Assessing Communicative Disorders


Form 13-1. continued

baby
radio
ordinary
sometimes
Put it away.
Open the door.
They don’t want any.
peanut butter and honey
What happened to the flowers?
Send it to your friend before Thursday.
(continues)
Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.
Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

485
NEUROCOGNITIVE
DISORDERS
CHAPTER 13 Assessment of Neurocognitive Disorders
Reading Words and Sentences Orally
Ask the client to read each word or sentence on the left-hand side of the page. Make a note of specific
difficulties.
baby_________________________________________________________________________
radio_________________________________________________________________________
ordinary______________________________________________________________________
sometimes____________________________________________________________________
Put it away. ___________________________________________________________________
Open the door. ________________________________________________________________
They don’t want any. ____________________________________________________________
peanut butter and honey_________________________________________________________
What happened to the flowers? ___________________________________________________
Send it to your friend before Thursday.______________________________________________

Writing Words and Sentences


Give the client a blank sheet of unlined paper and a pencil or pen. Ask him or her to write the following
words and sentences. Observe ease of writing and make a note of paraphasic or spelling errors, incomplete
sentences, and overall legibility.
Car _________________________________________________________________________
tree_________________________________________________________________________
summer______________________________________________________________________
I saw her. ____________________________________________________________________
We ate dinner. ________________________________________________________________
They went outside. ____________________________________________________________
The television set was broken. ___________________________________________________
He is saving his money for a rainy day. ____________________________________________
It’s too bad they can’t come tomorrow._____________________________________________
I would rather have chicken than spaghetti._________________________________________
(continues)
Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.
Form 13-1. continued
Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.
CHAPTER 13 Assessment of Neurocognitive Disorders
Form 13-2

Cognitive–Linguistic Evaluation
Name : Age : Date :
Primary Care Physician :
Medical Diagnosis :
Date of Incident :
Condition Prior to Incident :
Date of CT Scan/MRI: Findings :
Relevant Medical History : _______________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________

Medications :
Examiner’s Name :

Instructions: Administer selected sections or all sections as appropriate for the client. Specific instructions
are provided under each subheading. Make additional observations in the right-hand column. The client
will need a pen or pencil to complete the writing portion of the evaluation.

Orientation and Awareness


Ask the client the following questions. Score a plus (+) or minus (–) for correct or incorrect responses.
_____ What day is it?
_____ What month is it?
_____ What year is it?
_____ What season is it?
_____ Approximately what time do you think it is?
_____ What state are we in?
_____ What city are we in?
_____ What county are we in?
_____ Where do you live?
_____ What is the name of this building?
_____ Why are you in the hospital?
_____ How long have you been here?

(continues)
Resources for Assessing Communicative Disorders
Form 13-2. Continued

Orientation and Awareness (continued)


_____ When did you have your accident?
_____ What kind of problems do you have because of your accident?
_____ What is my name?
_____ What is my profession?
_____ Who is your doctor?
_____ About how much time has passed since we started talking together today?

Memory
Immediate Memory. Ask the client to repeat the following sequences or sentences. Score a plus ( +) or
minus (-) for correct or incorrect responses.
_____ 0, 7, 4, 2
_____ 8, 6, 0, 1, 3
_____ 2, 9, 1, 4, 6, 5
_____ Car, duck, ring, shoe
_____ Rain, desk, ladder, horse, cake
_____ The keys were found under the table.
_____ He always reads the newspaper before he has breakfast.
_____ After their victory, the baseball team had pizza and watched a movie.
_____ Ask the client to retell this story:
_____ Helen had a birthday party at the petting zoo. Ten of her friends came.
_____ All the children laughed when a goat was found eating the cake and ice cream.

Recent Memory. Ask the client the following questions. Score a plus (!) or minus (#) for correct or
incorrect responses.
_____ What did you have for breakfast?
_____ What did you do after dinner last night?
_____ What did you do after breakfast this morning?
_____ What else have you done today?
(continues)
Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.
Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

NEUROCOGNITIVE
DISORDERS
CHAPTER 13 Assessment of Neurocognitive Disorders
Form 13-2. Continued

Recent Memory (continued)


_____ Have you had any visitors today or yesterday?
_____ What other therapies do you receive?
_____ Who is your doctor?
_____ How long have you been a resident here?

Long-Term Memory. Ask the client the following questions. Score a plus (!) or minus (#) for correct or
incorrect responses.
_____ Where were you born?
_____ When is your birthday?
_____ What is your husband’s/wife’s name?
_____ How many children do you have?
_____ How many grandchildren do you have?
_____ Where did you used to work?
_____ How much school did you complete?
_____ Where did you grow up?
_____ How many brothers and sisters do you have?

Auditory Processing and Comprehension


Ask the client the following questions. Score a plus (!) or minus (#) for correct or incorrect responses.
_____ Is your last name Williams?
_____ Is my name Jim?
_____ Are you wearing glasses?
_____ Do you live on the moon?
_____ Have you had dinner yet?
_____ Do cows eat grass?
_____ Do fish swim?
_____ Do four quarters equal one dollar?
_____ Are there 48 hours in a day?
_____ Is Alaska part of the United States?
(continues)
Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.
Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

494 PART III Resources for Assessing Communicative Disorders


Form 13-2. Continued
Problem Solving
Ask the client the following questions. Score a plus (+) or minus (–) for correct or incorrect responses.
_____ What would you do if you locked your keys in your house?
_____ What would you do if your mail did not get delivered?
_____ What would you do if you could not find your doctor’s phone number?
_____ What would you do if your TV stopped working?
_____ What would you do if you forgot to put the milk away when you got home from the grocery store?

Logic, Reasoning, Inference


Ask the client what is wrong with these sentences. Score a plus (!) or minus (–) for correct or incorrect
responses.
_____ He put salt and pepper in his coffee.
_____ Six plus one is eight.
_____ I put my socks on over my shoes.
_____ Hang up when the phone rings.
_____ The dog had four kittens.
Ask the client what these expressions mean. Score a plus (!) or minus (–) for correct or incorrect responses.
_____ Haste makes waste.
_____ An apple a day keeps the doctor away.
_____ When it rains it pours.
_____ He’s a chip off the old block.
_____ Beauty is only skin deep.
Ask the client the following questions. Score a plus (!) or minus (–) for correct or incorrect responses.
_____ What is worn on your feet, knit, and used to keep you warm?
_____ What has a bushy tail, climbs trees, and stores nuts?
_____ What is thin and lightweight, used to wipe tears, and used during a cold?
(continues)

Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.

Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

CHAPTER 13 Assessment of Neurocognitive Disorders


Form 13-2. Continued

Logic, Reasoning, Inference (continued)


_____ How are a sweater, pants, and a blouse alike?
_____ How are orange juice, soda, and milk alike?
Thought Organization
Ask the client to answer the following questions or tasks. Score a plus (!) or minus (–) for correct or
incorrect responses.
_____ What does the word “affectionate” mean?
_____ What does the word “deliver” mean?
_____ What are the steps you follow to wash your hair?
_____ What are the steps you follow to make your bed?
_____ How would you plan a meal for two dinner guests?

Calculation
Ask the client to answer the following questions. Score a plus (!) or minus (–) for correct or incorrect
responses.
_____ If you went to the mall and spent $8.00 in one store and $7.50
in another store, how much did you spend?
_____ If tomatoes cost $1.50 per pound and you bought 2 pounds,
how much did you spend on tomatoes?
_____ If you went to the store with $3.00 and returned home with
$1.75, how much did you spend?
_____ If toothbrushes cost $3.00 each and you have $10.00,
how many toothbrushes can you buy?
_____ If you have a doctor’s appointment at 10:30 and it takes you
30 minutes to get there, what time should you leave?

Reading and Visual Processing


Ask the client to read the six words in each row and cross out the one that does not belong. Score a plus (!)
or minus (–) for correct or incorrect responses.

_____ Cow Apple Carrot Cheese Banana Oatmeal


_____ Desk Chair Blue Bed Couch Table

Ask the client to read the following sentences and do what they say. Score a plus (!) or minus (–) for
correct or incorrect responses.

_____ Look at the ceiling.


_____ Point to the door, then blink your eyes.
_____ Sing Happy Birthday.
Ask the client to read the following paragraph out loud and answer the questions about it. Score a plus (!)
or minus (–) for correct or incorrect responses.

Mark and Rick are brothers. They both entered a tennis


tournament, hoping to win the $1,000 grand prize. Mark won
his first two matches, but was eliminated after losing the third
match. Rick made it all the way to the semi-finals. He lost, but
was awarded a can of tennis balls as a consolation prize.

_____ Are Mark and Rick cousins?


_____ What sport did they play?
_____ What was the grand prize?
_____ Did one of them win the grand prize?
_____ Which one did the best in the tournament?

(continues)

Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.

Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

CHAPTER 13 Assessment of Neurocognitive Disorders


Form 13-2. continued
Show the client these two clocks and ask what time the clocks say. Score a plus (!) or minus (–) for correct
or incorrect responses.
Now ask the client to copy the clocks below. Note accuracy of construction.

(continues)

Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.

Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

PART III Resources for Assessing Communicative Disorders


Form 13-2. continued
Ask the client to put an x through all the circles on this page. Note the client’s attention to the left half of
the page.
(continues)

Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.

Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

CHAPTER 13 Assessment of Neurocognitive Disorders


Form 13-2. Continued

Write your name.


Write today’s date.

Write a short description of what you have done today in


speech therapy.

(continues)

Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.

2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

PART III Resources for Assessing Communicative Disorders


Form 13-2. Continued

Writing
Ask the client to complete the writing tasks presented on the previous page. Observe accuracy of response,
completeness and organization of response, legibility, and observance of left visual field. Make comments
in the right margin.
Write your name. _______________________________________________________
Write today’s date. _______________________________________________________
Write a short description of what you have done today in speech therapy.
______________________________________________________________________

Pragmatics and Affect


Check all behaviors observed during your assessment.
_____ Inappropriate physical proximity
_____ Inappropriate physical contacts
_____ Left visual field neglect
_____ Poor eye contact
_____ Lack of facial expression
_____ Gestures (inappropriate, absent)
_____ Lack of prosodic features of speech (intensity, pitch, rhythm)
_____ Poor topic maintenance
_____ Lack of appropriate turn taking
_____ Perseveration
_____ Presupposition (too much, too little)
_____ Inappropriately verbose
_____ Lack of initiation
_____ Easily distracted
_____ Frequent interruptions
_____ Impulsive
_____ Poor organization
_____ Incompleteness

Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.

Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

CHAPTER 13 Assessment of Neurocognitive Disorders

Form 13-33-3.
Assessment of Clients with Traumatic Brain Injury
Name: Age: Date:
Primary Care Physician:
Medical Diagnosis:
Date of Incident:
Condition Prior to Incident:
Date of CT Scan/MRI: Findings:
Relevant Medical History:

Medications:
Examiner’s Name:
Informant’s Name:
Instructions: Observe the client over an extended period of time and then answer each question.
Is the client aware of personal orientation (e.g., time, place)?

Does the client attend to stimuli?

How long can the client attend to a task (in seconds or minutes)?

(continues)
Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.

Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

PART III Resources for Assessing Communicative Disorders


Form 13-3. continued
What distracts the client the most (e.g., someone entering the room, noise from a TV or radio, too much
visual stimulation, etc.)?
Is the client able to shift attention from one activity to another?

Is the client able to attend to more than one activity at a time (e.g., converse while preparing a meal)?

Does the client attend to certain activities better than others?

What are the most difficult activities?

What are the easiest activities?

Is the client able to follow immediate directions?

Is the client able to follow complex directions?

(continues)
Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.

Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

CHAPTER 13 Assessment of Neurocognitive Disorders


Form 13-3. Continued

Is the client able to remember things that happened earlier that day?
Is the client able to remember things that happened earlier that month or year?

Is the client able to recall events that happened many years ago?

Is the client able to remember future activities (e.g., take the garbage out this afternoon, or take the roast
out of the oven in 1 hour)?

Is the client able to shift from one activity to another without difficulty?

Is the client able to follow a conversation that shifts from one topic to another?

Is the client able to change the topic appropriately during a conversation?

(continues)
Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.

Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

PART III Resources for Assessing Communicative Disorders


Form 13-3. Continued

What strategies does the client use to complete tasks?


Is the client aware of the strategies used?

How does the client respond to the question, “How did you do that?”

How does the client respond to problem-solving situations?

What are some things the client is able to problem-solve?

What are some things the client is unable to problem-solve?

How does the client respond to stressful situations?

What kinds of everyday tasks does the client have difficulties with?

What are some things that the client needs to do on a daily basis?

Is the client having difficulty with any of these things? If yes, identify.

(continues)
Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.

Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions
require it.

CHAPTER 13 Assessment of Neurocognitive Disorders


Form 13-3. Continued

Is the client able to convey thoughts in writing?


Is the client able to use good judgment during everyday tasks?

Does the client seem to have good safety awareness?

What is the client’s behavior like at home (passive, aggressive, compulsive, etc.)?

Please add additional comments about the client’s behaviors and abilities.

Copyright © 2016 Cengage Learning. All rights reserved. Permission to reproduce for clinical use granted.

Copyright 2016 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or
eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent
rights restrictions require

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