E3 Neurosensory Flashcards
If a pt is neurologically declining think about _______ first
ABCs- Airway, breathing Circulation
Physiological reasons-
Oxygenation… Are they hypoxic?
BP…. Are they Hypotensive?
What should be included in a basic Neuro assessment?
- General Survey: Speech, Acting, Appearance
- LOC
- Orientation: Person, Place, Time, Situation
Who needs a focused Neuro assessment?
-Neuro disorder/ disease
-Neurological change
-Neuro abnormal finding in basic finding
-Trauma (Head injury)
-Drug-induced states
-Neurological complaints
4 H’s of Neuro
Hypoxia
Hypoglycemia
Hypotension
Hypoventilation
Focused Neuro Assessments steps
- Subjective data
- Mental status
- Gait
- Reflexes
- Sensation
- Coordination
- Proprioception
- GCS/EMV
- Pupils
- Visual Fields
- Muscle Strength
- Speech
- Swallowing
- Gag
Describe Alert
-Awake
-Easily arousable
-Receptive & Responsive
Describe Lethargic (Somnolent)
-Not fully alert
-Drifts off to sleep when not stimulated
-Appears Drowsy
-Awakens to name
-Responds appropriately
-Slow to respond
-Not confused
Describe obtunded
-Sleeps most of the time
-Difficult to arouse: needs loud shout or vigorous shake
-Acts confused when aroused
-Speech mumbled or incoherent
-Requires constant stimulation to stay awake
Describe stupor or semi-comatose
-Spontaneously unconscious
-Responds only to vigorous shake or pain
-Groans, mumbles
-Not staying awake
Describe Comatose
-No meaningful response to stimuli
-Light-coma: no purposeful movement, some reflex activity
-Deep coma: No motor response
Glasgow Coma Scale (GCS)
3-15 Range
<7-9 Comatose
Brain injury:
Severe 8 or less: Lose airway reflex
Moderate 9-12
Mild 13-15
Proprioception
Body’s ability to sense movement, action, and location (Qtip Sharp/Dull test)
Coordination
Rapid alternating movements (Touch thumb to each finger on the same hand rapidly)
Nursing Problem list
-Acute Confusion
-Chronic Confusion
-Deficient knowledge
-Impaired memory
-Impaired verbal communication
-Risk for ineffective cerebral tissue perfusion
-Ineffective airway clearance
-Risk for aspiration
-Risk for falls
-Risk for injury
-Impaired physcial mobility
Who would you collaborate with for neuro?
-Nursing Assistant
-HCP
-Neurologist
-PT/OT
-Speech Language Pathologist
-RT
What is the goal of nursing care plan for neuro patient?
- Protect status and maintain safety
- Assist patient in gaining independence
Seizure Precautions
-Suction
-Bed low
-Padded rails
-O2
-remove uneeded furniture
(TBI or brain bleed can cause seizures)
X-rays
-Skull: look at bones of skull, common in children
-Spinal- First step in evaluating back/neck pain, traumatic injuries, etc
-Would NOT use for brain bleeds or strokes
What is the nurses responsibility for X-rays?
Explain procedure, Painless, Remove metal objects, hold still, make sure armband is on
CT scan
-Gold standard for stroke identification or brain bleed
-3D images of organs, bones, tissues
-Quickly detects hemorrhage, bone, vascular abnormalities, tumors, cysts, etc.
What is nurses responsibility for CT scan?
-Informed consent (for contrast)
-Iodine allergy (for contrast)
-Diet orders: NPO for some scans but not all
-Claustrophobic (PRN anxiety meds)
What is contrast?
-Contrast helps distinguish selected body areas from surrounding tissues
-PO (looking fir bowel poliferations), Rectal (Barium), or IV
-Iodine allergy (shellfish)
-IV –> often referred to as a CT angiogram (force fluids, monitor kidney function)
-Tough on kidneys: check creatinine
Absolute MRI contradictions:
-Implantable pediatric sternum device
-Metallic foreign body in the eue
-Triggerfish contact lens
-Gastric reflux device
-Insulin device
-Temporary transvenous pacing leads
MRI: Magnetic Resonance Imaging
-3D image from a 2D slice
-More detailed & Expensive
-No exposure to radiation
-Screen for metal and remove
-Remove medicated patches
-Remove O2 and EKG
-Loud & Claustrophobic
-Do NOT have to be NPO
General MRI contradictions
-Shrapnel
-Pregnancy
-Implanted drug infusion pumps
-Epidural catheters
-Feeding tubes
-Spinal fixation hardware
Neuro MRI contradictions
-Halo
-Neuro stimulation
-Bone fusion (spinal) stimulator
-Cochlear implants
-Intra cranial vascular clips
-EEF electrodes
-Ventricular catheters
Cardiac/Body contradictions
-Breast tissue expanders
-Prosthetic heart valves
-Pacemakers, ICDs, Pacing wires and loop recorders
-Penile implants
-Foley catheter with temp prob
What does a EEG do?
-Monitors brains electrical activity
-Helps to diagnose seizures
-Confirm brain death
-Completed sleeping, awake, and stimulated
Define Reception
Stimulation of a receptor such as light, touch, or sound
Define Perception
Integration & interpretation of the stimuli- any factor affecting LOC could impair sensory perception
Define Reaction
How we respond- only most important stimuli will elict a response
Factors influencing sensory function
-Age (Very old and Very Young)
-Meaningful stimuli (Pets, family, friends)
-Amount of stimuli (excessive can cause sensory overload)
-Social interaction
-Environmental factors (Job, activities)
-Cultural factors (African americans have increased incidence of glaucoma. or Monks known for their quiet environment)
Who is most at risk for sensory overload?
-Elderly
-Monks
-Amish
-Rural
-Acutely ill: away from routine
Common visual sensory deficits
-Presbyopia (age related farsightedness)
-Cataracts
-Computer vision
-Dry eyes
-Glaucoma
-Diabetic retinopathy
-Macular degeneration
Hearing and balance deficits
Hearing: Cercumen or Presbycusis (normal age related hearing loss)
Balance: Dizzines, Disequilibrium, Vertigo, Stroke residual prob
Taste and Tactile deficits
Taste: Xerostomia- thicker mucous, dry mouth
Tactile: Peripheral neuropathy, CNS injury, extremity injuries, Phantom limb
Who is effected by communication deficits?
-Severe visual deficits
-Neuromuscular disease
-Artificial airways (Trach)
-Aphasia
Expressive Aphasia
Inability to NAME common objects or express ideas in words or writing
Receptive Aphasia
Inability to UNDERSTAND written or spoken language
Caring for a patient with vision deficits
-Annouce presence
-Stay in field of vision
-Speak in warm, pleasant tone
-Explain care prior to starting care
-Orient to room
-Keep paths clear
-Put items in reach
-Assist with ambulation: Walk one step ahead
-Encourage use of corrective devices
-Teaching material in large red/orange print
-Minimize glare
-Clock cues to orient
Caring for a patient with auditory deficits
-Check for cerumen impaction
-Amplify sound if appropriate
-Add flashing lights for safety
-Slow speech in normal town
-Communication board
-Short sentences
-Augment teaching with written materials
-Educate and ensure proper use of hearing aids
Caring for a patient with taste and smell deficit
Taste:
-Well seasoned food
-Separate textured foods
-Serve most appealing foods
-Stimulate smell when appropriate
-Limit strong odors/ flavors
Smell:
-Smoke detector
-Check food for dates/appearance
-Dangers of chemicals
-Discourage use of gas applicances
Caring for a patient with olfaction deficit
-Smoke detector
-Check food dates/ appearance
-Dangers of cleaning with chemicals
-Discourage use of gas appliances
Caring for a patient with tactile deficits (Spinal cord injury or neuropathic issues)
-Touch therapy
-Turning/repositioning
-Pt can have hyperesthesia (overly sensitive)
-Minimize irritating stimuli
-Avoid loose fitting linens
-Thermometer to check water temp
-Don’t use heat/ice
-Wear well fitting shoes and check feet daily
Caring for a patient with communication deficits
-Patience
-Normal tone
-Simple short sentences, gestures for receptive aphasia
-Yes & No Q’s, communication boards for expressive aphasia
-Sign language interpreter
Causes of sensory deprivation
-Isolation
-Loss/impairment of senses
-Confinement
-Emotional disorders
-Brain injury
-Medications
Cognitive effects of sensory deprivation
-Decreased attention span
-Impaired memory
-Decreased problem solving
-Decreased ability to learn
Affective effects of sensory deprivation
-Boredom
-Crying
-Depression
-Increase physical stimulation
-Apathy
-Restlessness
-Increased anxiety
-Panic
Perceptual effects of sensory deprivation
-Change in visual or motor coordination
-Reduced color perception
-Less tactile accuracy
-Size and shape perception
-Spatial and time judgement
Nursing care for sensory deprivation patient
-Opportunity for stimuli (Shorter periods of time throughout day)
-Interaction
-Tactile stimulation (brushing hair, back rub)
-Reorientation
-Encourage 1-2 vistors
-Environmental change
-Assistive devices
What is sensory overload?
-Excessive stimuli
-Person’s tolerance is variable depending on fatigue, attitude, physical, or emotional well being
-Often confused with mood swings/ disorientation
Causes of sensory overload
-Pain
-Lack of sleep
-ICU/care
-Visitors/ staff
Symptoms of sensory overload
-Fatigue, sleepiness, irritability
-Disorientation
-Scattered/restless/ anxiety
-Inability to problem solve
-Racing thoughts
Nursing care for sensory overload
-Orient
-Control stimuli (turn off unneeded alarms, set alarm on watch)
-Uninterrupted periods
-Schedule
-Visitor control
-Control pain & be calm
What are the 4 safety priority for sensory alterations?
- Orientation to environment: reorient as needed, put items in same spot, clear paths
- Communication: advocate for pt and communicate sleep times to all staff
- Controlling sensory stimuli: avoid loud noises
- Self care promotion: Don’t assume they need your help, offer assistive devices, care is diff for new & old diagnosis
Remember, only the _____ knows if sensory abilities have improved
patient
Define migraine
Recurring headache characterized by unilateral throbbing pain
Premonitory symptoms and an aura may precede headache phase hours or days prior
Who is migraines most common in
-Females
-Cluster headaches more common in males
-Age 25-55
-Family History
Care of the patient with headaches and migraines
-1st rule out an intracranial or extracranial disease (Head CT)
-Meds: NSAIDS, tylenol, aspirin, Excedrin (adds caffeine)
-Triptan drugs for migraines
-High flow O2 for cluster headaches (non-rebreather)
Triptan drugs can affect
serotonin receptors, reduce neurogenic inflammation of cerebral blood flow vessels and cause vasodilation
-Take at start of migraine or aura phase
-Don’t take daily
What term best describes a patient who is difficult to arouse, need constant stimulation to stay awake, and who has incoherent speech?
Obtunded
The nurse is caring for a patient who has had brain surgery. The patient understands what the nurse says amd recognizes objects but has difficulty speaking. What is the name of the communication deficit?
Expressive aphasia
When the Nursing student aroused the pt, they had to shout loud to awaken patient and they were confused. How would the student best describe this?
Obtunded
The home health nurse is providing care for a blind patient. Which safety precaution is a high priority?
Remove all throw rugs
A 76 year old patient was admitted to the ICU three days ago. Which interventions would be most appropriate to decrease the risk of sensory deprivation? SATA
A. Ensure pt is educated on all of the unit routines and procedures on admission
B. Encourage a routine of social interaction
C. Provide a clock in the room
D. Encourage family visitors at all times
E. Encourage a balance of activity & rest periods
B, C, E
B. Encourage a routine of social interaction
C. Provide a clock in the room
E. Encourage a balance of activity & rest periods
