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Nur 333 Fun 2 > Neurnseosory (Exam 3) > Flashcards

Neurnseosory (Exam 3) Flashcards

1
Q

Neurological Assessment: First Step

A

-ABC’s

-Always think about priority for the patient having neurologically impaired patient

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2
Q

Basic Neuro Assessment

A

-General Survey
-LOC
-Orientation

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3
Q

4 H’s if you notice neurological changes

A

Hypoxia

Hypoventilation

Hypoglycemia

Hypotension

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4
Q

Focused Neuro Assessment

A

Look at slide

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5
Q

Level of Consciousness: Lethargic (Somonolent)

A

-Not fully alert

-Drifts off to sleep when not stimulated

-Appears drowsy

-AWAKENS to name

-Responds APPROPRIATELY

-Slow to Respond

-Someone you woke up in middle of night

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6
Q

Levels of Consciousness: Obtunded

A

-Sleeps most of the time

-Difficult to arouse-needs loud shout or virgrous shake

-Acts confused when aroused

-Speech mumbled or incoherent

-Requires constant stimulation to stay awake

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7
Q

Levels of Consciousness: Stupor

A

-CAN NOT STAY AWAKE

-Vigorous shake or pain

-Groans and mumbles

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8
Q

Levels of Consciousness: Comatose-Completely Unconscious

A

-No meaningful response to stimuli

-Light coma-no purposeful movement, some reflex activity

-Deep coma-no motor response

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9
Q

GCS

A

Glasco Coma Scale

Objective assessment with numeric value

<7-9 = comatose

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10
Q

What GCS score do we start to worry about airway

A

7-9

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11
Q

Brain Injury Classification: GCS

A

-Severe GCS 8 or less

-Moderate 9-12

-Mild 13-15

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12
Q

Proprioception

A

Body’s ability to sense movement, action, and location.

Sharp and Dull

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13
Q

Coordination

A

Rapid alternating movements

Touch thumb to each finger on the same hand quickly

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14
Q

Nursing Care: Neurological

A

PROTECT AIRWAY (Cannot cough or gag)

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15
Q

Seizure Precautions

A

Bring forward from safety lecture in NUR 324

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15
Q

Neuro Diagnostics: X-ray

A

-Skull- look at bones of skull, common in children

-Spinal- first step in evaluating back/neck pain, traumatic injuries (LEAVE COLLAR ON)

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16
Q

Neurological Diagnostics: CT scan

A

-Gold Standarded

-3D images for organs, bones, tissues

-Need contrast dye for circulation

-Quickly detects hemorrhage, bone, vascular abnormalities, tumors, cysts, etc

17
Q

Nursing Care: CT scan

A

-Informed consent (for contrast)

-Allergies to iodine (Contrast)

-Diet orders: NPA for some scans

-Claustrophobic

18
Q

What is contrast?

A

-PO, rectal, or IV

-Contrast helps distinguish selected body areas from surrounding tissues

-Can be iodine based—which is common allergy

-IV— often referred to as a CT angiogram (Hard on kidney)

-Force fluids, monitor for allergic reaction, monitor kidney function

19
Q

MRI

A

-Magnetic Resonance Imaging

-3-D image from a 2-D slice

-More detailed images than CT scan

-No exposure to radiation

-Expensive or last-resort for imaging but sometimes necessary

-Remove medicated patches

-Tattoos

-Book: Look for absolute and relative contraindications for MRI

20
Q

EEG:

A

Electroencephalogram

-Monitor brain electrical activity

-Helps to diagnose seizure

-Confirming brain death

-Electrodes place on the skull using special conduction paste

-Completed sleeping, awake, or stimulated

21
Q

Sensory Alteration 3 components

A
  1. Reception (Stimulation of receptors) (Light-Touch-Sound)
  2. Perception (Immigration and interpretation of stimuli)
  3. Reaction (How we respond)
22
Q

Sensory Atlerations

A

-Sensory Deficits

-Sensory Deprivation

-Sensory Overload

23
Q

Visual Sensory Deficits

A

-Presbyopia (age related far sightedness)

-Cataracts

-Computer Vision Syndrome

-Dry eyes

-Glaucoma

-Diabetic reitonpathy

-Macular degeneration

24
Q

Hearing and balance deficits

A

Presbycusis (aging hearing loss)

Cerumen accumulation

Dizziness

Diseuilibrium

25
Q

Taste Deficits

A

Xerostomia: Thicker mucous and dry mouth

26
Q

Tactile Deficits: Tactile

A

-Peripheral neuropathy

-CNS injuries

-Extremity injuries

27
Q

Communication Deficits

A

Severe visual deficits

Neuromuscular disease

Artificial airways

Aphasia

28
Q

Expressive Aphasia

A

Inability to name common objects or express ideas in words or writing

29
Q

Receptive aphasia

A

Inability to understand written or spoken language

30
Q

Know your hearing AIDS

A
31
Q

Caring for patient with tactile deficits

A

-Touch therapy

-Turning and reposting

Hyperesthesia: mimimize irritating stimuli and avoid loose fitting linens

Adaptations for tactile sensations: Water temp-Ice therapy-Shoes

32
Q

Sensory Deprivation: Cause and Effects

A

-Isolation, impairment of sense, confinement, emotional disorders, brain injury

-Cognitive-Affective-Perceptual

33
Q

Nursing Care: Sensory Deprivation

A

-Interaction

-Tactile stimulation

-Reorientation

-Encourage vistors

-Environment changes

-Assistive devices

34
Q

Sensory Overload: Causes

A

Pain

Lack of sleep

ICU

Visitors / staff

35
Q

Sensory Overload: Symptoms

A

-Fatigue

Disorientation

-Scattered/restless/anxiety

36
Q

Sensory Overload: Care

A

-Orient

-Control Stimuli

-Uninterrupted periods

-Schedule

-Visitor control

37
Q

Migraine

A

-Recurring headache characterized by UNILATERAL throbbing pain

-More common in females (cluster headaches more common in males)

-Premonitory symptoms and an aura may precede headache phase

38
Q

Headache: Three different kinds

A
  1. Tension: Feeling weight or a band squeezing around head. (Most common)
  2. Migraine: Unilateral in the temple on 1 side of the head. Pain can be bilateral
  3. Cluster: Headache pain is focused in and around 1 eye
39
Q

Care of the patient with Headaches and Mirgraines

A

-1st rule out an intracranial or extracranial disease

-Medications (NSAIDS, Tylenol, aspirin, combo drugs like exedrin

-Triptan drugs for migraines

-High-flow O2 for cluster headaches

TABLE 58.4 lewis

Nur 333 Fun 2 (12 decks)

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