Neurnseosory (Exam 3) Flashcards
Neurological Assessment: First Step
-ABC’s
-Always think about priority for the patient having neurologically impaired patient
Basic Neuro Assessment
-General Survey
-LOC
-Orientation
4 H’s if you notice neurological changes
Hypoxia
Hypoventilation
Hypoglycemia
Hypotension
Focused Neuro Assessment
Look at slide
Level of Consciousness: Lethargic (Somonolent)
-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
Levels of Consciousness: Obtunded
-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
Levels of Consciousness: Stupor
-CAN NOT STAY AWAKE
-Vigorous shake or pain
-Groans and mumbles
Levels of Consciousness: Comatose-Completely Unconscious
-No meaningful response to stimuli
-Light coma-no purposeful movement, some reflex activity
-Deep coma-no motor response
GCS
Glasco Coma Scale
Objective assessment with numeric value
<7-9 = comatose
What GCS score do we start to worry about airway
7-9
Brain Injury Classification: GCS
-Severe GCS 8 or less
-Moderate 9-12
-Mild 13-15
Proprioception
Body’s ability to sense movement, action, and location.
Sharp and Dull
Coordination
Rapid alternating movements
Touch thumb to each finger on the same hand quickly
Nursing Care: Neurological
PROTECT AIRWAY (Cannot cough or gag)
Seizure Precautions
Bring forward from safety lecture in NUR 324
Neuro Diagnostics: X-ray
-Skull- look at bones of skull, common in children
-Spinal- first step in evaluating back/neck pain, traumatic injuries (LEAVE COLLAR ON)
Neurological Diagnostics: CT scan
-Gold Standarded
-3D images for organs, bones, tissues
-Need contrast dye for circulation
-Quickly detects hemorrhage, bone, vascular abnormalities, tumors, cysts, etc
Nursing Care: CT scan
-Informed consent (for contrast)
-Allergies to iodine (Contrast)
-Diet orders: NPA for some scans
-Claustrophobic
What is contrast?
-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
MRI
-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
EEG:
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
Sensory Alteration 3 components
- Reception (Stimulation of receptors) (Light-Touch-Sound)
- Perception (Immigration and interpretation of stimuli)
- Reaction (How we respond)
Sensory Atlerations
-Sensory Deficits
-Sensory Deprivation
-Sensory Overload
Visual Sensory Deficits
-Presbyopia (age related far sightedness)
-Cataracts
-Computer Vision Syndrome
-Dry eyes
-Glaucoma
-Diabetic reitonpathy
-Macular degeneration
Hearing and balance deficits
Presbycusis (aging hearing loss)
Cerumen accumulation
Dizziness
Diseuilibrium
Taste Deficits
Xerostomia: Thicker mucous and dry mouth
Tactile Deficits: Tactile
-Peripheral neuropathy
-CNS injuries
-Extremity injuries
Communication Deficits
Severe visual deficits
Neuromuscular disease
Artificial airways
Aphasia
Expressive Aphasia
Inability to name common objects or express ideas in words or writing
Receptive aphasia
Inability to understand written or spoken language
Know your hearing AIDS
Caring for patient with tactile deficits
-Touch therapy
-Turning and reposting
Hyperesthesia: mimimize irritating stimuli and avoid loose fitting linens
Adaptations for tactile sensations: Water temp-Ice therapy-Shoes
Sensory Deprivation: Cause and Effects
-Isolation, impairment of sense, confinement, emotional disorders, brain injury
-Cognitive-Affective-Perceptual
Nursing Care: Sensory Deprivation
-Interaction
-Tactile stimulation
-Reorientation
-Encourage vistors
-Environment changes
-Assistive devices
Sensory Overload: Causes
Pain
Lack of sleep
ICU
Visitors / staff
Sensory Overload: Symptoms
-Fatigue
Disorientation
-Scattered/restless/anxiety
Sensory Overload: Care
-Orient
-Control Stimuli
-Uninterrupted periods
-Schedule
-Visitor control
Migraine
-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
Headache: Three different kinds
- Tension: Feeling weight or a band squeezing around head. (Most common)
- Migraine: Unilateral in the temple on 1 side of the head. Pain can be bilateral
- Cluster: Headache pain is focused in and around 1 eye
Care of the patient with Headaches and Mirgraines
-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
