Neurology Flashcards
priority of neurological patient
Assessment!
ABCs!
Who needs neuro assessment
Neurological disorder or disease
Neurologic change
Neurological abnormal finding during basic assessment
Trauma
Known drug-induced mental status changes
Any neurological complaints
4 H’s- *Hypoxia *Hypoglycemia *Hypotension *Hypoventilation
What is alert LOC
Awake
Easily arousable
Receptive and responsive
What is lethargic (somnolent) LOC
Not fully alert Drifts off to sleep when not stimulated Appears drowsy Awakens to name Responds appropriately to questions Slow to respond
What is Obtunded LOC
leeps 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
what is stupor or semi comatose LOC
Spontaneously unconscious
Responds only to vigorous shake or pain- has appropriate response
Groans, mumbles
What is Comatose- completely unconscious
No meaningful response to stimuli
Light coma- no purposeful movement, some reflex activity
Deep coma- no motor response
Pneumonic for Stoke
Balance Eyesight Face Arm Speech Time
what is proprioception
Recognizing where your limbs are in space
Nursing Problems with neuro dysfunction
Risk for decreased cerebral tissue perfusion Acute confusion Chronic confusion Deficient knowledge Impaired memory Unilateral neglect Impaired physical mobility Impaired verbal communication Impaired swallowing Risk for peripheral neurovascular dysfunction Risk for injury Risk for falls
Neuro plan of care
make it patient-centered
Goals are aimed to protect patient’s health status & maintain safety
Overall goal to assist patient in gaining independence in self-care
teams to collaborate with neuro patients
Nurse Nursing assistant HCP Neurologist PT/OT Speech language pathologist
nursing care for neuro patients
Perform basic and focused assessments & recognize changes
Monitor VS & LOC
VS changes can show signs of deterioration
Reorientation if confused
Report any changes to HCP & be sure to include updates during report
Protect airway
HOB elevated
Manage secretions
Oral suction
Safety for neuro patien
Adequate lighting, free of obstructions
Fall precautions
Bed low position, call light within reach
Frequent rounding
Room near nurses’ station or sit outside room
communication with patient
Calm approach with simple instructions
Always assume they can hear you
Explain all care, procedures, tasks
Speech language pathologist
nutritional concerns for patient
Dysphagia Aspiration precautions Enteral feedings IVFS TPN Strict I&Os
Skin care for patient
Monitor & Assess
Turn Q2H
Pressure redistribution
bowel or urinary issues
Incontinence or inability to go
Urinary retention or impaction
mobility
PROM or AROM
OOB to chair
PT/OT
patient sensory function
assess vision and hearing
patient pain management
may not be able to communicate pain
patient external stimuli
Minimize external stimuli
Dim lights
Quiet
patient sleep
Encourage sleep and minimize sleep disturbances
seizure precautions
Safety is key Protect airway Pad bed rails Oxygen set up in room Suction set up in room
skull x-ray
Used to examine bones making up skull
Not used as much due to availability of CT scan
Used in evaluation of children
Suture lines if abnormal head shape or size
Spinal X-ray
Evaluate back or neck pain
Degenerative arthritic changes
Traumatic injuries
Spinal alignment abnormalities
nursing care for xrays
Explain procedure
Painless
Remove metal objects
Avoid manipulation of head or back while obtaining
If spinal fracture suspected wear neck brace
CT Scan
Uses x-rays to produce 3 dimensional images of organs, bones & tissues
Aids in determining what part of brain is affected
Quickly detects hemorrhage, bone or vascular abnormalities, tumors, cysts
With or without IV contrast dye
CT nursing care
Informed consent if using contrast Must assess for allergies of iodine* Check diet orders Pt. claustrophobic? If contrast is administered- force fluids, monitor for allergic reaction & monitor kidney function
MRI
Uses computer generated radio waves & powerful magnetic field to produce detailed images
Computer creates a 3-dimensional image from 2-dimensional slice
Able to see brain, spinal cord, measure blood flow
Used to dx stroke, tumors, infection, injury, epilepsy
No exposure to radiation, very costly
Contrast - gadolinium
MRI nursing considerations
Obtain consent if contrast used
Must screen for metal
Remove all metal- glasses, telemetry, jewelry, dental work
Remove all medicated patches
Body art & permanent cosmetics may cause burns in MRI machine
Loud noises- most places provide headphones and music
Screen for claustrophobia
Can take up to 90 minutes to complete
EEG
Monitor brain’s electrical activity
Helps diagnose seizures, metabolic disorders, inflammation, and infection
Used to help evaluate sleep disorders
May be used to confirm brain death
Series of electrodes attached to skull using a special conducting paste
May complete while sleeping, awake, or stimulated
EEG nursing care
Educate
Check to see if HCP has ordered to stop sleeping aids, sedatives, tranquilizers
Avoid caffeine for 8 hours
No oils, creams, conditioner in hair for electrode placement
Provide support
Know your patient
3 components of any sensory experience
Reception
Perception
Reaction
What is reception
Stimulation of a receptor such as light, touch, or sound
what is perception
Integration and interpretation of stimuli
Any factor affecting level of consciousness impair sensory perception
what is reaction
Only the most important stimuli will elicit a reaction
Factors that influence sensory function
Age meaningful stimuli amt of stimuli social interaction environmental factors cultural factors
3 sensory alterations
defictis
deprivation
overload
what is sensory deficit
Deficit in the normal function of sensory reception and perception
what is sensory deprivation
Inadequate quality or quantity of stimulation
what is sensory overload
Reception of multiple sensory stimuli
People at Risk for Sensory Alterations
Older adults
Living in a confined environment
Acutely ill
7 Common sensory Visual Deficits
Presbyopia
Cataracts
Computer vision syndrome (digital eye strain)
Dry eyes
Glaucoma
Diabetic retinopathy
Macular degeneration
2 Common Sensory Hearing Deficits
Presbycusis (r/t aging)
Cerumen accumulation
2 common balance deficits
Dizziness
Disequilibrium
common sensory taste deficits
Xerostomia- thicker mucous & dry mouth
Common sensory tactile deficits
Peripheral neuropathy- numbness & tingling of affected area and stumbling gait
Central nervous system injuries
Extremity injuries
What is expressive aphasia (motor type)
Inability to name common objects or express simple ideas in words or writing
What is receptive aphasia (sensory type)
Inability to understand written or spoken language
Common Communication Deficits
Visual deficits may learn Braille
Neuromuscular diseases
Cause loss of muscle control and affect speaking
Artificial airways
Patients who have aphasia have varied degrees of inability to speak, interpret or understand language
Nursing care for Vision deficits (10)
Always announce your presence when entering room and indicate when leaving
Stay in patient’s field of vision if partial vision loss
Speak in warm, pleasant tones of voice
Explain what you are going to do before touching the person
Orient to furniture arrangement
Keep pathways clear
Put self-care items and call light in reach
Assist with ambulation walking a foot ahead
Minimize glare and encourage use of corrective lenses
Teaching materials should include large red or orange print
Nursing Care: Auditory Deficits (7)
Check for impacted cerumen
Amplification of sounds or flashing lights for safety
Slower speech and normal or lower tones
Communication boards
Short sentences and avoid ambiguous statements
Augment teaching with written material
How to use hearing aids properly
Health Promotion: Taste & Smell
Good oral hygiene
Well-seasoned food
Differently textured food eaten separately
Which foods are most appealing?
Stimulation of the sense of smell with aromas
Avoid mixing or blending foods b/c this makes it difficult to identify tastes
Chew food thoroughly - allows food to stimulate all taste buds
Make environment more pleasant with smells - mild detergents, fresh flowers; remove unpleasant odors
ptations for reduced olfaction
Unable to smell smoke _ detector
Check food dates & appearance
Teach about dangers of cleaning with chemicals and keep gas stoves and heaters in good working order
Tactile Deficits Health Promotion
Touch therapy through physical care
Nursing care for tactile deficits
Health Promotion: Touch
- Touch therapy through physical care
Turn & reposition
Overly sensitive (hyperesthesia)
- Minimize irritating stimuli
- Loose fitting bed linens help prevent touch
Adaptations for reduced tactile sensation
- Water heater not above 120
- Label faucets hot and cold
- Discourage use of heating pads
- Wear shoes that are well-fitted: check feet daily
Nursing Care: Communication Deficits
Allow patient time to communicate
Normal tone of voice
Be calm & patient
Use simple short questions and gestures (receptive aphasia)
Yes & No questions or communication board (expressive aphasia)
Laryngectomies Write notes Communication boards Laptop computers Speak with mechanical vibrators
Sign language
Causes of Sensory Deprivation (8)
Private room or confinement to monotonous environment
Isolation
Loss or impairment of senses
Confinement to bed - ordered bedrest, traction, mobility restrictions
Few to no visitors
No TV, radio, cell phone
Withdrawing or emotional disorders
No processing of stimuli secondary to medications or brain injury
effects of sensory deprivation: Cognitive
Reduced capacity to learn Inability to think or problem solve Poor task performance Disorientation/confusion Bizarre thinking Increased need for socialization Decreased attention span Difficulty concentrating Impaired memory
effects of sensory deprivation: Affective
Boredom Crying, depression, apathy Restlessness Increased anxiety Emotional lability Panic Increased need for physical stimulation
effects of deprivation: perceptual
Changes in visual/motor coordination Reduced color perception Less tactile accuracy Changes in ability to perceive size and shape Changes in spatial and time judgment
Nursing Care: Sensory Deprivation
Provide multisensory stimuli for short periods of time throughout the day
Provide frequent meaningful interaction
Increase tactile stimulation through physical care measures
Reorient frequently
Encourage visitors and social stimulation
Temporary change of environment if possible- sit by window, take outside
Provide large-print materials or electronic players
Provide pleasant aromas
Ensure use of assistive devices
Sensory Overload
Excessive stimuli prevent the brain from responding to or ignoring certain stimuli.
Overload prevents meaningful response by the brain.
A person’s tolerance to sensory overload can vary according to fatigue, attitude, and physical and emotional well-being
It is easy to confuse the behavioral changes associated with sensory overload with mood swings or simple disorientation.
sensory overload causes
Pain Lack of sleep Frequent treatments Room location ICU Tubes/lines Visitors & staff conversations Noises from monitoring equipment Alarms
Sensory overload symptoms
Fatigue Sleepiness Irritability Disorientation Decreased ability to problem-solve Increased muscle tension Racing thoughts Scattered attention Restlessness Anxiety
Nursing Care for sensory overload
Assess orientation & reorient as needed Control of excessive stimuli Provide dark glasses and earplugs Control pain Unhurried manner, low voice Assist with stress-reducing techniques Allow for uninterrupted rest periods Schedule routine of care and prepare client for procedures Limit visitors Provide new information gradually
Nursing care :Acute care
Orient to entire environment & reorient as needed
Use family as needed
Blind_ have them fill objects in room and determine boundaries, explain all furniture. Approach patient from the front
Keep all objects in same place
Clear path to restroom
Calm, unhurried approach
Communication boards
Sensitive pressure call lights
Speech Language Pathologist consult
