Neurology Flashcards
1
Q
priority of neurological patient
A
Assessment!
ABCs!
2
Q
Who needs neuro assessment
A
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
3
Q
What is alert LOC
A
Awake
Easily arousable
Receptive and responsive
4
Q
What is lethargic (somnolent) LOC
A
Not fully alert Drifts off to sleep when not stimulated Appears drowsy Awakens to name Responds appropriately to questions Slow to respond
5
Q
What is Obtunded LOC
A
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
6
Q
what is stupor or semi comatose LOC
A
Spontaneously unconscious
Responds only to vigorous shake or pain- has appropriate response
Groans, mumbles
7
Q
What is Comatose- completely unconscious
A
No meaningful response to stimuli
Light coma- no purposeful movement, some reflex activity
Deep coma- no motor response
8
Q
Pneumonic for Stoke
A
Balance Eyesight Face Arm Speech Time
9
Q
what is proprioception
A
Recognizing where your limbs are in space
10
Q
Nursing Problems with neuro dysfunction
A
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
11
Q
Neuro plan of care
A
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
12
Q
teams to collaborate with neuro patients
A
Nurse Nursing assistant HCP Neurologist PT/OT Speech language pathologist
13
Q
nursing care for neuro patients
A
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
14
Q
Safety for neuro patien
A
Adequate lighting, free of obstructions
Fall precautions
Bed low position, call light within reach
Frequent rounding
Room near nurses’ station or sit outside room
15
Q
communication with patient
A
Calm approach with simple instructions
Always assume they can hear you
Explain all care, procedures, tasks
Speech language pathologist
16
Q
nutritional concerns for patient
A
Dysphagia Aspiration precautions Enteral feedings IVFS TPN Strict I&Os
17
Q
Skin care for patient
A
Monitor & Assess
Turn Q2H
Pressure redistribution
18
Q
bowel or urinary issues
A
Incontinence or inability to go
Urinary retention or impaction
19
Q
mobility
A
PROM or AROM
OOB to chair
PT/OT
20
Q
patient sensory function
A
assess vision and hearing
21
Q
patient pain management
A
may not be able to communicate pain
22
Q
patient external stimuli
A
Minimize external stimuli
Dim lights
Quiet
23
Q
patient sleep
A
Encourage sleep and minimize sleep disturbances
24
Q
seizure precautions
A
Safety is key Protect airway Pad bed rails Oxygen set up in room Suction set up in room
25
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
26
Spinal X-ray
Evaluate back or neck pain
Degenerative arthritic changes
Traumatic injuries
Spinal alignment abnormalities
27
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
28
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
29
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
```
30
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
31
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
32
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
33
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
34
3 components of any sensory experience
Reception
Perception
Reaction
35
What is reception
Stimulation of a receptor such as light, touch, or sound
36
what is perception
Integration and interpretation of stimuli
| Any factor affecting level of consciousness impair sensory perception
37
what is reaction
Only the most important stimuli will elicit a reaction
38
Factors that influence sensory function
```
Age
meaningful stimuli
amt of stimuli
social interaction
environmental factors
cultural factors
```
39
3 sensory alterations
defictis
deprivation
overload
40
what is sensory deficit
Deficit in the normal function of sensory reception and perception
41
what is sensory deprivation
Inadequate quality or quantity of stimulation
42
what is sensory overload
Reception of multiple sensory stimuli
43
People at Risk for Sensory Alterations
Older adults
Living in a confined environment
Acutely ill
44
7 Common sensory Visual Deficits
Presbyopia
Cataracts
Computer vision syndrome (digital eye strain)
Dry eyes
Glaucoma
Diabetic retinopathy
Macular degeneration
45
2 Common Sensory Hearing Deficits
Presbycusis (r/t aging)
| Cerumen accumulation
46
2 common balance deficits
Dizziness
| Disequilibrium
47
common sensory taste deficits
Xerostomia- thicker mucous & dry mouth
48
Common sensory tactile deficits
Peripheral neuropathy- numbness & tingling of affected area and stumbling gait
Central nervous system injuries
Extremity injuries
49
What is expressive aphasia (motor type)
Inability to name common objects or express simple ideas in words or writing
50
What is receptive aphasia (sensory type)
Inability to understand written or spoken language
51
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
52
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
53
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
54
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
55
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
56
Tactile Deficits Health Promotion
Touch therapy through physical care
57
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
58
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
59
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
60
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
```
61
effects of sensory deprivation: Affective
```
Boredom
Crying, depression, apathy
Restlessness
Increased anxiety
Emotional lability
Panic
Increased need for physical stimulation
```
62
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
```
63
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
64
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.
65
sensory overload causes
```
Pain
Lack of sleep
Frequent treatments
Room location
ICU
Tubes/lines
Visitors & staff conversations
Noises from monitoring equipment
Alarms
```
66
Sensory overload symptoms
```
Fatigue
Sleepiness
Irritability
Disorientation
Decreased ability to problem-solve
Increased muscle tension
Racing thoughts
Scattered attention
Restlessness
Anxiety
```
67
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
```
68
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
