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NUR 333: > Neurosensory > Flashcards

Neurosensory Flashcards

1
Q

first step of neurological assessment

A

always check if pt can breathe before proceeding with neuro assessment
- makes sure that pt is neurologically intact to breath

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2
Q

beginning of neuro assess

A
  • general survey: speech, behavior, symmetry, facial expression
  • LOC: alert, lethargic
  • orientation: person, place, time, situation
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3
Q

who needs a focused neuro?

A
  • neuro disorder/disease
  • neurological changes
  • neuro abnormalities in basic findings
  • trauma
  • drug induced state
    -neurological complaints
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4
Q

what are the 4 h’s

A
  • hypoxia
  • hypoventilation
  • hypoglycemia
  • hypotension
    always rule out these before deciding neuro needed
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5
Q

focused neuro assessment looks at:

A
  • sub data, mental status, LOC, memory, mood, behavior, gait, reflexes, sensations, coordination, proprioception, GCS/EMV, pupils, visual field, muscle strength, speech, swallowing, gag
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6
Q

categories of LOC: alert

A
  • awake, easy to arouse, receptive, responsive
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7
Q

categories of LOC: lethargic

A
  • not fully alert
  • drifts to sleep when not stimulated
  • awakens to name and responds appropriately
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8
Q

categories of LOC: obtunded

A
  • sleeps most of the time
  • difficult to arouse so needs a loud shout or vigorous shake
  • acts confused when aroused
  • speech mumbled or incoherent
  • requires constant stimulation
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9
Q

categories of LOC: stupor

A
  • spontaneously unconscious
  • responds only to vigorous shake or pain
  • instantly asleep if there is no stimulation
  • groans, mumbles
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10
Q

categories of LOC: comatose

A
  • no meaningful response to stimuli
  • light coma, no purposeful movement, some reflex activity
  • deep coma, no motor response
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11
Q

GCS scale

A

objective assessment w possible scores of 3-15
- 7-9 comatose

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12
Q

GCS for brian classifications

A
  • severe injury: 8 or less
  • moderate: 9-12
  • mild: 13-15
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13
Q

proprioception

A

recognizing where your limbs are in space

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14
Q

coordination

A

rapid alternating movements
- ex: touch each finger w thumbs

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15
Q

concerns to look for in assessment

A
  • dec cerebral tissue perfusion
  • acute or chronic confusion
  • deficient knowledge
  • impaired memory
  • unilateral neglect
  • impaired physical mobility
  • impaired swallowing, verbal communication
  • risk for peripheral neurovascular dysfunction, injury, falls
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16
Q

plan of care for neurological issues

A
  • teamwork
  • priority goal: protects status and maintains safety
  • secondary goal: assist pt in gaining independence
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17
Q

nursing care plan

A
  • basic and focused assessment
  • vital signs and LOC
  • report changes to HCP, include updates
  • protect airway
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18
Q

safety for neuro pt

A

adequate lighting, no trip hazards, bed low and locked, hourly rounding, call light

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19
Q

nutritional and hydration needs

A
  • dysphagia; diff. swallowing
  • aspiration precautions
  • enteral feeding/PTN
  • IV fluids
  • strict I and Os
  • oral care
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20
Q

skin care

A
  • monitor and asses
  • q2 turn
  • pressure redistribution
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21
Q

mobility care

A
  • PROM/AROM
  • OOB to chair
  • PT/OT
    think about elimination needs
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22
Q

other care issues r/t neurological impair

A
  • sensory functioning
  • pain management
  • controlled environment (little disturbances)
  • incorporate pt and family care
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23
Q

seizure precautions

A
  • suction and O2 in the room
  • padded rails
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24
Q

x rays

A
  • skull: looks of bones to determine fractures, abnormal shapes/size, suture line development
  • spinal: first step to evaluate back/neck pain, shows arthritic changes, abnormalities, injuries, bad alignment
25
Q

nursing responsibilities for xrays

A
  • explain the procedures
  • painless, stay still
  • no metal
  • c collar is safe
26
Q

CT scan

A

3D image of organs, bones, tissues
- use contrast dye for circulation
- used to quickly detect hemorrhage, bone, vascular abnormalities, tumors, cysts

27
Q

nursing responsibilities for CT

A
  • informed consent
  • allergies to iodine
  • NPO if GI images
  • claustrophobic
28
Q

contrast

A
  • PO, IV, rectal
  • contrast helps distinguish selected body areas from surrounding tissue
  • can be iodine based which is a common allergy
  • IV often referred to CT angiogram –> force fluids, monitor for allergies, monitor kidney function
29
Q

MRI

A

magnetic resonance imaging: 3D image from a 2D slice
- more detailed than CT
- no exposure to radiation
- expensive so last resort
- screen for metal
- remove medical patches, tattoos can burn
- is a loud process

30
Q

EEG

A

electroencephalogram
- monitors brains electrical activity
- helps diagnosis seizure
- confirms brain death
- electrodes placed on the skull w conduction plates
- completed sleep, wake, stimulated

31
Q

sensory alterations

A
  • reception: stimulation
  • perception: interpretation
  • reaction: what to do w stimulus
    brain is smart about which stimulus to interpret
32
Q

factors influencing sensory function

A
  • age
  • meaningful stimuli: light, food
  • amount of stimuli: overload, isolation
  • social interaction: quality, supportive, risk sensory deprivation/processing problems
  • env factors: jobs, recreational activities
  • cultural factors: extremes like nuns, jail, rural
33
Q

sensory deficit

A

abnormal function of perception, reception

34
Q

sensory deprivation

A

inadequate quality or quantity of stimulation

35
Q

sensory overload

A

reception of multiple stimuli

36
Q

common visual sensory deficits

A
  • presbyopia
  • cataracts
  • computer vision
  • dry eyes
  • glaucoma
  • diabetic retinopathy
  • macular degeneration
37
Q

hearing and balance deficit

A

hearing
- presbycusis
- cerumen
balance
- dizziness
- disequilibrium

38
Q

taste deficits

A

xerostomia: thicker mucous, dry mouth

39
Q

tactile deficits

A
  • peripheral neuropathy
  • CNS injuries
  • extreme injuries
40
Q

communication deficit

A
  • severe visual deficits
  • neuromuscular disease (affects speech)
  • artificial airways
  • aphasia
    common w stroke brain injuries
41
Q

types of aphasia

A

expressive: inability to name common objects or express ideas in words/writing
-receptive: inability to understand written or spoken language

42
Q

caring for the vision deficit

A
  • announcing presence
  • stay in field of vision
  • speak in warm, pleasant tones
  • explain care prior to starting care
  • orient to room
  • keep paths clear
  • put items in reach
  • assist w ambulation
  • teaching material in large red/orange print
  • encourage corrective devices (contacts, glasses)
43
Q

caring for auditory pts

A
  • check for cerumen impaction
  • amplify sounds
  • add flashing lights for safety
  • slow speech in normal tones
  • communication boards
  • short sentences
  • limit open ended qs
  • augment teaching w written material
  • educate and ensure proper usage of hearing aids
44
Q

caring for taste and smell deficits

A
  • well seasoned food
  • separate textured food
  • serve most appealing foods
  • stimulate smell when appropriate
  • limit strong odors
  • good oral hygiene
  • eat slow
45
Q

reduced olfaction

A
  • smoke detector
  • check food dates/appearance
  • danger of cleaning chemicals (can’t smell gases)
  • gas appliances (make sure good use, or use other option)
46
Q

caring for pts w tactile deficits

A
  • touch therapy
  • turning/repositioning
  • pt can have hyperesthesia (minimize irritating stimulations)
  • adaptations for tactile sensations (water temp, shoes)
47
Q

caring for pts w communication deficits

A
  • patience
  • normal tone
  • short simple questions
  • yes/no qs
  • communication boards
  • sign language
48
Q

causes of sensory deprivation

A
  • isolation
  • loss/impairment of senses
  • confinement
  • emotional disorders
  • brain injury
49
Q

effects of sensory deprivation

A
  • cognitive: dec capacity to learn/problem solve effectively, poor task performance, confusion, express want for socialization but impaired memory, dec attention span, difficulty responding
  • effective: show boredom, crying, depression, restlessness, anxiety, panic, tension
  • perceptual: change in visual/motor coordination, less tactile accuracy, reduced color perception, change in shape/size and space/time judgement
50
Q

sensory overload

A

excessive stimuli
- tolerance is variable (fatigue, attitude, emotional wellbeing)
- often confused w mood swings/disorientation

51
Q

causes of sensory overload

A
  • pain
  • lack of sleep
  • ICU/care
  • visitor/staff
    prevents brain from responding to normal stimuli
52
Q

symptoms of sensory overload

A

fatigue, sleepiness
disorientation
scattered, restless, anxiety
inability to problem solve
increase tension
racing thoughts

53
Q

care for sensory overload

A

orient pt
control stimuli (control pain)
uninterrupted periods
schedule
visitor control

54
Q

nursing problems for sensory alterations

A
  • disturbed sensory perception
  • impaired verbal communication
  • impaired physical mobility
  • deficient knowledge
  • social isolation
  • unilateral neglect
  • self neglect and more
55
Q

making safety a priority

A
  • orientation to environment
  • communication
  • controlling stimuli
  • self care promotion
56
Q

evaluation of neurological

A

only pt can say if sensory deprivations have improved

57
Q

migraine

A

recurring headache characterized by unilateral throbbing pain
- common in females
- typically have aura that precede headache

58
Q

care of pt w migraines

A
  • rule out intracranial or extra-cranial disease
  • medications typically dont work
  • triptan drugs used
  • high flow O2 for cluster (6-8 L/10 mins)

NUR 333: (10 decks)

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