Neurosensory Flashcards
first step of neurological assessment
always check if pt can breathe before proceeding with neuro assessment
- makes sure that pt is neurologically intact to breath
beginning of neuro assess
- general survey: speech, behavior, symmetry, facial expression
- LOC: alert, lethargic
- orientation: person, place, time, situation
who needs a focused neuro?
- neuro disorder/disease
- neurological changes
- neuro abnormalities in basic findings
- trauma
- drug induced state
-neurological complaints
what are the 4 h’s
- hypoxia
- hypoventilation
- hypoglycemia
- hypotension
always rule out these before deciding neuro needed
focused neuro assessment looks at:
- sub data, mental status, LOC, memory, mood, behavior, gait, reflexes, sensations, coordination, proprioception, GCS/EMV, pupils, visual field, muscle strength, speech, swallowing, gag
categories of LOC: alert
- awake, easy to arouse, receptive, responsive
categories of LOC: lethargic
- not fully alert
- drifts to sleep when not stimulated
- awakens to name and responds appropriately
categories of LOC: obtunded
- 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
categories of LOC: stupor
- spontaneously unconscious
- responds only to vigorous shake or pain
- instantly asleep if there is no stimulation
- groans, mumbles
categories of LOC: comatose
- no meaningful response to stimuli
- light coma, no purposeful movement, some reflex activity
- deep coma, no motor response
GCS scale
objective assessment w possible scores of 3-15
- 7-9 comatose
GCS for brian classifications
- severe injury: 8 or less
- moderate: 9-12
- mild: 13-15
proprioception
recognizing where your limbs are in space
coordination
rapid alternating movements
- ex: touch each finger w thumbs
concerns to look for in assessment
- 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
plan of care for neurological issues
- teamwork
- priority goal: protects status and maintains safety
- secondary goal: assist pt in gaining independence
nursing care plan
- basic and focused assessment
- vital signs and LOC
- report changes to HCP, include updates
- protect airway
safety for neuro pt
adequate lighting, no trip hazards, bed low and locked, hourly rounding, call light
nutritional and hydration needs
- dysphagia; diff. swallowing
- aspiration precautions
- enteral feeding/PTN
- IV fluids
- strict I and Os
- oral care
skin care
- monitor and asses
- q2 turn
- pressure redistribution
mobility care
- PROM/AROM
- OOB to chair
- PT/OT
think about elimination needs
other care issues r/t neurological impair
- sensory functioning
- pain management
- controlled environment (little disturbances)
- incorporate pt and family care
seizure precautions
- suction and O2 in the room
- padded rails
x rays
- 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
nursing responsibilities for xrays
- explain the procedures
- painless, stay still
- no metal
- c collar is safe
CT scan
3D image of organs, bones, tissues
- use contrast dye for circulation
- used to quickly detect hemorrhage, bone, vascular abnormalities, tumors, cysts
nursing responsibilities for CT
- informed consent
- allergies to iodine
- NPO if GI images
- claustrophobic
contrast
- 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
MRI
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
EEG
electroencephalogram
- monitors brains electrical activity
- helps diagnosis seizure
- confirms brain death
- electrodes placed on the skull w conduction plates
- completed sleep, wake, stimulated
sensory alterations
- reception: stimulation
- perception: interpretation
- reaction: what to do w stimulus
brain is smart about which stimulus to interpret
factors influencing sensory function
- 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
sensory deficit
abnormal function of perception, reception
sensory deprivation
inadequate quality or quantity of stimulation
sensory overload
reception of multiple stimuli
common visual sensory deficits
- presbyopia
- cataracts
- computer vision
- dry eyes
- glaucoma
- diabetic retinopathy
- macular degeneration
hearing and balance deficit
hearing
- presbycusis
- cerumen
balance
- dizziness
- disequilibrium
taste deficits
xerostomia: thicker mucous, dry mouth
tactile deficits
- peripheral neuropathy
- CNS injuries
- extreme injuries
communication deficit
- severe visual deficits
- neuromuscular disease (affects speech)
- artificial airways
- aphasia
common w stroke brain injuries
types of aphasia
expressive: inability to name common objects or express ideas in words/writing
-receptive: inability to understand written or spoken language
caring for the vision deficit
- 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)
caring for auditory pts
- 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
caring for taste and smell deficits
- well seasoned food
- separate textured food
- serve most appealing foods
- stimulate smell when appropriate
- limit strong odors
- good oral hygiene
- eat slow
reduced olfaction
- smoke detector
- check food dates/appearance
- danger of cleaning chemicals (can’t smell gases)
- gas appliances (make sure good use, or use other option)
caring for pts w tactile deficits
- touch therapy
- turning/repositioning
- pt can have hyperesthesia (minimize irritating stimulations)
- adaptations for tactile sensations (water temp, shoes)
caring for pts w communication deficits
- patience
- normal tone
- short simple questions
- yes/no qs
- communication boards
- sign language
causes of sensory deprivation
- isolation
- loss/impairment of senses
- confinement
- emotional disorders
- brain injury
effects of sensory deprivation
- 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
sensory overload
excessive stimuli
- tolerance is variable (fatigue, attitude, emotional wellbeing)
- often confused w mood swings/disorientation
causes of sensory overload
- pain
- lack of sleep
- ICU/care
- visitor/staff
prevents brain from responding to normal stimuli
symptoms of sensory overload
fatigue, sleepiness
disorientation
scattered, restless, anxiety
inability to problem solve
increase tension
racing thoughts
care for sensory overload
orient pt
control stimuli (control pain)
uninterrupted periods
schedule
visitor control
nursing problems for sensory alterations
- disturbed sensory perception
- impaired verbal communication
- impaired physical mobility
- deficient knowledge
- social isolation
- unilateral neglect
- self neglect and more
making safety a priority
- orientation to environment
- communication
- controlling stimuli
- self care promotion
evaluation of neurological
only pt can say if sensory deprivations have improved
migraine
recurring headache characterized by unilateral throbbing pain
- common in females
- typically have aura that precede headache
care of pt w migraines
- rule out intracranial or extra-cranial disease
- medications typically dont work
- triptan drugs used
- high flow O2 for cluster (6-8 L/10 mins)
