Neurosensory

Question 1

first priority of a neuro assessment

Answer 1

Can they neurologically control their ABCs?

Question 2

Who needs a focused neuro assessment?

Answer 2

has neuro disease, tremor, seizure, trauma, neurological change, drug-induced state, neuro abnormal finding in basic

Question 3

4Hs of neurological changes

Answer 3

Hypoxia, hypoglycemia, hypoventilation, hypotension; check them first before moving on

Question 4

Alert LOC

Answer 4

awake, easy to arouse, receptive and responsive

Question 5

Lethargic

Answer 5

not fully alert, drifts off when unstimulated, awakens to name, slow to respond

Question 6

obtunded

Answer 6

mostly asleep, hard shake or shout to wake, speaks but hard to understand

Question 7

stupor or semi-comatose

Answer 7

can’t stay awake, groans and mumbles

Question 8

comatose; light vs deep

Answer 8

no meaningful stimuli response, light coma—w/o purposeful movement, deep coma–no motor response

Question 9

Comatose EMV

Answer 9

under 7-9

Question 10

Brain injury EMV (severe, moderate, mild)

Answer 10

<8, 9-12, 13-15

Question 11

proprioception

Answer 11

how you sense yourself in a space, action, and location

Question 12

Lowest GCS score

Answer 12

3

Question 13

coordination

Answer 13

rapid alternating movements like quickly touching each finger to your thumb

Question 14

Nursing responsibilities for neuro deficits

Answer 14

monitor VS and LOC, basic vs focused assessment, report chx to HCP and include updates in report, PROTECT AIRWAY–lift head of bed

Question 15

nursing care for neuro probs

Answer 15

calmly approach, assume they can hear you, fall safety, frequent rounding, may move closer to nurse station; good sleep, pain management (make sure you won’t mask neuro decline with meds), incorporate fam into care

Question 16

Seizure precautions

Answer 16

Suction, oxygen, padded rails

Question 17

x-ray

Answer 17

used for skull bones, common in kids; spinal–eval neck and back pain, degenerative changes; can be done with c-collar on

Question 18

CT scan or CAT scan and what it detects

Answer 18

3D picture of organs, bone, tissue; detects hemorrhage, bone, vascular abnormalities, tumors, cysts

Question 19

Contrast use, considerations, and route

Answer 19

Used for circulation on a CT; PO, IV, or rectal, iodine based; can be hard on the kidneys so force fluids

Question 20

Nursing care for CT scan

Answer 20

informed consent and iodine allergies (for contrast), may be NPO, give anti-anxiety meds if claustrophobic

Question 21

MRI

Answer 21

highly detailed 3D image of a slice of the brain; very expensive (last resort)

Question 22

MRI considerations

Answer 22

screen for metal, remove med patches and tattoos–can cause burns; get MRI compatible oxygen and electrodes; may need anti-anx meds

Question 23

EEG

Answer 23

monitors brain’s electrical activity, detect seizures, sleep disorders, helps to confirm brain death; completed while asleep, awake, or stimulated

Question 24

EEG considerations

Answer 24

may trigger seizures purposefully with lights, sound; electrodes stick very hard in hair

Question 25

3 parts of sensation

Answer 25

reception (stimuli), perception (interpretation), and reaction

Question 26

Fx influencing sensory function

Answer 26

extremes of age, meaningful stimuli, amount of stimuli, social interactions, environmental factors, cultural factors

Question 27

Hearing deficits

Answer 27

presbycusis, cerumen accumulation

Question 28

balance deficits

Answer 28

vertigo--dizzy and lack equilibrium

Question 29

Vision deficits

Answer 29

dry eyes, presbyopia, glaucoma, diabetic retinopathy, macular degeneration

Question 30

xerostomia

Answer 30

thicker mucus, dry mouth and loss of taste

Question 31

Tactile deficits

Answer 31

peripheral neuropathy, CNS injury, phantom pain

Question 32

communication deficits

Answer 32

neuromuscular control disease, expressive aphasia, receptive aphasia

Question 33

Expressive aphasia

Answer 33

know how they want to respond but just can't, can't name common objects

Question 34

Receptive aphasia

Answer 34

can't understand written or spoken language

Question 35

Care with visual deficits

Answer 35

announce when you enter the room, speak pleasant and calm, not too loud, explain what you are going to do, assist with ambulation, orient to the room, items in reach, teach material in RED and ORANGE, use corrective devices

Question 36

Care with hearing deficits

Answer 36

amplify sounds, educate on hearing aides, use short sentences, communication board, ask how they can hear you best, use flashing lights for safety, slow speech in normal tones

Question 37

Considerations for olfactory deficits

Answer 37

smoke detectors, gas appliances, dangers of using strong chemicals, check food date and label

Question 38

Considerations for taste and smell deficits

Answer 38

well-seasoned food, separate textured foods, have appealing foods bc anorexia is concern, limit very strong odors and flavors

Question 39

Considerations for tactile deficits

Answer 39

touch therapy, turn and reposition esp with dec sensation, pt can have hyperesthesia (overly stimulating); dec irritating stim, avoid loose fitting linens; careful of water temp, ice/heat therapy (don't use), well fitting shoes

Question 40

Sensory deprivation causes

Answer 40

isolation, loss of senses, confinement, emotional disorders, brain injury, prison, monks, amish

Question 41

Effects of sensory deprivation

Answer 41

Cognitive--dec problem-solving, dec ability to learn, dec attention; affective--cry, panic, anxious; Perceptual--dec color perception, time, and judgement

Question 42

Sensory deprivation considerations

Answer 42

give short amounts of stim thru day, tactile stim like brush hair, reorientation, encourage visitors/social stim but don't overwhelm, environmental changes, assistive devices

Question 43

Sensory overload

Answer 43

excess stimulation can prevent the brain from blocking out certain stimuli

Question 44

causes of sensory overload

Answer 44

pain, lack sleep, dec problem-solving, ICU care, visitors/staff

Question 45

Things that can inc sensory overload

Answer 45

mood, lack of sleep, pain,

Question 46

Sx of sensory overload

Answer 46

fatigue, restless, anx, dec problem-solving

Question 47

Care for sensory overload

Answer 47

orient and assess orientation, control stimulation, create uninterrupted periods, be calm in room, schedule care and rest, visitor control, calm presence in room

Question 48

How to evaluate patients

Answer 48

ask them about sensory problems, observe the patient or self-demonstrate their skills

Question 49

Migraine

Answer 49

recurring headache characterize by unilateral throbbing pain, more common with family hx, fem between 25-49; may be preceded by aura

Question 50

Migraine/HA care

Answer 50

r/o intracranial or extracranial disease, give NSAIDs, Tylenol, Excedrin, high flo oxygen for cluster headaches--use for about 10 minutes, may do head CT

Question 51

Triptans

Answer 51

affect Sr receptors, dec inflammation and cause vasoconstriction; used for migraines--take at beginning of migraine or during aura but is NOT preventative--don't take regularly for that

Question 52

Tension headache

Answer 52

most frequent in band around the forehead

Question 53

Migraine

Answer 53

usually unlateral in the temple on one side but pain can be bilateral

Question 54

Cluster headache

Answer 54

pain focused in and around 1 eye, may have face pain

Question 55

Sensory deprivation

Answer 55

Inadequate quality or quantity of stim

Question 56

What do you need to obtain before a CT?

Answer 56

Ask pt about iodine allergy and informed consent

Question 57

What colors are best for visual deficits?

Answer 57

Red and orange