Neurosensory Flashcards
first priority of a neuro assessment
Can they neurologically control their ABCs?
Who needs a focused neuro assessment?
has neuro disease, tremor, seizure, trauma, neurological change, drug-induced state, neuro abnormal finding in basic
4Hs of neurological changes
Hypoxia, hypoglycemia, hypoventilation, hypotension; check them first before moving on
Alert LOC
awake, easy to arouse, receptive and responsive
Lethargic
not fully alert, drifts off when unstimulated, awakens to name, slow to respond
obtunded
mostly asleep, hard shake or shout to wake, speaks but hard to understand
stupor or semi-comatose
can’t stay awake, groans and mumbles
comatose; light vs deep
no meaningful stimuli response, light coma—w/o purposeful movement, deep coma–no motor response
Comatose EMV
under 7-9
Brain injury EMV (severe, moderate, mild)
<8, 9-12, 13-15
proprioception
how you sense yourself in a space, action, and location
Lowest GCS score
3
coordination
rapid alternating movements like quickly touching each finger to your thumb
Nursing responsibilities for neuro deficits
monitor VS and LOC, basic vs focused assessment, report chx to HCP and include updates in report, PROTECT AIRWAY–lift head of bed
nursing care for neuro probs
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
Seizure precautions
Suction, oxygen, padded rails
x-ray
used for skull bones, common in kids; spinal–eval neck and back pain, degenerative changes; can be done with c-collar on
CT scan or CAT scan and what it detects
3D picture of organs, bone, tissue; detects hemorrhage, bone, vascular abnormalities, tumors, cysts
Contrast use, considerations, and route
Used for circulation on a CT; PO, IV, or rectal, iodine based; can be hard on the kidneys so force fluids
Nursing care for CT scan
informed consent and iodine allergies (for contrast), may be NPO, give anti-anxiety meds if claustrophobic
MRI
highly detailed 3D image of a slice of the brain; very expensive (last resort)
MRI considerations
screen for metal, remove med patches and tattoos–can cause burns; get MRI compatible oxygen and electrodes; may need anti-anx meds
EEG
monitors brain’s electrical activity, detect seizures, sleep disorders, helps to confirm brain death; completed while asleep, awake, or stimulated
EEG considerations
may trigger seizures purposefully with lights, sound; electrodes stick very hard in hair
3 parts of sensation
reception (stimuli), perception (interpretation), and reaction
Fx influencing sensory function
extremes of age, meaningful stimuli, amount of stimuli, social interactions, environmental factors, cultural factors
Hearing deficits
presbycusis, cerumen accumulation
balance deficits
vertigo–dizzy and lack equilibrium
Vision deficits
dry eyes, presbyopia, glaucoma, diabetic retinopathy, macular degeneration
xerostomia
thicker mucus, dry mouth and loss of taste
Tactile deficits
peripheral neuropathy, CNS injury, phantom pain
communication deficits
neuromuscular control disease, expressive aphasia, receptive aphasia
Expressive aphasia
know how they want to respond but just can’t, can’t name common objects
Receptive aphasia
can’t understand written or spoken language
Care with visual deficits
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
Care with hearing deficits
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
Considerations for olfactory deficits
smoke detectors, gas appliances, dangers of using strong chemicals, check food date and label
Considerations for taste and smell deficits
well-seasoned food, separate textured foods, have appealing foods bc anorexia is concern, limit very strong odors and flavors
Considerations for tactile deficits
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
Sensory deprivation causes
isolation, loss of senses, confinement, emotional disorders, brain injury, prison, monks, amish
Effects of sensory deprivation
Cognitive–dec problem-solving, dec ability to learn, dec attention; affective–cry, panic, anxious; Perceptual–dec color perception, time, and judgement
Sensory deprivation considerations
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
Sensory overload
excess stimulation can prevent the brain from blocking out certain stimuli
causes of sensory overload
pain, lack sleep, dec problem-solving, ICU care, visitors/staff
Things that can inc sensory overload
mood, lack of sleep, pain,
Sx of sensory overload
fatigue, restless, anx, dec problem-solving
Care for sensory overload
orient and assess orientation, control stimulation, create uninterrupted periods, be calm in room, schedule care and rest, visitor control, calm presence in room
How to evaluate patients
ask them about sensory problems, observe the patient or self-demonstrate their skills
Migraine
recurring headache characterize by unilateral throbbing pain, more common with family hx, fem between 25-49; may be preceded by aura
Migraine/HA care
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
Triptans
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
Tension headache
most frequent in band around the forehead
Migraine
usually unlateral in the temple on one side but pain can be bilateral
Cluster headache
pain focused in and around 1 eye, may have face pain
Sensory deprivation
Inadequate quality or quantity of stim
What do you need to obtain before a CT?
Ask pt about iodine allergy and informed consent
What colors are best for visual deficits?
Red and orange
