Neurosensory Flashcards
1
Q
Are they neurologically intact enough to…
A
protect their airway
2
Q
Who needs neuro assessment
A
- Neuro disorder/disease
- Neurological CHANGE
- Neuro abnormal finding in basic finding
- Trauma
- Drug-induced states
- Neurological complaints
3
Q
Neuro assessment
A
Orientation, LOC, general survey
4
Q
4 Hs
A
hypoxia
hypoglycemia
hypotension
hypoventilation
5
Q
Focused neuro assessment
A
Subjective data
Mental Status: LOC, orientation, memory, mood, behavior
Gait
Reflexes
Sensation
Coordination
Proprioception
GCS/EMV
Pupils
Visual fields
Muscle strength
Speech
Swallowing
Gag
6
Q
Level of consciousness normal
A
alert, awake, easily arousable, receptive, responsive
7
Q
Lethargic/Somnolent
A
- Not fully alert
- Drifts off to sleep when not stimulated
- Appears drowsy
- AWAKENS to name
- Responds APPROPRIATELY
- Slow to respond
8
Q
Obtunded
A
- Sleeps 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
9
Q
Stupor or Semi-comatose
A
- Spontaneously unconscious
- Responds only to vigorous shake or pain
- Groans, mumbles
10
Q
Comatose- Completely unconscious
A
- No meaningful response to stimuli
- Light coma- no purposeful movement, some reflex activity
- Deep coma- no motor response
11
Q
Important difference btw obtunded and stupor
A
Stupor - not staying awake
12
Q
Obtunded big changes
A
- loud shake or vigorous shake
- confused
- constant stimulation needed
13
Q
GCS/EMV
A
3-15
<7-9 = comatose
14
Q
Severe brain injury classification
A
8 or less = severe
9-12 = moderate
13-15 = mild
15
Q
Proprioception
A
body’s ability to sense movement, action, and location.
16
Q
Coordination
A
rapid alternating movements -> touch thumb to each finger on the same hand quickly
17
Q
Nutritional and hydration needs for neuro pts
A
Dysphagia
Aspiration precautions
Enteral feeding
IV fluids
TPN
Strict I&Os
Oral care
18
Q
Care issues r/t neurological impairment
A
- Sensory functioning
- Pain management
- Controlled environment– limiting disturbances when possible
- Incorporate patient and family in care
19
Q
Movement
A
passive and active ROM, OOB to the chair, get PT/OT
20
Q
Seizure precautions
A
- suction
- padded bed rails
- oxygen
21
Q
X-ray
A
Skull -> look at bones of skull, common in children
Spinal -> first step in evaluating back/neck pain, traumatic injuries, etc.
22
Q
CT Scan
A
- 3-D images of organs, bones, tissues
- For circulation: Need contrast dye
- Quickly detects hemorrhage, bone, vascular abnormalities, tumors, cysts, etc.
- Informed consent (for CONTRAST)
- Allergies to iodine (CONTRAST)
- Diet orders– NPO for some CT scans not all
- Claustrophobic
23
Q
Contract
A
- PO, rectal, or IV
- Contrast helps distinguish selected body areas from surrounding tissues
- Can be iodine based- which is a common allergy
- IV -> often referred to as a CT angiogram (CTA)
- Force fluids, monitor for allergic reaction, monitor kidney function
24
Q
Diagnostic tests
A
MUST HAVE ARMBAND
25
MRI: Magnetic Resonance Imaging
VERY LOUD
- 3-D image from a 2-D slice
- More detailed images than CT scan
- No exposure to radiation
- EXPENSIVE, so last-resort for imaging but sometimes necessary
- SCREEN FOR METAL– remove all metal
- Remove medicated patches (can cause burns)
- can't take regular EKG leads or normal oxygen tanks
26
EEG: Electroencephalogram
- Monitors brain's electrical activity
- Helps to diagnose seizures
- Confirming brain death
- Electrodes placed on the skill using special conduction paste
- Completed sleeping, awake, or stimulated
27
Factors influencing sensory function
- Age
- Meaningful stimuli
- Amount of stimuli
- Social interaction
- Environmental factors
- Cultural factors
28
Sensory alterations
Sensory Deficits
Sensory Deprivation
Sensory Overload
29
Common Visual Sensory Deficits
Presbyopia - declined ability to focus on near objects
Cataracts
Computer vision syndrome
Dry eyes
Glaucoma
Diabetic retinopathy
Macular degeneration
30
Hearing Deficits
Presbycusis (r/t aging) = hearing loss
Cerumen accumulation
31
Balance Deficits
Dizziness
Disequilibrium
32
Taste Deficits
Xerostomia: thicker mucous, dry mouth
- pts that have taste deficits
33
Tactile Deficits
Peripheral neuropathy
CNS injuries
Extremity injuries
34
Communication deficits
Who is affected?
- Severe visual deficits
- Neuromuscular disease
- Artificial airways
- Aphasia
35
Expressive aphasia
Inability to NAME common objects or express ideas in words or writing
36
Receptive aphasia
Inability to UNDERSTAND written or spoken language
37
Caring for pt with vision deficits
- 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 with ambulation
- Encourage use of corrective devices
- Teaching material in large red/orange print
38
Caring for a Patient with Auditory Deficits
- Check for cerumen impaction
- Amplify sounds
- Add flashing lights for safety
- Slow speech in normal tones
- Communication boards
- Short sentences
- Augment teaching with written material
- Educate and ensure proper use of hearing aides
39
Caring for Patients with Olfactory Deficits
Smoke detector
Check food dates/appearance
Dangers of cleaning with chemicals
Gas appliances
40
Caring for pts with gustatory deficits
Well seasoned-food
Separate textured foods
Serve most appealing foods
Stimulate smell when appropriate
Limit strong odors/flavors
41
Caring for Patient with Tactile Deficits
Touch therapy
Turning/repositioning
Pt. can have hyperesthesia
- Minimize irritating stimuli
- Avoid loose fitting linens
Adaptations for tactile sensations:
- Water temp.
- Ice/Heat therapy
- Shoes
42
Caring for the Patient with Communication Deficits
Patience
Normal tone
Simple short questions, gestures -> receptive aphasia
Yes & No questions, communication board -> expressive aphasia
Sign language
43
Sensory deprivation causes
Isolation
Loss/impairment of senses
Confinement
Emotional disorders
Brain injury
44
Sensory deprivation effects
Cognitive
Affective
Perceptual
45
Sensory deprivation care
Opportunity for stimuli -> think timing
Interaction
Tactile stimulation
Reorientation
Encourage visitors/social stimulation
Environment changes
Assistive devices
46
Sensory overload
Excessive stimuli -> overload
Person’s tolerance is variable
Often confused with mood swings/disorientation
47
Sensory overload causes
Pain
Lack of sleep
ICU/care
Visitors/staff
48
Sensory overload symptoms
Fatigue, sleepiness
Disorientation
Scattered/restless/anxiety
49
Sensory overload care
Orient
Control stimuli
Uninterrupted periods
Schedule
Visitor control
50
Migraine
- Recurring headache characterized by UNILATERAL throbbing pain
- More common in females [cluster headaches more common in males]
- Premonitory symptoms and an aura may precede headache phase
51
Pt care with HA and Migraine
- 1st- Rule out an intracranial or extracranial disease
- Medications- NSAIDS, Tylenol, aspirin, combo drugs like Excedrin (adds caffeine)
- Triptan drugs for migraines
- High-flow O2 for cluster headaches
