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NCM 118 > RESPONSE TO ALTERED SENSORY-PERCEPTUAL FUNCTION > Flashcards

RESPONSE TO ALTERED SENSORY-PERCEPTUAL FUNCTION Flashcards

1
Q

What are the 2 assessment?

A

Subjective Data
➔ Important Health Information
➔ Functional Health Patterns

Objective Data
➔ Physical Examination
➔ Diagnostic Studies

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2
Q
A
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3
Q

What are the 6 Physical Examination?

A
  1. Mental Status
  2. Cranial Nerve Function
  3. Motor function
  4. Sensory function
  5. Cerebellar function
  6. Reflexes
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4
Q

Components Of Mental Status
Keyword: GCM

A

General Appearance & Behavior
➔ It Includes Level Of Consciousness (Awake,
Asleep, Comatose), Motor Activity, Body
Posture, Dress & Hygiene, Facial Expression &
Speech

Cognition
➔ Note Orientation to Time, Place, Person &
Situation. Memory, General Knowledge, Insight,
Judgment, Problem Solving & Calculation

Mood & Affect
➔ Note Any Agitation, Anger, Depression, Or
Euphoria & Appropriateness of These States.

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5
Q

12 cranial nerves and their function

A

I. Olfactory - smell

II. Optic - from retina of eyes (vision)

III. Oculomotor - 4 eyes movement muscles & levator
palpebrae muscle
Parasympathetic: smooth
muscle in eyeball

IV. Trochlear - one eye
movement muscle, the
superior oblique muscle

V. Trigeminal - from forehead, eye, superior nasal cavity

Maxillary branch - from inferior nasal cavity, face, upper teeth, mucosa of superior mouth

Mandibular branch - from surfaces of jaw, lower teeth, mucosa of lower mouth, & anterior
tongue
Motor: to muscles of
mastication

VI. Abducens - lateral rectus
of the eye

VII. Facial - facial muscles of
expression & cheek muscle
Sensory: taste from anterior
two thirds of tongue

VIII. Vestibulocochlear
Vestibular Branch
Cochlear Branch - equilibrium
sensory organ, the
vestibular apparatus
Sensory: from auditory
sensory organ, the cochlea

IX. Glossopharyngeal - pharynx &
posterior tongue, including
taste
Motor: to superior
pharyngeal muscle

X. Vagus - from much of
viscera of thorax &
abdomen
Motor: to larynx & middle
& inferior pharyngeal
muscles
Parasympathetic: heart,
lungs, most of digestive
system

XI. Accessory -sternocleidomastoid &
trapezius muscles

XII. Hypoglossal - muscles of
tongue

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6
Q

Includes assessment of strength, tone,
coordination, & balance

A

MOTOR FUNCTION

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7
Q

4 motor functions

A
  1. Strength & symmetry
  2. Tone
  3. Cerebellar Function (Coordination & Balance)
  4. Coordination & Cerebellar
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8
Q

What motor function is this?

“Ask the patient to push & pull against resistance
of your arm as it opposes flexion & extension of
the patient’s muscle”

A

Strength & Symmetry

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9
Q

What motor function is this?

“Passively moving the limbs thru their rom, there
should be a slight resistance to these movements”

A

Tone

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10
Q

What motor function is this?

Observe the patient’s stature (posture while
standing) & gait
➔ Romberg’s tests

A

Cerebellar Function

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11
Q

What motor function is this?

Finger to nose test & heel to shin test

A

Coordination & Cerebellar

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12
Q

Terms Associated to Motor Function

  1. Mild weakness of the arm is demonstrated by
    downward drifting of the arm or pronation of
    the palm
  2. Flaccidity
  3. Spasticity
  4. Spasm of muscles
  5. Slow, writhing, involuntary movements of
    extremities
  6. Involuntary, purposeless, rapid motions
  7. Impairment of muscle tone
A
  1. Pronator drift
  2. Hypotonia
  3. Hypertonia
  4. Myoclonus
  5. Athetosis
  6. Chorea
  7. Dystonia
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13
Q

3 Test for sensory function
Keyword: TVP

A
  1. Touch, pain & temperature
  2. Vibration sense
  3. Position sense
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14
Q

Other word for PROPRIOCEPTION

A

Position sense

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15
Q

Involuntary contractions of muscles

0
1+
2+
3+
4+

A

reflexes

0 - no response
1+ diminished
2+ normal
3+ increased (can be normal)
4+ hyperactive

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16
Q

7 Common Assessment Abnormalities

A
  1. Mental Status
  2. Speech
  3. Eyes
  4. Sensory System
  5. Reflexes
  6. Motor System
  7. Spinal Cord
  8. Cranial Nerves
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17
Q

Enumerate Glascow Coma Scale (GCS) & NIHSS Stroke Scale

A

NIHSS Stroke:

0 - No stroke
0-4 - Minor stroke
5-15 - Moderate stroke
16-20 - Moderate to severe stroke
21-42 - Severe stroke

GCS:

Eye opening response - 4
Best Verbal response - 5
Best Motor response - 6
Total score:
Best response = 15
Comatose client = 8 or less
Totally unresponsive = 3

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18
Q

Full Outline of Unresponsiveness (Four) Score

Minimum score:
Maximum score:
The lower the score,

A

Minimum score: 0
Maximum score: 16
The lower the score, THE GREATER THE COMA

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19
Q

DIAGNOSTIC STUDIES (Identify what department belongs to):

  1. CSF is aspirated by needle
    insertion in L3-4 or L4-5
    interspace to assess many CNS diseases.
  2. Simple x-ray of skull & spinal column is done to detect fractures, bone erosion, calcifications, abnormal vascularity.
  3. Serial X-ray visualization of intracranial & extracranial
    blood vessels is performed to detect vascular lesions &
    tumors of brain. Contrast
    medium is used.
  4. Computer-assisted x-ray of multiple cross sections of body parts to detect problems such as hemorrhage, tumor, cyst, edema, infarction, brain
    atrophy, & other abnormalities. Contrast media may be used to
    enhance visualization of brain structures.
  5. Imaging of brain, spinal cord & spinal canal by means of magnetic energy.
    - Has greater contrast in
    images of soft tissue structures than CT scan.
  6. Uses differential signal
    characteristics of flowing blood to evaluate extracranial &
    intracranial blood vessels.
  7. Measures metabolic activity of brain to assess cell death or damage.
  8. A method of scanning similar to PET, but it uses more stable substances & different detectors.
  9. X-ray of spinal cord & vertebral column after injection of contrast medium into subarachnoid space.
  10. Electrical activity of brain is recorded by scalp electrodes to evaluate seizure disorders, cerebral disease, CNS effects of
    systemic diseases, brain death.
  11. Electrical activity associated with nerve & skeletal muscle is recorded by insertion of needle
    electrodes to detect muscle & peripheral nerve disease.
  12. Combined ultrasound & pulsed doppler technology
  13. Same technology as carotid duplex, but evaluates blood
    flow velocities of the
    intracranial blood vessels.
A
  1. Lumbar puncture (CSF Analysis)
  2. Skull & Spine X-rays
  3. Cerebral Angiography
  4. CT scan (Computed Tomography)
  5. MRI (Magnetic Resonance Imaging)
  6. MRA (Magnetic Resonance Angiography)
  7. PET Scan (Positron Emission Tomography)
  8. SPECT (Single-photon Emission Computed Tomography)
  9. Myelogram
  10. EEG (Electroencephalography)
  11. EMG (Electromyography) & Nerve Conduction Studies
  12. Carotid duplex studies
  13. Transcranial doppler

2-9 = RADIOLOGY
10-11 = ELECTROGRAPHIC STUDIES
12-13 = ULTRASOUND

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20
Q

5 Neurologic Alterations
Keyword: ITAST

A
  1. Increase Intracranial Pressure
  2. Traumatic Head Injury
  3. Acute Ischemic Stroke
  4. Seizure Disorders & Epilepsy
  5. Traumatic Spinal Cord Injury
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21
Q

The hydrostatic force measured in the brain CSF
compartment

A

Intracranial pressure

22
Q

3 components that maintains the ICP?
Keyword: BBC

A

Brain tissue
Blood
CSF

23
Q

Normal ICP ranges from __ to ___mmHg

A

5 -15 mmHg

24
Q

ICP = _____ + ______+ _____
Keyword: C + B + C

A

ICP = Pcerebrum + Pblood + PcsF

25
Q

The skull is a rigid bowl that offers little flexibility for changes in the size of the three intracranial components.

A

Monro-Kellie Doctrine (Compensatory Mechanism)

26
Q

Concentration of PCO2 affects the cerebral
blood flow.

A

Cerebral Blood Flow

27
Q

The amount of blood in milliliters passing
through _____ g of brain tissue in 1 minute.

28
Q

abnormal accumulation of water/fluid associated with
increase volume of brain tissue.

A

Cerebral Edema

29
Q

The automatic adjustment in the diameter of the cerebral blood vessels by the brain to maintain a constant blood flow during changes in arterial blood pressure (BP).

A

Autoregulation

30
Q

The pressure needed to ensure blood flow to
the brain

A

Cerebral Perfusion Pressure

31
Q

Formula of Cerebral Perfusion Pressure

A

CPP = MAP – ICP

32
Q

Normal range of MAP

A

70-100 mmHg

33
Q

<50mmHg means?

A

irreversible neurologic damage

34
Q

Formula of MAP

A

MAP = (2 x DBP) + SBP divided by 3

35
Q

A potentially life-threatening situation that results from an increase in any or all of the 3 components (brain tissue, blood & CSF) within
the skull.

A

Intracranial pressure

36
Q

How do you know when the patient has increase ICP?

A

Changes in level of consciousness

37
Q

4 Planning of ICP

A
  1. Maintain a patent airway
  2. Have ICP within normal limits
  3. Demonstrate normal fluid & electrolyte balance
  4. Have no complications secondary to immobility
    and decreased LOC
38
Q

Elevation of head of bed __-___degrees with head in a neutral position (to decrease/ drain
CSF & fluids)

A

30-45 degrees

39
Q

Maintenance of CPP >___ mmHg

40
Q

Maintenance of systolic arterial pressure between ___&___ mmHg( to maintain cerebral perfusion)

A

100 & 160 mmHg

41
Q

Drug Therapy of ICP
Keyword: COHA

A
  1. Corticosteroids (Dexamethasone)
  2. Osmotic diuretic
    (Mannitol)
  3. Histamine(H2) receptor antagonist or Photon Pump Inhibitor
    (Decrease GI ulcers & bleeding)
  4. Antiseizure drugs
    (Phenytoin)
42
Q

4 Nursing Implementation of ICP
Keyword: RFMP

A
  1. Respiratory Function
  2. Fluid & Electrolyte balance
  3. Monitoring ICP
  4. Protection from Injury
43
Q

A broad classification that includes any injury or trauma to the scalp, skull, or brain.

A

Head Injury

44
Q

Serious form of head
injury

A

Traumatic head injury

45
Q

3 Types of heads injury
Keyword: SSH

A
  1. Scalp Lacerations
  2. Skull Fractures
  3. Head Trauma
46
Q

An easily recognized type of external head trauma.

A

Scalp Lacerations

47
Q

Frequently occur with head trauma (Caused by trauma)

A

Skull Fractures

48
Q

5 Types of Skull Fractures:
Keyword: SCDBO

A
  1. Simple
  2. Comminuted
  3. Depressed
  4. Basal
  5. Open
49
Q

SKULL FRACTURES
Fractures may be closed or open, depending on
the ____________ or ______ into the air sinuses or dura

A

presence of a scalp laceration
extension of the fracture

50
Q

Brain injuries are categorized as ____ & _______

A

Diffuse (Generalized) injury
Focal (Localized) injury

NCM 118 (1 decks)

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