RESPONSES TO ALTERED PERCEPTION Flashcards by Renren Dominguez

Family History Assessment

Inquire about age of onset (eg, present at birth

SDAA

spina bifida; developed in childhood—Duchenne
muscular dystrophy; developed in adulthood—
Huntington disease, Alzheimer’s disease,
amyotrophic lateral sclerosis

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is a medical imaging procedure that uses
x-rays and digital computer technology to
create detailed pictures of the body.

Computerized tomography (CT) Scan

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non-invasive, painless and
uses a small amount of radiation to produce
images; it has a high degree of sensitivity for
detecting lesions.

CT scanning

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Nursing Interventions (CT SCAN)

A review of relaxation techniques may be helpful for
patients with

claustrophobia

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If a contrast agent is used, the patient must be
assessed before the CT scan for an

iodine/shellfish
allergy, because the contrast agent used may be
iodine based.

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is a test that uses powerful magnets, radio
waves, and a computer to make detailed
pictures of the inside of your body.

Magnetic resonance imaging (MRI)

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is a type of nuclear medicine imaging.
● is a nuclear imaging technology that enables
visualization of metabolic processes in the
body

Positron emission tomography (PET)

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is an angiographic procedure that involves
inserting a catheter into a blood vessel in the
groin or arm

Cerebral angiography

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Patient will be monitored for____________
after a catheter cerebral angiography
before going home

4 to 6 hours

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is the pressure required to move sufficient
amounts of blood to the brain (cerebral blood
flow), which maintains life and prevents brain
ischemia.

Cerebral perfusion pressure (CPP)

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Cerebral Perfusion Pressure (CPP) is
calculated as the

mean arterial blood
pressure (MBP) – mean intracranial
pressure (ICP).

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Formula: CPP =

MABP - ICP

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The CPP will fall if the MABP drops, or if the
ICP rises without a corresponding rise in
systemic blood pressure

Cerebral perfusion pressure (CPP

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The increased CPP can lead to

increased cerebral blood flow.

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are the ones whose
patient care requires ICP monitoring as they
have expertise in neurological assessment
and monitoring device management.

Neuroscience nurses

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Normal adults
Intracranial pressure monitoring

< 10 - 15 mm Hg

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s a pressure wave along the artery that
offers various information on cardiovascular
conditions.

Pulse wave form

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non-invasive, painless ultrasound
technique that uses high-frequency sound
waves to measure the rate and direction of
blood flow inside vessels.

Transcranial Doppler

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The test examines and records the speed of
the blood flow in arteries known as the

Circle of Willis,

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There is no specific preparation necessary
for this test. Patients do not need to change
their diet or liquid intake prior to a TCD.

Transcranial Doppler

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a valuable tool to assess brain function
● provides noninvasive, real-time information
about brain activity
● Small flat metal discs called electrodes are
attached to your scalp with wires

Continuous electroencephalogram (EEG

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Avoid eating or drinking anything
containing caffeine for at least 8
hours before the test.

Continuous electroencephalogram (EEG)

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s the most common scoring system used to
describe the level of consciousness in a
person following a traumatic brain injury.

Glasgow Coma Scale (GCS)

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Routine assessment of a patient’s mental
status includes evaluating their level of
consciousness, as well as their overall
appearance, general behavior, affect and
mood, general speech, and cognitive
performance.

Level of mental status

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Common screening tools used to assess mental status include:

● Glasgow Coma Scale ● National Institutes of Health Stroke Scale (NIHSS) ● Mini-Mental State Exam (MMSE)

is a standardized tool that is commonly used to assess patients suspected of experiencing an acute cerebrovascular accident (i.e., stroke)

National Institutes of Health Stroke Scale (NIHSS)

is commonly used to assess a patient’s cognitive status when there is a concern of cognitive impairment.

Mini-Mental Status Exam (MMSE)

Mini-Mental Status Exam (MMSE) is sensitive and specific in detecting

delirium and dementia

MMSE Score of 24-30 indicates

no cognitive impairment

MMSE18-23 indicates

mild cognitive impairment

MMSE Score less than 18 indicates

severe cognitive impairment

Olfactory Nerve

Ask the patient if they have noticed any change in sense of smell

Optic Nerve

Visual Acuity (VA) – Assess VA with a Snellen chart.

Oculomotor, Trochlear, and Abducens Nerves (Assessment of cranial nerves III, IV, and VI):

● Pupillary light reflex ● Pupillary accommodation ● Ocular movements

● Sensation requires both light touch and pin prick assessment ● Motor function is checked by the muscles of mastication

Trigeminal Nerve

Facial Nerve

Initially assess for symmetry in the face at rest ● Ask the patient to perform the following movements

6. Vestibulocochlear Nerve CN VII

If any hearing loss suspected, perform Rinne’s and Weber’s test

Glossopharyngeal and Vagus Nerves - CN IX and CN X nerves can be assessed together:

Ask the patient to open the mouth wide and say ‘ah’, using a tongue depressor to visual the palate and posterior pharyngeal wall (assessing CN IX and X)

Accessory Nerve

The accessory nerve is a purely motor branch to the trapezius and sternocleidomastoid muscles:

can be assessed by asking the patient to turn their head to each side, against the examiners resistance

Sternocleidomastoid

can be assessed by asking the patient to shrug their shoulders, against the examiners resistance

Trapezius

The hypoglossal nerve is a purely motor branch to the muscles of the tongue:

Hypoglossal Nerve

alternatively you can ask the patient to quickly tap their foot on the floor as fast as possible) if abnormal, this is called

dysdiadochokinesia.

Cerebral testing CEREBELLAR FUNCTION RAPID ALTERNATING MOVEMENTS

FINGER TO NOSE & FINGER TO FINGER TEST HEEL TO SHIN GAIT TANDEM

Have patient run their heel down the contralateral shin (this is equivalent the finger to nose test).

HEEL TO SHIN

GAIT TANDEM

the patient is instructed to walk placing one foot directly in front of the other, heelto-toe. Normal patients are able to walk without swaying

SENSORY ASSESSMENT ❖ PAIN

The patient is seated with eyes closed, hands in lap and palms down. ● Test by: Alternating sharp & dull w/ pt’s eyes closed

TEMPERATURE

Ask the patient if an ophthalmoscope handle feels cool or warm when touched to the hands, feet and cheeks.

LIGHT TOUCH

Wisp of cotton Touch lightly - avoid pressure ● Ask patient: ➔ To respond when touch is felt ➔ Compare one area with another

Ask the patient to close his eyes and extend his arms straight ahead with the palms facing upward and observe for 20- 30 seconds

Upper Extremity Drift

The arm is placed across the chest with the elbow at a ninety degree angle. The examiner strikes the triceps tendon just above the elbow

TRICEPS

The patellar tendon is struck directly, just below the patella. The quadriceps muscle in the thigh is observed or felt through a heavily clothed patient

KNEE JERK

ANKLE JERK

The foot is held at ninety degrees. The Achilles tendon is struck directly and the calf muscle are observed for contraction

Shoes and socks are removed. The foot is elevated and supported with the examiner's hand or knee.

Babinski Reflex (Plantar response)

are often psychologically traumatic or occur within a broader context of psychological trauma, such as military combat or recurrent interpersonal violence

Traumatic brain injury (TBI)

This type of stroke is caused by a blockage in an artery that supplies blood to the brain. The blockage reduces the blood flow and oxygen to the brain, leading to damage or death of brain cells.

Acute ischemic stroke

Evaluate stroke patient using FAST

Face Arms Speech Time

is traumatic injury leading to damage of the spinal cord, resulting in temporary or permanent change to neurological function, including paralysis

Traumatic spinal cord injury

TSCI can be classified: is damage occurring across the whole spinal cord width, leading to complete loss of sensation and paralysis below the level of injury

Complete injury

y is the injury is spread across part of the spinal cord thereby only partially affecting sensation or movement below the level of injury

TSCI can be classified 2. Incomplete injury:

BLEEDING MANAGEMENT A. External Bleeding Management ❖ Direct Pressure Method

Apply firm, direct pressure sufficient to stop the bleeding. 2. Apply pressure using hands or pad ensuring that sufficient pressure is maintained and that pressure remains over the wound.

In Direct Pressure Method:

. Don’t remove the embedded object it may plugging the wound and restricting bleeding. 2. Pace padding around or above and below the object and apply pressure over the pads.

As a LAST resort and only when other methods failed. ● It may be applied to a limb to control life – threatening bleeding like traumatic amputations of limb or injury with massive blood loss

Tourniquet method

B. Internal Bleeding ● Some times it difficult to recognize. ● Signs and symptoms – Universal :

Pale Skin Pain. ● Tenderness or swelling over or around the affected area ● Changing of vital signs

the neurosurgeon will create one or two small holes within the skull, followed by an incision in the dura if necessary, in order to drain the blood clot.

Evacuation of blood clots Two surgical treatment options to remove the blood clot: 1. .Burr hole drainage

➢ the neurosurgeon will remove a section of bone to create access, then remove the blood clot.

Evacuation of blood clots Two surgical treatment options to remove the blood clot: Craniotomy

are compounds in foods that scavenge and neutralise free radicals. ➢ These include the nutrient antioxidants, vitamins A, C and E, and the minerals copper, zinc and selenium

Antioxidants

Sources of antioxidants :

✓ Plant foods are rich sources of antioxidants. ✓ Fruits and vegetables ✓ Nuts, wholegrains ✓ Some meats, poultry and fish

are chemicals found in plants that protect plants against bacteria, viruses, and fungi. Eating large amounts may decrease the risk of developing certain cancers as well as diabetes, hypertension, and heart disease

Phytochemicals

✓ reduced inflammation and blood sugar levels ✓ improved vision and heart health ✓ improve brain function, fight off bacteria ✓ reduce symptoms of ulcerative colitis

Bilberry

Bilberry fruit contains chemicals known as

anthocyanosides, --excellent antioxidant properties. They scavenge damaging particles in the body known