RESPONSES TO ALTERED PERCEPTION Flashcards
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
is a medical imaging procedure that uses
x-rays and digital computer technology to
create detailed pictures of the body.
Computerized tomography (CT) Scan
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
Nursing Interventions (CT SCAN)
A review of relaxation techniques may be helpful for
patients with
claustrophobia
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.
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)
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)
is an angiographic procedure that involves
inserting a catheter into a blood vessel in the
groin or arm
Cerebral angiography
Patient will be monitored for____________
after a catheter cerebral angiography
before going home
4 to 6 hours
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)
Cerebral Perfusion Pressure (CPP) is
calculated as the
mean arterial blood
pressure (MBP) – mean intracranial
pressure (ICP).
Formula: CPP =
MABP - ICP
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
The increased CPP can lead to
increased cerebral blood flow.
are the ones whose
patient care requires ICP monitoring as they
have expertise in neurological assessment
and monitoring device management.
Neuroscience nurses
Normal adults
Intracranial pressure monitoring
< 10 - 15 mm Hg
s a pressure wave along the artery that
offers various information on cardiovascular
conditions.
Pulse wave form
non-invasive, painless ultrasound
technique that uses high-frequency sound
waves to measure the rate and direction of
blood flow inside vessels.
Transcranial Doppler
The test examines and records the speed of
the blood flow in arteries known as the
Circle of Willis,
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
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
Avoid eating or drinking anything
containing caffeine for at least 8
hours before the test.
Continuous electroencephalogram (EEG)
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)
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
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
- 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
- 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
