Neurnseosory (Exam 3) Flashcards
(40 cards)
Neurological Assessment: First Step
-ABC’s
-Always think about priority for the patient having neurologically impaired patient
Basic Neuro Assessment
-General Survey
-LOC
-Orientation
4 H’s if you notice neurological changes
Hypoxia
Hypoventilation
Hypoglycemia
Hypotension
Focused Neuro Assessment
Look at slide
Level of Consciousness: Lethargic (Somonolent)
-Not fully alert
-Drifts off to sleep when not stimulated
-Appears drowsy
-AWAKENS to name
-Responds APPROPRIATELY
-Slow to Respond
-Someone you woke up in middle of night
Levels of Consciousness: Obtunded
-Sleeps most of the time
-Difficult to arouse-needs loud shout or virgrous shake
-Acts confused when aroused
-Speech mumbled or incoherent
-Requires constant stimulation to stay awake
Levels of Consciousness: Stupor
-CAN NOT STAY AWAKE
-Vigorous shake or pain
-Groans and mumbles
Levels of Consciousness: Comatose-Completely Unconscious
-No meaningful response to stimuli
-Light coma-no purposeful movement, some reflex activity
-Deep coma-no motor response
GCS
Glasco Coma Scale
Objective assessment with numeric value
<7-9 = comatose
What GCS score do we start to worry about airway
7-9
Brain Injury Classification: GCS
-Severe GCS 8 or less
-Moderate 9-12
-Mild 13-15
Proprioception
Body’s ability to sense movement, action, and location.
Sharp and Dull
Coordination
Rapid alternating movements
Touch thumb to each finger on the same hand quickly
Nursing Care: Neurological
PROTECT AIRWAY (Cannot cough or gag)
Seizure Precautions
Bring forward from safety lecture in NUR 324
Neuro Diagnostics: X-ray
-Skull- look at bones of skull, common in children
-Spinal- first step in evaluating back/neck pain, traumatic injuries (LEAVE COLLAR ON)
Neurological Diagnostics: CT scan
-Gold Standarded
-3D images for organs, bones, tissues
-Need contrast dye for circulation
-Quickly detects hemorrhage, bone, vascular abnormalities, tumors, cysts, etc
Nursing Care: CT scan
-Informed consent (for contrast)
-Allergies to iodine (Contrast)
-Diet orders: NPA for some scans
-Claustrophobic
What is contrast?
-PO, rectal, or IV
-Contrast helps distinguish selected body areas from surrounding tissues
-Can be iodine based—which is common allergy
-IV— often referred to as a CT angiogram (Hard on kidney)
-Force fluids, monitor for allergic reaction, monitor kidney function
MRI
-Magnetic Resonance Imaging
-3-D image from a 2-D slice
-More detailed images than CT scan
-No exposure to radiation
-Expensive or last-resort for imaging but sometimes necessary
-Remove medicated patches
-Tattoos
-Book: Look for absolute and relative contraindications for MRI
EEG:
Electroencephalogram
-Monitor brain electrical activity
-Helps to diagnose seizure
-Confirming brain death
-Electrodes place on the skull using special conduction paste
-Completed sleeping, awake, or stimulated
Sensory Alteration 3 components
- Reception (Stimulation of receptors) (Light-Touch-Sound)
- Perception (Immigration and interpretation of stimuli)
- Reaction (How we respond)
Sensory Atlerations
-Sensory Deficits
-Sensory Deprivation
-Sensory Overload
Visual Sensory Deficits
-Presbyopia (age related far sightedness)
-Cataracts
-Computer Vision Syndrome
-Dry eyes
-Glaucoma
-Diabetic reitonpathy
-Macular degeneration
