neurosensory exam 3 Flashcards
(28 cards)
who needs a focused neuro assessment?
neurological disorder or disease
neurologic change
neurological abnormal finding during basic assessment
trauma
known drug-induced mental status changes
any neurological complaints
4 HYPO’s - hypoxia, hypoglycemia, hypotension, hypoventilation
lethargic (somnolent)
not fully alert
drifts off to sleep when not stimulated
drowsy
responds appropriately to questions
-what a normal person is when you wake them up in the middle of the night they awake to name may just be slow
obtunded
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
- not ready to wake up from surgery
- took too many opioids
stupor or semi-comatose
spontaneously unconscious
responds ONLY to vigorous shake or pain-has appropriate response
-groans, mumbles, gets angry
- DO NOT have appropriate speech patterns
this is when we start to worry about airway/breathing
comatose
NO meaningful response to stimuli
light coma-no purposeful movement, some reflex activity
deep coma- no motor response
what does the acronym BE FAST stand for and what does it signify?
SIGNS OF STROKE
Balance difficulties
Eyesight changes
Face weakness
Arm weakness
Speech difficulties
Time call 911
propricopetion
recognizing where your limbs are in space
how to assess for coordination
rapid alternating movements - touch thumb to each finger on same hand quickly
what is an X-ray used for ?
to examine bones
what is the nursing care for an X-ray?
explain procedure - painless
remove metal objects
avoid manipulation of head or back while obtaining
if spinal fracture suspected –> wear neck brace
what is a CT scan?
uses x-rays to produce 3D images of organs, bones, & tissues
aids in determining what part of brain is affected
quickly detects hemorrhage, bone or vascular abnormalities, tumors, cysts
- when using IV contrast dye - looks at vascular - is there a problem with blood vessels in brain?
what is an MRI
uses computer generated radio waves & powerful magnetic field to produce detailed images
computer creates a 3D image from a 2D slice
able to see brain, spinal cord, measure blood flow
used to detect stroke, tumors, infection, injury, epilepsy
NO EXPOSURE TO RADIATION
contrast - gadolinium
nursing care for MRI
NO pace makers, NO metal
remove medicated patches
loud noises
can take up to 90 minutes to complete
EEG (Electroencephalography)
monitor brain’s electrical activity
diagnose- seizures, metabolic disorders, inflammation, infection, sleep disorders
-can confirm brain dead
series of electrodes attached to skull using a special conducting paste
can be done sleeping, awake, or stimulated
what are the three components of normal sensation
reception
perception
reaction
what is reception
stimulation of a receptor such as a light, touch, or sound
what is perception
integration of interpretation of stimuli
any factor affecting LOC impairs sensory perception
what is reaction
only the most important stimuli will elicit a reaction
what factors influence sensory function
age - being old causes risk for sensory alterations meaningful stimuli amount of stimuli social interaction environmental factors cultural factors
what are the three sensory alterations
sensory deficits
sensory deprivation
sensory overload
sensory deficits
deficit in the normal function of sensory reception and perception
EX. i have terrible vision without contact so at night i bump into things
sensory deprivation
inadequate quality or quantity of stimulation
sensory overload
reception of multiple sensory stimuli
people at risk for sensory alterations
older adults
living in a confined environment
acutely ill
