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
