Nursing Fundamentals II Neuro-Sensory

olanjones's version from 2016-07-19 15:42

General Assessment

Question Answer
What are the 5 major parts of the physical examination for a neuro-sensory assessment?Mental status, Cranial nerves, Motor system, Sensory System, Reflexes
When performing a mental status exam what should be assessed? Behavior (LOC, facial expression, speech, mood/affect), Orientation, Memory, Judgment (thought process/content), Mini-mental exam, (If indicated also Depression/Suicidal thoughts)
What are the three responses tested in the Glasgow Coma Scale? Eye opening response, Verbal response, Motor response
What is the maximum score for the Glasgow Coma Scale? 15 (indicates only minor brain injury) REMEMBER - this scale is only used on patients with impaired LOC (not for alert patients)
What are the 6 states of awareness? Fully conscious, Disoriented, Confused, Somnolent, Semi-comatose, Coma

Awareness States

Question Answer
Fully consciousalert; oriented x 3; understands verbal and written communication
Disorientednot oriented to time, place, or person
Confusedreduced awareness, easily bewildered, poor memory, misinterprets stimuli, impaired judgement
Somnolentextreme drowsiness but will still respond to stimuli
Semi-comatosecan be aroused by extreme or repeated stimuli
Comadoes not respond to verbal stimuli

Cranial Nerve Testing

Question Answer
CN I (olfactory)Vision is obscured, use identifiable smell under one nostril at a time; Only tested when patient c/o difficulty smelling not associated with congestion
CN II (optic)Test visual acuity, visual fields, use ophthalmoscope to visualize ocular fundus
CN III, IV, VI (oculomotor, trochlear, abducens)Check for ptosis, PERRLA, EOMs (ask about diplopia), Nystagumus
CN V (trigeminal)Test motor and sensory function - muscles of mastication, corneal/blink reflex, check all 3divisions of nerve (ophthalmic, maxillary, mandibular) for light touch & sharp vs dull sensation, muscle strength
CN VII (facial)Test facial mobility and symmetry (smile, frown, raise eyebrows, puff out cheeks), If indicated check sense of taste with sugar, salt, lemon juice (not routine testing)
CN VIII (acoustic/vestibulocochlear)Test ability to hear normal conversation, whisper test, Weber (tuning fork on top of head, where is sound from) & Rinne (turning fork near ear, when does sound stop) tests, Visualize TM & cone of light with otoscope
CN IX, X (glossopharyngeal, vagus)Test motor function of palate & uvula, gag reflex, swallow ability; Sensory function not generally tested (CN 9 controls taste on posterior 1/3 of tongue)
CN XI (spinal accessory)Examine sternomastoid and trapezius muscles for size & strength (turn head, shrug shoulders against resistance)
CN XII (hypoglossal)Inspect tongue for wasting or tremors; Have client stick out tongue and say light, tight, dynamite

Motor Assessments

Question Answer
What is assessed during a motor exam?Muscle size (compare bilaterally), Muscle strength, Tone, Involuntary movement, Balance (cerebellar function)
How is muscle strength rated?on a scale of 0-5/5: 0 = no contraction, 1 = muscle flicker, but no movement, 2 = movement possible, but not against gravity, 3 = movement possible against gravity, but not against resistance, 4 = movement possible against some resistance, 5 = normal strength
How is muscle tone assessed?move extremities through PROM
How is balance assessed?using gait, tandem walking, Romberg, knee bend/hop in place one leg at a time, rapid alternating movements, finger to nose/finger to finger, heel to shin
How are deep tendon reflexes (DTRs) rated?on a 4 point scale: 0 = no response, 1 = hypoactive, 2 = normal, 3 = more than normal, 4 = hyperactive
What reflexes are elicited during an exam?biceps, triceps, brachioradialis, quadriceps (knee jerk), Achilles (ankle jerk), and test for clonus by briskly dorsiflexing the foot
What are superficial reflexes?abdominal, cremasteric, plantar (Babinski)

Sensory Assessments

Question Answer
What is assessed during a sensory exam?Light touch, Pain & Temperature, Vibration, Position sense (kinesthesia), Tactile discrimination (stereognosis, graphesthesia, two-point discrimination, extinction, point location)
What is sensoristasis?optimal state of sensory arousal (not overloaded, not deprived)
What is often the response to sensory deprivation?person becomes more aware of remaining stimulus and perceives it in a disoriented manner
What is often the response to sensory overload?person is unable to process the amount/intensity of stimuli (3 factors contribute – internal stimuli, external stimuli, inability to disregard stimuli selectively)
What are sensory deficits?impaired reception, perception (or both) of one or more of the senses (e.g. blindness, deafness)
What is social deprivation?withdrawal from contact to avoid embarrassment or dependence on others (reports of lack of meaningful communication with others,absence of opportunities to discuss fears or concerns that facilitate coping mechanisms)
What is cultural deprivation?lack of culturally assistive, supportive, or facilitative acts
What factors affect sensory stimulation?Developmental stage, Medications, Lifestyle/Personality, Culture, Stress, Illness, Environment
Clinical signs of sensory deprivation/overloadChanges in attention span, Changes in thought process, Emotional lability, Changes in behavior/usual routines
What are the possible effects of sensory-perceptual alterations on self-care ability and safety?Impairments may: inhibit a person's ability to maintain their home, communicate, prevent accidental self-injury, place them at risk for isolation

Tactile discrimination / Sensory Nerve Conduction

Question Answer
Stereognosisability to identify common objects by sense of touch/manipulation
Graphesthesiaability to feel writing on the skin by sense of touch
Two-point discriminationability to tell whether one or two areas of the skin are being touched simultaneously
Extinctionfailure to perceive touch on one side of the body when two symmetrical areas of the body are touched simultaneously
Hyperesthesiamore than normal sensation
Hypoesthesialess than normal sensation
Paresthesiaabnormal sensation such as burning, pain, or electrical shock
Anesthesialoss of sensation

Sensory Nursing Process

Question Answer
Interventions for clients with sensory deprivationencourage use of glasses, hearing aides; communicate frequently, maintain meaningful interactions; provide art, media, clocks, textured objects, social interaction, crosswords/games
Interventions for clients with sensory overloadminimize unnecessary light, noise, and distraction; provide dark glasses/earplugs; control pain; provide orienting cues; private room, limit visitors; speak in low tones, give new info gradually
Supporting visual functionannounce your presence, stay in field of vision, speak in warm, pleasant tones, explain before touching, explain sounds in environment, indicated when conversation has ended and you are leaving the room
Supporting auditory functionconvey presence before initiating conversation, decrease background noise, talk at moderate rate/normal tone, do not over-articulate, make sure person can see you easily, change subject at slower rate
Promoting orientation to TPPprovide consistent caregiver, address person by name, introduce yourself, identify time/place, place calendar/clock in room, encourage family to visit, schedule activities, provide adequate sleep
What is the goal of a Coma Stimulation Program?to prevent environmental sensory deprivation which may slow recovery and development of CNS function and further depress impaired brain functioning
What is the goal of a TBI MinStim Program?to prevent sensory overload by keeping stimulation within parameters that allow for the possible slower cognitive functions associated with TBI

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