Neurosensory Nursing Review

Neurosensory Assessment Notes

Introduction

  • Professor Carolyn Brown thanks Dr. Jessica Thompson

  • Course: NUR 333

Objectives

  • Review:
      - Components of basic and focused neurological assessments
      - Neurological diagnostic tests and nursing care related to these tests
      - Nursing neurological interventions

Neurological Assessment

First Step: Neurological Assessment

  • Always consider priority for the patient with neurological impairment:
      - A: Airway
      - B: Breathing
      - C: Circulation

Overview: Basic Neuro Assessment

Components of Basic Neuro Assessment

  • General Survey

  • Level of Consciousness (LOC):
      - Person
      - Place
      - Time
      - Situation

  • Orientation:

Focused Neuro Assessment

Definition

  • A focused assessment is required in the presence of:
      - Neuro disorder/disease
      - Neurological change
      - Neurological abnormal finding in basic assessment
      - Trauma
      - Drug-induced states
      - Neurological complaints

4 H's of Focused Assessment

  • HYPOXIA

  • HYPOGLYCEMIA

  • HYPOTENSION

  • HYPOVENTILATION

Subjective Data Collection

  • Mental Status:
      - LOC
      - Orientation
      - Memory
      - Mood
      - Behavior

  • Physical Examination:
      - Gait
      - Reflexes
      - Sensation
      - Coordination
      - Proprioception
      - Glasgow Coma Scale (GCS)/Eye Opening, Motor & Verbal Responses
      - Pupils
      - Visual Fields
      - Muscle Strength
      - Speech
      - Swallowing
      - Gag Reflex

Level of Consciousness (LOC)

Levels of Alertness

  • Alert:
      - Awake
      - Easily arousable
      - Receptive & responsive

  • Lethargic (Somnolent):
      - Not fully alert
      - Drifts off to sleep when not stimulated
      - Appears drowsy
      - Awakens to name; responds appropriately
      - Slow to respond

  • 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

  • Stupor or Semi-comatose:
      - Spontaneously unconscious
      - Responds only to vigorous shake or pain
      - Groans, mumbles

  • Comatose:
      - Completely unconscious
      - No meaningful response to stimuli
      - Light coma: no purposeful movement, some reflex activity
      - Deep coma: no motor response

Glasgow Coma Scale (GCS)

Overview

  • Objective assessment with a numeric value

  • Possible scores range from 3 to 15
      - Scores ≤7-9 indicate comatose state

Brain Injury Classification

  • Severe: GCS 8 or less

  • Moderate: GCS 9-12

  • Mild: GCS 13-15

GCS Components

  • Eye Opening Response:
      - 6: Spontaneous
      - 5: To speech
      - 4: Opens eyes when asked

  • Motor Response:
      - 6: Obeys verbal command
      - 5: Localizes pain
      - 4: Flexion withdrawal

  • Verbal Response:
      - 5: Oriented x3 (appropriate)
      - 4: Conversation confused
      - 3: Speech inappropriate

Proprioception and Coordination

  • Proprioception:
      - Body’s ability to sense movement, action, and location

  • Coordination:
      - Rapid alternating movements (e.g., touch thumb to each finger on the same hand quickly)

Nursing Problems

Common Concerns

  • Acute confusion

  • Chronic confusion

  • Deficient knowledge

  • Impaired memory

  • Impaired verbal communication

  • Risk for ineffective cerebral tissue perfusion

  • Ineffective airway clearance

  • Impaired swallowing

  • Risk for aspiration

  • Risk for falls

  • Risk for injury

  • Impaired physical mobility

Plan of Care

Teamwork

  • Collaborators:
      - Nurse
      - Nursing assistant
      - Healthcare provider
      - Neurologist
      - Physical (PT) / Occupational therapy (OT)
      - Speech Language Pathologist
      - Respiratory Therapist

Goals

  • Protect status and maintain safety

  • Assist patient in gaining independence

Nursing Care

  • Implement basic & focused assessments

  • Monitor vital signs and LOC

  • Report changes to HCP

  • Include updates in report

  • Protect airway

Nutritional and Hydration Needs

Considerations

  • Dysphagia management

  • Aspiration precautions

  • Enteral feeding if necessary

  • IV fluids

  • Total Parenteral Nutrition (TPN)

  • Strict input & output (I&O) monitoring

  • Oral care management

Skin Care & Mobility

Skin Management

  • Monitor and assess skin condition

  • Turn the patient every 2 hours if in bed

  • Implement pressure redistribution techniques

Mobility Management

  • Passive Range of Motion (PROM) or Active Range of Motion (AROM) exercises

  • Get out of bed (OOB) to chair

  • Involve PT/OT for mobility assistance

Other Care Issues Related to Neurological Impairment

  • Monitor sensory functioning

  • Manage pain effectively

  • Control environment to limit disturbances

  • Incorporate patient and family in care

Seizure Precautions

  • Review outlined safety measures from previous lecture (NUR 324)

Neurological Diagnostics

Types of Radiological Assessments

  • X-rays:
      - Skull X-ray: Check for bone abnormalities; common in children
      - Spinal X-ray: Initial assessment for back/neck pain, traumatic injuries

  • CT Scan:
      - Generates 3-D images of organs, bones, tissues
      - Notes: Requires contrast dye for circulation studies, quickly detects hemorrhage, vascular abnormalities, tumors, and cysts
      - Nursing care considerations:
        - Obtain informed consent for contrast
        - Check allergies to iodine
        - Monitor dietary restrictions (NPO) for some scans
        - Help manage claustrophobic issues if present

Contrast

  • Definition:
      - Materials taken orally, rectally, or intravenously
      - Helps differentiate particular body areas from surrounding tissues
      - Often iodine-based, with a common allergy risk
      - Monitoring required:
        - Force fluids
        - Monitor for allergic reactions
        - Monitor kidney function

MRI: Magnetic Resonance Imaging

  • Produces 3-D images from 2-D slices

  • Provides more detailed images than CT scans

  • Advantages: no radiation exposure

  • Disadvantages: expensive, considered a last resort but may be necessary

  • Pre-scan considerations:
      - Screen for metal presence
      - Remove all metal and medicated patches
      - Be aware of absolute and relative contraindications

EEG: Electroencephalogram

  • Monitors electrical activity in the brain

  • Useful in diagnosing seizures and confirming brain death

  • Electrodes are placed on the scalp using special conduction paste

  • Can be performed while the patient is asleep, awake, or stimulated

Sensory Alterations

Influencing Factors

  • Age

  • Meaningful stimuli

  • Amount of stimuli

  • Social interaction

  • Environmental factors

  • Cultural factors

Types of Sensory Alterations

  • Sensory Deficits:
      - Visual, auditory, taste, tactile impairments

  • Sensory Deprivation:
      - Causes: isolation, loss/impairment of senses, confinement, emotional disorders, brain injury
      - Effects: cognitive, affective, perceptual disturbances

  • Sensory Overload:
      - Symptoms include fatigue, disorientation, anxiety
      - Common causes: pain, lack of sleep, sensory continuous stimulation

Common Visual Sensory Deficits

  • Presbyopia: Age-related vision changes

  • Cataracts: Clouding of the lens

  • Computer Vision Syndrome: Eye strain from screens

  • Dry Eyes: Insufficient lubrication

  • Glaucoma: Increased intraocular pressure

  • Diabetic Retinopathy: Damage stemming from diabetes

  • Macular Degeneration: Loss of central vision

Hearing and Balance Deficits

Hearing Issues

  • Presbycusis: Age-related hearing loss

  • Cerumen Accumulation: Earwax build-up impacting hearing

Balance Issues

  • Dizziness and disequilibrium are common complaints

Taste & Tactile Deficits

Taste Issues

  • Xerostomia: Thickened mucous and dry mouth

Tactile Issues

  • Result in peripheral neuropathy, CNS injuries, extremity injuries

Communication Deficits

Affected Populations

  • Individuals with severe visual deficits, neuromuscular diseases, artificial airways, or aphasia

Types of Aphasia

  • Expressive Aphasia: Inability to name common objects or express ideas

  • Receptive Aphasia: Inability to understand written or spoken language

Care strategies for Sensory Deficits

Vision Deficits

  • Announce presence, stay in field of vision

  • Use warm, pleasant tones for communication

  • Explain care prior to starting

  • Orient patients to surroundings

  • Keep paths clear and items within reach

  • Encourage use of corrective devices and provide teaching materials in large print

Auditory Deficits

  • Assess for cerumen impaction

  • Amplify sounds where possible

  • Use safety measures, including flashing lights

  • Communicate in slow, normal tones

  • Short sentences as needed

  • Provide written material adjunct to verbal instructions

Olfactory and Gustatory Management

  • Serve well-seasoned foods and stimulate smell appropriately

  • Limit strength of strong odors/flavors used

  • Implement safety features like smoke detectors to manage risks associated with reduced olfaction

Tactile Management

  • Touch therapy and repositioning strategies

  • Monitor for hyperesthesia and minimize irritating stimuli

  • Adaptations for tactile sensations, including managing water temperature and using ice/heat therapy

Communication Deficits

  • Exhibit patience; use normal tones

  • Employ simple, short questions and gestures for receptive aphasia

  • Use yes/no questions and communication boards for expressive aphasia

  • Incorporate sign language where applicable

Nursing Problems for Sensory Alterations

  • Disturbed Sensory Perception

  • Impaired Verbal Communication

  • Impaired Physical Mobility

  • Deficient Knowledge

  • Self-Neglect

  • Unilateral Neglect

  • Situational Low Self-Esteem

  • Impaired Social Interaction

  • Social Isolation

  • Self-Care Deficit (bathing, dressing, feeding, etc.)

  • Impaired Nutrition

  • Anxiety/Fear/Ineffective Coping

  • Risk for Injury, Falls, and Thermal Injuries

Priority in Care

  • Maintain patient safety through orientation to environment

  • Effective communication strategies

  • Control sensory stimuli

  • Promote self-care initiatives

Evaluation

Importance of Patient Input

  • Outcomes assessed through patient observation and requests for self-demonstration

  • Reassess and adjust care if no improvement is observed

Migraine & Headache Care

Definition of Migraine

  • A recurring headache characterized by unilateral throbbing pain

  • More prevalent in females, while cluster headaches are more common in males

  • May be preceded by:
      - Premonitory symptoms
      - Aura

Care for Headaches and Migraines

  • Rule out any intracranial or extracranial disease prior to treatment

  • Medications include:
      - NSAIDs, Tylenol, Aspirin
      - Combination drugs like Excedrin (adds caffeine)
      - Triptan drugs specifically for migraines
      - High-flow oxygen for cluster headaches

  • Reference: Table 58.4 in Lewis textbook