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29 Cards in this Set
- Front
- Back
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NS |
responsible for many fuctions full assessment requires time and attention to detail LOC, physical status, chief complaint collect all equipment before beginning |
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Nurological System |
behavior and appearance- nonverbal and verbal language- aphasia |
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neurological system |
intellectual function memory knowledge abstract thinking association judgement cranial nerve function |
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motor function |
coordination higher extremity/fine motor lower extremity/ gross motor |
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Glasgow Coma Scale |
eye opening- spontaneous, to speech, to pain, none verbal response- oriented, confused, inappropriate, incomphensible, none motor response- obeys commands, localizes to pain, withdrawn to pain, flexion to pain, extension to pain, none max score -15 |
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NS Reflexes |
0- no response 1+ - sluggish/diminshed 2+ - active/expected response 3+- more brisk than expected, slightly hyperactive 4+ brisk and hyperactive with intermittent of transient clonus |
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NS reflexes cont'd. |
position tap tendon briskly compare corresponding sides |
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Evaluation |
have patients goals been bet. How do you feel about not being able to dress yourself and make your own meals? which exercises do you find most helpful? |
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Terminology |
senses: sight/visual hearing/auditory touch/tactile smell/olfactory taste/gustatory postion and motion/ kinesthetic
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stereognosis |
a sense that allows a person to recognize the size, shape, and texture of an object |
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Scientific knowledge base |
sensory reception involves the stimulation of sensory nerve fibers and the transmission of impulses to higher centers within the brain |
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normal senstation |
reception: stimulation of a receptor such as light, touch, or sound. perception: itegration and interpretation of stimuli reaction: only the most important stimuli will elicit a reaction |
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sensory deficits |
deficit in the normal function of sensory reception and perception |
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sensory deprivation |
inadequate quality or quantity of stimulation decrease attention/difficulty concentrating |
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sensory overload |
reception of multiple sensory stimuli |
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assessment |
person at risk mental status ability to perform self care environmental hazards social support physical assessment health promotion habbits use of assistive devices other factors affecting perception |
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Aphasia definitions |
patients with aphasia have varied degrees of inabilkity to speak, interpret, or understand language |
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expressive aphasia |
motor type of aphasia is the inability to name common objects or express simple ideas in words or writing. |
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sensory or receptive aphasia |
inability to understand written or spoken language global aphasia- both |
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nursing diagnosis |
impaired verbal communication risk for injury impaired physical mobility bathing self-care deficit situational low self-esteem |
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planning |
include family members use standards as guide patner with patient to set realistic goals make safety top priority consider community based resources value other professional contribution. |
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implementation |
patients can learn to adjust to sensory impairments at any age with proper support and resources |
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health promotion |
screening preventive safety- trauma, vaccines use of contact lenses, eye glasses, hearing aids promotion of meaningful stimuli creating a safe enviroment communication |
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acute care |
orientation to the environment- address patient by name, place call light within reach, use nightlight, reduce clutter.. control stimuli- reduce sensory overload, combine nursing activities, control extraneous noise safety measures. |
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Evaluation |
patient is only person who can tell you if sensory ability has improved from nursing interventions |
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eyes - external eye structure |
position and alignment eye browls eyelids lacriminal apparatus conjuctive and sclera corneas pupils and irises PERLA |
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Eyes |
Visual acuity extraocular movements visual fields |
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Ears |
Auricles Texture tenderness lesions color pain cerumen ear canals and eardrums |
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ears |
hearing acuity= ototoxicity |
