Neurosensory
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| Scale used to measure LOC | Glasgow Coma Scale
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| Glasgow Coma Scale score needed to be considered "completely alert and oriented" | An assessment totaling 15
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| Glasgow Coma Scale score that indicates a "comatose client" | An assessment totaling 7 or less
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| Three areas that the Glasgow Coma Scale measures | Eye response, motor response, verbal response
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| What is sensory or receptive aphasia? | The loss of the ability to comprehend written or spoken words.
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| Two types of sensory aphasia. | Auditory (or acoustic) and Visual.
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| What ability is lost to patients with auditory aphasia? | The ability to understand the symbolic content associated with sounds.
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| What ability is lost to patients with visual aphasia? | The ability to understand written or printed figures.
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| What are the five sensory functions? | Touch, pain, temperature, position, tactile discrimination
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| Reception Definition | The process of receiving stimuli or data
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| Perception Definition | Conscious organization and translation of the data or stimuli into meaningful data.
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| The five senses | Touch, Taste, Hearing, Sight, Smell
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| Kinesthetic definition | Awareness of position or movement of body parts
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| Stereognosis definition | Object perceived through touch
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| What does RAS stand for? | Reticular Activating System
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| Where is the RAS? | In the brain-stem
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| What does the RAS do, and name two components of the RAS. | Mechanism for arousal. REA (Reticular excitatory area) and the RIA (Reticular inhibitory area).
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| Awareness Definition | Ability to perceive and internal and external stimuli and respond appropriately.
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| Characteristic of normal awareness | Can handle multiple stimuli at one time.
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| Sensoristasis | Describes the state in which a person is in optimal arousal.
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| Oh, Oh, Oh, To, Touch, And, Feel, A, Girls, Vagina, Ah, Heaven | (you know you want to laugh) Cranial Nerve Mnemonic
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| Some Say Money Matters But My Brother Says Big Brains Matter Most | Mnemonic for Sensory, Motor, or both nerve classifications
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| Name the three sensory nerves | Olfactory, Optic, Vestibulcochlear
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| Name the five motor nerves | Ocular motor, Trochlear, Abducens, Accessory, Hypoglossal
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| Name the four nerves that classify as both sensory and motor nerves | Trigeminal, Facial, Glossopharynx, Vagus
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| Sensory Overlaod | Generally occurs when a person is unable to process or manage the amount or intensity of sensory stimuli.
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| Sensory Deficit | Impaired reception, perception, or both, of one or more senses.
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| Signs and symptoms of sensory overlaod | Complaints of fatigue. Irritability, anxiety, restlessness. Periodic or general disorientation. Reduced problem-solving ability or task performance. Muscle tension. Scattered attention/racing thoughts.
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| Signs and symptoms of sensory deprivation | Excess drowsiness. Decreased attention span, difficulty concentrating, decreased problem solving. Impaired memory. Disorientation, confusion, nocturnal confusion. Hallucinations. Crying. Depression. Easily annoyed. Emotionally unstable.
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| Factors that contribute to sensory overlaod | Pain, dyspnea or anxiety. Noisy healthcare facility, contact with many strangers. Inability to disregard stimuli selectively. Stress.
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| Factors that contribute to sensory deficit | Blindness, hearing loss, medications.
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| Ways to prevent sensory overlaod | Minimize light, noise, and distraction. Control pain. Provide orientation cues such as a clock or calendar. Limit visitors. Plan care for uninterrupted periods of sleep. Speak in low tones.
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| Ways to prevent sensory deprivation | Encourage use of glasses/ hearing aids. Address by name. Provide telephone, radio, clock, newspaper and books. Pet therapy. Increase tactile stimulation (back rub, foot and hair care). Encourage family interaction and mind-stimulating activities.
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| Description of "Full Consciousness" | Alert; oriented to time, place, person; understands verbal and written words.
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| Description of "Disoriented" | Not oriented to time, place, or person.
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| Description of "Confused" | Reduced awareness, easily bewildered; poor memory, misinterprets stimuli; impaired judgement.
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| Description of "Somnolent" | Extreme drowsiness but will respond to stimuli.
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| Description of "Semicomatose" | Can be aroused by extreme or repeated stimuli.
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| Description of "Coma" | Will not respond to verbal stimuli.
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| Acute Confusion | Delirium
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| Chronic Confusion | Dementia
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| Explain Delirium | Has an abrupt onset and a cause that, when treated, reverses the confusion.
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| Explain Dementia | Has symptoms that gradual and irreversible
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| Cranial nerve I and how to assess it | Olfactory - sense of smell. Have the patient identify distinctive odors like coffee or mint.
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| Cranial nerve II and how to assess it | Optic - Responsible for vision/visual fields. Have patient read smallest letter on Snellen Eye scale held at 14 inches. Check visual fields with confrontation (cover one eye to test visual fields individually)
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| Cranial nerve III and how to assess it | Ocularmotor - Responsible for 4 of the 6 eye movements (Eyelids, pupil reaction, accommodation, and tracking). "Follow my penlight" test: eyes should move smoothly and coordinated in all directions.
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| Cranial nerve IV and how to assess it | Trochlear - Responsible for outward and downward eye movements. "Follow my penlight".
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| These three nerves are tested together to asses eyes. | CNIII (optic), CNIV (Ocularmotor), and CNVI (abducens)
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| Cranial nerve V and how to assess it | Trigeminal - Responsible for facial sensation, movement of jaw and corneal reflexes. Test by light touch with cotton ball on face with patients eyes closed. Clenching teeth. Corneal is only done in ICU.
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| Cranial nerve VI and how to assess it | Abducens - Responsible for lateral eye movement. "Follow my penlight".
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| Cranial nerve VII and how to assess it | Facial - Observe for facial symmetry (smile, clench eyes, raise eyebrows, puff out cheeks). Assess whether or not patient can identify tastes.
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| Cranial nerve VIII and how to assess it | Auditory - Hearing and balance. Use Rhomberg Test for balance. For hearing, rub fingers next to ear, whisper test, Webber test, Rinne test.
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| Webber Test | Strike a tuning fork and place it on the middle of the patients head. Assess where sound is best heard (left ear, right ear, or both).
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| Rinne Test | Strike a tuning fork and place it on mastoid bone behind patients ear (patient signals when sound is no longer heard) then move the tuning fork next to patients ear canal (patient signals again). Record length of time sound was heard.
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| Cranial nerve IX and how to assess it | Glossopharyngeal - Ask patient to swallow, move tongue up, down, and side to side. Assess for taste on posterior tongue.
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| Cranial nerve X and how to assess it | Vagas - Assess speech and swallowing. Uvula should be mid-line when tongue is out and patient says "ahh" and palate and uvula should rise.
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| Cranial nerve XI and how to assess it | Spinal Accessory - Have patient shrug shoulders against your hands while providing resistance. Have patient turn their head against the resistance of your hand.
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| Cranial nerve XII and how to assess it | Hypoglossal - Have patient protrude the tongue and move it from side to side. Assess for abnormal alignment.
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| These two nerves are assessed together for gag reflex and tongue alignment. | CNIX (Glossopharyngeal) and CNX (Vagas)
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