Nursing Study Guide/Care of Neurosensory Needs
Eye care can replace the client's own reflex to blink and weep. Eye care aims to keep the exposed conjunctiva moist, preventing tissue damage.
- Observe hand-hygiene procedure.
- Explain your intentions to client, regardless of their perceptual ability to give them adequate warning.
- Use a kidney dish or absorbent material over client's cheek to catch drips.
- Use a fresh wipe for each stroke, use sterile isotonic irrigation fluid.
- Always wipe from medial (inner) to lateral (outer) eye, mimic the natural flow of tears to cleanse the eye.
Lubricants or artificial tears are commonly instilled to prevent dehydration of the conjunctiva, some preparations may require authorization by nurse practitioner or other prescriber. Common medications are anti-biotics, anti-inflammatory, anti-glaucoma drugs. Each client should have their own container where possible. Nurses should consider removing contact lenses from clients unable to perform their own eye care over a period of days to prevent conjunctivitis. In unconscious or anaesthetized clients, it is usual to nurse clients with eyes closed or taped shut. Document care on completion, including adverse findings & discard materials correctly.
Permanent hearing loss occurs from long exposure to excessive noise. Ear plugs or occlusive headphones are advised for any client in a noisy activity, such as power tools or drum kit. Some clients may experience an accumulation of cerum in the external canal. Nurses should advise clients that a cerum softener may be advantageous in dislodging the 'potato'. Clients may be advised to us a gentle stream of warm water, such as tilting their own head in the shower to loosen the ear wax. It is highly dangerous to insert anything into the auditory meatus and if these measures are not successful, then a referral is required (eg. for ear syringe treatment by a suitably trained and insured practitioner). Most clients with hearing aids, or their relatives, will be able to replace the aids after nursing hygiene measures.
Consist of vital signs with Glascow coma scale (0=deceased - 15=alert), pupil and motor strength determination.
There is reliable evidence that
- The Glasgow Coma Scale can be used as an effective tool to assess neurological status and has a higher inter-rater compatibility with experienced staff.
- It is important not to take any aspect of the neurological assessment in isolation.
Joanna Briggs Institute publication JBI2150 'Neurological assessment'
Care of unconscious client
Use a Waterlow Scale to help assess for pressure-sore risk. Jane Johnson (1994) British Journal of Nursing October 13, 1994 page 926