Handouts in Perception and Coordination

By: France A. Turiano-Caayao, RN,Ph.D.

Clinical Manifestations of Metabolic and Structural Causes of Coma(Huether)

Manifestations Metabolically Induced Structurally Induced

Coma Coma
Blink to threat(CNII,VII) equal Asymmetric
Extraocular movement Roving eye movt’s Gaze paresis, nerve palsy
Pupils (CNII,III) Equal and reactive, may be Asymmetric or nonreactive;
dilated, pinpoint, or may be midposition(mid-
midposition and fixed brain injury), pinpoint(pons
injury)
Corneal reflex symmetric response Asymmetric response
(CN V, VII)
Grimace to pain (CN VII) symmetric response Asymmetric response
Motor function movt symmetric response Asymmetric response
tone symmetric response Paratonic, spastic, flaccid,
asymmetric response
posture symmetric response Decorticate, esp if
symmetric; decerebrate,
esp if asymmetric
Deep tendon reflexes symmetric Asymmetric
Babinski’s sign Absence or symmetric present
responses
sensation symmetric symmetric

Altered Level of Consciousness

 LOC is the most critical clinical index of nervous system function, with alterations indicating
either improvement or deterioration of the individual’s condition.
 A person who is alert and oriented to self, others, place and time is considered to be
functioning at the highest level of consciousness, which implies full use of all the person’s
cognitive capacities.
 Diencephalon – acts primarily as a relay station for all sensation except smell.
- All memory, pain impulses and sensation pass through this.
 Hypothalamus – endocrine system
- Maintain fluid balance
- Maintain temp.regulation – promote vasoconstriction and
vasodilatation.
- Hunger center
- Appetite control
- Sleep-wake cycle center, bp, emotional responses
- ANS –regulate activities of the internal. Maintenance
/restoration of the ANS.
  Pons – in the brain stem with midbrain and medulla oblongata; situated in front
of the cerebellum between the midbrain and the medulla and is a bridge
between the two halves of the cerebellum and between the medulla and the
midbrain.
- CN V through VIII originate in the pons. Contains motor and
sensory pathways. Portion help regulate respiration.
 From this normal alert, levels of consciousness diminish in stages.
o Confusion – loss of ability to think rapidly and clearly; impaired judgement and
decision making;
o disorientation – beginning loss of consciousness; disorientation to time followed by
disorientation to place and impaired memory; lost last is recognition of self;
functional in activities of daily living
o Delirium – motor restlessness; increased disorientation, transient hallucinations;
delusions possible; requires some assistance with ADLs
o Obtundation – mild to moderate reduction in arousal (awakeness) with limited
response to the environment(decreased alertness); falls asleep unless stimulated
verbally or tactilely; answers questions with minimum response; psychomotor
retardation; requires complete assistance with ADLs.
o Stupor – a condition of deep sleep or unresponsiveness from which the person may
be aroused or caused to open eyes only by vigorous and repeated
stimulation(arousal but not alert); response is often withdrawal or grabbing at
stimulus(little or no spontaneous activity); severe disorientation
o Coma – no verbal response to the external environment or to any
stimuli(unarousable), noxious stimuli such as deep pain or suctioning do not yield
motor movement(unresponsive to external stimuli or internal needs); determination
commonly documented using Glasgow coma scale score.

Light coma – asso with purposeful movt on stimulation

Coma – asso with nonpurposeful movement only on stimulation

Deep coma – asso with unresponsiveness or no responses to any stimulus.

Five areas of neurologic function to help identify the cause:

 LOC
 Breathing pattern
 Papillary changes
 Eye movement and reflex responses
 Motor responses

Most severe neurologic impairment – flaccidity

Nurse monitors parameters such as respiratory status, eye signs, and reflexes on an ongoing
basis.

Table 61-1 summarizes the assessment and clinical significance of the findings.

Increased Intracranial Pressure

Brain tissue – 1400g

Blood – 75 ml
CSF – 75 ml
 Are in a state of equilibrium and produce ICP. – normal state – 0 to 10 mmHg. And 15
mmHg –upper limit
 Monro-Kellie hypothesis
S/S
• Changes in level of consciousness –earliest sign
• Slurring of speech/delay in response –early sign
• Any change in condition
– Restlessness(Without apparent cause), confusion, increasing drowsiness,
increased respiratory effort, and purposeless movements. – neuro dysfunction –
from compression of the brain due to swelling from hemorrhage or edema, an
expanding lesion, or combi of both.
Late signs
 Cushing’s triad
- Seen when cerebral blood flow decreases significantly. When ischemic,
the vasomotor center triggers an increase in arterial pressure in an effort
to overcome the increased ICP.
- A sympathetically mediated response causes an increase in the systolic
BP with a widening of the pulse pressure and cardiac slowing. This
response is seen clinically as an increase in systolic BP, widening of the
pulse pressure, and reflex slowing of the heart rate.
- It is a late sign requiring immediate intervention.
- The brain ability to autoregulate becomes ineffective and decompensation
(ischemia and infarction begins).
- The pt. exhibits changes in mental status and v/s – bradycardia,
hypertension, bradypnea (Cushing’s triad)
- This may lead to herniation(shifting of brain tissue from an area of high
pressure to an area of lower pressure) .
- Leads to cessation of cerebral blood flow – results in cerebral ischemia,
infarction, and brain death

Seizure Disorder
 Paroxysmal events asso with abnormal electrical discharge of neurons in the brain.
Simple Partial seizure:
o sensory symptoms(flashing lights, smells, auditory hallucinations
o autonomic symptoms (sweating, flushing, pupil dilation)
o psychic symptoms (dream states,anger, fear)

Complex partial Seizure

 o altered LOC
o amnesia
Absence seizure
o a brief change in LOC indicated by blinking or rolling of the eyes, a blank stare, and
slight mouth movements
Myoclonic seizure
o brief involuntary muscular jerks of the body or extremities
generalized tonic-clonic seizure
o typically beginning with a loud cry
o change in LOC
o body stiffening, alternating between muscle spasm and relaxation
o tongue biting, incontinence, labored breathing, apnea, cyanosis
o upon wakening, possible confusion and difficulty talking
o drowsiness, fatigue, headache, muscle soreness, weakness

Atonic seizure
o general loss of postural tone
o temporary loss of consciousness

Dx tests:
CT scan and MRI –density reading of the brain and indicate structural abnormalities
EEG – show paroxysmal abnormalities that confirms the dx of seizure(A negative EEG doesn’t
rule out seizure d/o coz the paroxysmal abnormalities occur intermittently)
Others:

RANCHOS LOS AMIGOS SCALE

• Level I
– No response to stimuli. Appears in deep sleep.
• Level II
– Generalized response. First reaction may be to deep pain. Has delayed,
inconsistent responses.
• Level III
– Localized response. Inconsistent response.
• Level IV.
– Confused. Agitated. Excitable behavior, may be abusive
• Level V
– Nonagitated. Confused. Inappropriate. Usually disoriented. Follows task for 2 to
3 minutes., but easily distracted by environment, frustrated.
• Level VI
– Confused, appropriate. Follows simple directions consistently. Memory and
attention increasing. Self-care tasks performed without help.
• Level VII
– Automatic appropriate. If physically able, can carry out routine activities.
Appears normal. Needs supervision for safety.
• Level VIII
– Purposeful. Alert. Oriented. May have decreased abilities relative to premorbid
state.
Remember:

• Rapid deterioration of the LOC, from minutes to hours, usually indicates am acute
neurologic disorder requiring immediate intervention.
• A gradually decreasing LOC, from weeks to months, may reflect a progressive or
degenerative neurologic disorder.
• Pupil
• The size and equality of the pupils and their reaction to light are an assessment of the
3rd cranial nerve.

Note: PLEASE REFER TO YOUR BOOK RE: ALOC, Increased ICP. thanks