BACHELOR OF SCIENCE IN NURSING

OUTCOME BASED CLINICAL LEARNING 1

COURSE MODULE COURSE UNIT WEEK
1 1 16
PERCEPTION AND COORDINATION

● Read course and unit objectives

● Read study guide prior to class attendance
● Read required learning resources; refer to unit terminologies for jargons
● Proactively participate in classroom discussions
● Participate in weekly discussion board (Canvas)
● Answer and submit course unit tasks.

● Personal computer, laptop or android phone with stable internet connection

At the end of the course unit (CM), learners will be able to:
Cognitive:
● Identify the components of a nursing diagnosis.
● Compare nursing diagnoses, medical diagnoses and collaborative problems.

Affective:
● Organize assessment data as to the taxonomy of nursing diagnosis.

Psychomotor:
 ● Differentiate the various types of nursing diagnoses.
● Develop nursing diagnoses of various formats based from a set of assessment cues.
● Formulate a nursing diagnosis based on the given assessment data.

Perception – it is a mental process by which the brain selects, organizes and interprets
sensations
Coordination – movement of parts together, the skillful and balanced movement of different
parts of the body at the same time

THE NERVOUS SYSTEM

Nerve cells or neuron- the functional unit
CONSIST OF:

1.Central Nervous system (CNS) - includes the brain and spinal cord

2.Peripheral Nervous system (PNS) – includes the cranial nerves and the spinal nerves

subdivided into:

Autonomic nervous system – controls body functions such as breathing and heartbeat
Symphathetic nervous system – fight or flight response
 Parasymphathetic nervous system – rest and digest; feed and breed

Somatic nervous system – consists of afferent nerves, sensory nerves and efferent nerves

Types of Neurons ( functional classifications)

•Sensory neurons (Afferent) – transmit impulses from peripheral receptors to the CNS
•Motor neurons (Efferent) – conduct impulses from CNS to muscles and to the glands
•Interneurons (Internuncial) – connecting links between afferent and efferent neurons.

Physiology of the Brain

FRONTAL LOBE - personality and behavior

- motor function

- Broca’s area (expressive speech)

- concentration, abstract thoughts

PARIETAL LOBE - Sensation

- Awareness of the body parts

- Orientation in space and spatial relationship

OCCIPITAL LOBE - vision

TEMPORAL LOBE - hearing, taste and smell

- Wernicke’s area (receptive speech)

- Interpretive area
BRAIN STEM - ( pons, medulla, midbrain)

- cardiac, vasomotor, respiratory centers

THALAMUS - interpretation of sensation

HYPOTHALAMUS - temperature control

- water metabolism

- control of hormonal secretion

- heart rate

- peristalsis

- appetite control

- thirst center

- sleep wake cycle

CRANIAL NERVES - conducts special senses ( smell, visual, hearing).

- it also generalized sense impulses (pain, pressure, touch, vibration,
temperature, deep muscle sense)
- serve various parts of the head and neck
- 2 pairs in the anterior brain and 10 pairs in brain stem
- sensory nerves, motor nerves and mixed nerves
Cranial Nerves ( CN)
CN I OLFACTORY - Sensory - sense of smell
CN II OPTIC - Sensory - vision
CN III OCULOMOTOR - Motor - pupillary reflex,extrinsic muscle movement
(raise of the eyelid)
CN IV TROCHLEAR - Motor - eye muscle movement
 CN V TRIGEMINAL - Mixed - scalp,upper eyelid,teeth clenching, movement
of mandible
CN VI ABDUCENS - Motor - extrinsic muscle movement of the eye (moves
the eyes outward away from the nose)
CN VII FACIAL - Mixed - Facial movements and taste (anterior ⅔ of the
tongue)
CN VIII VESTIBULOCOCHLEAR - Sensory - vestibular branch - balance
cochlear branch - hearing
CN IX GLOSSOPHARYNGEAL - Mixed - Gag and swallowing reflex and taste
(posterior 3rd of tongue)
CN X VAGUS - Mixed - talking and swallowing
CN XI ACCESSORY - Motor - movement of the trapezius and
sternocleidomastoid muscles
CN XII HYPOGLOSSAL - Motor - movement of the tongue

PATTERNS FOR NEURO ASSESSMENT

- Mental status
- Cranial nerves
- Motor and sensory function
- Reflexes

ASSESSING THE MENTAL STATUS

● Speech and language abilities

● Sensorium
● Memory
 ● Calculation
● Abstract thinking
● Mood and Emotional states
● Perception and thought process
● Judgements

SPEECH AND LANGUAGE

● Rate of speech
● Ability to pronounce words
● Tone of voice
● Volume of voice
● Speak clearly and smoothly
● Ability to respond to questions

CHANGE COULD BE INDICATIVE OF;

● Depression
● Schizophrenia
● Obsessive-compulsive disorder
● Organic brain syndrome
● Anxiety

SENSORIUM
ORIENTATION TO:

● Date
● Time
● Place
● Reason for being here

LEVEL OF ALERTNESS

● - Full alertness to coma

● - Posture, gait, body movements

Changes may be related to:

 ● Cortical disease
● Brain stem disease
● Stroke
● Seizure
● Hypoglycemia

MEMORY
● Date of birth
● ID number
● Names and ages of any children, grandchildren or siblings
● Educational history with dates and events

● Work history with dates and job description

● Long – term memory loss may indicate:

Cerebral cortex damage which occurs in Alzheimer’s disease

CALCULATIONS

● Simple to more difficult mathematical problems

● Inability to calculate:
- Organic brain disease
- Lack of exposure to mathematical concepts
- Nervousness
● Poor calculations should NOT be considered an abnormal finding

ABSTRACT THINKING
● Similarities and differences between two objects or topics.
● Age and culture influences
● Proverb and its meaning

Reflects:

● Lack of education
● Mental retardation

Dementia:
 ● Bizarre response
● Schizophrenia
● Depression

MOOD AND EMOTION

● Body language
● Facial expressions
● Communication technique
● Facial expression and tone should be congruent with the content
● Reflect the current situation
● Lack of emotional response
● Lack of change in facial expression
● Flat voice tones
● Anxiety and depression
● Fear and anger
● Overconfidence and irritability

PERCEPTION AND THOUGHTS

● Logical and relevant

● Awareness of reality
● Disturbed thought process
● Neurologic dysfunction or mental disorder
● Disturbance in sense or reality
● Hallucination and illusion

JUDGEMENTS

● the ability to make considered decisions or come to sensible conclusions.

● Evaluate the situation and decide upon a realistic course of action.
● Plans should reflect the reality of the client’s health, psychological stability and family
situation and obligations

Related to:
● Emotional disturbances
● Schizophrenia
 ●

●
Neurologic dysfunction

LEVEL OF CONSCIOUSNESS

LETHARGY - open eyes, answer questions and falls back to sleep

OBTUNDED - open eye to loud voice, responds slowly with confusions, seems unaware of
environment

STUPOR - awakes to vigorous shake or painful stimuli but returns to unresponsive sleep

COMA - unresponsive to all types of stimuli, eye closed.

ASSESSING CRANIAL NERVES

● SNELLEN CHART (CN II)

● ROSENBAUM NEAR VISION CARD
● CORNEAL REFLEX (CN V) never in alert patient
● WEBER ‘s TEST ( forehead)
● RINNE TEST (mastoid process) CN VIII
● OPHTHALMOSCOPE
● PENLIGHT
● STERILE COTTON BALL
● SUBSTANCE TO SMELL OR TASTE
 ○

MOTOR AND SENSORY FUNCTION

 1. TANDEM WALKING/ HEEL TO TOE TEST
- assessing clients with drug and alcohol intoxication, motor neuron weakness and muscle
weakness.
2. ROMBERG’S TEST
- coordination and balance; assessing if there is damage in the posterior columns of the
spinal cord
3. FINGER TO NOSE TEST
- assessing if there cerebellar disease
4. RAPID ALTERNATING MOVEMENTS
- upper motor neuron weakness
5. HEEL TO SHIN TEST
- disease of the posterior spinal tract

Ataxic gait
- wide base and uneven steps with tendency to sway
Scissors gait
- spastic lower limbs, and movement on stiff, jerky movements
Propulsive gait
- walking pattern characterized by a rigid, stooped posture and inability to oppose
forward momentum
Steppage gait
- Foot drop walk
- Flexes and raises the knee higher than usual
Festinating gait
- Parkinson’s walk
 - festinare ( to hurry) gait
Waddling gait
- myopathic gait
- caused by muscle weakness in the pelvic girdle

PROBLEM WITH MOTOR FUNCTION

Fasciculation - muscle twitch, spontaneous involuntary muscular contraction and relaxation,

involving fine muscle fibers
Tic- is an abrupt, uncontrollable movement or sound that deviates from personal normal gestures
Tremor -involuntary rhythmic shaking movement in one or more parts of your body
Dystonia - is a movement disorder in which a person’s muscles contract uncontrollably.
- it affect the body part to twist involuntarily resulting in repetitive movements or
abnormal postures
Myoclonus - refers to a quick involuntary muscle jerk.
PROBLEM WITH SENSORY FUNCTION
LIGHT TOUCH

• Anesthesia - Is the inability to perceive the sense of touch.

• Hyperesthesia - Is an increased sensation
• Hypesthesia - A decreased but not absent sensation
PAIN ( SHARP AND DULL)

• Analgesia - Absence of pain sensation

• Hypalgesia - Decreased pain sensation

STEREOGNOSIS - Ability to identify an object without seeing it.

- Inability to identify a familiar object could indicate cortical disease

GRAPHESTHESIA - Ability to perceive writing on the skin.

- Inability to perceive a number on the skin may indicate cortical disease.
REFLEXES

● are stimulus-response activities of the body

● they are fast, unpredictable, innate and involuntary actions to stimuli.
● the reflex activity takes place in the spinal cord and interpreted in the cerebral
level
REFLEX CHART
- Neuromuscular disease, spinal cord injury, lower motor neuron disease - absent
or diminished reflex
- Upper motor neuron disease - hyperactive
- Clonus - alternating flexion and extension.
TRICEPS REFLEX PATELLAR REFLEX

BRACHIORADIALIS BICEPS REFLEX

ACHILLES ANKLE JERK PLANTAR REFLEX

BABINSKI REFLEX

ABDOMINAL REFLEX
CREMASTERIC REFLEX

CLINICAL MANIFESTATIONS OF PATIENT WITH NEUROLOGIC PROBLEM

● Partial or complete paralysis
● Muscle weakness
● Seizures
● Difficulty of reading and writing
● Poor cognitive abilities
● Unexplained pain
● Decreased alertness
GLASGOW COMA SCALE
- is an objective measure to describe the level of consciousness
- used to assess patients in a coma and the initial score can correlate the severity of brain
injury and prognosis.
- it is based on the client’s response in 3 areas (EVM )
- with a total score of 15

15 - best response patient is awake and oriented

8 or below – comatose patient

3 - deep coma/ totally unresponsive

GLASGOW COMA SCALE

EYE OPENING 4 - spontaneous

3 - to voice

2 - to pain

1 - no response

VERBAL RESPONSE 5- oriented

4 - converse but confused

3 - speech inapproriate

2 - sound incomprehensible

1- no response

MOTOR RESPONSE 6 - obeys verbal command

5 - localizes to pain
 4- flexion withdrawal

3 - abnormal flexion

2- abnormal extension

1 - no response

DIAGNOSTIC PROCEDURE FOR NEURO CLIENT

● SKULL AND SPINE X-RAY STUDIES

- simple x-ray films or imaging test to determine fractures, calcifications and c-spine injury.

● ELECTROENCEPHALOGRAPHY

- a recording of the electrical activity of the brain to physiologically asses the cerebral
activity, may also use to assess sleep disorders, metabolic disorders and encephalitis

Nursing responsibilities:
- explain to the client that the procedure is painless and there is no danger of
electrical shock.
- determine from the physician if any medication should withheld before the
procedure
- coffee, tea , cola and other stimulants are prohibited before examinations
- client hair should be clean before the examination and after the procedure, assist
client to wash electrode paste out of hair

● MAGNETIC RESONANCE IMAGING

- machine that records the signal from the cells in a manner that provide
information to evaluate soft tissue structure
- Also produce detailed images of the brain and the brain stem
Nursing responsibilities:
 - Inform the client that the procedure will take approximately 1 hour
- all metal objects should be removed from the client

●
- The client will be placed in a long magnetic tunnel for the procedure
Poor candidates for MRI include the following :
- client with pacemakers
- client with implanted insulin pumps
- pregnant clients
- obese clients
- any client who requires life support equipment

COMPUTERIZED AXIAL TOMOGRAPHY SCAN (CAT scan)

- computer-assisted x-ray examination of the thin cross sections of the brain to identify
hemorrhage, tumor, edema infarctions and hydrocephalus.

- machine is large donut shaped tube with table through the middle

Nursing responsibilities:

- explain the appearance of scanner to client and explain importance of remaining absolutely
still during the procedure

- remove all objects from client’s hair

- client only receives fluid for 4-6 hours prior to the procedure

- Dye will be injected via IV, assess for iodine allergy and advise the client the he/she may
experience a flushing or warm sensation when the dye is injected

- contrast dye may discolor the urine for about 24 hours

LUMBAR PUNCTURE
- a needle is inserted into the lumbar area at the L4-L5 level and spinal fluid is withdrawn.
 - contra indicated in presence of increased ICP
- normal spinal fluid values: total protein 15-60 mg/100mL

glucose 50-80mg/100mL

CSF cell count 0-5 WBC

no red blood cells

spec. gravity 1.007

no microorganism present

Nursing responsibilities
Before the test

- have the client or the S.O signed the consent

- have the client empty the bladder
- explain the position
 - advised physician if there is a change in neurological status of the client before
the test
-
After the test
- keep the client flat on bed for t least 3 to 4 hours
- encourage high fluid intake
- observe for the spinal fluid leak from the puncture site
TRANSCRANIAL DOPPLER (TCD)
- is a non-Invasive, painless ultrasound technique that uses high-frequency sound
to measure the rate and direction of the blood flow inside the vessels.
POSITRON EMISSION TOMOGRAPHY (PET)
- in Nuclear medicine, a procedure that measures the metabolic activity of the cell.
ARTERIOGRAPH (ANGIOGRAM)
- an X-ray of the arteries and veins to detect blockage or narrowing of the blood
vessels.

MEDICATIONS USE IN CLIENT WITH NEUROLOGICAL IMPAIRMENTS

● Levetiracetam (Keppra)
● Valproic acid
● Phenobarbital (Luminal)
● Diazepam (Valium)
● Acetazolamide
● Mannitol (Osmitrol)
● Citicoline
● Dexamethasone
● Phenytoin
en.m.wikipedia.org
oncolink.org
www.mgh.org
kidshealth.org
www.radiologymasterclass.co.uk
iem-student.org
www.mdcalc.com
myhealth.alberta.ca

COURSE TASK
1. Read and analyze the 2 Critical thinking scenarios in the Canvas each scores 25
points.

Scenario #1 - Nurse Gal is caring for a client who had a right sided paralysis
and diagnosed as Cerebrovascular accident (CVA). The Nurse assessed the
GCS and she observed that the patient is drowsy and the eye open with
painful stimuli, conversant but disoriented when talked to, can obey verbal
command. How will you rate the neuro vital sign of this client? (E_V_M_)

Scenario # 2 - A 49-years old Laboratory Technician was brought to JRRMMC

Emergency Room Complex because of Head Injury due to Fall. He is unable to respond
to questions but moaning when stimulated, flexion of the arms noted as if making a fist,
eyes don’t open to any verbal and pain stimulus. Based on this objective assessment
rate the GCS of this client. (E_V_M_)
 2. Make a 5 Drug study that is commonly used for client with
Neurological impairments