RESPONSES TO

ALTERED PERCEPTION
Christian John B. Timogan, RN, USRN
ANATOMY AND
PHYSIOLOGY
 NERVOUS SYSTEM
CENTRAL NERVOUS PERIPHERAL NERVOUS
SYSTEM (CNS) SYSTEM (PNS)
 Brain & Spinal Cord

SOMATIC NERVOUS AUTONOMIC NERVOUS

SYSTEM (SNS) SYSTEM (ANS)
 Voluntary Movements  Sympathetic
 Parasympathetic
CENTRAL NERVOUS
SYSTEM
 CEREBRUM
 Consist of right and left hemispheres

 Each hemispheres receives sensory information and

controls the opposite side of the body.
 CEREBRAL CORTEX
FRONTAL LOBE
 Personality
 Attention / Focus
 Speech: Brocha’s Area (Expressive)
 Thinking / Judgment

PARIETAL LOBE
 Touch
 Taste
 Temperature
 CEREBRAL CORTEX
TEMPORAL LOBE
 Memory of sound
 Hearing and Smelling
 Speech: Wernicke’s Area (Receptive)

OCCIPITAL LOBE
 Vision
 Memory
 CEREBRAL CORTEX
LIMBIC SYSTEM
 Emotional and visceral patterns for survival
• Feeding
• Sleeping
• Reproduction
• Fight or flight response

 Learning and memory

 CEREBELLUM
 Balance and coordination
 BRAIN STEM
MID BRAIN
 Auditory and Visual REFLEX

PONS
 Pattern of breathing

MEDULLA OBLONGATA
 Controls heart rate and respiratory rate, coughing & vomiting
 DIENCEPHALON
HYPOTHALAMUS
 Controls BP and Temperature
 Regulates sympa and parasympa responses
 Hormone release

THALAMUS
 Pain threshold
 Capable of suppressing minor sensation
PERIPHERAL
NERVOUS
SYSTEM
 CRANIAL NERVES
I - OLFACTORY
 Sense of Smell
 Sensory
 Assessment: With eyes closed, patient is asked to
identify familiar odors (Coffee, Cinnamon)
 Abnormal: Anosmia – Loss of sense of smell

II - OPTIC
 Sense of Sight / Vision
 Sensory
 Assessment: Snellen’s Chart (Normal: 20/20)
 Abnormal: Hemianopia, Blindness
 CRANIAL NERVES
III – OCULOMOTOR
 Pupillary constriction & dilation
 Motor
 Assessment: PERRLA
 Abnormal: (-) PERRLA

IV - TROCHLEAR
 6 Cardinal Gaze movement
 Motor
 Assessment: Cardinal Field of Gaze Assessment
 Abnormal: Nystagmus
 CRANIAL NERVES
V - TRIGEMINAL
 TriCHEWminal – For chewing
 Facial SENSATION
 Both
 Assessment: Wisp of cotton
 Abnormal: Absent of sensation and jaw weakness

VI – ABDUCENS
 Eye movement side-to-side (AbduSIDE-TO-SIDE)
 Motor
 Assessment: Test for bilateral eye movement
 Abnormal: Double Vision
 CRANIAL NERVES
VII - FACIAL
 Facial MOVEMENT
 Anterior 2/3 of tongue sensation
 Both
 Assessment: Ask patient to smile and wrinkle forehead
 Abnormal: Facial weakness

VIII - VESTIBULOCOCHLEAR
 Sense of hearing, balance, and coordination
 Sensory
 Assessment: Weber’s / Rinne Test and Romberg Test
 Abnormal: Deafness and Impaired balance
 CRANIAL NERVES
IX – GLOSSOPHARYNGEAL
 Swallowing
 Posterior 1/3 of the tongue sensation
 Both
 Assessment: Food tasting
 Problem: Augeusia / Dysphagia

X - VAGUS
 Movement of Uvula / Gag Reflex
 Parasympathetic sensation
 Both
 Assessment: Tongue Depressor
 Abnormal: Absent Gag Reflex
 CRANIAL NERVES
XI - ACCESSORY
 Neck movement
 Motor
 Assessment: Ask the patient to turn head and shrug
shoulders
 Problem: Weak / Absent Shoulder Shrug

XII - HYPOGLOSSAL
 Tongue movement
 Motor
 Assessment: Ask patient to move tongue side to side
 Problem: Dysphagia / Slurred Speech
 CRANIAL NERVES
Oh - Olfactory Some - Sensory
Oh
1. - Optic Says - Sensory
Oh - Oculomotor Money - Motor
To - Trochlear Matters - Motor
Touch - Trigeminal But - Both
And - Abducens My - Motor
Feel - Facial Brother - Both
Virgin - Vestibulocochlear Says - Sensory
Girls - Glossopharyngeal Big - Both
Vagina - Vagus Boobs - Both
And - Accessory Matters - Motor
Hymen - Hypoglossal Most - Motor
 31 PAIRS SPINAL NERVES
CERVICAL – C1 – C8

THORACIC – T1 – T12 T – Twelve

LUMBAR – L1 – L5 L – Lima

SACRAL – S1 – S5 S - Sinko

COCYX - 1
31 PAIRS SPINAL NERVES
C1 – C4 – Diaphragm
C5 – T1 – Arms
T2 – T6 – Chest
T7 – T12 – Abdomen
L1 – L5 – Legs
S1 – S3 – GI & GU
S4 – S5 – Genitals
AUTONOMIC
NERVOUS
SYSTEM
AUTONOMIC NERVOUS SYSTEM
SYMPATHETIC NERVOUS SYSTEM
 Fight or Flight Response
 Increase Everything; Decrease GI & GU

PARASYMPATHETIC NERVOUS SYSTEM

 Dominates during relaxed situations
 Decrease Everything; Increase GI & GU
CHECKPOINT
QUESTION
SYMPATHETIC PARASYMPATHETIC

Pupil Dilation Vomiting Hypertension

Bronchoconstriction Diarrhea Polyuria
Tachycardia Constipation Inc. Appetite
Vasoconstriction Bradypnea Viscous Saliva
Vasodilation Oliguria Penile Erection
ASSESSMENT OF
NEUROLOGICAL
SYSTEM
 NEURO ASSESSMENT
CEREBRAL FUNCTION
 Assess degree of wakefulness / alertness
 Note the intensity of stimulus to cause a response
 Apply a painful stimulus over the nailbed with a blunt
instrument
 Ask questions to assess orientation to person, place, and time
 NEURO ASSESSMENT
GLASGOW COMA SCALE
 3 Areas:
• Eye Opening
• Verbal Response
• Motor Response
 Scores Interpretation:
• 15 = highest score; patient is fully oriented and alert
• <7 = comatose patient
• 3 = Deep coma
NEURO ASSESSMENT
 NEURO ASSESSMENT
FOUR SCORE
 Full Outline of UnResponsiveness
 Use in critically ill patients to assess coma severity
 4 Areas:
• Eye Response
• Motor Response
• Brainstem Reflex
• Respiration
 Scores Interpretation: The lower the scores, the deeper the
coma
NEURO ASSESSMENT
 DIAGNOSTIC TEST
SKULL AND SPINAL X-RAY
 Identifies fracture, dislocation, compression, and spinal cord
problem
 Nursing Care:
1. Provide support for the confuse of combative client
2. Remove metal items
3. Maintain immobilization
4. Thick or heavy hair should be documented – could
affect the interpretation of the result.
 DIAGNOSTIC TEST
CT - SCAN
 Used for diagnosing neurological disorder of the brain or the
spine
 May or may not require injection of a dye
 Can detect:
1. Hemorrhage
2. Tumors
3. Abscess
4. Cerebral Edema
5. Hydrocephalus
6. Shifts of brain structures
 DIAGNOSTIC TEST
CT - SCAN
 Nursing Care:
1. Assess for iodine allergy
2. Assess for renal function prior to the procedure
2. Instruct to lie still on a movable table
3. Inform the patient of possible discomforts
4. Assess for claustrophobia
6. Increase fluids after the procedure
5. Remove any objects from the head (wig, earrings, pins)

NOTE: Clients may be given the dye even if they report an

allergy; they may be treated with antihistamine / corticosteroid
 DIAGNOSTIC TEST
MAGNETIC RESONANCE IMAGING
 Used for diagnosis of degenerative diseases, intracranial and
spinal abnormalities
 Not useful when looking bony abnormalities
 No metals when doing test
 Assess for claustrophobia

ELECTROENCEPHALOGRAPHY (EEG)
 Graphic recording of electrical activity of the brain by placing
electrodes to the scalp
 Avoid stimulants 24 – 48 hours prior to the test
 DIAGNOSTIC TEST
CEREBRAL ANGIOGRAPHY
 Injection of a contrast material to visualize the cerebral
arteries and assess for blockage.
 Common insertion site: FEMORAL ARTERY
 Post op Interventions:
1. Maintain bed rest for 12 hours
2. Apply sandbags to immobilize the inserted limb
3. Pressure dressing to the site to prevent bleeding
4. Apply ice bag to injection site
INCREASE INTRACRANIAL
PRESSURE
Monro – Kellie Hypothesis:
“Skull is incompressible”
Brain – 80%
CSF - 10%
Blood - 10%
 INCREASED ICP
 Normal: 0-15 mmHg

 Causes:
• Brain abscess
• Brain Hemorrhage
• Brain edema
• Hydrocephalus
 INCREASED ICP
 Initial Sign: Altered Level of Consciousness (Cerebrum will be the first affected)
- Restlessness
- Confusion
- Disorientation
- GCS alteration

 Late Sign: - Decrease Level of Consciousness (Lethargy)

- Seizure
- Projectile Vomiting - Indicates medulla oblongata
damage
 INCREASED ICP
- Cheyne – Stoke Respiration – Indicates pons damage
 INCREASED ICP
- Cheyne – Stoke Respiration – Indicates pons damage
- Decerebrate Posture
- High - pitched cry (newborn)
- Bulging fontanels (newborn)
- Cushing’s Triad – Indicates brain stem damage

Inc. Systolic BP FEVER Dec. RR and HR

Wide Pulse Pressure

 INCREASED ICP
 Management:
1. Maintain patent airway
2. Position: Semi-fowlers with head and neck at midline
3. Adequate oxygenation to neutralize acidity of the brain
- DON’T HYPEROXYGENATE = Brain alkalosis = Seizure
4. Loose, comfortable clothes
5. Quite, Calm, Non – stimulating environment
6. Seizure and Aspiration precaution
7. Stool softeners; NO ENEMA AND SUPPOSITORY
8. Surgery: Ventriculostomy – To monitor ICP
 INCREASED ICP
9. Medications:
• IV mannitol - For cerebral edema
- Check BP before administration
- Check urine output during therapy
• Dexamethasone - Steroids for cerebral inflammation
10. DON’TS:
• Valsalva Maneuver
• Routine suctions
• Lumbar puncture
• Coughing / Sneezing
CEREBROVASCULAR
ACCIDENT
 CEREBROVASCULAR ACCIDENT

 Disruption of blood supply to the brain

 Causes:
• Thrombus Formation
• Hypertension
• Atherosclerosis
• Diabetes Mellitus
• Aneurysm
 CEREBROVASCULAR ACCIDENT
 Risk Factors:
• Age: 45 years old and above
• Obesity
• Estrogen Therapy – Increases clotting ability
• Hereditary
• Sedentary lifestyle
• Smoking
• Alcoholism

 2 Types:
• Ischemic
• Hemorrhagic
 CEREBROVASCULAR ACCIDENT
 2 Areas affected:
• Left Hemispheric Stroke
- Paralysis to the right side of the body
- Right visual field deficit
- Aphasia
- Altered intellectual ability
- Slow, cautious behavior
• Right Hemispheric Stroke
- Paralysis to the left side of the body
- Left visual field deficit
- Increase distractibility
- Lack of awareness of deficits
 CEREBROVASCULAR ACCIDENT
 What to assess:
• Facial drooping
• Arm defect
• Slurred speech
• Time – To measure the severity of brain damage and for
the drug administration
 CEREBROVASCULAR ACCIDENT
 Signs and Symptoms:
• Aphasia:
- BROCHA’S APHASIA – Unable to speak fluently
- WERNICKE’S APHASIA – Unable to comprehend
- GLOBAL APHASIA – Combined
- Management:
1. Short, one at a time task
2. Independence promotion
3. Make simple direction
4. Alternative communication style
5. Provide time to verbalize concerns
 CEREBROVASCULAR ACCIDENT
 Signs and Symptoms:
• Paralysis (Hemiparesis)
- Weakness of 1 side of the body
- Management:
1. Quad cane on the UNAFFECTED SIDE
 CEREBROVASCULAR ACCIDENT
 Signs and Symptoms:
• Paralysis (Hemiparesis)
- Weakness of 1 side of the body
- Management:
1. Quad cane on the UNAFFECTED SIDE
2. Slipping tub bath
 CEREBROVASCULAR ACCIDENT
 Signs and Symptoms:
• Paralysis (Hemiparesis)
- Weakness of 1 side of the body
- Management:
1. Quad cane on the UNAFFECTED SIDE
2. Slipping tub bath
3. Electric wheel chair
4. Avoid – Roller Walker
 CEREBROVASCULAR ACCIDENT
 Signs and Symptoms:
• Foot drop (Plantar Flexion)
- Management:
1. High topped sneakers
2. Foot board

• Neglect Syndrome (Unilateral Neglect)

- Inability to identify for weak side
- Management:
1. Instruct the patient to touch the weak side
2. Offer a mirror
 CEREBROVASCULAR ACCIDENT
 Signs and Symptoms:
1. • Homonymous Hemianopia (Half Vision)
 CEREBROVASCULAR ACCIDENT
 Signs and Symptoms:
Homonymous Hemianopia (Half Vision)
•
- Management:
1. Scan the environment
2. Move side-to-side
3. Initially; Approach from unaffected side
4. Latter; Approach from affected side
• Dysphagia
– Management: NPO until swallowing is assessed by Speech Therapist
1. Soft foods, thick liquid
2. Small feeding with supplements
3. Position upright when eating
 CEREBROVASCULAR ACCIDENT
 Drug Management:
• Striptokinase – Thrombolytics (for ischemic stroke)
- Ideally given within 4-8 hours
- Not given in Hemorrhagic stroke
• Antihypertensives
INTRACRANIAL
HEMORRHAGE
 INTRACRANIAL HEMORRHAGE
EPIDURAL SUBDURAL SUB INTRA
1. ARACHNOID CEREBRAL
Location Between Between Dura Between Pia Brain
Skull & & Arachnoid Mater & parenchyma
dura mater Arachnoid
Blood Vessel Middle Cortical Vein Berry Hemorrhagic
Affected Meningeal Aneurysm Stroke
Artery
Hallmark Lucid Gradual Thunder drop Sudden
Interval Deterioration headache Onset
(Worst headache
of his / herlife)
 INTRACRANIAL HEMORRHAGE
EPIDURAL SUBDURAL SUB INTRA
1. ARACHNOID CEREBRAL
Location Between Between Dura Between Pia Brain
Skull & & Arachnoid Mater & parenchyma
dura mater Arachnoid
Blood Vessel Middle Cortical Vein Berry Hemorrhagic
Affected Meningeal Aneurysm Stroke
Artery
Hallmark Lucid Gradual Thunder drop Sudden
Interval Deterioration headache Onset
(Worst headache
of his / herlife)
 INTRACRANIAL HEMORRHAGE
 Management:
1. 1. Craniotomy
• Supratentorial – Superior to tentorium cerebelli
 INTRACRANIAL HEMORRHAGE
 Management:
1. 1. Craniotomy
• Supratentorial – Superior to tentorium cerebelli
- Post op Position: Semi – Fowlers

• Infratentorial – Inferior to tentorium cerebelli

- Post op Position: Flat
 TRAUMATIC
BRAIN INJURY
 TRAUMATIC BRAIN INJURY
 2 Types:
1. • CLOSED
- CONCUSSION – Jarring of the brain
- CONTUSION – Bruising of the brain
• Coup – Same side to the site of injury
• Counter – Coup – Opposite side to the site
• Coup – Counter – Coup – Bouncing back
 TRAUMATIC BRAIN INJURY
 2 Types:
1. • OPEN (Skull Fracture)
- LINEAR – Fine line on the skull
- Most common
- DEPRESSED – Skull is driven inward
- COMMINUTED – Skull is fragmented
- BASAL – SKULL

 Signs & Symptoms:

• Racoon’s Eye – Periorbital Edema
• Battle Sign – Ecchymosis of Mastoid Bone
• CSF leakage (Assess for Halo Sign)
SPINAL CORD
INJURY
 SPINAL CORD INJURY
 Injury to the spinal cord which characterized by a decrease
or
1. loss of sensory and motor functions below the level of
injury

 Causes:
• Motor vehicle accidents
• Gunshot injuries
• Falls
• Sports injuries
• Whiplash injury – Neck
• Transection – Due to sharp objects
• Hyper rotation
 SPINAL CORD INJURY
 Risk factors:
•
1. Young age
• Alcohol and drug abuse
• Male

 Types of Spinal Cord Injury

CERVICAL SCI THORACOLUMBAR SCI

PARALYSIS - Quadriphlagia - Paraphlagia (Lower body)

PRIORITY - Respiratory - Elimination

 SPINAL CORD INJURY
 Management
1. 1. Stabilize the airway (Jaw Thrust Maneuver)
2. Immobilization (Flat, firm surface)
3. Cervical collar
4. Transport client as a unit
5. Do not attempt to realign body parts
6. Suctioning may be indicated, but with caution
7. Position change q 2 hours
8. Intermittent catheterization for bladder distention
9. Anticoagulants
10. Anti-embolic stockings
 SPINAL CORD INJURY
 Complication: AUTONOMIC DYSREFLEXIA
- Life threatening condition that occurs in patients with SCI
1.
above T6 level.

- Impairs the normal equilibrium between sympathetic and

parasympathetic divisions

 Causes:
• Bladder distention (Most common)
• Bowel impaction
• UTI
• Pressure ulcers
 SPINAL CORD INJURY
 Pathophysiology:
Lower body irritation (Distended bladder)
1.

Stretched bladder sends nervous impulse to the spinal cord

When the impulse reaches T6, it would lead into

Norepinephrine release

Vasoconstriction

Increase Blood Pressure

 SPINAL CORD INJURY
Increase Blood Pressure to the brain

Brain will interpret that the cause of Inc. Pressure is fluid

overload from distended bladder

However, taman ra
sa T6 ang impulse

Brain will send signal to the bladder to urinate it

 SPINAL CORD INJURY
 Manifestations:
1.
• Hypertension
• Throbbing / Pounding headache
• Diaphoresis
• Piloerection
• Bradycardia
• Blurring of vision
• Warm and flushed – Above the level of injury
• Cold and Pale – Below the level of injury
 SPINAL CORD INJURY
 Management:
1.
1. Position the patient in sitting position to decrease BP
2. Catheterization
3. Check for fecal impaction
4. Monitor blood pressure
5. Antihypertensive medication: HYDRALAZINE
THANKS!
Do you have any questions?
christiantimogan@gmail.com

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