DISTURBANCE IN

PERCEPTION &
COORDINATION
Mr. Carlo S. Hidalgo
The Nervous
System
The Nervous System
 Master controlling and communicating
system of the body
 3 Overlapping Functions:
 Uses sensory receptors to interpret stimulus
 Uses integration to process the input
 Uses motor output to elicit a response to the
stimulus
3 Division of Nervous System
- Central Nervous System (CNS)
- Peripheral Nervous System
- Autonomic Nervous System

 These three parts integrates all

physical, intellectual and
emotional activities
Central Nervous System
 It includes the brain and spinal cord;
occupies the dorsal body cavity

- acts as the integrating and

command centers of the nervous
system and the peripheral nervous
system
Brain
Brain
 It is consist of Cerebrum (Cerebral
Cortex), the brain stem and the
cerebellum.
 It collects, integrates and interprets all
stimuli
Cerebrum
 It gives us the ability to think and reason

 It is enclosed in three membrane layers

called meninges

 It has four lobes and two hemispheres,

these lobes controls specific functions
The Lobes of the Cerebrum
 Parietal lobe
 Occipital lobe
 Temporal lobe
 Frontal lobe
Diencephalon
 It contains:
- Thalamus
- Hypothalamus
Brain Stem
 It is located beneath the diencephalon and
is divided into the midbrain, pons, and
medulla.
 It relays messages between the cerebrum
and diencephalon and the spinal cord
 It regulates automatic body functions such
as heart rate, breathing, swallowing and
coughing
1. Midbrain – Extends from the
mammillary bodies to the pons inferiorly

- Corpora quadrigemina – 4 rounded

nuclei protrusions that are reflex centers
for hearing and vision
2. Pons – Controls the rate of breathing
“bridge”; area of the brain stem that is
mostly made up of fiber tracts

3. Medulla Oblongata – the most

inferior part of the brain stem; merges
with the spinal cord without obvious
change in structure
 3. Medulla Oblongata – Breathing
Center
- Contains many nuclei that regulate
vital visceral activities; control of heart
rate, blood pressure, swallowing,
vomiting
4. Reticular Formation – Extends the
entire length of the brain stem; diffuse
mass of gray matter
Cerebellum
 It facilitates smooth, coordinated muscle
movements and equilibrium
Spinal Cord
 The primary path for nerve impulses
traveling between peripheral areas of the
body and the brain.
 It contains the sensory – to – motor
pathway known as the reflex arc
 It is made up of an H shaped mass of gray
matter, divided into the dorsal and ventral
horns
Peripheral Nervous System

 Includes the peripheral and cranial

nerves
 Peripheral sensory nerves transmit
stimuli from sensory receptors in the
skin, muscles, sensory organs and
viscera
The Peripheral Nervous
System
 Nerves are classified as
o Afferents – carry impulses towards the
CNS
o Efferents – carry impulses towards the
muscles
o Mixed – Carries both sensory and
motor fibers
 Cranial Nerves – 12 pairs
- nerves serving the head and neck
- VAGUS NERVE – is the only pair of
Cranial Nerves that extends to the
thoracic and abdominal cavities
- described by name, number, course
and major function
- most cranial nerves are mixed nerves
except for the Optic, Olfactory and
Acoustic Nerve (pure sensory)
CRANIAL
NERVES
Cranial Nerves

 On Old Olympus Treeless Top

A Finn And German Viewed A
Hop
 “Oh Oh Oh To Touch And Feel
A Girls V_____ Ah Heavenly”
 Cranial Nerves
Cranial Nerves Functions

I.Olfactory SE Smell

II.Optic SE Visual acuity, Visual Fields

III. Oculomotor Movements of eye muscles- pupils lens

MO and levator palpabrae
IV.Trochlear MO Moves the superior oblique muscle

V.Trigeminal MI Innervates the skin of the face, nasal mucosa;

sensations of teeth
*corneal reflex; Movement of mus of mastication
VI.Abducens MO Movements of the lateral rectus muscle of the eyes
VII. Facial MI Movements of facial muscle
Taste from anterior 2/3 of the tongue

VIll. Vestibulocochlear Hearing

SE Balance

IX.Glossopharyngeal Taste from posterior 1/3 of the tongue

MI Motor to superior pharyngeal muscles

X. Vagus MI Sensory to the viscera of the thorax and abdomen

Innervates the larynx and middle and inferior
pharyngeal muscles (hoarseness & movement of
palate)
Parasympathetic: heart, lungs and most of
digestive system
XI. Accessory MO Movements of trapezius and stemocleidomastoid
muscles

XII. Hypoglossal MO Protrusion of tongue

CN.I Olfactory - Sensory

 Sense of Smell

 Let patient smell, coffee, tobacco, Vanilla,

Peanut butter, Lime, Chocolate while eyes
are closed
CN II Optic - Sensory
 Visual acuity
 Snellen’s
chart-distance vision
 Rosenbaum / Jagger’s chart-near vision
 Visual fields confrontation test
 Check of peripheral vision; 11/2 -2 feet
 Your own visual field must be normal
Visual Field Confrontation test
  Myopia
 Hyperopia
 Presbyopia
 Astigmatism
 Cataracts
 Glaucoma
 Homonymous
hemianopsia
CN III Oculomotor - Motor
CN IV Trochlear - “
CN VI Abducens - “
 Assess Pupil Reaction- Direct and
Consensual Reaction
 Six cardinal positions of gaze – EOM
 Corneal light reflex – reflection of light in
the cornea should be located
symmetrically; light 12-15 in. away
 Mydriasis
 Miosis
 Anisocoria – Unequal size of
pupils = may be from CNS
disorder
 Ptosis -
Assessing Eye Movements
 Extraocular movements – for conscious
patients: follow fingers for full range of eye
motions
 For unconscious:
 Oculocephalic reflex - doll’s eyes.
 Oculovestibular reflex – cold caloric test
Sensations of Face
Muscles of Mastication
 CN V Trigeminal – Mixed Sensory and
Motor
 Assess Sensations of cornea, Skin of face
 Sensations “touch” – tongue and teeth
 Assess movements of muscles of
mastication
CN VII. Facial mixed Sensory and
Motor
 Motor Function of Face
Taste sensation of Tongue
 Ask client to smile, close eyes, raise
eyebrows, pout mouth
 Test anterior 2/3 of tongue for diff. taste
sensation
 Bell’s Palsy
CN VIII – Auditory

 Hearing
 Gross Hearing acuity test – Normal tone of
voice and Whispered voice
 Watch tick Test
 Weber’s test – bone conduction test
 Rinne’s test – comparison of air and bone
conduction
Hearing
 Weber’s test positive – if sound is louder in
impaired ear – bone conductive hearing
loss; if sound is louder in normal ear –
sensorineural hearing loss
 Weber’s negative - normal = if sound felt
on both ears are equal
Weber’s Test
Rinne’s Test
Hearing
Rinne’s test positive – normal =
Air conduction > Bone conduction

Rinne’s negative – Abnormal =

Bone conduction = Air conduction
Bone conduction > Air conduction
CN IX – Glossopharyngeal – Mixed
Sensory and motor

 Test – gag reflex

 Tongue movement – CN IX and CN XII

Hypoglossal
CN X – Vagus – Mixed Sensory
and motor

 Together with assessment of CN IX- test

patient for hoarseness of voice
CN XI– Accessory Spinal Nerve
motor

 Ask Client to shrug shoulders against

resistance
 Move head against resistance
The Autonomic Nervous
System
 Composed of a special group of
neurons that regulates cardiac muscle,
smooth muscles of the visceral organs
and glands
 Critical to the stability of our internal
environment (homeostasis)
 Controls adjustments needed to best
support body activities; fine-tuning
occurs without our awareness or
attention
The Autonomic Nervous
System
 Sympathetic Nervous System
- Mobilizes the body during extreme
situations (fear, exercise, rage, stress)
- Enables the body to cope rapidly and
vigorously with situations that threaten
homeostasis
- Functions to provide the best conditions
for responding to some threat
The Autonomic Nervous
System
 Parasympathetic Division
- Chiefly concerned with promoting
normal digestion and elimination and with
conserving body energy
- Decreases demands on the
cardiovascular system
Things to know:
 Broca’s area – Gives us the ability to speak;
found in front of the Central Sulcus of
Rolando; usually found in the left hemisphere
 Higher intellectual reasoning is found in the
anterior part of the frontal lobes; language
comprehension; memory in both temporal
and frontal lobes
 Wernicke’s area – Located at the
junction of the temporal, parietal and
occipital lobes; allows one to sound out
words; found in the right hemisphere

 Corpus Callosum – connects the 2

hemispheres
 Basal Nuclei – Several islands of gray
matter buried deep within the white matter
of the cerebral hemispheres
- Help regulate voluntary motor activities
by modifying instructions sent to the
skeletal muscles by the frontal lobe
- Produces dopamine; a neurotransmitter
 Neurologic
Assessment
 History Taking

 Current Health Status

 Previous Health Status

 Family Health

 Lifestyle
Current health status
 Discover the patient’s chief complaint by asking this
sample questions:
 Why have you come to the hospital?
 What has been bothering you lately?
 Do you have headaches? If so, how often? What
precipitates them?
 Do you ever feel a tingling or numbness? If so,
Where?
 How’s your memory and ability to concentrate?
 Do you have trouble urinating? Walking?
 Do you have trouble reading or writing?
Current health status
 Using the patient’s own words, document
his reasons for seeking care
 If the patient is suffering from neurologic
disorder you can expect reports of
headaches, motor disturbance,
seizures, sensory deviations or an
altered level of consciousness (LOC).
Previous health status
 Many chronic diseases can affect
neurologic system.
 Ask if he has had any:
- major illnesses
- recurrent minor illnesses
- accidents , injuries
- surgical procedures , allergies
Family health status
 Information about the patient’s family may
reveal a hereditary disorder.
 Ask if anyone in the family has had
diabetes, cardio or renal disease, HPN,
cancer, bleeding disorder, mental disorder
or a stroke
Lifestyle
 Cultural and social background
 Educational level
 Occupation
 Drug use
Physical Assessment
 Mental Status
 Cranial nerve function
 Sensory function
 Motor function
 reflexes
Mental Status
 Listen and watch for clues to the patients
orientation and memory.
 It involves evaluating the patients:
- LOC
- Appearance and behavior
- Speech
- Cognitive function
- Constructional ability
QUICK CHECK OF MENTAL STATUS
Question
What’s your name?
What’s today’s date?
What year is it?
Where are you now?
How old are you?
Where were you born?
What did you have for
breakfast?
Who’s the Phil. President?
Can you count back from 20 to Attention and calculation
1?
Why are you here?
Function screened
Orientation to person
Orientation to time
Orientation to time
Orientation to place
Memory
Remote memory
Recent memory
General knowledge
Judgement
Cranial Nerves
 It provides valuable information about the
status of the CNS, particularly the brain
stem
 The optic, oculomotor, trochlear and
abducens are more vulnerable to an
increase in intracranial pressure than other
cranial nerves.
 GLASGOW COMA SCALE
- An objective measure to describe LOC.

 Eye Opening
 Motor Response
 Verbal Response

*GCS of 7 – candidate for intubation

 Eye Opening
4 – open eyes spontaneously
3 – open eyes when told to
2 – open eyes only to painful
stimuli
1 – doesn’t open eyes in
response to stimuli
 Verbal Response
5 – oriented to time, place,
orientation
4 – engages in conversation,
confuse in content
3 – words spoken but conversation
not sustained
2 – groans or evoked pain
1 – no response
 Motor Response
6 – obeys command
5 – localizes painful stimuli
4 – moves away from painful
stimulus
3 – decorticate (abnormal flexion)
2 – decerebrate (abnormal
extension)
1 – no response
GCS VALUES
**Should not be considered a
complete assessment tool
**Not a sensitive tool for
evaluation of altered sensorium
**Does not account for aphasia as
well as lateralization
GCS VALUES
Best
possible score = 15
Moderate disability = 11
Coma = 7
Lowest possible score = 3
 Level of Consciousness
- Most sensitive indicator of changes in
neurologic status of the patient.
I. Alert – conscious, coherent, cognitive
-alert, awake, responsive to stimuli
- follows commands and responds
completely and appropriately to stimuli
II. Lethargic, somnolence, drowsiness or
obtunded
III. Stupor
- physical and mental activities are
minimal. Person inaccessible to many
stimuli.
- requires vigorous stimulation for a
response.
IV. Light Coma
- does not respond to ordinary stimuli
but may respond to painful stimuli.
V. Deep Coma
- Limbs flaccid and motionless, muscles,
tendon, plantar reflexes absent.
- No reaction to painful stimuli, abnormal
motor responses, incontinence present.
- Pupils constricted or dilated and
unresponsive to light; corneal and
pharyngeal reflexes are minimal or
absent.
 Sensory Perception
 Stereognosis – ability to perceive sensory stimuli.
 Agnosia – inability to perceive stimuli.
 Global aphasia
 Receptive aphasia
 Expressive aphasia
 5 Areas of Sensation:

- Pain
- Light Touch
- Vibration
- Position
- Discrimination
 Motor Function
Regulating mechanisms:
1. Frontal lobe – motor center; responsible for
voluntary, purposeful, coordinated
movement.
Apraxia – inability to perform fine motor
activities.
Agraphia – inability to write.
Cerebellum – (center for balance)equilibrium,
sense of posture, direction.
Ataxia – uncoordinated movement.
Coordination
 Finger to nose – eyes open then closed
 Distance – 18 inches
 Rapid alternating movements; thumb to finger
position
 Heel to shin
 Romberg test – with eyes closed; no swaying for 5
seconds
 Coordination – heel to toe fashion and then stand
on each foot
Finger to Nose test
Alternating Supination &
Pronation of Hands to Knees
Heel to Shin test
Heel to Toe walk
Romberg’s
Test
Frontal Lobe
 General Appearance
- involuntary, unpurposeful,
uncoordinated movement, asymmetry
of face, muscle dystrophy.
 Muscle Power
- weakness (“paresis”)
- paralysis (“plegia”)
 Muscle Tone
- flaccidity (hypotonicity)
- rigidity (hypertonicity)
Plegia(Paralysis)
 Muscle Volume
Atrophy – Loss of muscle movement.
Hypertrophy – Increase in muscle
volume.
 Muscle Movement

Bradykinesia – Slow muscle movement

not associated with weakness.
Akinesia – Absence of muscle
movement.
Atrophy
Bradykinesia
Muscle
 Visual scanning of
 Symmetry
 Contour
 Size (e.g. atrophy)
 Involuntary movement
 Palpation
 Tone )tension present in a resting muscle
 Testing of strength
Muscle Strength
Functional level Lovett Scale Grade % of normal

No evidence of contractility 0 0 0

Evidence of slight contractility Trace 1 10

Complete ROM minus gravity Poor 2 25

Complete ROM with gravity Fair 3 50

Complete ROM with some Good 4 75

resistance
Complete ROM vs. gravity with Normal 5 100
full resistance
Muscle strength test
Reflexes
 Defect in sensory pathways from tendons &
muscles or the motor component
 Plantar reflex – start from the heel
 Babinski reflex – normal in children before they
can walk (lesions of the pyramidal tract or motor
nerves
 Grasp reflex – normal in infants < 4 mo old
 Present if with widespread brain damage
Deep Tendon Reflexes
 Grading of reflexes
 4+ - brisk, hyperactive
 3+ - more brisk than normal
 2+ - normal
 1+ - low normal, slightly diminished
 0 – no response
Reflexes
 Function of reflex arcs and the spinal cord
segment
 Biceps- C5,6
 Brachioradialis - C5,6
 Triceps - C6, 7, 8
 Patellar - L2, 3, 4
 Ankle - S1, 2
 Plantar - L4, 5; S1, 2
 Meningeal

 Brudzinski
Meningeal

 Kernig
Biceps reflex
Triceps reflex
Patellar reflex
Achilles reflex
Babinski Reflex
 Diagnostic
Assessment
Imaging Studies
 Computed Tomography (CT Scan)
 Isotope Brain Scan
 Magnetic Resonance Imaging (MRI)
 Positron Emission Tomography (PET)
 Skull and Spinal X- rays
Computed Tomography Scan
 It combines radiology and computer
analysis of tissue density (with the use of
dye) to study the intracranial structures.
CT Scan
 Spine scan will diagnose:
- Herniated disk
- Spinal cord tumors
- Spinal stenosis
CT Scan
 Brain scan can detect:
- Brain contusion
- Brain calcifications
- Cerebral Atrophy
- Hydrocephalus
- Inflammation
- Space – occupying lesions
- Vascular anomalies
CT Scan
 Nursing Consideration:
- Confirm that the patient isn’t allergic to
iodine or shellfish
- If the test calls for a contrast medium,
explain that an I.V. catheter will be
inserted
- Explain to the patient that he may feel
flushed or notice a metallic taste in his
mouth when the contrast is injected
 Nursing consideration:
- The procedure will last for 10 to 30 mins

- Encourage the patient to resume normal

activities and a regular diet after the test

- The contrast medium may discolor his

urine for 24 hours, and suggest that he
drink more fluids to help flush the medium
out of his system
Isotope Brain Scan
A scanning device monitors the brain’s
uptake of a radioactive isotope
 It will detect cerebral lesions, neoplasms,
brain abscess, cerebral edema,
hematoma, infarction
Isotope Brain Scan
 Nursing Consideration:
- Withhold medications, as ordered
- Confirm that the patient isn’t allergic to
iodine or shellfish
- If the test calls for a contrast medium,
explain that an I.V. catheter will be
inserted
Isotope Brain Scan
 Nursing Consideration:
- Tell the patient that he’ll be asked to change
the position several times during the
procedure while the technician takes picture
of his brain
- Unless contraindicated, suggest that he drink
more fluids to help flush the contrast medium
out of his system
Magnetic Resonance Imaging
 Generates detailed pictures of body
structures. The test may involved the use
of contrast medium.
 MRI provides superior contrast of soft
tissues, sharply differentiating healthy,
benign and cancerous tissue and clearly
revealing blood vessels.
MRI
 Nursing Consideration:
- Explain that the procedure can take up to 1 ½
hours and that he’ll be remain still for intervals
of 5 to 20 minutes
- Have the patient remove all metallic items
- The test is painless but the machinery may
seem loud and frightening
- Provide sedation, as ordered, to promote
relaxation
Positron Emission Tomography
(PET)
 This technology can help reveal cerebral
dysfunction associated with tumors,
seizures, TIA’s, head trauma, some
mental illnesses, Alzheimers, Parkinsons
and MS
 Can help evaluate the effect of drug
therapy and neurosurgery
SKULL & SPINAL X-RAYS
 SkullX-ray is taken from two angles:
Anteroposterior (AP) and Lateral.
Waters’ view to examine frontal and
maxillary sinuses, facial bones and
eye orbits. Towne’s view to examine
the occipital bone
 Skull x-rays help detect:
- fractures
- bony tumors or calcifications
- space occupying lesions
- vascular abnormalities
Spinal X-rays
 It detects:
- Spinal fractures
- Displacement & Subluxation
- Destructive lesions
- Arthritic changes
- Structural abnormalities
Cerebral Angiography
 It detects:
- Stenosis or occlusion
associated w/ thrombi
- Aneurysms
- Locate vessel displacement
associated w/ tumors, abscesses,
cerebral edema, hematoma, or
herniation
 Nursing Consideration:
- Confirm that he is not allergic to iodine
or shellfish
- Feeling of flushed sensation in his face
as the dye is injected
- Monitor the catheter injection site for
signs of bleeding
- Monitor the peripheral pulse in the arm
or leg used for catheter insertion
 - Monitor the patient for neurologic
changes and such complications as
hemiparesis, hemiplegia, aphasia,
and impaired LOC
- Monitor for adverse reaction to
the contrast medium
Electroencephalography
 It is recording of the brains
continuous electrical activity.
 It will identify:

- seizure disorder
- head injuries
- intracranial lesions
 - TIA’s
- stroke
- brain death
Nursing Consideration:
- Explain that the physician will apply
paste and attached the electrodes to
areas of skin of the head and neck
after these areas have been lightly
abraded to ensure good contact
- Discuss any specific activity that the
patient will be asked to perform, such as
hyperventilating for 3 minutes or
sleeping depending on the purpose of
EEG
- Use acetone to remove any remaining
paste from the patient’s skin
- Resume normal activities, as ordered
TREATMENTS
 Drug Therapy
Adrenergic blockers (Ergotamine
Tartrate, Dihydroergotamine
mesylate)
Anticonvulsants (Carbamazepine,
clonazepam, diazepam, valproate)
Antiparkinson agents (Benztropine,
levodopa, tolcapone, carbidopa –
levodopa)
Calcium Channel Blockers (Nimodipine)
Cortocosteroids (Dexametahsone,
Prednisone)
Diuretics (Mannitol)
Opiod Analgesics (Codeine, Morphine)
SURGERY
-The only viable intervention when a
neurologic disorder is life –
threatening
- Cerebellar stimulator implantation,
cerebral aneurysm repair,
craniotomy and intracranial
hematoma aspiration
Cerebellar Stimulator
Implantation
2 electrodes are position in the patients
cerebellum. The electrodes are
connected to a power source and pulse
generator.
 The generator sends electrical impulses
to the electrodes which stimulates
nerve fibers in cerebellar cortex
 These electrical impulses help
regulate uncoordinated
neuromuscular activity.
 Benefits for the patient may include a
reduction in spasticity and abnormal
movements, improved muscle,
clearer speech and decrease number
of seizures
 PatientPreparation:
- The patient will be in general
anesthesia
- The patient’s head will be shaved
and positioned in a special headrest
- The surgeon will have four
incisions for implanting the electrodes
( 2 on head, one on neck & one in
abdomen)
Monitoring and aftercare
 Assess the neurologic status and
vital signs every hour for the first 24
hours
 WOF signs of complications, such as
increase ICP, infection & fluid
imbalance
 Provide IV fluids if the patient
experiences excessive nausea &
vomiting
 Observe for seizures or spasticity, and
record occurrences to help doctor
evaluate the effectiveness of the device
 Keep the patient on bed rest until the
2nd post operative day.
 Elevate the head 15 to 30 degrees,
and turn the patient every 2 hours
 slowly increase the patients activity,
but make sure he avoids overexertion
 Check the dressing regularly for
excessive bleeding or drainage.
Assess suture line for signs of infection
 Administer antibiotics and analgesic
Home Care Instruction
 Teach the patient and family how to
change a dressing and recommend to
change it every 2 days until the
surgeon removes the sutures
 Describe the signs of infection
 Record any seizure activity for the
doctor to evaluate the effectiveness of
the operation
Cerebral Aneurysm Repair
 it clamp the affected artery, wrap the
aneurysm wall with synthetic material
or clip or ligate the aneurysm
Patient Preparation
 Tell the patient and family that he’ll
be monitored in the ICU before and
after the surgery, where he will be
observed for signs of bleeding,
vasopasm and increase ICP
Monitoring and aftercare
 gradually increase the patients level
of activity
 Monitor the incision site
 Monitor neurologic status and V/S
 Provide patient and family with
emotional support
Home care instruction
 Continue take the prescribed
anticonvulsant to minimize seizure
 Emphasize the importance of
returning for scheduled follow up
 Refer the patient of family to a
support group
Craniotomy
 Involves creation of incision into the
skull to expose the brain.
 Potential complications, include
infection, hemorrhage, respiratory
compromise, Increase ICP
Preparation
 Patients head will be shaved
 Discuss the recovery period
 Tell the patient to expect headache and
facial swelling for 2 – 3 days
 Performed & document a baseline neuro
assessment
 ICU after surgery
Monitoring & Aftercare

 Gradually increase level of activity

 Monitor incision site
 Monitor neurologic status and VS
 Provide emotional support
Home Care Instruction
 Teach proper wound care
 Remind the patient to continue taking
prescribed anticonvulsant medication
to minimize seizure
 Emphasize on returning for
scheduled follow up
Nursing Diagnosis
 Impaired Physical Mobility
Expected outcomes ( Will show no
evidence of complications, Will achiev
the highest level of mobility & Will
maintain muscle strength and joint
ROM)
Impaired Skin Integrity
 Expected outcome ( Will maintain
intact skin integrity, Will not develop
complications & will maintain the
optimal nutrition needed)
Impaired urinary elimination
 Expected outcomes ( Will empty his
bladder completely & regularly &
Patient won’t develop UTI
Impaired Gas Exchange
 Expected outcomes ( Patient will not
develop a respiratory infection, will
maintain optimal oxygen saturation
level)
Thank YOU !