WEEK 12 Diagnostics Altered Perception

RESPONSES TO ALTERED
PERCEPTION
DIAGNOSTIC ASSESSMENT
CEREBRAL PERFUSION
INTRACRANIAL PRESSURE
- to identify increased pressure early in its
course (before cerebral damage occurs),
to quantify the degree of elevation, to
initiate appropriate treatment, to provide
access to CSF for sampling and drainage,
and to evaluate the effectiveness of
treatment.
- normal adult ICP: 5 to 15 mm Hg
CEREBRAL PERFUSION
INTRACRANIAL
PRESSURE
- Intraventricular
Catheter
- aka
Ventriculostomy
CEREBRAL PERFUSION
Ventriculostomy
- Complication:
- Infection
- Meningitis
- Ventricular collapse
- Occlusion of the catheter by brain tissue or
blood
- Problems with the monitoring system.
CEREBRAL PERFUSION
INTRACRANIAL
PRESSURE
- Subarachnoid
Screw or Bolt
CEREBRAL PERFUSION
Subarachnoid Screw or Bolt
- Complication:
- Infection
- Blockage of the screw by clot or brain
tissue, which leads to a loss of pressure
tracing and a decrease in accuracy at
high ICP readings.
INTRACRANIAL PRESSURE DEVICE
● https://www.youtube.com/watch?v=oeLCiecrMuE
● https://www.youtube.com/watch?v=W6wXd9MfElk
CEREBRAL PERFUSION
CEREBRAL PERFUSION PRESSURE
- the amount of pressure needed to maintain
blood flow to the brain.
● CPP is regulated by two balanced opposing
forces:
• Mean arterial pressure (MAP) is the driving
force that pushes blood into the brain.
• Intracranial pressure (ICP) is the force that
keeps blood out.
• Normal CPP: 70-100 mmHg
CEREBRAL PERFUSION
Indication
● Traumatic brain injury
● Poor grade subarachnoid hemorrhage
● Stroke
● Intracerebral hematoma
● Meningitis
● Acute liver failure
● Hydrocephalus
CEREBRAL PERFUSION
●Formula
○ CPP = MAP – ICP
Ex.
BP: 130/73 ICP: 14 mmHg
CEREBRAL PERFUSION
MAP = [SBP + 2(DBP)] ÷ 3
MAP = [130+2(73)] ÷ 3
MAP = (130+146) ÷ 3
MAP = 276 ÷ 3
MAP = 92 mmHg
● CPP = MAP – ICP

CPP = 92mmHg – 14
CPP = 78 mmHg
CEREBRAL OXYGENATION
JUGULAR VENOUS OXIMETRY
- Jugular venous oximetry is a method of analyzing
the balance between oxygen supply and demand to
the brain.
JUGULAR VENOUS OXIMETRY
- Jugular venous oxygen saturation (SjvO2)
- Normal ranges: 55% to 70%.
Partial Brain Tissue Oxygenation
Monitoring
- Measures the amount of oxygen that is
reaching the brain tissue oxygenation (PbtO2)
- Normal: 25-35mmHg
- Continuous, real time measurement
Catheter (probes):
-LICOX
– measures O2 and temp
-CODMAN
– measures O2,
CO2, and Ph
NON-INVASIVE MONITORING
TRANSCRANIAL DOPPLER
- Uses the same noninvasive
techniques as carotid flow
studies but records the blood
glow velocities of the
intracranial vessels.
- Arterial flow velocities can be
measured through thin areas
of the temporal and occipital
bones of the skull.
TRANSCRANIAL DOPPLER
Nursing Interventions
1. The patient is informed that this is a
noninvasive test, that a handheld transducer
will be placed over the neck and the orbits of
the eyes, and that a water-soluble jelly is used
on the transducer.
2. Either of these two low-risk tests can be
performed at the patient’s bedside
ELECTROENCEPHALOGRAM (EEG)
- represents a record of the electrical activity
generated in the brain
Procedure:
- For a baseline recording, the patient lies quietly
with both eyes closed.
- The patient may be asked to hyperventilate for
3 to 4 minutes or to look at a bright, flashing
light for photic stimulation.
- A sleep EEG may be recorded after sedation
because some abnormal brain waves are seen
only when the patient is asleep.
Nursing Intervention:
- Sometimes recommended that the patient be
deprived of sleep the night before the EEG.
- Antiseizure agents, tranquilizers, stimulants, and
depressants should be withheld 24 to 48 hours
before an EEG
- Coffee, tea, chocolate, and cola drinks are omitted
from the meal before the test because of their
stimulating effect.
- The patient is informed that the standard EEG
takes 45 to 60 minutes; a sleep EEG requires 12
hours.
- The patient is assured that the procedure does
not cause an electric shock and that the EEG is a
diagnostic test, not a form of treatment.
- An EEG requires the patient to lie quietly during
the test.
- Sedation is not advisable, because it may lower
the seizure threshold in patients with a seizure
disorder and it alters brain wave activity in all
patients.
- The nurse needs to check the prescription
regarding the administration of antiseizure
medication prior to testing.
- Routine EEGs use a water-soluble lubricant
for electrode contact, which can be wiped
off and removed by shampooing later.
- Sleep EEGs involve the use of collodion
glue for electrode contact, which requires
acetone for removal.
NEAR-INFRARED
SPECTROSCOPY
- is a noninvasive tool,
gives a venous weighted
estimate of the regional
cerebral oxygen
saturation (rSO2).
PERCEPTION
NEUROLOGIC ALTERATIONS
TRAUMATIC ALTERATIONS
Head Injuries
● A broad classification that includes injury to the
scalp, skull, or brain.
● Traumatic brain injury (TBI)

○ falls (35.2%)
○ motor vehicle crashes
○ being struck by objects
○ assaults
Head Injuries
●Incidence
Age Group
○ Children 0 to 4 years old,
○ Adolescents 15 to 19 years
○ Adults 65 years and older
Sex
○ Males > Females
Head Injuries
Head Injuries
Scalp Injury
Isolated scalp trauma is generally classified as a
minor injury.
- Abrasion
- Contusion
- Laceration
- Subgaleal hematoma
- Avulsion
Head Injuries
● Skull Fractures
- A skull fracture is a break in the continuity of
the skull caused by forceful trauma.

- Type and Location
- Linear, comminuted, and
depressed skull fractures
- Frontal, temporal,
and basilar skull fractures.
Head Injuries
● Skull Fractures
Head Injuries
● Clinical Manifestation
- Persistent, localized Pain

- Swelling
- Hemorrhage: nose, pharynx, ear, conjunctiva
- Ecchymosis: Battle’s sign
- CSF otorrhea, rhinorrhea
- Serious Complication:
- Meningeal Infection
Head Injuries
● Assessment and Diagnostics

- Computed Tomography (CT) scan: skull fracture
- Magnetic Resonance Imaging (MRI)
Head Injuries
● Medical Management
- Non-depressed skull fracture: no surgical
treatment
- Depressed skull fracture:
- Requires surgery with
elevation of the skull and
debridement, within 24hrs.
Head Injuries
● Brain Injury
○ Clinical Manifestation:
- Altered level of consciousness
- Confusion
- Pupillary abnormalities
- Altered or absent gag reflex
- Absent corneal reflex
- Sudden onset of neurologic deficits
- Changes in vital signs
- Vision and hearing impairment
- Sensory dysfunction
- Headache
- Seizures
Head Injuries
● Brain Injury
Classification:
○ Closed (Blunt) Brain Injury - occurs when the head
accelerates and then rapidly decelerates or collides
with another object and brain tissue is damaged but
there is no opening through the skull and dura.
○ Open brain injury - occurs when an object
penetrates the skull, enters the brain, and damages
the soft brain tissue in its path, or when blunt trauma
to the head is so severe that it opens the scalp, skull,
and dura to expose the brain.
Head Injuries
● Brain Injury: TYPES
Head Injuries
● Cerebral Contusions are scattered areas

of bleeding on the surface of the brain,
most commonly along the undersurface and
poles of the frontal and temporal lobes.
● They occur when the brain strikes a ridge

on the skull or a fold in the dura mater, the
brain's tough outer covering.
Head Injuries
Contusion: Sign and symptoms

- Alteration or loss of consciousness
- Stupor and confusion
- Hematoma formation
- Hemorrhage and edema
Head Injuries
Intracranial Hemorrhage
- collections of blood in the
brain that may be
epidural, subdural, or
intracerebral.
- Major symptoms are
frequently delayed until the
hematoma is large enough to
cause distortion of the brain
and increased ICP.
Head Injuries
● Brain Injury: Intracranial Hemorrhage
Epidural Hematoma
- Blood may collect in the epidural
(extradural) space between the skull

and the dura mater.
- Symptom:
- Expanding Hematoma
- Brief loss of consciousness
Head Injuries
Epidural Hematoma
- Management:
- Craniotomy
- Burr Hole
Head Injuries
Subdural Hematoma
- a collection of blood between the dura
and the brain, a space normally

occupied by a thin cushion of fluid.
- A subdural hemorrhage is more
frequently venous in origin and is
caused by the rupture of small vessels
that bridge the subdural space.
Head Injuries
Subdural Hematoma:
- Acute Subdural Hematoma: Major
- develop over 24 to 48 hours.
- Subacute Subdural Hematoma: Less severe

- appear between 48 hours and 2 weeks after the
injury.
Head Injuries
Subdural Hematoma:
- Chronic Subdural Hematoma: Minor
- Time between injury and onset of

symptoms can be lengthy: 3 weeks to
months.
Head Injuries
Intracerebral Hemorrhage and Hematoma
- Bleeding into the parenchyma of the
brain.
- Cause: head injuries, e.g., missile

injuries, bullet wounds, stab injuries
MANAGEMENT:
1. Depends on the extent of injury

2. Patient is transported from the scene
of the injury on a board with the head
and neck maintained in alignment
with the axis of the body.
3. A cervical collar should be applied
and maintained until cervical spine
x-rays have been obtained and the
absence of cervical spinal cord injury
(SCI) documented.
MANAGEMENT: Therapy
1. All therapy is directed toward preserving brain
homeostasis and preventing secondary brain injury,
which is injury to the brain that occurs after the original
traumatic event.
2. Secondary trauma: cerebral edema, hypotension, and
respiratory depression that may lead to hypoxemia and
electrolyte imbalance.
3. Treatments to prevent secondary injury include
stabilization of cardiovascular and respiratory function
to maintain adequate cerebral perfusion, control of
hemorrhage and hypovolemia, and maintenance of
optimal blood gas values.
Increased Intracranial Pressure
Increased Intracranial Pressure
Most common symptoms of an ICP:
• Headache
• Blurred vision
• Feeling less alert than usual
• Vomiting
• Changes in your behavior
• Weakness or problems with moving or
talking
• Lack of energy or sleepiness
Management:
Nursing Management: Assessment
Nursing Management: Diagnosis
• Risk for ineffective cerebral tissue perfusion
• Deficient fluid
• Imbalanced nutrition: less than body requirements
• Risk for injury (self-directed and directed at others)
• Risk for imbalanced body temperature
• Risk for impaired skin integrity
• Ineffective coping related to brain injury
• Disturbed sleep pattern
• Interrupted family processes
• Deficient knowledge
Nursing Management: Intervention
Maintaining The Airway
• Maintaining the unconscious patient in a position that

facilitates drainage of oral secretions, with the head of the
bed elevated about 30 degrees to decrease intracranial
venous pressure
• Establishing effective suctioning procedures (pulmonary

secretions produce coughing and straining, which increase
ICP)
• Guarding against aspiration and respiratory insufficiency

Maintaining The Airway
• Closely monitoring arterial blood gas values to assess the

adequacy of ventilation. The goal is to keep blood gas
values within normal limits to ensure adequate cerebral
blood flow.
• Monitoring the patient who is receiving mechanical

ventilation for pulmonary complications such as acute
respiratory distress syndrome and pneumonia
Monitoring Neurologic Function
• Level of Consciousness.
• Vital Signs.
• Motor Function.
• Other Neurologic Signs.

Monitoring Fluid and Electrolyte Balance
Promoting Adequate Nutrition
Preventing Injury
Maintaining Body Temperature
Maintaining Skin Integrity

Monitoring and Managing Potential Complications
- Decreased Cerebral Perfusion Pressure

- Cerebral Edema and Herniation.
- Impaired Oxygenation and Ventilation.
PERCEPTION
PART 2
NEUROLOGIC ALTERATIONS
TRAUMATIC SPINAL CORD INJURY
Spinal Cord Injury (SCI)

● Damage to any part of the spinal
cord or nerves at the end of the
spinal canal.
● The condition often causes
permanent changes in strength,
sensation, and other body functions
below the site of the injury.

● Spinal cord lesions are classified as:
○ Complete – total loss of sensation
and voluntary motor function.
○ Incomplete – mixed loss of
sensation and voluntary motor
function.

● Paraplegia – paralysis of the lower body.
● Tetraplegia (Quadriplegia) – paralysis of all
four extremities.
• Clinical Manifestation
• Type and Level of Injury
• Incomplete spinal cord lesion: Area
• C-1 to C-3: Tetraplegia with total

loss of muscular/respiratory
function.
• C-4 to C-5: Tetraplegia with
impairment, reduced pulmonary
capacity, complete dependency for
ADLs.
• C-6 to C-7: Tetraplegia with some
arm/hand movement allowing some
independence in ADLs.
• C-7 to T-1: Tetraplegia with limited

use of thumb/fingers, increasing
independence.
• T-2 to L-1: Paraplegia with intact arm
function and varying function of
intercostal and abdominal muscles.
• L-1 to L-2 or below: Mixed
motor-sensory loss; bowel
and bladder dysfunction.
Assessment and Diagnostic

Findings
- Lateral Cervical Spine X-ray
- CT Scan
- MRI – ligamentous Injury is

suspected.
- Myelogram – visualize the spinal
axis.
- Head and Chest Imaging
- ECG Monitoring
Emergency Management
- Rapid assessment, immobilization,
extrication, and stabilization or control of
life-threatening injuries, and transportation
to the most appropriate medical facility.
- The patient must always be maintained in
an extended position.
- No part of the body should be twisted or
turned, and the patient is not allowed to sit
up.
Medical Management
- Respiratory Therapy:
- Oxygen
- Diaphragmatic Pacing – Electrical
stimulation of the phrenic nerve.
Medical Management
- Skeletal Fraction Reduction and Traction
Medical Management
Medical Management
- Halo Device
Medical Management
- Thoracic and lumbar injuries are
usually treated with surgical
intervention followed by immobilization
with a fitted brace.
- Traction is not indicated either before
or after surgery, due to the relative
stability of the spine in these regions.
Surgical Management
• Compression of the cord is evident.
• The injury results in a fragmented or
unstable vertebral body.
• The injury involves a wound that
penetrates the cord.
• Bony fragments are in the spinal canal.
• The patient’s neurologic status is
deteriorating.
Management: Acute Complications

- Spinal And Neurogenic Shock
- The spinal shock associated with
SCI reflects a sudden depression
of reflex activity in the spinal cord
(areflexia) below the level of injury.

- Spinal Shock
- S/sx:
- Absent sensation, paralyzed, and
flaccid, and the reflexes are absent.
- Affected bladder and bowel function
- Bowel Distension and paralytic ileus

- Spinal And Neurogenic Shock
- Neurogenic shock develops as a
result of the loss of autonomic
nervous system function below the
level of the lesion.

- Neurogenic Shock
- S/sx:
- Dec BP, HR, Cardiac Output
- Venous pooling in the extremities and
peripheral vasodilation.
- Fever – Less perspiration in the
paralyzed body part.

- Venous Thromboembolism
- Complication of immobility
- S/sx: DVT and PE
- Txmnt: Low dose anticoagulant,
Anti-embolic stocking

Nursing Management: Assessment
- Breathing Pattern and ability to cough
- Lung sound
- Motor and Sensory Function
- Glasgow Coma Scale: Neurologic exam
- Reflexes
- Bladder paralysis and distention
- Temperature

Nursing Management: Diagnosis
- Ineffective airway clearance
- Impaired physical mobility
- Ineffective breathing pattern
- Risk for injury
- Risk for impaired skin integrity
- Impaired elimination
- Acute pain

- Assess respiratory function by
asking patient to take a deep breath.
Note presence or absence of
spontaneous effort and quality of
respirations (labored, using
accessory muscles).

- Auscultate breath sounds. Note
areas of absent or decreased breath
sounds or development of
adventitious sounds (rhonchi).

- Note strength or effectiveness of
cough.
- Observe skin color for

developing cyanosis, duskiness.
- Assess for abdominal distension and

muscle spasm.

- Maintain patent airway: keep head in
neutral position, elevate head of bed
slightly if tolerated, use airway
adjuncts as indicated.
- Assist patient in “taking control” of

respirations as indicated. Instruct in
and encourage deep breathing,
focusing attention on steps of

- Assist with coughing as indicated for
level of injury (have patient take
deep breath and hold for 2 sec
before coughing, or inhale deeply,
then cough at the end of a slow
exhalation). Alternatively, assist by
placing hands below diaphragm and
pushing upward as patient exhales
(quad cough).

- Assist with coughing as indicated for
level of injury (have patient take
deep breath and hold for 2 sec
before coughing, or inhale deeply,
then cough at the end of a slow
exhalation). Alternatively, assist by
placing hands below diaphragm and
pushing upward as patient exhales
(quad cough).

- Proper body alignment is maintained at
all times.
- Patients may tolerate changes in

position poorly and require monitoring
of blood pressure when positions are
changed.

- Contractures and other complications
may be prevented by range-of-motion
exercises that help preserve joint
motion and stimulate circulation. Passive
range-of-motion exercises should be
implemented as soon as possible after
injury.

- These patients are allowed to move
gradually to an erect position. A neck
brace or molded collar is applied when
the patient is mobilized after traction is
removed

- Preventing Injury Due To Sensory and

Perceptual Alterations
- Maintaining Skin Integrity


- Improving Bowel Function
- Maintaining Urinary Elimination


- Monitor and managing potential acute

complication
- Education: Home Care

ACUTE ISCHEMIC STROKE
Cerebrovascular Disorder
- refers to a functional abnormality
of the central nervous system
(CNS) that occurs when the blood
supply to the brain is disrupted.
Stroke
- Ischemic
- Hemorrhagic
Ischemic stroke
- also known as cerebrovascular accident (CVA),
“Brain Attack”
- is a sudden loss of function resulting from

disruption of the blood supply to a part of the
brain.
Ischemic stroke
5 types based on cause:

1. Large artery thrombotic strokes (20%)
2. Small penetrating artery thrombotic strokes (25%),
3. Cardiogenic embolic strokes (20%),
4. Cryptogenic strokes (30%), and
5. other (5%)
Ischemic stroke
● Large artery thrombotic strokes are caused by
atherosclerotic plaques in the large blood vessels
of the brain.
● Thrombus formation and occlusion at the site of

the atherosclerosis result in ischemia and
infarction
Ischemic stroke
Small penetrating artery
thrombotic strokes affect one or
more vessels.
- the most common type of
ischemic stroke.
- also called lacunar strokes
because of the cavity that is

created after the death of
infarcted brain tissue.
Ischemic stroke
Cardiogenic embolic strokes are associated with
cardiac dysrhythmias, usually atrial fibrillation.
Ischemic stroke
Cryptogenic strokes - which have no known cause.
Other causes, such as illicit drug use, coagulopathies,

migraine, and spontaneous dissection of the carotid or
vertebral arteries.
Ischemic stroke: Pathophysiology
Decreased cerebral blood

flow
Aerobic respiration
Anaerobic respiration
Loss of function
Ischemic stroke: Manifestation
• Numbness or weakness of the face, arm, or leg,
especially on one side of the body
• Confusion or change in mental status
• Trouble speaking or understanding speech
• Visual disturbances
• Difficulty walking, dizziness, or loss of balance or
coordination
• Sudden severe headache
● Motor Loss
• Hemiplegia, hemiparesis
• Flaccid paralysis and loss of or decrease in the
deep tendon reflexes (initial clinical feature)
followed by (after 48 hours) reappearance of
deep reflexes and abnormally
increased muscle tone (spasticity)
● Communication Loss
• Dysarthria (difficulty speaking)
• Dysphasia (impaired speech) or aphasia (loss of
speech)
• Apraxia (inability to perform a previously learned
● Perceptual Disturbances and Sensory Loss
• Visual-perceptual dysfunctions (homonymous
hemianopia [loss of half of the visual field])
• Disturbances in visual-spatial relations
(perceiving the relation of two or more objects in
spatial areas), frequently seen in patients with
right hemispheric damage
• Sensory losses: slight impairment of touch or
more severe with loss of proprioception; difficulty
in interrupting visual, tactile, and auditory stimuli
● Impaired Cognitive and Psychological
Effects
• Frontal lobe damage: Learning capacity,
memory, or other higher cortical intellectual

functions may be impaired.
Such dysfunction may be reflected in a
limited attention span, difficulties in
comprehension, forgetfulness, and lack of
motivation.
• Depression, other psychological problems:
emotional lability, hostility, frustration,

Ischemic stroke: Prevention
Ischemic stroke: Complications
• Tissue ischemia. If cerebral blood flow is

inadequate, the amount of oxygen supplied
to the brain is decreased, and tissue
ischemia will result.
• Cardiac dysrhythmias. The heart

compensates for the decreased cerebral
blood flow, and with too much pumping,
dysrhythmias may occur.
● Ischemic stroke:
Assessment and Diagnostic Findings
• CT scan
• PET scan
• MRI
• Cerebral angiography
• Lumbar puncture
• Transcranial Doppler ultrasonography
• EEG
• Skull x-ray
• ECG and echocardiography

Assessment and Diagnostic Findings
• Laboratory studies to rule out systemic
causes
• CBC, platelet
• Clotting studies
• VDRL/RPR
• Erythrocyte sedimentation rate (ESR)
• Chemistries (glucose, sodium)
●Ischemic stroke:
Medical Management
• Recombinant tissue plasminogen
activator
• Increased ICP.
• Management of increased ICP includes
osmotic diuretics
• Maintenance of PaCO2 at 30-35 mmHg
• Positioning to avoid hypoxia through
elevation of the head of the bed.
Medical Management
• Endotracheal Tube. There is a possibility of
intubation to establish patent airway if

necessary.
• Hemodynamic monitoring.
• Neurologic assessment to determine if the

stroke is evolving and if other acute
complications are developing
●Ischemic stroke:
Surgical Management
• Carotid endarterectomy.
• This is the removal of atherosclerotic
plaque or thrombus from the carotid
artery to prevent stroke in patients
with occlusive disease of the
extracranial cerebral arteries.
• Hemicraniectomy.
• Hemicraniectomy may be performed
for increased ICP from brain edema
in severe cases of stroke.
● Ischemic stroke: Nursing Mgt
Nursing Assessment
• Change in level of consciousness or
responsiveness.
• Presence or absence of voluntary or involuntary
movements of extremities.
• Stiffness or flaccidity of the neck.
• Eye opening, comparative size of pupils, and
pupillary reaction to light.
• Color of the face and extremities; temperature and
moisture of the skin.
• Ability to speak.
• Presence of bleeding.
• Maintenance of blood pressure.
Nursing Assessment
• Mental status (memory, attention span, perception,
orientation, affect, speech/language).
• Sensation and perception (usually the patient
has decreased awareness of pain and
temperature).
• Motor control (upper and lower extremity
movement); swallowing ability, nutritional and
hydration status, skin integrity, activity tolerance,
and bowel and bladder function.
• Continue focusing nursing assessment on
impairment of function in patient’s daily activities.
Nursing Diagnosis
• Impaired physical mobility
• Acute pain
• Deficient self-care
• Disturbed sensory perception
• Impaired urinary elimination
• Disturbed thought processes
• Impaired verbal communication
• Risk for impaired skin integrity

• Positioning
• Prevent flexion of feet
• Prevent adduction of shoulder
• Prevent edema
• Full range of motion
• Prevent venous stasis
• Regain balance
• Personal hygiene
• Manage sensory difficulties
• Manage sensory difficulties
• Visit a speech therapist
• Voiding pattern
• Be consistent in patient’s activities
• Assess skin
● Improving Mobility and Preventing Deformities
• Position to prevent contractures; use measures to
relieve pressure, assist in maintaining good body alignment,
and prevent compressive neuropathies.
• Apply a splint at night to prevent flexion of affected extremity.
• Prevent adduction of the affected shoulder with a
pillow placed in the axilla.
• Elevate affected arm to prevent edema and fibrosis.
• Position fingers so that they are barely flexed; place hand in
slight supination. If upper extremity spasticity is noted, do not
use a hand roll; dorsal wrist splint may be used.
• Change position every 2 hours; place patient in
a prone position for 15 to 30 minutes several times a day.
● Establishing an Exercise Program
• Provide full range of motion four or five times a day
to maintain joint mobility, regain motor control,
prevent contractures in the paralyzed extremity, prevent
further deterioration of the neuromuscular system, and
enhance circulation. If tightness occurs in any area, perform a
range of motion exercises more frequently.
• Exercise is helpful in preventing venous stasis, which
may predispose the patient to thrombosis and
pulmonary embolus.
• Observe for signs of pulmonary embolus or excessive cardiac
workload during exercise period (e.g., shortness
of breath, chest pain, cyanosis, and increasing pulse rate).
• Supervise and support the patient during exercises;
plan frequent short periods of exercise, not longer
● Preparing for Ambulation
• Start an active rehabilitation program when
consciousness returns (and all evidence of
bleeding is gone, when indicated).
• Teach patient to maintain balance in a sitting
position, then to balance while standing (use a tilt
table if needed).
• Begin walking as soon as standing balance is
achieved (use parallel bars and have a wheelchair
available in anticipation of possible dizziness).
• Keep training periods for ambulation short and
frequent.
● Preventing Shoulder Pain
• Never lift patient by the flaccid shoulder or pull on
the affected arm or shoulder.
• Use proper patient movement and positioning (e.g.,
flaccid arm on a table or pillows when patient is
seated, use of sling when ambulating).
• Range of motion exercises are beneficial, but avoid
over strenuous arm movements.
• Elevate arm and hand to prevent dependent edema
of the hand; administer analgesic agents as
indicated.
●Ischemic stroke: Nursing Mgt
● Enhancing Self Care
• Encourage personal hygiene activities as soon as the patient can sit
up; select suitable self-care activities that can be carried out with one
hand.
• Help patient to set realistic goals; add a new task daily.
• As a first step, encourage patient to carry out all self-care activities
on the unaffected side.
• Make sure patient does not neglect affected side; provide assistive
devices as indicated.
• Improve morale by making sure patient is fully dressed during
ambulatory activities.
• Assist with dressing activities (e.g., clothing with Velcro closures; put
garment on the affected side first); keep environment uncluttered and
organized.
• Provide emotional support and encouragement to prevent fatigue and
discouragement.
● Managing Sensory-Perceptual Difficulties
• Approach patient with a decreased field of vision on
the side where visual perception is intact; place all
visual stimuli on this side.
• Teach patient to turn and look in the direction of
the defective visual field to compensate for the loss; make
eye contact with patient, and draw attention to affected side.
• Increase natural or artificial lighting in the room;
provide eyeglasses to improve vision.
• Remind patient with hemianopsia of the other side of
the body; place extremities so that patient can see them.
● Maintaining Skin Integrity
• Frequently assess skin for signs of breakdown,
with emphasis on bony areas and dependent

body parts.
• Employ pressure relieving devices; continue
regular turning and positioning (every 2 hours

minimally); minimize shear and friction when
positioning.
• Keep skin clean and dry, gently massage the
healthy dry skin and maintain adequate

● Improving Communication
• Reinforce the individually tailored program.
• Jointly establish goals, with the patient taking an active part.
• Make the atmosphere conducive to communication, remaining sensitive
to patient’s reactions and needs and responding to them in an
appropriate manner; treat the patient as an adult.
• Provide strong emotional support and understanding to allay anxiety;
avoid completing patient’s sentences.
• Be consistent in schedule, routines, and repetitions. A written schedule,
checklists, and audiotapes may help with memory and concentration; a
communication board may be used.
• Maintain patient’s attention when talking with the patient, speak slowly,
and give one instruction at a time; allow the patient time to process.
• Talk to aphasic patients when providing care activities to provide social
contact.
● Attaining Bowel and Bladder Control
• Perform intermittent sterile catheterization during the
period of loss of sphincter control.
• Analyze voiding pattern and offer urinal or bedpan
on patient’s voiding schedule.
• Assist the male patient to an upright posture for
voiding.
• Provide high fiber diet and adequate fluid intake (2
to 3 L/day), unless contraindicated.
• Establish a regular time (after breakfast) for toileting.

WEEK 12 Diagnostics Altered Perception

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WEEK 12 Diagnostics Altered Perception

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RESPONSES TO ALTERED

● CPP = MAP – ICP

● Traumatic brain injury (TBI)

- A skull fracture is a break in the continuity of

the skull caused by forceful trauma.

- Persistent, localized Pain

● Assessment and Diagnostics

● Cerebral Contusions are scattered areas

● They occur when the brain strikes a ridge

Contusion: Sign and symptoms

(extradural) space between the skull

and the brain, a space normally

- develop over 24 to 48 hours.

- Subacute Subdural Hematoma: Less severe

- Time between injury and onset of

- Cause: head injuries, e.g., missile

1. Depends on the extent of injury

• Feeling less alert than usual

• Changes in your behavior

• Weakness or problems with moving or

• Maintaining the unconscious patient in a position that

• Establishing effective suctioning procedures (pulmonary

• Guarding against aspiration and respiratory insufficiency

• Closely monitoring arterial blood gas values to assess the

• Monitoring the patient who is receiving mechanical

• Other Neurologic Signs.

Monitoring Fluid and Electrolyte Balance

Promoting Adequate Nutrition

Maintaining Body Temperature

Maintaining Skin Integrity

Monitoring and Managing Potential Complications

- Decreased Cerebral Perfusion Pressure

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)

• C-1 to C-3: Tetraplegia with total

Spinal Cord Injury (SCI)

• C-7 to T-1: Tetraplegia with limited

Spinal Cord Injury (SCI)

Assessment and Diagnostic

- MRI – ligamentous Injury is

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)

Management: Acute Complications

Spinal Cord Injury (SCI)

Management: Acute Complications

Spinal Cord Injury (SCI)

Management: Acute Complications

Spinal Cord Injury (SCI)

Management: Acute Complications

Spinal Cord Injury (SCI)

Management: Acute Complications

Spinal Cord Injury (SCI)

Spinal Cord Injury (SCI)