7.3 Neurological, Musculoskeletal & Integumentary Conditions

Neurological, Musculoskeletal, and Integumentary Conditions

This final systems section covers neurological emergencies, mobility disorders, and skin integrity - all frequent on the CPNRE and REx-PN because they test safety, aspiration prevention, and complication recognition. Keep the ABCs and least-restrictive, protective interventions in mind for every scenario.

Stroke (Cerebrovascular Accident)

A stroke (cerebrovascular accident, CVA) is a sudden interruption of cerebral blood flow, either ischemic (a clot, about 80% of strokes) or hemorrhagic (a bleed). Recognize it quickly with FAST: Face drooping, Arm weakness, Speech difficulty, and Time to call 911. Ischemic stroke may be treated with a thrombolytic (tPA) within a narrow time window, so the exact time of symptom onset is critical. Deficits are contralateral: right-sided weakness points to a left-brain stroke, which is often accompanied by aphasia.

The most tested post-stroke concern is dysphagia and aspiration. Implement a swallowing assessment and aspiration precautions: keep the client upright during and after meals, supervise eating, and provide thickened liquids or a texture-modified diet as ordered, because thin liquids are the highest aspiration risk. Reposition frequently to prevent pressure injuries and support the weak side.

Seizures

During a generalized tonic-clonic seizure, the priority is protection and airway: ease the client to the floor, turn them onto their side (recovery position) to prevent aspiration, cushion the head, remove nearby hazards, loosen tight clothing, and time the seizure. Never insert anything into the mouth and never restrain the limbs - both actions cause injury. Stay with the client throughout. Afterward, expect a postictal period of confusion and drowsiness; document the duration and features. Status epilepticus (a seizure lasting more than 5 minutes or repeated seizures without recovery) is a medical emergency.

Parkinson's, MS, and Dementia

• Parkinson's disease: dopamine deficiency causes a resting tremor, rigidity, bradykinesia (slow movement), a shuffling gait, and a mask-like face. Fall and aspiration risk are high; it is treated with levodopa-carbidopa.
• Multiple sclerosis (MS): demyelination produces variable weakness, fatigue, and visual changes, usually in a relapsing-remitting pattern. Manage fatigue, prevent injury, and avoid heat, which worsens symptoms.
• Dementia (for example Alzheimer disease) is a progressive, irreversible cognitive decline. Contrast it with delirium, which is acute, fluctuating, and reversible. Use consistent routines, reorientation, and a safe environment for dementia; delirium demands a search for an underlying cause such as infection, hypoxia, or a medication effect.

Musculoskeletal Conditions

For fractures, assess neurovascular status using the 6 P's: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia (coolness). The feared complication is compartment syndrome - unrelenting pain, especially on passive stretch - which is a surgical emergency; once it is suspected, do not elevate the limb above the heart or apply ice, because both reduce perfusion. After hip surgery, prevent dislocation and venous thromboembolism.

Osteoarthritis is wear-and-tear joint degeneration that worsens with activity, while rheumatoid arthritis is an autoimmune, symmetrical disease with prolonged morning stiffness. Osteoporosis is low bone density leading to fragility fractures; teach adequate calcium, vitamin D, and weight-bearing exercise along with fall prevention.

Integumentary: Pressure Injuries, Wounds, and Burns

Pressure injuries are staged by tissue depth:

Prevention is the priority: reposition at least every 2 hours, keep the skin clean and dry, manage moisture and nutrition, and use pressure-redistributing surfaces. Assess wounds for size, depth, exudate, and infection (redness, warmth, purulent drainage, and odour), and maintain sterile technique during dressing changes, never reaching across the sterile field.

Burns are classified by depth: superficial (epidermis only, like a sunburn), partial-thickness (painful and blistered), and full-thickness (leathery and painless because nerves are destroyed). Estimate the extent with the Rule of Nines. Priorities are the ABCs (airway or inhalation injury first), fluid resuscitation, pain control, and infection prevention.

Surgical Skin Emergencies

Two must-know post-operative wound emergencies are dehiscence (wound edges separate) and evisceration (organs protrude). For evisceration, cover the exposed bowel with sterile saline-moistened gauze to keep it moist, position the client supine with the knees flexed, keep them NPO, and notify the surgeon urgently - never push the organs back in. Common traps include placing an object in a seizing client's mouth, giving thin liquids to a stroke client with dysphagia, and massaging or elevating a limb with suspected compartment syndrome.

Ischemic vs Hemorrhagic Stroke

Because tPA can be fatal when the cause is a bleed, a CT scan must rule out hemorrhage before it is given - which is why establishing the exact time of symptom onset is a heavily tested priority.

Increased Intracranial Pressure

Rising intracranial pressure (ICP) is an emergency: a decreasing level of consciousness is the earliest and most sensitive sign, followed by headache, vomiting, and pupillary changes. The late Cushing triad - rising systolic pressure with a widening pulse pressure, bradycardia, and irregular respirations - signals impending brain herniation. Elevate the head of the bed about 30 degrees, keep the head midline, and avoid activities that further raise ICP.

Clinical Judgment in Action

Three days after an ischemic stroke, a client coughs and "gurgles" while drinking thin water at lunch. The priority is not to encourage more fluids but to stop oral intake, sit the client fully upright, and request a swallowing reassessment, because thin liquids carry the highest aspiration risk. Withholding the tray protects the airway; pushing fluids or laying the client flat are classic exam traps that lead to aspiration pneumonia.