Neurological & Musculoskeletal Disorders

Neurological and musculoskeletal nursing care focuses on rapid neurological assessment, preservation of cerebral perfusion pressure, emergency management of convulsive states, and maintenance of neurovascular integrity following skeletal trauma.

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1. Cerebrovascular Accident (CVA / Stroke)

A stroke involves acute focal neurological impairment resulting from vascular disruption within the brain, classified into ischemic and hemorrhagic etiologies:

• Ischemic Stroke (85% of cases): Caused by thrombotic occlusion of an atherosclerotic cerebral vessel or embolic occlusion (commonly arising from cardiac mural thrombi in atrial fibrillation). Manifests as sudden numbness or weakness, facial asymmetry, and speech deficits.
• Hemorrhagic Stroke (15% of cases): Caused by rupture of an intracerebral vessel (intracerebral hemorrhage, commonly secondary to chronic uncontrolled hypertension) or rupture of a saccular aneurysm / arteriovenous malformation into the subarachnoid space (subarachnoid hemorrhage / SAH). SAH is characteristically heralded by a sudden, excruciating "worst headache of my life" (thunderclap headache), vomiting, meningismus (nuchal rigidity, Kernig's and Brudzinski's signs), and rapid deterioration of consciousness.

FAST Assessment & Acute Thrombolysis

Rapid clinical recognition follows the FAST screening algorithm: Facial droop, Arm drift, Speech difficulty, Time to initiate emergency response.

• Emergency Diagnostic Step: An immediate non-contrast head CT scan must be performed within 20 minutes of arrival to rule out intracranial hemorrhage before administering antithrombotic therapies.
• Intravenous Thrombolytic Therapy: Recombinant tissue plasminogen activator (rtPA / Alteplase 0.9 mg/kg, maximum 90 mg; 10% given as IV bolus over 1 minute, remaining 90% infused over 60 minutes) administered within 4.5 hours of symptom onset (time last known normal).
• Absolute Contraindications to rtPA:
  1. Evidence of intracranial hemorrhage on CT.
  2. Clinical presentation suggestive of subarachnoid hemorrhage.
  3. Previous intracranial hemorrhage or history of cerebral aneurysm / vascular malformation.
  4. Ischemic stroke, severe head trauma, or intracranial surgery within the prior 3 months.
  5. Active internal bleeding or major surgery within 14 days.
  6. Platelet count < 100,000/μL, INR > 1.7, or PT > 15 seconds.
  7. Severe uncontrolled hypertension at presentation (Systolic BP > 185 mmHg or Diastolic BP > 110 mmHg refractory to IV labetalol or nicardipine).
• Post-Stroke Nursing Care:
  • Position head of bed (HOB) at 30° with head and neck in neutral midline alignment to promote venous return.
  • Maintain permissive hypertension in non-thrombolysed ischemic stroke (up to 220/120 mmHg) to sustain penumbral perfusion; maintain BP < 180/105 mmHg for 24 hours following rtPA.
  • Screen for dysphagia using a bedside swallow evaluation prior to oral intake.
  • Aphasia Subtypes: Broca's Aphasia (Expressive): Damage to frontal lobe; comprehension intact, but patient struggles to articulate words. Use simple yes/no questions, communication boards, and allow adequate time to respond. Wernicke's Aphasia (Receptive): Damage to superior temporal lobe; patient speaks fluently with nonsensical words ("word salad") and cannot comprehend spoken or written language.
  • Unilateral Neglect: Inattention to the affected side (typically left side in right-hemisphere lesions). Initially place personal items within the intact visual field, then progressively teach the patient to consciously scan the affected environment.

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2. Increased Intracranial Pressure (ICP)

Normal Intracranial Pressure (ICP) ranges from 5 to 15 mmHg in a supine adult. Pathological intracranial hypertension is defined as sustained ICP > 20 mmHg.

The Monro-Kellie Hypothesis & Cerebral Perfusion

The Monro-Kellie hypothesis states that the cranial vault is a rigid, non-compliant container with a fixed internal volume composed of three components: Brain tissue (80%), Blood (10%), and Cerebrospinal Fluid (CSF, 10%). An increase in the volume of one component must be compensated by an equal decrease in the volume of another (displacement of CSF into spinal subarachnoid space or venous blood into internal jugular veins); otherwise, ICP rises precipitously.

$\text{Cerebral Perfusion Pressure (CPP)} = \text{Mean Arterial Pressure (MAP)} - \text{Intracranial Pressure (ICP)}$

Normal CPP is 60 to 80 mmHg. A CPP < 50 mmHg results in cerebral ischemia and cellular death, while a CPP < 30 mmHg causes irreversible neuronal necrosis.

Clinical Manifestations: Early vs. Late Signs

• Earliest and Most Sensitive Indicator: Altered Level of Consciousness (LOC)—restlessness, irritability, confusion, lethargy, or decreased responsiveness.
• Early Physical Signs: Dull, constant headache (frequently worse in the morning and aggravated by coughing or straining), projectile vomiting without preceding nausea, and visual changes (papilledema, blurred vision, diplopia).
• Late Signs (Brainstem Compression & Herniation):
  • Coma and unresponsiveness.
  • Pupillary changes: Ipsilateral sluggish or dilated, fixed pupil ("blown pupil" indicating third cranial nerve compression from uncal herniation), progressing to bilateral fixed dilated pupils.
  • Motor posturing: Decorticate Posturing (Abnormal Flexion): Flexion of arms, wrists, and fingers with adduction of upper extremities and internal rotation of lower extremities (indicates cerebral hemispheric or corticospinal tract lesion). Decerebrate Posturing (Abnormal Extension): Rigid extension, adduction, and hyperpronation of arms with plantar flexion of feet (indicates severe midbrain or brainstem compression; carries a poorer prognosis).
  • Cushing's Triad: A late physiological reflex signaling impending transtentorial or tonsillar herniation.

Comparison: Cushing's Triad vs. Hypovolemic Shock

Nursing Interventions to Reduce ICP

1. Positioning: Elevate HOB to 30°; maintain head and neck in neutral alignment without acute rotation, flexion, or hyperextension to prevent jugular venous compression.
2. Avoid Valsalva Maneuver: Administer stool softeners, avoid breath holding, avoid vigorous coughing, and space nursing activities to prevent cumulative spikes in ICP.
3. Controlled Suctioning: Endotracheal suctioning elevates ICP. Pre-oxygenate with 100% O2, limit suction passes to < 10 seconds, and avoid vigorous routine suctioning.
4. Osmotic Diuretics (Mannitol 20%): Draws free water from the parenchymal tissue into the intravascular space via an osmotic gradient. Administer IV with an in-line filter to trap crystals. Monitor serum osmolality (maintain < 320 mOsm/kg) and serum electrolytes. Hypertonic saline (3%) is an effective alternative.
5. Controlled Ventilation: Maintain normal arterial blood gases. Avoid hypercapnia (PaCO2 > 45 mmHg), which causes potent cerebral vasodilation and increased ICP. Controlled mild hyperventilation (targeting PaCO2 30–35 mmHg) produces temporary cerebral vasoconstriction, reserved as an emergency rescue maneuver.

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3. Glasgow Coma Scale (GCS)

The Glasgow Coma Scale is an objective, standardized clinical tool evaluating depth of impaired consciousness across three behavioral responses: Eye Opening (E), Verbal Response (V), and Motor Response (M).

Scoring Interpretation:

• Total score ranges from 3 (deep coma / brain death) to 15 (fully alert, oriented).
• Score ≤ 8: Indicates severe head injury and coma. Clinical Maxim: "GCS 8, Intubate"—the patient cannot maintain airway patency or protective cough/gag reflexes, necessitating immediate endotracheal intubation.
• Score 9–12: Moderate brain injury.
• Score 13–15: Minor brain injury.

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4. Epilepsy, Seizure Disorders & Status Epilepticus

A seizure is a transient occurrence of signs or symptoms resulting from abnormal, excessive, synchronous neuronal firing in the brain.

Generalized Tonic-Clonic (Grand Mal) Phases

1. Aura: Sensory or psychic warning sign (olfactory, visual, or epigastric sensation).
2. Tonic Phase (10–20 seconds): Sudden loss of consciousness, sustained muscular contraction, jaw snapping shut, tongue biting, sustained expiration ("epileptic cry"), apnea, and cyanosis.
3. Clonic Phase (30–60 seconds): Rhythmic, violent bilateral jerking of extremities, hyperventilation, frothing at the mouth, diaphoresis, and bowel/bladder incontinence.
4. Postictal Phase: Flaccid relaxation, deep stertorous sleep, gradual awakening with profound confusion, amnesia, severe headache, and muscle soreness.

Nursing Management During a Seizure

• Patient Safety (Primary Priority): Ease patient to the floor if seated or standing; clear surrounding area of hard, sharp objects; pad side rails of the bed.
• Airway & Positioning: Turn the patient onto their side (recovery position) to facilitate oral drainage and prevent aspiration. Loosen constrictive clothing around the neck.
• ABSOLUTE PROHIBITIONS: Never restrain the patient's limbs (causes fractures and dislocations). Never force anything into the patient's mouth (tongue depressors, fingers, or airways cause dental fractures and airway obstruction).
• Observation: Note the exact time of onset, duration, sequence of motor movements, eye deviation, pupillary changes, and postictal behaviors.

Status Epilepticus Emergency Protocol

Status epilepticus is defined as continuous seizure activity lasting ≥ 5 minutes, or two or more recurrent seizures without full recovery of consciousness between episodes. Prolonged seizures induce metabolic acidosis, hyperthermia, and neuronal necrosis.

• First-Line Pharmacotherapy: Rapid-acting IV benzodiazepine: Lorazepam (Ativan) 0.1 mg/kg IV push (up to 4 mg) at 2 mg/min, or Diazepam (Valium) 5–10 mg IV push.
• Second-Line Anticonvulsants: IV loading dose of Phenytoin (15–20 mg/kg) or Fosphenytoin.
  • CRITICAL PHENYTOIN SAFETY RULE: Phenytoin is highly alkaline (pH 12) and precipitates immediately when mixed with dextrose. It must only be diluted in 0.9% Normal Saline. Administer via a large-bore vein using an in-line filter at an infusion rate not exceeding 50 mg/min (not exceeding 25 mg/min in elderly) with continuous ECG monitoring. Rapid infusion precipitates profound hypotension, complete heart block, and ventricular fibrillation.

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5. Musculoskeletal Trauma: Fractures & Complications

A fracture is a disruption in the structural continuity of bone.

• Fracture Classifications: Transverse (straight across the bone shaft), Oblique (at an angle across the bone), Spiral (coiling around bone from twisting force), Comminuted (splintered into ≥ 3 fragments), Greenstick (incomplete break with one cortex bent; exclusive to flexible pediatric bones), and Open / Compound (skin barrier breached; bone exposed to external contamination, carrying severe osteomyelitis risk).

Acute Compartment Syndrome (ACS)

Elevated tissue fluid pressure within an unyielding fascial compartment impairs capillary perfusion, causing irreversible muscle and nerve ischemia within 4 to 6 hours.

• The 6 Ps of Neurovascular Assessment:
  1. Pain: Disproportionate to the injury, unrelieved by potent opioids, and dramatically exacerbated by passive stretching of involved muscles (the earliest, most reliable diagnostic indicator).
  2. Paresthesia: Numbness, tingling, "pins and needles" sensation (early sign of nerve ischemia).
  3. Pallor: Pale, cool extremity with sluggish capillary refill.
  4. Poikilothermia: Affected extremity assumes the ambient room temperature.
  5. Paralysis: Late, ominous indicator of irreversible neuromuscular damage.
  6. Pulselessness: Late, terminal finding signaling complete arterial occlusion.
• Emergency Interventions: Immediately loosen constrictive dressings or bivalve the cast (cutting plaster on both sides). Maintain the extremity at the level of the heart (do NOT elevate above heart level, which reduces arterial perfusion, and do NOT apply ice, which causes vasoconstriction). Notify the surgeon immediately; definitive treatment is an emergency surgical fasciotomy to relieve compartment pressure.

Fat Embolism Syndrome (FES)

Release of fat globules from bone marrow into the systemic circulation following fractures of long bones (femur, tibia) or pelvis.

• Classic Clinical Triad (occurring 24 to 72 hours post-injury):
  1. Respiratory Dysfunction: Hypoxemia (PaO2 < 60 mmHg), tachypnea, dyspnea, and bilateral diffuse infiltrates ("snowstorm" appearance) on chest radiograph.
  2. Neurological Changes: Restlessness, confusion, agitation, delirium, and coma.
  3. Petechial Rash: Non-palpable petechiae over the anterior chest, axillae, neck, and conjunctiva (pathognomonic sign caused by microvascular embolization).
• Prevention & Care: Early immobilization and surgical stabilization of long bone fractures; high-flow oxygen, mechanical ventilation, and fluid resuscitation.

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6. Traction Systems & Cast Care

• Skin Traction (Buck's Traction): Direct traction applied to the skin using adhesive tape, foam boots, and bandages, with weights of 5 to 7 lbs (2.3–3.2 kg). Used temporarily to relieve muscle spasms and immobilize fractures of the hip or femur prior to surgery. Inspect skin for breakdown over bony prominences.
• Skeletal Traction: Traction applied directly to bone using surgically inserted pins, wires (Kirschner wire), or tongs (Gardner-Wells), utilizing weights of 15 to 30 lbs. Used for long-term fracture reduction.
  • Principles of Traction: Weights must hang freely suspended off the floor at all times; ropes must remain unobstructed within the center of pulleys; never lift or remove weights without a physician's order; maintain counter-traction by keeping the patient centered in bed.
  • Pin Site Care: Cleanse pin sites using sterile chlorhexidine or normal saline daily; monitor for erythema, purulent drainage, or pin loosening.
• Cast Nursing Care:
  • Plaster of Paris: Dries in 24 to 72 hours. Handle damp casts with the palms of hands only (never fingertips, which create internal pressure indentations leading to pressure necrosis). Leave cast exposed to air; do not cover with blankets.
  • Fiberglass: Dries rapidly in 20 to 30 minutes; lightweight and water-resistant.
  • Patient Education: Instruct patient never to insert objects (knitting needles, coat hangers) inside the cast to relieve itching. Use a cool-setting hairdryer instead.

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7. Joint Disorders: Osteoarthritis vs. Rheumatoid Arthritis