3.3 Neurological, Musculoskeletal & Oncological Nursing Care

Neurological Nursing Management

Cerebrovascular Accident (Stroke)

A stroke occurs when there is ischemia (inadequate blood flow) to a part of the brain or hemorrhage into the brain, resulting in the rapid death of brain cells. "Time is brain"—rapid assessment and intervention are critical to preserving neurological function and minimizing permanent deficits.

Disease Comparison: Ischemic vs. Hemorrhagic Stroke

Nursing Interventions for Acute Stroke

• Assessment: Utilize the NIH Stroke Scale (NIHSS) to quantify neurological deficits. Ascertain the exact time of symptom onset ("last known well" time).
• Diagnostics: Obtain a non-contrast CT scan of the head immediately upon arrival to rapidly rule out hemorrhage, which dictates the treatment pathway.
• tPA Administration: Must be administered within 3 to 4.5 hours of symptom onset for eligible ischemic stroke patients. Monitor vigilantly for signs of intracranial or systemic bleeding.
• Blood Pressure Management: Permissive hypertension is often allowed in ischemic stroke (e.g., up to 220/120 mmHg) to maintain cerebral perfusion to the penumbra. However, if giving tPA, BP must be carefully controlled (<185/110 mmHg) before, during, and after administration to prevent hemorrhagic conversion.

Increased Intracranial Pressure (ICP)

Normal ICP is 5-15 mmHg. A sustained elevated ICP decreases cerebral perfusion pressure (CPP) and can lead to fatal brain herniation.

Clinical Manifestations of Increased ICP

• Early Signs: A change in the Level of Consciousness (LOC) is the earliest and most sensitive indicator (e.g., restlessness, confusion, lethargy). Other early signs include a constant headache and vomiting (often projectile and without preceding nausea).
• Late Signs (Cushing's Triad): Indicates severe brainstem compression and impending herniation.
  1. Bradycardia (slow heart rate)
  2. Systolic hypertension with a widening pulse pressure (e.g., BP goes from 140/90 to 180/60)
  3. Irregular respirations (e.g., Cheyne-Stokes respirations)
• Pupillary Changes: Fixed, dilated pupils indicate herniation.

Nursing Interventions for ICP

• Positioning: Elevate the head of the bed (HOB) to 30 degrees to promote jugular venous drainage. Keep the head and neck in neutral alignment.
• Medications: Administer Osmotic Diuretics (Mannitol) and hypertonic saline to draw fluid out of edematous brain tissue. Corticosteroids (Dexamethasone) may be used specifically for tumor-related edema.
• Environmental Control: Minimize environmental stimulation, prevent hypoxia and hypercapnia (which cause cerebral vasodilation), control fever aggressively, and avoid clustering nursing care, as cumulative activities can cause dangerous spikes in ICP.

Seizures and Epilepsy

Seizures are abnormal, sudden, excessive discharges of electrical activity within the brain.

• During a Seizure: Prioritize patient safety. Protect the airway, turn the patient to the side to prevent aspiration, loosen restrictive clothing, and pad the side rails. Do NOT insert anything into the mouth or attempt to restrain the patient. Time the duration of the seizure.
• Postictal Phase: The period following a seizure where the patient is typically lethargic, confused, and difficult to arouse. Maintain a patent airway, provide supplemental oxygen if needed, and allow the patient to rest.
• Status Epilepticus: Continuous seizure activity lasting >5 minutes or recurrent seizures without full recovery of consciousness between them. This is a profound medical emergency leading to cerebral hypoxia. It is treated rapidly with IV Benzodiazepines (Lorazepam, Diazepam) to halt the seizure, followed by long-acting antiepileptic drugs (Phenytoin, Levetiracetam) to prevent recurrence.

Musculoskeletal Nursing Management

Fractures and Orthopedic Emergencies

Fracture care focuses on proper immobilization, anatomical alignment, pain management, and preventing neurovascular complications.

Compartment Syndrome

A life-threatening surgical emergency where increased pressure within a confined muscle compartment compromises circulation and tissue function. Irreversible ischemic muscle and nerve damage can occur within 4-6 hours if untreated.

• Assessment (The 6 Ps):
  1. Pain: Severe, intense pain that is out of proportion to the injury and unrelieved by opioid analgesics. Pain on passive stretch is a hallmark sign.
  2. Pressure: The compartment feels tense, firm, and swollen.
  3. Paresthesia: Numbness, tingling, or a "pins and needles" sensation (an early sign of nerve ischemia).
  4. Pallor: Pale skin, poor capillary refill.
  5. Paralysis: Loss of motor function (a late and ominous sign).
  6. Pulselessness: Diminished or completely absent pulses distal to the injury (a very late sign).
• Interventions: Do NOT elevate the limb above the heart level (it decreases arterial inflow). Do NOT apply ice (causes vasoconstriction). Notify the healthcare provider immediately; prepare the patient for an emergency fasciotomy to relieve the pressure.

Fat Embolism Syndrome (FES)

Most common following fractures of long bones (e.g., femur, tibia) or pelvic fractures. Fat globules from the bone marrow enter the systemic circulation and lodge in the pulmonary or cerebral microvasculature.

• Classic Triad: Hypoxemia (respiratory distress, tachypnea), Neurologic abnormalities (confusion, altered LOC), and a Petechial rash (tiny red spots on the chest, axilla, and neck).
• Interventions: Supportive care, oxygenation, and early immobilization of the fracture to prevent further fat emboli release.

Osteoporosis

A chronic metabolic bone disease characterized by low bone mass, structural deterioration of bone tissue, and increased bone fragility.

• Prevention/Education: Encourage weight-bearing exercises (e.g., walking) to stimulate bone formation. Ensure adequate intake of Calcium and Vitamin D. Implement fall prevention strategies in the home.
• Medications: Bisphosphonates (e.g., Alendronate) inhibit osteoclast-mediated bone resorption. Critical instruction: They must be taken on an empty stomach first thing in the morning with a full glass of plain water, and the patient must remain fully upright for at least 30 minutes to prevent severe esophageal irritation and ulceration.

Oncological Nursing Management

Cancer Treatments and Side Effects

Chemotherapy and radiation target rapidly dividing cancer cells but inadvertently damage rapidly dividing normal cells, leading to systemic side effects affecting the bone marrow, GI tract mucosa, and hair follicles.

Bone Marrow Suppression (Myelosuppression)

1. Neutropenia: A dangerous decrease in white blood cells, resulting in a severe risk of life-threatening infection.
   • Neutropenic Precautions: Strict hand washing, assign a private room, prohibit fresh flowers or plants, and avoid raw/unwashed fruits and vegetables. Monitor temperature meticulously; a fever >100.4°F (38°C) in a neutropenic patient is a medical emergency requiring immediate broad-spectrum antibiotics.
2. Thrombocytopenia: A decrease in platelets, leading to a severe bleeding risk.
   • Bleeding Precautions: Instruct the patient to use soft-bristle toothbrushes, use only electric razors, avoid IM injections and invasive procedures, and prevent falls. Monitor for petechiae, ecchymosis, hematuria, and melena.
3. Anemia: A decrease in red blood cells, causing fatigue, weakness, and hypoxia.
   • Interventions: Administer Epoetin alfa (Epogen) to stimulate RBC production. Cluster nursing care activities to conserve the patient's energy and allow for adequate rest periods.

Oncologic Emergencies

• Tumor Lysis Syndrome (TLS): Rapid destruction of large numbers of tumor cells (often following initial chemotherapy for leukemia or lymphoma) releases massive amounts of intracellular contents into the bloodstream. It results in hyperkalemia, hyperuricemia (which can cause acute kidney injury), hyperphosphatemia, and secondary hypocalcemia. Treat aggressively with IV hydration and Allopurinol to decrease uric acid.
• Superior Vena Cava (SVC) Syndrome: Structural tumor compression of the SVC leading to reduced venous return from the head and neck. Presents with severe facial edema, prominent jugular vein distention, and dyspnea. Treat emergently with radiation or chemotherapy to rapidly shrink the compressing tumor.