1

UNIVERSITY OF NAMIBIA
FACULTY OF HEALTH SCIENCES SCHOOL OF NURSING AND PUBLIC HEALTH BACHELOR DEGREE IN NURSING SCIENCE (CLINICAL) STUDYGUIDE FOR MODULE III: NNGN 3780

COMPILED BY: DR M VAN DER VYVER JANUARY 2010

INDEX

1.

Introduction

2.

Class attendance

3.

Tests / examination

4.

Objectives of this subject

5.

Prescribed sources for this subject

6.

Recommended sources

MODULE 1

MODULE 2

MODULE 3

MODULE 4

MODULE 5

MODULE 6

4 INTRODUCTION General Nursing Science Module III (NNGN 3780) holds a National Qualification Framework level 7 and is a credit bearing-module of 24. The module includes theoretical and clinical units. It is presented in the third year of study and is a pre-requisite for promotion to General Nursing Science IV (NNGN 3880). The module introduces the student to advanced concepts that promote the application of the nursing process and nursing theories in the specialized health care disciplines. These disciplines include the central and peripheral nervous system, musculoskeletal system, genito-urinary systems (male and female), ophthalmology, conditions of the ear & nose and oncology. The student is expected to have developed cognitive-, critical thinking-, psychomotor, and affective skills. The module builds on competencies achieved in previous modules. Competencies include the phases of the nursing process: assessment, nursing diagnoses, planning, implementation, and evaluation of patient needs that evolve from the specialized disciplines. This module is presented by means of the lecture method, group discussions, assignments, self-study, peergroup teaching and class room presentations. The student is required to uphold academic integrity at all times and be actively involved in class room discussions, simulation laboratory and activities in the clinical environment. The student is expected to obtain all the prescribed material for the module and actively participate in his/her educational process. The student is expected to be punctual in both clinical and classroom setting and attend at least 80% of classes and 100% clinical learning. Clinical nursing skills will be acquired at the training hospitals of Namibia, i.e. Windhoek Central Hospital, Katutura Hospital and Oshakati Hospital. Students are allocated to two specialized disciplines in the clinical areas. The placement areas will provide students the opportunity to correlate theory of specified specialized disciplines and practice. MODULE DESCRIPTOR MODULE TITLE: General Nursing Science Module 3 CODE: NNGN 3710 NQF LEVEL: 7 CONTACT HOURS: 4 theoretical hours and 20 practical hours per week/28 weeks CREDITS: 24 MODULE ASSESSMENT: Continuous assessment: theory 5 tests/assignments per year; practical: Objective structural clinical evaluations (OSCE) and evaluations in clinical practice environment, simulation and work books Examination: Theory: Two (2) three (3) hour paper at the end of the year Practical: Objective structural clinical evaluation OSCE in wards and simulation, Problem solving. The weight between continuous assessment and examination is 50/50 PREREQUISITES: General Nursing Science Module 2 and Applied Biological Science

5 module 2

MODULE DESCRIPTION: Building on skills gained in module 2, this module introduces the student to more advanced concepts that promote the application of the nursing process and nursing theories in the area of the adult in the specialized health care disciplines, i.e. central and peripheral nervous system, musculoskeletal system, genito-urinary systems, ophthalmology, ear and nose, and oncology conditions that are prevalent in Namibia. The student will have opportunities to work collaboratively with members of a health care team in the specialized environments of the training hospitals of Namibia. Skills laboratory will provide the student with simulation experiences to master selected skills before s/he is allocated to the health care environment. Nursing care of the HIV/AIDS infected client features strongly through out this module.

Module 111 builds on competencies achieved in Module 11.These are assessment, diagnosis, planning, implementation, and evaluation of patient needs that evolve from the specialized disciplines prevalent in Namibia. The conceptual framework for this module is based on the major concepts (meta paradigm) of nursing and includes nursing, health, environment, and person as well as education.

EXIT LEARNING OUTCOMES: Upon completion of this module, the student nurse:

1.

Practices comprehensive and individualized nursing care in the specialized health care discipline of the central and peripheral nervous system (Unit 1).The student uses scientific knowledge and nursing theory as basis for professional practice in the application of the nursing process. Health (wellness) of the person (patient/client) is promoted, maintained, and increased.

2.

Practices comprehensive and individualized nursing care in the specialized health care discipline of the genito-urinary system (Unit 2).The student uses scientific knowledge and nursing theory as basis for professional practice in the application of the nursing process.

3.

Practices comprehensive and individualized nursing care in the specialized health care discipline of the musculoskeletal system (Unit 3).The student uses scientific knowledge and nursing theory as basis for professional practice in the application of the nursing process.

4.

Practices comprehensive and individualized nursing care in the specialized health care discipline of oncology (Unit 4).The student uses scientific knowledge and nursing theory as basis for professional practice in the application of the nursing process.

6 5. Practices comprehensive and individualized nursing care in the specialized health care discipline of opthalmology (Unit 5).The student uses scientific knowledge and nursing theory as basis for professional practice in the application of the nursing process.

6.

Practices comprehensive and individualized nursing care in the specialized health care discipline of the ear and nose (Unit 6).The student uses scientific knowledge and nursing theory as basis for professional practice in the application of the nursing process.

SPECIFIC LEARNING OUTCOMES

UNIT 1: CENTRAL AND PERIPHERAL NERVOUS SYSTEM On completion of this unit, you should be able to: 1 Cerebral vascular disorders: Apply the nursing process in the care of a patient suffering from a stroke (cerebro vascular accident) Define stroke; Describe the patophysiology: Differentiate between the pathologic mechanisms of cerebral hemorrhage and cerebral infarction; Distinguish between the types of stroke: intracerebral hemorrhage, subarachnoid hemorrhage, subdural hemorrhage, extradural hemorrhage, cerebral thrombosis cerebral embolism Explain what is meant by the following diagnostic studies in relation to stroke: CF scan MRA Pulsed transcranial Doppler EEG Brain scan Arteriography Duplex ultrasound Skull roentgenogram Describe the multidisciplinary plan with regard to Emergency management Surgical interventions: carotid endarterectomy, evacuation of intracerebral clot or hematoma, ICP monitoring, endotracheal intubation or tracheostomy (cross refer module II) Medications: antiplatelet agents, anticoagulants, diuretics, corticosteroids, anticonvulsants, narcotic analgesics, antipyretics General management: Coagulation studies, intake and output monitoring,, anticoagulation therapy, electrolyte and blood sugar monitoring, bed rest and positioning, elevation of head of bed, nasogastric

7 feedings, indwelling catheterization, elastic stockings, sequential compression devices, seizure precautions, hemodynamic monitoring, physical therapy. Apply the nursing process in the care of patients suffering from stroke: Accurately perform an individualized nursing assessment Demonstrate the ability to correctly record selected findings on the Glasgow Coma Scale (GCS) Identify health needs Compile a nursing care plan Formulate nursing diagnosis Special attention should be given to the following NANDA health needs: Ineffective cerebral tissue perfusion related to hemorrhage and/or increased intracranial pressure Risk for disturbed sensory perception (visual, auditory, kinestic, gustatory, tactile, olfactory) related to cerebral hemorrhage and/or increased intracranial pressure Risk injury related to seizures Risk for aspiration related to enteric feeding via nasogastric tube (cross refer Module II) Impaired physical mobility related to altered sensory and neuromuscular status (cross refer Module I) Self-care deficits (feeding, bathing/hygiene, dressing, grooming, and toileting) related to neurological impairment (cross refer Module 1) Risk for impaired skin integrity related to prolonged immobility (cross refer Module I) Knowledge deficit related to lack of knowledge of care after discharge from hospital Formulate goals Formulate expected outcomes against which nursing care can be evaluated Correctly identify nursing interventions Accurately record the process

2 Trauma: Apply the nursing process in the care of a patient suffering from craniocerebral trauma (head injury) Define craniocerebral trauma; Describe the patophysiology: Differentiate between the pathologic mechanisms of cerebral hemorrhage and cerebral infarction; Distinguish between the types of stroke: intracerebral hemorrhage, subarachnoid hemorrhage, subdural hemorrhage, extradural hemorrhage, cerebral thrombosis cerebral embolism Explain what is meant by the following diagnostic studies in relation to stroke: Skull roentgenogram Cervical roentgenogram Chest roentgenogram CT scan MRI

8 Pulsed transcranial Doppler EEG Serum osmolarity Serum electrolytes Urine osmolarity Cerebral angiography Arterial blood gases (ABGs) Describe the multidisciplinary plan with regard to Emergency management Surgical interventions: Suturing lacerations, debridements of wounds, ventricular catheter, ventriculostomy, cranioplasty, shunting procedures for hydrocephalus, craniectomy, craniotomy, tracheostomy, skull trephine (bur holes) Medications: diuretics, anticonvulsants, analgesics/antipyretics, histamine antagonist, antacids, antibiotics General management: intake and output monitoring, positioning, elevation of head of bed, nutritional support (enteral feedings, intravenous hyperalimentation), indwelling catheterization, seizure precautions, GCS. Apply the nursing process in the care of patients suffering from craniocerebral trauma: Accurately perform an individualized nursing assessment Demonstrate the ability to correctly record selected findings on the Glasgow Coma Scale and other relevant records Identify potential complications Identify health needs Compile a nursing care plan Formulate nursing diagnosis Special attention should be given to the following NANDA health needs: Ineffective airway clearance related to impaired cough reflex Ineffective breathing pattern related to neuromuscular impairment and/or increased intracranial pressure Impaired gas exchange related to ineffective breathing pattern Ineffective tissue perfusion related to primary injury or increased intracranial pressure Impaired verbal communication related to neurologic impairment Risk for chronic confusion related to organic or cognitive impairment Ineffective cerebral tissue perfusion related to hemorrhage and/or increased intracranial pressure Risk for disturbed sensory perception (visual, auditory, kinestic, gustatory, tactile, olfactory) related to cerebral hemorrhage and/or increased intracranial pressure Risk injury related to seizures Risk for aspiration related to enteric feeding via nasogastric tube (cross refer Module II)

9 Impaired physical mobility related to altered sensory and neuromuscular status (cross refer Module I) Self-care deficits (feeding, bathing/hygiene, dressing, grooming, and toileting) related to neurological impairment (cross refer Module 1) Risk for impaired skin integrity related to prolonged immobility (cross refer Module I) Knowledge deficit related to lack of knowledge of care after discharge from hospital Formulate goals Formulate expected outcomes against which nursing care can be evaluated Correctly identify nursing interventions Accurately record the process

3 Trauma: Apply the nursing process in the care of a patient suffering from spinal cord trauma Define spinal cord trauma; Describe the patophysiology: vertebral injuries, spinal cord injuries, spinal schock, autonomic hyperreflexia Differentiate between the pathologic mechanisms of cerebral hemorrhage and cerebral infarction; Distinguish between the types of stroke: intracerebral hemorrhage, subarachnoid hemorrhage, subdural hemorrhage, extradural hemorrhage, cerebral thrombosis cerebral embolism Explain what is meant by the following diagnostic studies in relation to stroke: Roentgenograms CT scan MRI Spinal puncture Myelography Serum electrolytes Describe the multidisciplinary plan with regard to Emergency management Surgical interventions: Decrompression laminectomy, Harrington rods, endotracheal intubation, Gardner-Well tongs, spinal fusion for stabilization, wound debridement, suturing lacerations, treatments for spastic, gastrostomy or jejunostomy tube placements Medications: Corticosteroid protocol, antianxiety agents, muscle relaxants, anticoagulants, laxatives, histamine antagonist, antacids,antihypertensives General management: positioning, nutritional support, indwelling catheterization, intake and output recording, urine sugar and acetone, guaiac, methods to stabilize the vertebral column, bed board and firm mattress, occupational therapy, physical therapy, social services, sexual counseling, psychsocial counseling Apply the nursing process in the care of patients suffering from spinal cord trauma: Accurately perform an individualized nursing assessment: muscle function according to level of spinal cord injury,

10 Identify potential complications Identify health needs Compile a nursing care plan Formulate nursing diagnosis Special attention should be given to the following NANDA health needs: Ineffective airway clearance related to impaired cough reflex (cross refer craniocerebral trauma) Ineffective breathing pattern related to impaired cough reflex (cross refer craniocerebral trauma) Impaired gas exchange related to respiratory muscle weakness or paralysis (cross refer craniocerebral trauma) Ineffective spinal tissue perfusion related to spinal tissue edema and hypoxia Risk for disturbed sensory perception (visual, auditory, kinestic, gustatory, tactile, olfactory) related to neuromuscular dysfunction (cross refer craniocerebral trauma) Risk injury related to seizures Risk for aspiration related to enteric feeding via nasogastric tube (cross refer Module II) Impaired physical mobility related to instability of spine or paralysis (cross refer Module I) Self-care deficits (feeding, bathing/hygiene, dressing, grooming, and toileting) related to neuromuscular impairment (cross refer Module 1) Risk for impaired skin integrity related to prolonged immobility (cross refer Module I) Bowel incontinence related to neuromuscular impairment Impaired urinary elimination related to neuromuscular and/or sensory motor impairment Disturbed body image related to change in body functioning Knowledge deficit related to lack of knowledge of care after discharge from hospital Formulate goals Formulate expected outcomes against which nursing care can be evaluated Correctly identify nursing interventions Accurately record the process

4 Apply the nursing process in the care of a patient suffering from headache Define headache Describe the patophysiology: differentiate between primary-, tension -, secondary- and tractioninflammatory headaches. Explain what is meant by the following diagnostic studies in relation to headaches: Cervical and skull roentgenograms CT scan MRI Diagnostic lumbar puncture Cerebral angiography

11 Neurologic history and examination Describe the multidisciplinary plan with regard to Emergency management Medications: analgesic/anti-inflammatory agents, nonsteroidal anti-inflammatory drugs, antidepressants General management: application of heat or cold to affected areas, dietary counseling, psychological counseling Apply the nursing process in the care of patients suffering from headache: Accurately perform an individualized nursing assessment Identify potential complications Identify health needs Compile a nursing care plan Formulate nursing diagnosis Special attention should be given to the following NANDA health needs: Acute and chronic pain related to severe headache Anxiety related to discomfort Knowledge deficit related to lack of knowledge of care after discharge from hospital Formulate goals Formulate expected outcomes against which nursing care can be evaluated Correctly identify nursing interventions Accurately record the process

5 Apply the nursing process in the care of a patient suffering from seizure disorder Define seizures Describe the patophysiology: differentiate between partial and generalized seizures. Explain what is meant by the following diagnostic studies in relation to seizures: Skull roentgenograms CT scan MRI Blood studies Cerebral angiography Neurologic history and examination EEG Lumbar puncture Describe the multidisciplinary plan with regard to Emergency management Medications: antiepileptic drugs

12 General management: Seizure precautions, emergency equipment at bedside Apply the nursing process in the care of patients suffering from headache: Accurately perform an individualized nursing assessment Identify potential complications Identify health needs Compile a nursing care plan Formulate nursing diagnosis Special attention should be given to the following NANDA health needs (remember to cross refer): Ineffective airway clearance related to obstruction with secretions Ineffective breathing pattern related to obstructed airway Impaired gas exchange related to ineffective breathing Knowledge deficit related to lack of knowledge of care after discharge from hospital Formulate goals Formulate expected outcomes against which nursing care can be evaluated Correctly identify nursing interventions Accurately record the process

6 Cerebral infection: Apply the nursing process in the care of a patient suffering from brain abscess Define brain abscess Describe the patophysiology: Explain what is meant by the following diagnostic studies in relation to brain abscess: Roentgenograms to locate associated suppurative processes: skull, sinuses, mastoid processes, chest CT scan MRI Brain scan Describe the multidisciplinary plan with regard to Emergency management Surgery Medications: antiinfective agents, anticonvulsants General management: Apply the nursing process in the care of patients suffering from brain abscess: Accurately perform an individualized nursing assessment Identify potential complications Identify health needs Compile a nursing care plan Formulate nursing diagnosis Special attention should be given to the following NANDA health needs:

13 Ineffective airway clearance related to cerebrovascular status Ineffective breathing pattern related to cerebrovascular status Impaired gas exchange related to ineffective breathing Ineffective cerebral tissue perfusion related to high risk for intracranial hypertension Acute pain related to increased intracranial pressure Risk for disturbed sensory perception (visual, auditory, kinestic, gustatory, tactile, olfactory) related to cerebral hemorrhage and/or increased intracranial pressure Risk injury related to seizures or altered level of consciousness Risk for infection related to hematogenous dissemination of pathogen Knowledge deficit related to lack of knowledge of care after discharge from hospital Formulate goals Formulate expected outcomes against which nursing care can be evaluated Correctly identify nursing interventions Accurately record the process

7 Cranial and peripheral nerve disorders: Apply the nursing process in the care of a patient suffering from Bells Palsy Define Describe the patophysiology Describe the multidisciplinary plan with regard to Bells Palsy Medications: Prednisone, Acyclover, analgesics General management: Warm moist heat, massage, facial exercises, swallowing precautions, nutritional consultation Apply the nursing process in the care of patients suffering from brain abscess: Accurately perform an individualized nursing assessment Identify potential complications Identify health needs Compile a nursing care plan Formulate nursing diagnosis Special attention should be given to the following NANDA health needs: Acute or chronic pain related to cranial nerve VII irritation Imbalanced nutrition, less than body requirements, related to inability to digest food Knowledge deficit related to lack of knowledge of care after discharge from hospital Formulate goals Formulate expected outcomes against which nursing care can be evaluated Correctly identify nursing interventions Accurately record the process

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8 Cranial and peripheral nerve disorders: Apply the nursing process in the care of a patient suffering from Guillain-Barr Syndrome Define Describe the patophysiology: Explain what is meant by the following diagnostic studies in relation to the disorder: CSF sampling EMG Pulmonary function test Describe the multidisciplinary plan with regard to Emergency management Surgery: tracheotomy Medications: Corticosteroids, intravenous immunoglobulin, antiinfective agents, prophylactic antibiotics, anticoagulatns General management: cardiac monitoring, hemodynamic monitoring, respiratory support/ mechanical ventilation, intubation or tracheostomy, plasma pheresis, chest physio therapy, ABGs, nutritional maintenance, special eye care, bowel/bladder management, physical therapy, psychosocial counseling Apply the nursing process: Accurately perform an individualized nursing assessment Identify potential complications: respiratory failure, sepsis, syndrome of inappropriate antidiuretic hormone (SIADH) Identify health needs Compile a nursing care plan Formulate nursing diagnosis Special attention should be given to the following NANDA health needs: Ineffective airway clearance related to weakened cough reflex Ineffective breathing pattern related to neuromuscular paralysis Impaired gas exchange related to ineffective breathing pattern Risk for aspiration related to use of enteral feedings Impaired physical mobility related to neuromuscular impairment Risk for disuse syndrome related to muscle paralysis and prolonged immobility Self-care deficits (feeding, bathing/hygiene, dressing/grooming, and toileting related to impaired neurologic and mobility status Anxiety related to altered sensory and motor functions Knowledge deficit related to lack of knowledge of care after discharge from hospital Formulate goals Formulate expected outcomes against which nursing care can be evaluated

15 Correctly identify nursing interventions Accurately record the process

9 Degenerative disorders: Apply the nursing process in the care of a patient suffering from Multiple sclerosis Define Describe the patophysiology: Explain what is meant by the following diagnostic studies in relation to the disorder: CSF sampling CT scan MRI scan Describe the multidisciplinary plan with regard to Surgery: contralateral thalamotomy, rhizotomy, nerve root blocks, tenotomy, myotomy Medications: Immunotherapy, ACTH, Corticosteroids, muscle relaxants, anticholernergics, plasmapheresis General management: Braces, splints, wheelchair, walker, cane, nutritional support, physiotherapy, occupational therapy, hydrotherapy, speech therapy, Social services Apply the nursing process: Accurately perform an individualized nursing assessment Identify potential complications: Aspiration, respiratory failure, chronic pain Identify health needs Compile a nursing care plan Formulate nursing diagnosis Special attention should be given to the following NANDA health needs: Ineffective airway clearance related to decreased energy and fatigue Ineffective breathing pattern related to musculoskeletal imapairment Impaired gas exchange related to ineffective breathing pattern Risk for aspiration related to use of enteral feedings Impaired urinary elimination related to neuromuscular impairment Self-care deficits (feeding, bathing/hygiene, dressing/grooming, and toileting related to impaired neurologic and mobility status Knowledge deficit related to lack of knowledge of care after discharge from hospital Formulate goals Formulate expected outcomes against which nursing care can be evaluated Correctly identify nursing interventions Accurately record the process

16 10 Degenerative disorders: Apply the nursing process in the care of a patient suffering from Parkinsons disease Define Describe the patophysiology: Explain what is meant by the following diagnostic studies in relation to the disorder: Serum examination Chest roentgenograms CT scan EEG Swallowing studies Gastrointestinal studies Describe the multidisciplinary plan with regard to Surgery Medications: Anticholernergics, Antiparkinsonism agents, Dopamine antagonists, antidepressants, Insomnia agents General management: Heat massage, wheelchair, walker, cane, nutritional support, physiotherapy, bowel and bladder programme, occupational therapy, hydrotherapy, speech therapy, Social services Apply the nursing process: Accurately perform an individualized nursing assessment Identify potential complications: Aspiration, nausea/vomiting Identify health needs Compile a nursing care plan Formulate nursing diagnosis Special attention should be given to the following NANDA health needs: Risk for aspiration related to impaired swallowing Acute or chronic confusion related to cognitive impairment Impaired physical mobility related to decreased neuromuscular functioning Impaired urinary elimination related to neuromuscular impairment Self-care deficits (feeding, bathing/hygiene, dressing/grooming, and toileting related to impaired neuromuscular function Imbalanced nutrition: less than body requirements, related to impaired neuromuscular function Risk for fluid volume deficit related to inability to drink sufficient fluids Constipation related to neuromuscular impairment Impaired verbal communication related to neuromuscular impairment Knowledge deficit related to lack of knowledge of care after discharge from hospital Formulate goals Formulate expected outcomes against which nursing care can be evaluated

17 Correctly identify nursing interventions Accurately record the process 11 Degenerative disorders: Apply the nursing process in the care of a patient suffering from Myasthenia Gravis Define Describe the patophysiology: Explain what is meant by the following diagnostic studies in relation to the disorder: Tensilon test Chest roentgenograms EMG CSF analysis Describe the multidisciplinary plan with regard to Surgery: tracheotomy, thymectomy Medications: Cholinnesterasie inhibitors, immunosuppressive drugs, IV immunoglobulin, plasmapheresis General management: Mechanical ventilation, bronchoscopy, physiotherapy, occupational therapy, swallow precautions, Social services Apply the nursing process: Accurately perform an individualized nursing assessment Identify potential complications: Myasthenia Gravis crisis, cholinergic crisis, respiratory failure, Aspiration, Identify health needs Compile a nursing care plan Formulate nursing diagnosis Special attention should be given to the following NANDA health needs: Risk for aspiration related to impaired swallowing Acute or chronic confusion related to cognitive impairment Impaired physical mobility related to decreased neuromuscular functioning Self-care deficits (feeding, bathing/hygiene, dressing/grooming, and toileting related to impaired neuromuscular function Imbalanced nutrition: less than body requirements, related to impaired neuromuscular function Risk for fluid volume deficit related to inability to drink sufficient fluids Constipation related to neuromuscular impairment Impaired verbal communication related to neuromuscular impairment Knowledge deficit related to lack of knowledge of care after discharge from hospital Formulate goals Formulate expected outcomes against which nursing care can be evaluated

18 Correctly identify nursing interventions Accurately record the process

CLINICAL LEARNING INSTRUMENTS

NEUROLOGICAL ASSESSMENT 1 Purpose

The purpose of the procedure is to guide the student nurse in the neurological assessment of a patient. A neurological assessment is done on any patient who has had a head injury or experience symptoms of increased intracranial pressure 2 a) Procedure Indications Neurological assessment will be done on any patient, who displays symptoms of neurological disorder e.g. a fit, is comatose, for poisoning, a motor vehicle accident, etc. b) Objectives A nurse should be able to perform neurological observations correctly support patient and family psycho-socially perform accurate recordkeeping understand altered physiology of a patient with increased intracranial pressure. !Nursing alert It is very important that the nurse who admits the patient to the ward does accurate neurological observations in order to provide quality care to the patient. If neurological observations are not done correctly and accurate, serious complications can occur to the detriment of the society. c) Infection control Wash hands before and after handling the patient d) Equipment needed

Equipment as for vital signs; Diagnostic set for assessing pupils e) Neurological Assessment Action Ascertain diagnosis Assess and record level of consciousness When intracranial pressure increases to a point Rationale/Explanation

19 where the brains ability to adjust has reached its limits, neural function is impaired and may be expressed in changes in the level of Assessment of level of consciousness based on three objective behaviours: 1. Eye opening Tested by applying stimuli beginning at the top of categories and work down and record the best response. If impaired, either from trauma at time of injury or subsequent rise in intracranial Eye opening is closely linked to being awake and alert. This is controlled by the reticular activating system, a collection of neurons in the brain stem, hypothalamus and thalamus and depends on sensory input to be stimulated. a) Spontaneous: b) Opens eyes to verbal command: Eyes open spontaneous without any stimulus c) Opens eyes to pain: Approach in normal voice; or then greater verbal stimulus (raise voice) Touch patients hand; shoulder or apply peripheral pain stimulus e.g. place patients finger (3rd and 4th digits are sensitive) between d) No response: If you are satisfied that sufficient stimuli were used and yet eyes did not open If both eyelids are swollen from trauma or surgery, record C (closed) 2. Best verbal response This assesses two elements of cerebral functioning: It examines the comprehension and transmission of sensory input, verbal or physical. It reflects the ability to articulate or express a reply your thumb and a pen. Increase pressure gradually until the best response is seen. Pressure may also be applied directly to nail bed but this may result in bruising or marking pressure, it will require a greater sensory input to produce a response of eye opening. consciousness. As patient is moving down the list of options, it indicates a worsening situation.

a) Orientation: This depends on the area involved in the b) Confused brain. To elicit best verbal response, you begin at the top of categories and work down

20 to place patient correctly. c) Inappropriate words: Who (his name), where he is When it is (month and time) If one or more questions are incorrectly answered. d) Incomprehensible sounds: e) None 3. Best motor response The upper limbs are assessed and the best responses of the two arms is recorded. a) Obey commands When conversational exchange is absent tendency to use words and not sentences Replies are often obtain by physical stimulation (e.g. peripheral pain stimulus) rather than verbal stimulation e.g. questioning Mumbling, groaning, screaming

b) Localize to pain: Initially a central pain stimulus is used: Give instructions like Supra orbital ridge pressure is an alternative: rest your hand on patients head and flat of thumb is placed on supra orbital ridge or eyebrow. Pressure is gradually increased until best response. Patient must try to remove the stimulus or reach at least the level of the chin. c) Normal flexion: This is the response you would expect if you touched a live hot plate. It is a combination of movements involving flexion at the elbow, abduction of upper arm and extension of wrist and movement is generally rapid. d) Abnormal flexion Response is slower. There is bending at elbow, adduction of upper and wrist flexion. e) Extension: Appears as straightening of the elbow joint with adduction and internal rotation of the limb, often accompanied by wrist It is best to have patient obey two different commands twice. The trapezius pinch is safe: the shoulder is partially exposed and the trapezius muscle is grossly pinched. Pressure is gradually increased until best response is seen. This technique is not used if there is damage to the orbital structure or local facial or skull fractures. put out your tongue move your toes lift up your arms

21 flexion. f) None: When the brain stem function is so depressed that it allows no sensory input and no motoric output, then there will be no response seen to a pain stimulus. Assess vital signs

This response suggests the subcortical brain has been affected. Although clinical features do not always occur Blood pressure or may happen too late for effective management, the nurse should be aware of classical triad of clinical features which are Pulse Respiration Temperature clues to the existence of I.I.C.P. (increased intracranial pressure) I.I.C.P. may significantly reduce cerebral blood flow. The resultant ischaemia stimulates the vasomotor centres and the systemic pressure rises to maintain cerebral blood flow. The changes in bloodpressure, i.e. rising systolic pressure and widening pulse pressure curve accompanied by bradycardia and respiratory irregularities may be indicative of a rise in intracranial pressure. Pupil reaction Because of damage to the heat regulating centre in the brain or severe intracranial infection, neurological and neurosurgical patients often develop very high temperatures. Such temperature elevations must be controlled, because the increased metabolic demands by the brain will overburden brain circulation resulting in cerebral deterioration. Persistent hyperthermia is indicative of brain stem damage.

22 Indicate whether pupils are equal in size, dilated or unequal [Refer to Procedure on Assessment of Emergency and/or Trauma Patient through primary & secondary survey] (308322R00D) f) Evaluation Rationale/Explanation Score ranges between 3 and 15. The level of responsiveness/consciousness is the most important measure of the patients condition. A score of 9 or more indicates absence of coma and 3 indicates absence of reaction

Action After assessment, calculate coma score and record score

g)

Recording Rationale/Explanation

Action As indicated in the above assessment. Clear accurate recording is essential to render quality care. Nursing care plan can be compiled from the observations only

PREPARATION OF A PATIENT FOR A LUMBAR PUNCTURE 1 Purpose The purpose of this procedure is to guide the student nurse on the preparation for and assistance to the medical practitioner when a patient has to undergo a lumbar puncture. A lumbar puncture is the procedure where spinal fluid is obtained for therapeutic and /or diagnostic purposes. 2 Procedure a) Indications Spinal fluid is obtained for examination such as for suspected infection by bacteria, viruses, fungi or spirochaetes suspected intrachranial subarachnoid haemorrhage eg. Ruptured aneurysm multiple sclerosis; presence of immunoglobin abnormalities Guillain-Barre Syndrome: increased protein concentration Carcinoma of central nervous system: cytological studies measure and relieve spinal fluid pressure detection spinal subarachnoid block administer antibiotics intrathecally in certain cases of infection investigations such as myelography Contra-indications Local infection at puncture site Suspected raised intracranial pressure b) Objectives The nurse should Have basic knowledge on the procedure to assist the medical practitioner effectively Know the indications (purposes) and contra-indications of the procedure to apply to her/his patient

23 Assess the patient to determine the condition of the patient and the reason why a lumbar puncture will be done on this patient Do appropriate planning for the procedure Explain procedure to patient Position patient correctly Assist doctor during procedure Care for the patient post procedure Record procedure and all observations Take care of the spinal fluid specimen until it reaches the laboratory

!Nursing alert The post procedure care of the patient is very important to prevent complications common to this procedure namely nausea & headache. c) Infection control Asepsis is of utmost importance because the procedure gives way right into the spinal cord. The site should be disinfected and sterile equipment should be used. d) Equipment needed Lumbar puncture pack; Syringes and needle Hibitane 0,5% & Alcohol 70% Lignocaine 1% Specimen bottles ; Variety of needles to insert Sterile gloves for medical practitioner

e)

Assessment Rationale/explanation Nurse should have theoretical knowledge of the disorder suspected in the patient Do neurological observations if applicable

Action Ascertain patients diagnosis to determine the indication of the procedure for this patient Assess condition of the patient in order to have a data base f) Planning

Action Identify patient Explain procedure Reassure patient & clarify any uncertainties Get informed consent from the patient g) Implementation

Rationale/explanation Ensure safe medical care On patients level of understanding Verify if patient understand the procedure to protect the rights of the patient

Action Clean top and bottom tray of trolley Wash hands Obtain equipment and place on the trolley as follows: Top: Lumbar puncture pack & Surgical gloves LP needle & Manometer Syringe and needles Local anaesthesia (Lignocaine 1%) Hibitane in water 1/1000 Bottom: hand washing solution & specimen tubes

Rationale/explanation With Hibitane 0,5% in Alcohol 70% in line with aseptic technique With Povidine or Hibiscrub as available in the institution

24 linen saver & unsterile receiver with adhesive plaster and scissors Check packs for sterility Wash hands Open packs Position patient correctly Lateral: head, knees and hip flexed OR Sitting, back to front on chair - in sitting position with knees bend under lumbar area Position linen saver Assist doctor during procedure pour in cleaning solution without contamination of gallipot clean top of vial of local anaesthetic for draw up position patient with pillow under head and between legs instruct patient to arch lumbar segment and draw up knees to abdomen, clasping knees with hands entry into the subarachnoid space assist patient throughout the examination in maintaining this position by supporting him behind his knees and neck for sitting position: have patient straddle a straight back chair and rest his head against arms In obese patients and those who have difficulty in assuming the side lying position this posture may allow more accurate identification of the spinous processes and interspaces Physician Prepares skin Infiltrates skin and subcutaneous spaces with local anaesthetic agent Introduce the spinal needle at L3-4 or L4-5 interspace. Needle is advanced until the give of the ligamentum is felt and the needle enters the subarachnoid space Manometer is attached to spinal needle Nurse assist patient to slowly straighten his legs

Checking: dampness, tears & wetness

Without contamination

This position offers maximal widening of interspinous space and ensure easier

To prevent local and systemic infection Local anaestethic is given to minimize pain

This manoeuvre prevents a false increase in intra spinal fluid pressure. Muscle tension and compression of abdomen gives falsely high pressures. Hyperventilation may lower a truly devoted pressure. Talking can elevate CSF pressure. With respiration there is normally some fluctuation of spinal fluid in the manometer.

Instruct patient to breath quietly (not to hold his breath or strain) and not to talk. The initial pressure reading is obtained by measuring the level of the fluid column after it comes to a rest. About 2 3 ml of spinal fluid is placed in each of 3 test tubes for observation, and laboratory analysis Beckenstedt test An assistant compresses the Jugular vein(s) for 10 seconds Pressure readings are made at 10 second intervals

Normal range of spinal fluid pressure with the test is made when a spinal subarachnoid block is suspected (tumor, vertebral fracture or dislocation) In normal persons there is a rapid rise in pressure of jugular compression with rapid return to normal when the compression is released. If the

25 pressure fails to rise and falls slowly, there is evidence of a block due to a lesions compressing the spinal subarachnoid pathways. This test is not done if an intracranial lesion is suspected. Patient in the lateral position is 70 180 mmHO. To prevent contamination of site

Cover site of puncture ( wound) Spray trolley Wash hands Remove linen saver Ensure patient is comfortable with minimum disturbance Open bed screens Clear up rinse soiled equipment dressing linen in dirty linen bag dispose needles in pour bottle g) Evaluation

Action Observe the spinal fluid as it drains from the tube

Assess condition of patient after procedure measure vital signs: blood pressure & pulse respiration temperature neurological observations, if applicable observe pallor excessive perspiration h) Recording

Rationale/explanation Spinal fluid should be clear and colourless. Bloody spinal fluid may indicate cerebral contusion, (bruise) laceration, subarachnoid haemorrhage, or traumatic tap. NB: Lie in preferred position, (lateral, back)

Action Record neurological observations before and after procedure

Complete labels of specimen with all information Send to laboratory

Rationale/explanation In patients progress report date and time type of procedure indication of procedure vital observations after procedure doctor who performed procedure If specimen is send to laboratory Specific information e.g. spinal fluid pressure

i)

Possible complications and preventative measures: Potential shock Check vital signs (pulse, respiration and blood pressure) every 15 minutes for four times, then every hour for four times, then as per routine. Observe puncture site for redness, swelling or drainage. Make sure patient takes in fluid Keep the patient horizontal (prone, supine, or on his side) for 6 24 hours. Monitor neurological observations as ordered. Not to get out of bed for 6 24 hours Patient to report headache, backache and muscle spasm of back and thigh Assess for neck stiffness and mild fever Report to doctor Potential meningeal irritation

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MODULE REQUIREMENTS AND EXPECTATIONS.

The student nurse has to successfully complete of this module to advance to module 4 of General Nursing Science.

S/he is required to uphold academic integrity at all times and be actively involved in class room discussions and simulation laboratory and activities in the clinical environment.

The student is expected to acquire/obtain al the prescribed material for the module and actively participate in her/his educational process.

The student nurse is expected to be punctual in both clinical and classroom setting and attend at least 80% of classes and 100 % clinical learning.

For academic appraisal or in the event of the student experiencing any academic or practical problems, s/he is expected to make an appointment with the lecturer.

The student internalizes the norms and values of the profession.

The student should comply with the prescribed clinical teaching hours.

CURRENT LECTURERS:

Dr M van der Vyver (Windhoek Campus) Ms S M Ashipala (Oshakati Campus)

ISSUE DATE: 2008

NEXT REVISION DATE: 2011.