Unit VI- Care of the Client Experiencing Neuromuscular Problems

Behavioral Objectives / Content Outline / Clinical Objectives / Learning opportunities
  1. Apply the terms listed in the content column appropriate to the client situation.
  1. Compare and contrast the normal anatomy and physiology to the pathophysiology of the disease processes in the neuromusculo-skeletal system across the lifespan.
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  1. Application of terms
  1. Amyotrophic Lateral Sclerosis (ALS) (Lou
Gehrig’s disease)
  1. Astigmatism
  2. Ataxia
  3. Audiometry
  4. Aura
  5. Carpal tunnel syndrome
  6. Cerebral palsy
  7. Coup, contracoup
  8. Decerebrate
  9. Decorticate
  10. Dyskinetic
  11. Enucleation
  12. Lead poisoning
  13. Macular degeneration
  14. Meniere’s syndrome
  15. Myopia
  16. Otosclerosis
  17. Osteogenesis imperfecta
  18. Papilledema
  19. Pica
  20. Presbyopia
  21. Proprioception
  22. Rhizotomy
  23. Sensorium
  24. Spastic
  25. Stapedectomy
  26. Subluxation
  27. Trigeminal neuralgia
  1. Anatomy & physiology of the neuromusculo- skeletal system
C. Developmental considerations
  1. Infant
  2. Child
  3. Adolescent
  4. Adult
5. Older adult / Use current technology to enhance client care.
Act as a role model in maintaining client confidentiality.
Assume accountability when using independent clinical judgment and established protocols.
Identify learning needs of clients related to health promotion, maintenance and risk reduction.
Collaborate with others to develop and modify individualized teaching plans based upon developmental and health care learning needs.
Individualize and implement established teaching plans.
Evaluate learning outcomes of the client receiving instruction.
Modify teaching methods to accommodate client differences.
Apply knowledge of how changes in clients’ personal behavior improve client’s health. / Readings:
Lewis 8th ed (2011)
Adams 3rd ed (2011)
McKinney 3rd ed (2009)
VCR:
#M051 - Acute Neurological Care: Head
Injury
#M052 - Acute Neurological Care:
Spinal Cord Injury
#M020 - Physical Assessment – The
Neurologic System
#0168 - Eye Surgery Perioperative
Nursing Practice
  1. Analyze factors included in the assessment of the client experiencing complex problems of the neuromusculo-skeletal systems, including the develop-mental and cultural considerations.
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  1. Pathophysiology of neuromusculo-skeletal
system
  1. Central nervous system: Brain and spinal cord
a. ACES
  1. Peripheral nervous system
  2. Neurotransmitters
  3. Musculoskeletal system: Bones, muscles, and joints
  4. Increased intracranial pressure
  1. Assessment of neuromusculo-skeletal system
  2. Interview
  3. Chief complaint
  4. History of present illness
  5. Prior medical history
  6. Medication history (prescription/non-prescription)
  7. Family/social/occupational history
/ Serve as model and resource for health education and information.
Analyze client data to compare expected and achieved outcomes for client.
Identify and communicate reasons and rationales for deviation from plan of care to interdisciplinary health care team.
Modify plan of care and/or expected outcomes.
Evaluate and communicate / #5035 – Physical Examination of the
Neurologic System
  1. Differentiate between the etiology, pathophysiology, and clinical manifestations of selected complex neuromuscular problems.
  1. Discuss the analysis, planning implementation and evaluation for the nursing management of clients with complex neuromuscular problems.
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  1. Knowledge of health maintenance
  2. Identify risk factors for neuromuscular disease
  1. Physical examination
  2. Neurological assessment
  3. Glasgow coma scale
  4. Cranial nerve assessment
  5. Dermatome chart
  6. Motor
1)Ability to move extremities
2)Strength
3)Reflexes
4)Presence/absence of tremors
5)Sensation
  1. S/S of meningeal irritation
  2. Kernig’s sign
  3. Brudzinski’s sign
  4. Opisthotonus
  5. Photophobia
  6. Nuchal rigidity
  7. Ophthalmalogical examination; assessment of visual acuity
  8. Pain
  9. Vital signs
  10. Breathing pattern
  11. Range of motion
  12. Visual inspection of vertebral column
  1. Diagnostic tests
  2. Radiology
  3. Skull series
  4. X-rays
  5. Myelogram
  6. Magnetic resonance imaging (MRI)
  7. Computed axial tomography (CT scan)
  8. Laboratory studies
  9. Complete Blood Count (CBC)
  10. Serum lead level
  11. Assessment of cerebral spinal fluid
  12. Culture and sensitivities
  13. Serum drug levels
  14. Arterial blood gases
  15. Pulmonary function tests
  16. Pulse oximeter
  17. Electroencephalogram (EEG)
  18. Lumbar puncture
  19. Tonometry
  20. Cultural influences
  21. Hereditary
  22. Environmental
  23. Health beliefs/practices
  24. Developmental
  25. Age specific assessment data
  26. Muscle tone
  27. Vital signs
  28. Nutritional
  29. Behavioral/emotional response to health care providers
  1. Complex neuromuscular problems
  1. Intracranial Pressure (ICP)
  2. Head injury
  3. Seizures
  4. Spinal cord injury
  5. Meningitis
  6. Herniated disc
  7. Multiple sclerosis
  8. Parkinson’s disease
  9. Osteoarthritis
  10. Eye disorders
  11. Cataract
  12. Glaucoma
  13. Retinal detachment
K. Amputation
  1. Selected nursing diagnoses, implementation, evaluation
A. Impaired physical mobility
  1. Independent interventions
a. Neurological assessment
  1. Immobility interventions
/ quality and effectiveness of therapeutic interventions.
Use evaluation tools to measure processes and outcomes.
  1. Collaborative interventions
  1. Collaborate with physical therapy
regarding exercises, activity
b. Collaborate with occupational therapy regarding promotion of self care
c. Maintain bracing, traction, dressing as prescribed
  1. Administer prescribed medications and monitor for desired/adverse/side effects
1)Antispasmodics/muscle
relaxants
2) Anticholinergics
3)Anti-Parkinson’s
4)Dopamine-agonists
  1. Recognition of complications
  1. Contractures
  2. Spasticity
  3. Thrombophlebitis
  4. Orthostatic hypotension
  5. Autonomic hyperreflexia
  6. Hemorrhage
  7. Neurogenic shock
  1. The client will have improved physical
mobility as evidenced by:
a. Maintains usual range of motion
b. Performs own active exercises
  1. Performs at highest level of self
care
  1. Absence of contractures
  2. Stable vital signs
  3. High risk for injury: Seizure disorder
1. Independent interventions
  1. In the hospital, maintain seizure
precautions
  1. Assess for precipitating event
  2. Encourage stress management;
improve coping skills
  1. Assess lifestyle and environment
  2. Encourage client to follow a regular
  3. routine
  1. Avoid excessive dietary stimulants
  2. Avoid alcohol
  3. Encourage adequate rest, sleep
  4. Avoid photic stimulation
  5. Encourage 100% compliance to
prescribed medication regimen
2. Collaborative interventions
  1. Administer medications and
monitor for desired/adverse/side
effects
1) Anticonvulsants
  1. Referral to community resources
1)Vocational rehabilitation
2)Epilepsy Foundation of America
3)Parkinson’s Disease Foundation
4)Spinal Cord Injury Society
5)Multiple Sclerosis Society of America
  1. Recognition of complications
  2. Status epilepticus
  3. Aspiration
  4. Trauma to tongue or head
3. The client will not experience injury due to seizures
C. Altered health maintenance: Knowledge deficit of the management of post-op eye surgery
  1. Collaborative interventions
  2. Lens replacement
  3. Scleral buckling/banding
  4. Corrective laser surgeries
  5. Client teaching
  1. Assess readiness to learn, ability,
knowledge
  1. Assist client as necessary (impaired
vision, eyes patched)
  1. Orient client to room
  2. Discuss wearing eye shield or
glasses as ordered
  1. Avoid any pressure to affected eye
  2. Discuss eye medications
1)Mydriatics
2)Miotics
3)Anticholinergic
4)Others
  1. How to administer eye medications
  2. Frequent hand washing
  3. Prescribed position
  4. Activity limitations
  5. Actions to be avoided: Coughing,
sneezing, vomiting, bending,
excessive straining, lifting heavy
objects, rubbing eyes
  1. Recognition of complications
  1. Hemorrhage
  2. Increased intraocular pressure
  3. Infection
  4. Unrelieved pain
  5. Light flashes
  6. Vision changes
  7. Community resources
  1. Home health
  2. American Foundation for Blind
  3. National Federation of the Blind
  4. National Association for Visually
Handicapped
  1. The postop eye surgery client will have improved health maintenance as evidenced by:
  1. Identifying activities to avoid
  1. Identifying reportable signs and
symptoms
  1. Describing the purpose and side
effects of medications
  1. Demonstrating administration of eye
drops
  1. Utilizing community resources
  2. High risk for injury: Increase intracranial
pressure
  1. Independent interventions
  1. Maintain airway; monitor for
hypoxia
  1. Neurological assessment
  2. Vital signs
  3. Proper positioning with neck in
neutral alignment
  1. Avoid excessive suctioning
  2. Monitor IVs, fluid intake closely
  3. Maintain seizure precautions
  4. Monitor for cerebrospinal fluid
leaks
  1. Monitor for hypothermia
2. Collaborative interventions
  1. Administer prescribed medications
and monitor for desired/adverse/side
effects
1)Corticosteroids
2)Osmotic diuretics
3)Loop diuretics
4)Isotonic IV solutions
5)Antibiotics
6)Neuromuscular blocking agent (Botox)
  1. Collaborate with respiratory
therapist to prevent hypoxia
3. Postoperative nursing care following
craniotomy or burr holes, carotid
endarterectomy
  1. Recognition of complications
  2. Increasing intracranial pressure
  3. Herniation of brain
  4. Brain damage, death
  1. Meningitis
  1. The client will have decreased risk for injury and will not experience an increase in intracranial pressure as evidenced by:
  2. Stable or improving neuro signs
  3. Stable vital signs
c. Absence of seizures
d. Absence of cerebrospinal fluid leaks
  1. Normal arterial blood gases and
pulse oximeter
E. Pain related to musculoskeletal problems
1. Independent interventions
  1. Assess the pain
  2. R/O complications
  3. Take an action
1)Encourage client to comply with prescribed bedrest and positioning
2)Diversional activities
3)Guided imagery
4)Relaxation techniques
5)Gentle massage
6) Promote proper body mechanics
2. Collaborative interventions
  1. Administer prescribed medications
and monitor for desired/adverse/side
effects
1)Muscle relaxants
2)Analgesics
3)Nonsteroidal anti-inflammatory
agents (NSAID)
  1. Collaborate with physical therapist
  2. The client will state pain has decreased to <3 (on a 1 – 10 scale) 30 minutes after nursing interventions

N:Spring\RNSG 2414 UnitVI - Neuromuscular Reviewed 06/11