This area focuses on the nursing care of patients with problem affecting the neurological system, such as cerebrovascular accidents, multiple sclerosis, Parkinson's disease, myasthenia gravis, brain tumors, spinal cord injuries, seizure disorders, and head trauma. Sensory dysfunction include such problems as glaucoma, Meniere's disease, otosclerosis, and cataracts. Musculoskeletal dysfunction includes such problems as rheumatoid arthritis, joint replacement, degenerative joint disease, contractures, fractures, scoliosis, gout, slipped femoral epiphysis, and lumbar disc disease.

A. Theoretical framework - basis for care

1. Types of neurological, sensory, and musculoskeletal dysfunctions

a. Age-related conditions (for example: scoliosis, osteoporosis, juvenile rheumatoid arthritis, Legg-Calve-Perthes disease, cataracts, presbyopia, presbycusis)

b. Degenerative conditions (for example: multiple sclerosis, degenerative joint disease, Parkinson's disease, myasthenia gravis, Huntington's chorea, disc problem)

c. Conditions of altered neurological pathways (for example: seizure disorders, head injuries, spinal cord injuries, cerebrovascular accidents)

d. Conditions of musculoskeletal dysfunction (for example: fractures, joint replacement, slipped femoral epiphysis)

e. Conditions of altered sensation (for example: glaucoma, cataracts, detached retina, loss of hearing, paresthesia)

2. Clinical manifestations of neurological, sensory, and musculoskeletal dysfunction

a. Impaired motor function (for example: paralysis, immobility, muscular weakness, ataxia)

b. Impaired sensory function (for example: neurovascular deficits, paresthesia, visual and hearing impairments)

c. Altered neurological status (for example: seizure activity, changes in level of consciousness, coma)

d. Altered vital signs (for example: indicators of increased intracranial pressure)

e. Alterations in behavior (for example: flat affect, scanning speech, masked facies, emotional lability)

f. Alterations in comfort (for example: acute and chronic pain)

g. Alterations in mental status (for example: confusion, slowed thought processes, disorientation)

3. Factors influencing the patient's response to neurological, sensory and musculoskeletal dysfunction

a. Age and physiological factors (for example: postmenopausal women)

b. Psychological factors (for example: stress)

c. Socioeconomic and cultural factors (fore example: lifestyle, environmental factors, nutritional status)

d. Presence of other illness (for example: diabetes mellitus)

e. Site of dysfunction (for example: level of spinal cord injury)

f. Extent or severity of involvement (for example: exacerbations or remission, local or systemic involvement)

4. Theoretical basis for interventions to promote, restore, or maintain neurological, sensory, and musculoskeletal function

a. Medications (for example: analgesics, anti-inflammatory agents, hormone replacement therapy, antibiotics, anticholinergics, antimetabolites, steroids, myotics, mydriatics, osmotic diuretic, antiseizure medications)

b. Activity and positioning (for example: exercises, assistive devices, logrolling)

c. Immobilization devices (for example: traction, casts, external fixation devices)

d. Patient monitoring (for example: neurological assessment, vital signs, neurovascular assessment)

e. Preoperative and postoperative care (for example: craniotomy, open reduction with internal fixation of the fracture, cataract removal, iridectomy, lens implantation, laminectomy)

B. Nursing care related to theoretical framework

1. Assessment - gather and synthesize data about the patient's health status in relation to the patient's functional health patterns

a. Gather assessment data

1) Obtain the patient's health history (for example: subjective symptoms, nutritional status, medications, history of trauma, family history, onset of symptoms, occupation)

2) Assess factors influencing the patient's response to neurological, sensory, and musculoskeletal dysfunction (see IIIA3)

3) Obtain objective data related to the patient's neurological, sensory, and musculoskeletal dysfunction (for example: clinical manifestations, altered vital signs, Glasgow coma scale, reflexes, behavioral responses, range of motion)

4) Review laboratory and other diagnostic data (for example: cerebrospinal fluid results, diagnostic imaging modalities, hemoglobin and hematocrit in the patient postoperatively, sedimentation rate)

b. Synthesize assessment data (see IIIB1a [1-4] above)

2. Analysis - identify the nursing diagnosis (patient problem) and determine the expected outcomes (goals) of patient care

a. Identify actual or potential nursing diagnoses (for example: impaired physical mobility related to muscular weakness; impaired verbal communication related to altered speech patterns; activity intolerance related to weakness; diversional activity deficit related to prolonged bed rest; ineffective individual coping related to mood swings)

b. Set priorities (for example: based on Maslow's hierarchy of needs, based on the patient's developmental level)

c. Establish expected outcomes (patient-centered goals) for care (for example; patient's skin will remain intact, patient will be able to communicate needs, patient will be free of injury)

3. Planning - formulate specific strategies to achieve the expected outcomes

a. Consider factors influencing the patient's response to neuromuscular, sensory, and musculoskeletal dysfunction in planning patient care (see IIIA3)

b. Plan nursing measures on the basis of established priorities to help the patient achieve the expected outcomes (for example: monitor traction devices, reinforce crutch-walking instruction)

4. Implementation - carry out nursing plans designed to move the patient toward the expected outcomes

a. Use nursing measures to protect the patient (for example: assist a patient who is visually impaired to ambulate, provide abductor devices for a patient following hip replacement, prevent fluid overload in a patient who is on fluid restriction, provide safety measures for a patient with seizures)

b. Use nursing measures to promote, maintain, or restore the patient's neurological, sensory, or musculoskeletal functioning and/or prevent complications (for example: perform passive range-or-motion exercise for a patient with paralysis, maintain skeletal traction for a patient with a fractured femur, elevate the casted extremity, administer prescribed eyedrops to a patient with glaucoma)

c. Use nursing measures to minimize patient discomfort (for example: assist with mechanical devices, administer anti-inflammatory medications to the patient with arthritis, promote or limit activity, apply heat and cold treatments)

d. Use nursing measures specific to prescribed medications (for example: administer antiseizure medications on a regular schedule to control seizure activity, monitor the bowel movements of a patient receiving stool softeners, emphasize the need to adhere to steroid therapy, monitor body weight for a patient who is receiving corticosteroids)

e. Use nursing measures to assist the patient and/or significant others to cope with the health problem (for example: refer a patient with multiple sclerosis to a support group, suggest that the significant others of a patient with myasthenia gravis learn cardiopulmonary resuscitation techniques)

f. Provide information and instruction (for example: provide information to patients undergoing diagnostic tests such as angiograms, EEGs, CAT scans, magnetic resonance imaging [MIR], and lumbar punctures; instruct the patient about the medication regimen; instruct the patient regarding the use of community resources; instruct the patient regarding the use of assistive devices; emphasize the need for follow-up care; reinforce rehabilitation instruction)

5. Evaluation - appraise the effectiveness of the nursing interventions relative to the nursing diagnosis and the expected outcomes

a. Assess and report the patient's response to nursing actions relative to the expected outcomes (for example: patient is free from pain, patient verbalizes the need for follow-up care, patient verbalizes the need to take medication at the prescribed time, alterations in the patient's condition)

b. Revise the patient's plan of care as necessary (for example: increase observation to q15 minutes for a patient with increased intracranial pressure, revise the exercise schedule for a patient in traction)