Neurological conditions can have profound effects on individuals' physical, cognitive and emotional wellbeing. If neurological disorders are not assessed or managed properly, they can have significant and potentially life-threatening consequences. The specific effects will depend on the type and severity of the condition, as well as other factors such as the age and overall health of the affected person.
A comprehensive assessment and effective management of neurological disorders within an evidence-based practice approach are crucial to minimise the risk of complications, improve quality of life and extend life expectancy. This requires a multidisciplinary approach involving health professionals, carers and family members. Nursing professionals are a key part of this team; they are responsible for assessing patients' needs and developing personalised care plans that address their unique symptoms and concerns.
A full assessment of the nervous system can involve a range of tests and evaluations, depending on the specific concerns or symptoms that are present – as outlined in the previous article (Teixeira, 2024), this may include laboratory tests (such as blood and cerebrospinal fluid testing), imaging tests, electrophysiological tests and nerve conduction studies. It will also include a comprehensive medical history, physical examination and mental status examination.
This article uses a case study to illustrate some of the considerations within a nursing assessment and the formulation of a care plan. The specific concerns and support required will vary depending on the individual patient's condition; the aim here is to show how the nurse would seek to promote patient empowerment and facilitate self-management.
Case study
Presenting complaint
Alex Brown is a 62-year-old man who was admitted to the hospital 3 days ago with sudden confusion, dysarthria, right-sided hemiparesis and paraesthesia. To protect Mr Brown's anonymity and confidentiality, a pseudonym has been given, in keeping with the Nursing and Midwifery Council (2018)Code. On arrival, a CT scan was performed, which confirmed an ischaemic stroke on the left hemisphere of his brain. Intravenous thrombolysis was started with alteplase as per National Institute for Health and Care Excellence (NICE) (2022) guidelines, 3 hours after the first symptoms. Mr Brown was then transferred to the stroke unit of that same hospital for continuous monitoring and acute management of his stroke.
Social history
Currently working in a financial, office-based job, Mr Brown is married and has two adult children. His father died from a myocardial infarction when he was in his sixties, and his mother is alive and in her eighties but has several health issues, including type 2 diabetes and arthritis. Information received from his wife was that Mr Brown used to be independent, not requiring assistance from others to perform his activities of daily life. Moreover, he is agnostic but considers himself spiritual.
Prior medical history
- Hypertension, controlled with amlodipine 10 mg orally once a day
- Hypercholesterolaemia, managed with atorvastatin 20 mg orally once a day
- Moderate smoker, 36 pack-year.
Nursing diagnosis and care plan
When formulating a nursing care plan for Mr Brown, it is crucial to uphold certain principles that guide the care provided. One such principle is taking a holistic approach that considers Mr.Brown's physical, emotional and psychological wellbeing. By addressing his unique needs, preferences and goals, the care plan can promote comprehensive and individualised care. Additionally, basing interventions on evidence-based practice ensures that the chosen strategies are effective and supported by relevant evidence. A person-centred approach empowers Mr Brown to actively participate in his care, fostering collaboration and shared decision-making. Last, emphasising continuity and co-ordination among the healthcare team ensures that Mr Brown receives consistent and well co-ordinated care throughout his recovery journey, facilitating optimal outcomes.
For the purpose of this article, and this case study in particular, five nursing diagnoses (among many other possible ones) are considered and prioritised for Mr Brown's nursing care plan:
- Impaired physical mobility related to right-sided hemiparesis and paraesthesia secondary to stroke
- Impaired verbal communication related to confusion and dysarthria secondary to stroke
- Risk of aspiration related to dysphagia secondary to stroke
- Risk for impaired nutrition related to decreased appetite and dysphagia secondary to stroke
- Risk of stroke complications related to inadequate medication concordance, lack of knowledge about stroke management, and limited engagement in lifestyle modifications.
The next step would be considering the goals and interventions for each of these five nursing diagnoses, addressing the principles discussed above and applying them within a short and long-term plan.
Nursing care plan
Mobility
Goal: To improve physical mobility and regain functional independence.
Nursing interventions:
- Assess Mr Brown's mobility limitations, using the Bedside Mobility Assessment Tool (BMAT) (Boynton et al, 2014; Lininger et al, 2021); pain, using the Faces Pain Scale (Edwards et al, 2020); and sensory deficits, using the revised Nottingham Sensory Assessment (rNSA) (https://www.nottingham.ac.uk/medicine/documents/published-assessments/nsaform.pdf) (Wu et al, 2016)
- Collaborate with the physiotherapy team to develop an individualised exercise programme comprising a range of motion, strengthening and balance exercises/training; ensure that these are scheduled regularly and encourage Mr Brown's active participation in the exercises
- Provide assistance with mobility and transfers (eg bed mobility, sitting, standing, and walking), and educate Mr Brown and his family on proper device use (such as walkers, canes or braces to enhance his mobility and safety)
- Assist Mr Brown and instruct him on performing active range of motion exercises for his right upper and lower limbs, emphasising the importance of regular stretching and movement to prevent joint stiffness and contractures (Han et al, 2017)
- Assess risk for falls and follow/apply recommendations accordingly – for example, Stroke Assessment of Fall Risk (SAFR) (Breisinger et al, 2014)
- Provide education to Mr Brown and his family on fall-prevention strategies, such as removing obstacles, using grab bars in the bathroom, wearing anti-slip footwear, and maintaining a clutter-free environment to reduce the risk of tripping or falling (Denissen et al, 2019)
- Co-ordinate with the occupational therapy team to develop strategies to improve functional abilities due to right-sided hemiparesis and neglect; this may include activities to enhance fine motor skills, co-ordination and activities of daily living (Hatem et al, 2016)
- Monitor progress, document changes and modify the care plan, as needed.
Communication
Goal: To facilitate effective communication and improve Mr Brown's ability to express thoughts and needs.
Nursing interventions:
- Assess the extent of confusion and dysarthria; this should include speech articulation, word-finding difficulties and comprehension abilities
- Identify and implement any alternative means of communication, such as gestures, writing or assistive communication devices (Stroke Association, 2013)
- Collaborate with the speech and language therapy team to develop a personalised communication plan and provide support during therapy sessions to encourage Mr Brown's active participation and practice
- Implement techniques and exercises recommended by the speech and language therapy team to improve speech articulation and language comprehension
- Use clear and simple language, provide visual clues and gestures to aid in comprehension, and use repetition and paraphrasing to reinforce understanding (American Stroke Association, 2018)
- Give Mr Brown time to process information and formulate responses, avoiding interrupting or finishing sentences for him and allowing him to complete his thoughts
- Introduce and assist Mr Brown in using augmentative and alternative communication methods/devices, such as communication boards or speech-generating devices, to supplement verbal communication (Huang et al, 2021)
- Create a supportive communication environment by minimising distractions and noise in the environment, maintaining eye contact and use of non-verbal cues, and involving family members/caregivers in communication strategies
- Acknowledge and address any frustration or emotional distress related to impaired communication; if needed, consider liaising with psychologists or counsellors for additional support
- Regularly evaluate and document Mr Brown's progress, adjusting interventions accordingly.
Aspiration risk
Goal: To prevent aspiration and ensure safe swallowing.
Nursing interventions:
- Assess swallowing function and observe for signs of dysphagia, such as coughing, choking, or difficulty swallowing liquids/solids
- Collaborate with the speech and language therapy and dietitian teams to develop a personalised dysphagia management plan
- Implement safe swallowing techniques, such as positioning Mr Brown in an upright position during meals and for at least 30 minutes afterward; encourage him to take small bites and sips, and chew food thoroughly; teach him swallowing techniques such as the chin tuck or head turn (Choy et al, 2023)
- Provide supervision and assistance during meals as required, offering verbal clues/reminders to pace eating and encouraging proper swallowing techniques
- Modify food and liquid consistency (eg pureed, minced, soft food and/or thickened liquids), based on assessed swallowing abilities
- Teach the importance of oral hygiene to prevent respiratory infections
- Monitor for signs of aspiration (eg coughing, choking or changes in breathing patterns) and complications (eg pneumonia or respiratory distress)
- Regularly reassess swallowing function and modify the care plan in collaboration with the speech and language therapy and dietitian teams.
Nutrition
Goal: To ensure adequate nutrition and prevent complications related to decreased appetite and dysphagia
Nursing interventions:
- Assess Mr Brown's nutritional status by evaluating his weight, body mass index, nutritional intake and signs of malnutrition (eg muscle atrophy and/or poor skin integrity); consider using the Malnutrition Universal Screening Tool (https://www.bapen.org.uk/must-and-self-screening/must-calculator), also laboratory values (eg serum albumin, pre-albumin, lymphocyte count, transferrin) (Sabbouh and Torbey, 2018)
- Collaborate with the dietitian to develop an individualised nutrition plan for Mr Brown, considering modifications in texture, consistency, and portion size of meals (as mentioned above for risk of aspiration); ensure the plan includes adequate calories, protein, vitamins, and minerals for Mr Brown (Ko and Shin, 2022)
- Assist and encourage Mr Brown on regular teeth brushing, flossing, and mouth rinsing
- Provide adaptive feeding techniques and equipment, such as utensils with built-up handles or plate guards, to assist Mr Brown in self-feeding
- Monitor fluid intake, ensuring Mr Brown maintains adequate hydration by offering small, frequent sips of fluid throughout the day
- Evaluate and address factors affecting appetite (eg medication side effects, depressed mood or pain)
- Regularly reassess Mr Brown's nutritional status and adjust interventions accordingly.
Reducing risk of complications
Goal: To minimise the risk of complications associated with stroke through medication concordance, knowledge enhancement, and engagement in lifestyle modifications.
Nursing interventions:
- Assess Mr Brown's current knowledge and understanding of stroke management, medication regimen and lifestyle modifications
- Provide comprehensive education about stroke complications and the importance of medication adherence, lifestyle modifications (such as diet, exercise and smoking cessation), and regular follow-ups with the healthcare team
- Administer medication prescribed for the management of stroke or prevention of complications and evaluate its effectiveness. This might include antiplatelet agents (eg aspirin), anticoagulants once intravenous thrombolysis has been completed (eg warfarin), calcium channel blockers (eg amlodipine, as per previous prescription for Mr Brown) or statins (eg atorvastatin, as per previous prescription for Mr Brown) (NICE, 2022)
- Collaborate with the multidisciplinary team to ensure clear communication and consistent messaging regarding the management of stroke and prevention of complications
- Assess barriers to medication concordance and develop strategies to address them, such as simplifying medication schedules, providing reminders, or involving a family member or caregiver in medication management (Paterson et al, 2017; Elnaem et al, 2020)
- Encourage the use of reminder systems, such as pill organisers or smartphone/tablet app to enhance medication adherence
- Provide written materials or visual aids to reinforce key points about stroke management, medication regimen and lifestyle modifications
- Promote engagement in healthy lifestyle behaviours, such as regular exercise, a balanced diet and smoking cessation, by discussing the benefits and providing resources or referrals to appropriate support services (Lennon et al, 2021)
- Monitor and evaluate the effectiveness of education and interventions through regular follow-ups and reassessments of knowledge, adherence and lifestyle changes
- Provide ongoing support, encouragement and reinforcement of positive behaviours, and adherence to the care plan.
Conclusion
Neurological conditions, such as stroke, can have profound effects on individuals' physical, cognitive, and emotional wellbeing. By developing a comprehensive understanding of the nervous system and associated disorders, nurses can provide competent and compassionate care, tailored to each patient's unique needs.
Nurses skilled in the care of individuals with neurological disorders contribute significantly to the multidisciplinary healthcare team, collaborating with physicians, speech and language therapists, physiotherapists, occupational therapists, dietitians and other health professionals. Indeed, their expertise in neurological assessments, medication management, rehabilitation strategies and patient education enhances the quality of care and improves patient outcomes.
KEY POINTS
- Neurological disorders pose significant risks to the multiple dimensions of the health of an individual if not properly managed, requiring comprehensive assessment and evidence-based management strategies to minimise complications and improve quality of life
- Nursing professionals play a crucial role in multidisciplinary teams, conducting thorough assessments and developing personalised care plans to address the diverse needs of patients with neurological disorders
- Effective nursing care plans for individuals with neurological disorders prioritise holistic approaches, evidence-based interventions, person-centred care and continuity of care, to promote patient empowerment and optimise outcomes
- Collaboration between health professionals enhances the quality of care and supports individuals with neurological disorders through assessments, medication management, rehabilitation and education
CPD reflective questions
- Reflect on the psychological impact of stroke on both the patient and their family. How might you support them effectively through the emotional challenges associated with stroke recovery?
- Are there specific aspects of caring for patients with stroke where you feel your skills may need some development? How could you enhance your knowledge and skills in these areas to provide more comprehensive and evidence-based care?
- Recall a patient you have cared for who has had a stroke. In hindsight, how could their management have been improved to better address their unique needs and optimise their recovery journey? What strategies would you implement differently in similar cases moving forward?