The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [238]
Evidence-based approaches
Principles of care
The general principles of care mentioned earlier in the chapter are all relevant to this section. However, there are also some other principles that need to be considered for these patients. For those with acute and long-standing neurological issues, principles of moving and positioning can be applied at any time along their treatment trajectory for those with rehabilitation potential, deteriorating function and those requiring palliative management. Posture and postural control will be affected in these patients. ‘Posture’ describes the biomechanical alignment and orientation of the body to the environment (Shumway-Cook and Woollacott 2001), ‘postural control’ provides orientation and balance (Lundy-Ekman 2007). Positional influences in the patient with neurological impairment may affect spinal, pelvic and shoulder girdle alignment with risk of soft tissue shortening due to the following potential problems.
Flattened lumbar spine.
Extended thoracic spine.
Pelvis tilted backwards.
Retracted hip.
Elevated shoulder, retracted scapula.
Feet tend toward plantarflexion (Shumway-Cook and Woollacott 2001).
Therefore, additional considerations should be applied for the neurological patient with severe tonal management issues. These should always be discussed with the physiotherapist.
Preprocedural considerations
The general principles of moving and positioning patients can be applied when assisting those with complex neurological impairment. Patients with neurological impairment may be able to participate in usual transfer techniques but risk assessment will consider several additional factors. This section will identify considerations for staff in their decision making. Where there is any doubt when moving patients with complex needs, guidance should be sought from a physiotherapist/occupational therapist.
Patients with neurological deficits may vary in their presentation on a daily basis. The additional considerations for positioning and moving patients with neurological impairment are listed in Box 7.4.
Box 7.4 Considerations for moving patients with neurological impairment
Variations in tone, for example flaccidity or spasm.
Cognitive problems including attention deficit.
Behavioural problems.
Communication problems.
Variable client ability, for example ‘on/off’ periods for patients with Parkinson’s disease and patients with changing presentations, for example multiple sclerosis, degenerative conditions.
Sensory and proprioceptive problems, including reduced midline awareness
Pain/altered sensitivity.
Decreased balance and co-ordination.
Visual disturbance.
Varying ability over 24 hours, for example, fatigue at the end of the day, at night.
Effects of medication.
Varying capability of the patient according to the experience and/or skill mix of handler(s).
Post surgery, presence of tracheotomy, chest and other drains.
Traumatic and non-traumatic spinal injury – risk of spinal instability.
Importance of maintaining privacy and dignity.
(CSP 2008, p.26)
Equipment
Splints and orthoses
In advanced spasticity, it is often the soft tissue changes that contribute most to subsequent disability, such as limb deformity leading to poor function and problems with regard to hygiene, positioning, transferring and feeding and making the individual prone to pressure sores (O’Dwyer et al. 1996). Therapeutic splinting may maintain and assist function (Edwards 1998, Raine et al. 2009, Shumway-Cook and Woollacott 2001).
An orthosis or splint is an external device designed to apply, distribute or remove forces to or from the body in a controlled manner in order to control body motion and prevent alteration in the shape of body tissues. The aim is to compensate for weak or absent muscle function