WELCOME TO WARD 23b
NINEWELLS HOSPITAL
JUNIOR (1st year)
STUDENT NURSE
ORIENTATION PACKAGE
Name………………...
Mentor……………
Last Reviewed Dec 2014
CONTENTS
 Welcome
 Objectives
 Revision of Anatomy and Physiology
 Common Terminology
 Routine Investigations
 Equipment
 Evaluation Sheet
WARD ORIENTATION
1 Introduction to you mentor
2 Orientation to the ward, the telephone system and the bleep system.
3 Location of emergency equipment (Arrest Trolley, Defibrillator Emergency buzzer, Oxygen
and Suction points)
Emergency telephone number for fire/cardiac arrest -2222 Ward 23b
4 Explanation of the fire drill/equipment/fire exits
5 Introduction to ward staff and members of the multidisciplinary team.
6 Off duty
7 Orientated to teaching packages and ward post-operative guidelines.
Welcome to ward 23b
Welcome to ward 23b, and to the Neurosciences Directorate. Ward 23b is a 20-bedded ward.
Within this there are 4 high dependency beds. All trauma cases and patients requiring certain
types of surgery to their head are nursed in this area. Ward 23b is a mixed ward. We deal with
all types of surgery pertaining to the head and spine. A daily ward round takes place each
morning where all patients are seen. Each Monday morning there is a multidisciplinary
meeting where all the patients are discussed with all the members of the team. There are two
nursing teams within the ward: the red team and the green team. 12 hour shifts are worked in
the ward. You will work the core 8 hour shift pattern.
The main types of surgery you will see during your placement with us include:
Craniotomy for removal of cerebral lesion
Lumbar discectomy for removal of prolapsed intravertebral disc
Cervical fusion
Neurosurgery is an exciting area and you will also see a variety of other types of surgery to
enhance your Neurosurgical knowledge while you are with us.
Senior members of staff:
Consultants: Mr Ballantyne , Mr Mowle and Mr Galea, Mr Hossain-Ibrahim
Head of Patient Care: Sandra Larkin
Senior Charge Nurse: Paola Niven
Charge Nurses: Ruth Jolly, Karen Kose, Clare Napper
We hope you enjoy your placement with us.
NURSING OBJECTIVES
DISCUSSED
1 Observe and participate in
patients personal hygiene needs
(washing, dressing, eye and mouth
care)
2 Observe and participate in
urinary catheter care.
3 Observe and participate in
recording of vital signs (SEWS).
Observe use of Glasgow Coma
Scale- Neurological Observations
4 Observe and participate in
pressure area care. Explanation of
special beds and mattresses
5 Observe and participate in the
admission and discharge procedure
of the Neuroscience patient
6 Observe and participate in
monitoring the nutritional needs of
the Neuroscience patient. Be aware
of feeding aids
7 Observe other types of
nutritional support (Nasogastric,
PEG Feeding)
8 Observe and participate in
monitoring and recording fluid
intake and output
9 Observe and have explanation of
nursing documentation.
10 Explanation of infection control
practices and participation in use
of PPE and hand hygiene
11 Observe and participate in
communication with all members
of the multi-disciplinary team
12 Visit physiotherapy department
with Neuroscience patient
13 Visit occupational therapy
department with Neuroscience
patient
DEMONSTRATED
ACHIEVED
Revision of the Anatomy and Physiology of the Nervous System
The Skull
The skull is a bony structure and is made up of two parts, the cranium and the face.
The cranium consists of eight bones:
One frontal bone (This is the bone of the forehead)
Two parietal bones (These bones form the sides and the top of the skull)
Two temporal bones (These bones lie on either side of the head and are divided into four
parts)
One occipital bone (This bone forms the back of the head and part of the base of the skull)
One sphenoid bone (This bone forms the middle portion of the base of the skull)
One ethmoid bone (This bone forms the anterior part of the base of the skull and helps to form
the orbital cavity, the nasal septum and the lateral walls of the nasal cavity)
The Brain
The brain makes up about one fiftieth of the body weight and lies within the cranial cavity.
The structures that form the brain are:
The cerebrum of fore brain-This is made up of the cerebral hemispheres, the thalamus and the
basal ganglia.
The brain stem-This is made up of the midbrain, the pons varolli and the medulla oblongata.
The cerebrum or hind brain.
The Meninges
The brain and the spinal cord are completely surrounded by three membranes known as the
meninges. Starting with the outer these are:
The dura mater-A double layer that lines the inside of the skull. The outer layer is the
periosteum of the bone. The inner layer extends throughout the skull creating compartments.
There are four folds of dura in the skull cavity, which support and protect the brain. The spinal
dura is a continuation of the inner layer. The outer layer stops at the foramen magnum.
The arachnoid mater-Thin and delicate, it loosely encloses the brain. The spinal arachnoid is a
continuation of the cerebral arachnoid. As it contains blood vessels it can be damaged by
lumbar or cisternal puncture which can result in haemorrhage.
The pia mater-Mesh like and vascular, it covers the surface of the brain. It dips down between
the convolutions of the brain surface. When it reaches the spinal cord it is thicker, firmer and
less vascular.
The Spine
The spine is made up of 32-34 vertebrae, which are grouped in 5 regions:
 7 Cervical-The cervical vertebrae are smaller than those in the other areas of the spine.
The first vertebra is known as the atlas. The second vertebra is known as the axis. Each of
these are unique in shape. The axis has a projection called the odontoid peg upon which
the atlas sits. This allows for the rotational movement of the head.
 12 Thoracic-The thoracic vertebrae are intermediate in size, but become larger as they
reach the lumbar vertebrae.
 5 Lumbar-The lumbar vertebrae are the largest.
 5 Sacral-The vertebrae now start to decrease in size as weight is transferred to the hip
bones and the legs.
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3-5 fused-Which is known as the coccyx
Along with the intervertebral discs the vertebrae form a jointed column. When viewed from
the side it has curvatures, concave posteriorly in the cervical and lumbar regions, and concave
anteriorly in the thoracic and sacral regions. When a child is born the spine has a single
primary curve, concave anteriorly. The secondary curves in the cervical and the lumbar
regions appear in the first two years of a child’s life as they learn to hold their head up and
learn to walk.
Movement of the spine
Movement between the individual vertebrae is restricted in order to protect the spinal cord.
Movement of the spine as a whole consists of a) Flexion b)Extension c)Lateral flexion
d)Rotation. There is more movement in the cervical and the lumbar regions than anywhere
else.
Suggested further reading:Hickey, JV. (1997). “The clinical practice of Neurological and
Neurosurgical Nursing. Fourth Edition. Chapter Five Pages 35-79.
ROUTINE INVESTIGATIONS
CT Scan
CT Scan stands for computerised axial tomography scan. Beams of x-ray slice through the
patient’s body and are read by a detector on the opposite side. The scan shows varying
densities of tissue. It is useful for identifying cranial lesions such as abscesses, cysts,
haematomas, hydrocephalus and primary and metastatic tumours.
MRI Scan
Similar to a CT scan but no radiation is used. The images are extremely clear and detailed. It
provides anatomical information about the chemistry and physiology of living tissue.
Particularly effective in detecting necrotic tissue, oxygen deprived tissue, small malignant
tumours and degenerative disease within the central nervous system. When lying on the MRI
table the patient is in a strong magnetic field. Any patients with invasive metallic objects, i.e.
aneurysm clips or pacemakers cannot be exposed to MRI.
Angiography
The cerebral vessels are visualised by the injection of radio-opaque contrast medium and then
a series of x-rays are taken. It is performed to demonstrate abnormalities in the cerebral blood
flow and also to demonstrate how vascular defects are in relation to the position of the
cerebral arteries, i.e. cerebral aneurysms, arteriovenous malformations (AVM).
Lumbar Puncture
A spinal needle is inserted into the space between lumbar vertebrae 3 and 4 or 4 and 5 to
obtain a specimen of cerebrospinal fluid, (CSF) for analysis. It may also be carried out to
measure the pressure of CSF, to introduce drugs or for spinal anaesthesia during surgery.
TYPES OF CEREBRAL TUMOUR
Tumours involving cerebral hemispheres are likely to present with epilepsy and progressive
motor and sensory deficits on the opposite side. Frontal or temporal tumours may produce
psychiatric symptoms and may reach a large size before being recognised. Progressive visual
problems may be due to compression of the visual pathways by i.e. meningioma or
craniopharingioma. Posterior fossa tumours present with headaches, papilloedema and
possibly poor balance and co-ordination.
Gliomas
The most common primary intracranial tumour and the range of malignancy is wide. Radical
excision is practically impossible, as there is no clear edge to the tumour.
Glioblastomas
Rapid growing, not controlled by therapy, prognosis poor.
Astrocytomas
Show a wide variation in malignancy. Some evolve slowly over many years. Surgical
treatment is of limited value and there is no effective therapy.
Meningeomas
These are benign and from 15% of all intracranial tumours. If the meningioma is removed
completely the outlook is good. Even when the tumour is not completely removed growth may
continue very slowly. There is recurrence.
Accoustic Neuromas
Symptoms: tinnitis, deafness and vertigo.
Deafness and vestibular loss on the affected side are often present before surgery and persist
afterwards. Facial palsy can also be present. Some surgeons advise partial excision. The
outlook is much better when the tumour is small.
Pituitary Tumour
Symptoms: Visual problems, headaches, paresis of extraocular muscles, endocrine disorders
(e.g. acromegaly, and gigantism)
Surgical removal is usually carried out via a transnasal route and then followed by
radiotherapy. Prognosis is very good to excellent.
HEAD INJURY
Approximately one million people in the United Kingdom attend hospital each year following
a head injury. Of these 1000,000 are admitted to hospital and 10,000 are transferred to a
neurosurgical unit.
(Gentleman and Patey, 1998)
Head injury is more common in males than females. The commonest age group is 15-29 and
then over 65 years of age.
Some of the common causes of head injury seen in ward 23b are: Road Traffic Accidents,
Falls, Assaults, Sports Injuries and Industrial Accidents.
Types of Injury
Diffuse Injury
 Concussion: The word concussion means to shake violently. A cerebral concussion is
defined as a transient, temporary neurogenic dysfunction caused by mechanical force to
the brain.
 Diffuse axonal injury: Is a primary injury of diffuse microscopic damage to axons in the
cerebral hemispheres, corpus callosum and brain stem.
(Hickey, 1997)
Focal Injuries
 Cerebral Contusion: Bruising of the surface of the brain
 Cerebral Laceration: Traumatic tearing of the cortical surface of the brain
 Intracranial Haemorrhage: A common complication of head injury. Can occur beneath
a fracture or from an acceleration-deceleration injury.
(Hickey,
1997)
Penetrating Injuries
These can be described as:
 Tangential injuries where the cranial cavity is not entered but the result of the injury is a
depressed skull fracture, scalp laceration, and meningeal and cerebral contusionlaceration.
 Penetrating injuries where the cranial cavity is entered resulting in bone fragments, hair
etc within the brain.
(Hickey, 1997)
Damage to the skull
If the skull is fractured the bone will heal itself. The reason that patients are admitted to
hospital is as a precaution to prevent further injuries such as infection. If the fracture is
depressed with fragments projecting inwards then there is an increased risk of infection and
epilepsy.
Assessment of conscious level
The Glasgow Coma Scale (GCS) WAS DEVELOPED IN Glasgow in 1974 and is now used
all over the world to standardise observations for the objective and accurate assessment of
level of consciousness. The GCS is especially useful to monitor changes in unstable comatose
patients and during the first few days after an injury. In ward 23b all patients sustaining and
trauma/surgery to their head will be assessed using the Glasgow Coma Scale.
Head injury is a vast subject and this is a very brief overview. Therefore I have suggested
further reading material below.
Suggested further reading
Hickey, J.V., (1997). “The clinical practice of Neurological and Neurosurgical Nursing”.
4th Edition. Lippincott, Philadelphia.
References
Gentleman, D. and Patey, R. (1998). Trauma Care: Beyond the resuscitation room. Chapter
six. Head Injury. Driscoll, P and Skinner D. (Eds). BMJ Publishing Group.
Hickey, J.V. (1997). The clinical practice of neurological and neurosurgical nursing. 4th
Edition. Lippincott, Philadelphia.
SUBARACHNOID HAEMORRHAGE
Sub arachnoid haemorrhage (SAH) and intracranial aneurysm have been conditions of humans
for thousands of years. (Morita et al., 1998)
The incidence of subarachnoid haemorrhage is estimated to be around 1-8% of the population.
Aneurysms most commonly occur at the bifurcation of the major arteries within the Circle of
Willis as the arterial wall is weaker here. The two most common sites are the anterior
communicating artery (35-40%) and the middle cerebral artery (20-25%). Multiple aneurysms
are found in 20-30% of all patients. The most common age group is 40-60 years of age with a
female to male ratio of 3:2 (Rees et al., 2002).
Clinical Presentation
Sudden onset of severe headache is the most common presenting symptom of aneurysmal
rupture. The patient may or may not have nausea and vomiting. Depending on the severity of
the SAH the patient’s neurological status may be intact, poor or even deteriorate rapidly after
admission. These patients are always monitored closely using the Glasgow Coma Scale. The
prognosis of SAH is very much dependant on the initial clinical presentation (conscious level
and neurological deficit) as this is a good indicator of the severity of the brain injury. Other
factors that can also influence the outcome of SAH include delayed cerebral arterial;
vasospasm, hydrocephalus and aneurysm re-rupture (Morita et al., 1998).
Treatment
The first choice of treatment for a cerebral aneurysm is coiling or embolisation. Because this
procedure is not currently performed in Dundee, patients are transferred to Edinburgh as
emergency transfers, have the procedure performed and return to us when their condition is
stable.
Nursing Care
 Bed rest and nursed flat
 Fitted with anti-embolitic stockings
 Full set of vital signs and Glasgow Coma Scale recorded. ½-4 hourly depending on the
patient’s condition.
 Nursed in as quiet an environment as possible and visitors restricted as patient’s condition
dictates
 Regular analgesia prescribed and given for headache
 Ensure a fluid intake of 3 litres in 24 hours
 Close observation of intake and output by accurate fluid balance
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Administer prescribed apperients and ensure patient does not become constipated
The patient may require to have a urinary catheter passed due to enforced bed rest and
high fluid intake
Complications
 Seizures
 Hydrocephalus
 Re-bleeding
 Cerebral vasospasm
Early specialist rehabilitation improves the quality of life for patients, (Hickey, 1997).
Again subarachnoid haemorrhage is a vast subject and this is a very brief overview.
References
Hickey, J.V. (1997). The clinical practice of Neurological and Neurosurgical Nursing. 4th
Edition. Lippincott, Philadelphia.
Morita, A., Puumala, M.R., Meyer, F.B(1998). Outcomes in Neurological and Neurosurgical
Disorders. Chapter six. Intracranial aneurysms and subarachnoid haemorrhage. Swash M (Ed).
CambridgeUniversity Press.
Rees, G., Shah, S., Hanley, C., Brunker, C. (2002). Subarachnoid Haemorrhage: a clinical
overview. Nursing Standard. 16, 42, 47-54.
Some Common Terms Used In Neurosurgery
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ACROMEGALY-Overgrowth of the skeleton and organs due to excessive release of
growth hormone from a pituitary tumour
ADENOMA-Benign Tumour
ANEURYSM-Abnormal dilation of an artery
ANGIOMA-Congenital swollen collection of blood vessels
APHASIA-Loss of the ability to speak
APRAXIA-Loss of skilled movements despite preservation of power, sensation and coordination
ATAXIA-Loss of the ability to co-ordinate voluntary movements
BULBAR PALSY-Weakness of the tongue, pharynx, and larynx due to disease of the
lower cranial nerves
CEPHALIC-Relating to the head
CONTUSION-Bruising
CORDOTOMY-Neurosurgical procedure to destroy specific pathways in the spinal cord
CRANIOPHARYNGIOMA-Congenital tumour of the base of the skull
CRANIOPLASTY-A repair to the skull to re-establish the contour and integrity of the
skull
CSF-Cerebro-spinal fluid
CRANIOTOMY-Neurosurgical procedure to open the cranial cavity
DIABETIS INSIPIDOUS-Failure of the posterior pituitary gland causing reduced release
of anti-diuretic hormone
DISCECTOMY-Surgical removal of a disc
DYSARTHRIA-Inability to pronounce
DYSPHAGIA-Inability to swallow
EPIDURAL-Upon or external to the dura
EXTRADURAL-External to the dura mater
FACETECTOMY-Surgical procedure to remove part of the facet joint
FENESTRATION-The surgical creation of an opening
GLIOMA-Malignant tumour of the glial cells of the brain
HEMIANOPIA-Loss of sight affecting one half of the visual field
HEMIPARESIS-Weakness of one side of the body
HYDROCEPHALUS-An excess of CSF inside the skull due to an obstruction in the
normal CSF circulation
LAMINECTOMY-Removal of the vertebral lamina
LOBECTOMY-Surgical resection of a lobe of the brain
MENINGITIS-Inflammation of the meninges
MENINGES-The surrounding membranes of the brain and spinal cord
MENINGIOMA-Slow growing tumour arising in the meninges
NEUROMA-Tumour derived from nerve cells
NYSTAGMUS-To and fro movement of the eyes
PAPILLOEDEMA-Swelling of the optic nerves
PHOTOPHOBIA-Intolerance of light
POSTERIOR FOSSA-Back of the skull
PTOSIS-Abnormal dropping of the eyelid
QUADRIPLEGIA-Paralysis affecting all four limbs
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RHINORRHEOA-CSF leak from the nose
SEIZURE-Sudden disturbance of consciousness or sensorimotor function
SPONDYLOSIS-Degeneration of the spine
SUBARACHNOID SPACE-Between the arachnoid and pia mater layers. Contains CSF
SUBDURAL-Beneath the dura mater
SYRINGOMYELIA-Expanding cavity within the spinal cord
THALAMOTOMY-Neurosurgical procedure to destruct part of the thalamus
Orientation Package
Evaluation
1 Did the information in the orientation package help you to become familiar with the ward
environment?
2 Was the information useful and aimed at the correct level for you?
3 Were you introduced to your mentor?
4 Did you work sufficiently with your mentor to be able to achieve the set learning objectives
in the package?
5 Did you feel the learning objectives were relevant and achievable?
6 Do you feel there is sufficient learning material in the ward to enhance your knowledge of
Neurosurgery?
7 Is there anything you would have liked to be included in this package?
Space has been left after each question for you to comment. Please feel free to do so. We
value your comments and would ask that you fill out this evaluation sheet and hand it back at
the end of your placement.