Student name

Practice Assessor

Practice Supervisor
University & cohort

Placement dates
 WARD PROFILE

Bernard Sunley Ward is a 28 bedded male Neurosurgical Unit, consisting of four bays
and three side rooms.
Nursing staff on Bernard Sunley work the following shifts:
0745 – 2015 day shift
1945 – 0815 night shift
There will be a bedside handover at the start of every shift, so you should be on the
unit five minutes prior to the start of your shift to see who you will be mentored by that
day and your allocation of patients. This will be visible in the ward diary.

Daily Routine

0745 Handover
0815 Morning drug round.
Breakfast prepared by ward hostess & given out by staff
Assist all patients that need help to sit out for breakfast.
0900 Assist patients with their wash.
1000 Observations
Continue to assist patients with their ADLs, liaising with ward therapists.
Doctors rounds take place approximately between 0900 – 1100, with the nurse-in-
charge.
1200 Midday drug round

1200 – 1300 Lunch(Protected Meal time)

As part of the European Directive on Nutrition, this ward has a period of protected
mealtimes for patients, in order to allow patients to enjoy their meals without being
disturbed. Patients with Red Trays will require assistance to eat.

1300 – 1400 Patient Rest Period.

1400 Observations
Complete and review Nursing Care Plans
Review fluid balance charts & bowel charts
Complete Waterlow scores, nutrition assessments and SSKIN bundles
Answer call bells ward-wide
1800 Evening drug round
Dinner
Observations
Complete patient evaluations
1945 Handover
Important Information

Our emergency number is 2222

Emergencies consist of any clinical emergency – not just cardiac arrest
However please state cardiac arrest whatever the cause as switchboard operators
respond best to this. You must then clearly state your location:
‘Bedspace’
Bernard Sunley Ward
3rd Floor, Chandler Wing
The National Hospital for Neurology and Neurosurgery

The red emergency alarm found at each bedside only notifies ward staff of an
emergency situation.

Telephones& Bleeps

To bleep: Dial 11, listen to the automated message which will prompt you for the bleep
number, followed by the phone extension number you are calling from, followed by the
# key.
Within the hospital all departments are reached via their extension numbers.
If you cannot find the appropriate number please dial 0 for the operator (The operator
is based at the main hospital so always clarify that you want the National).
For an outside line, dial 9 before entering the number.
Bernard Sunleys direct line is 0203 4484703 or 0203 4483263
For eating, there is a cafeteria on site located on the lower ground, called the
Spice of Life, open from 8am – 8pm.
There are also cafeterias around the corner at the Homeopathic Hospital and Great
Ormond Street Hospital (GOSH).

Hospital policies
It is a good idea to familiarise yourself with our hospital policies, please ask your
mentor where they can be found.

Visitor policy:
Visiting times 14:00-19:00
Try to limit visitors to 2 per patient at a time.
Encourage visitors to bring food daily rather than storing in ward fridge.
 BASIC NEUROSCIENCE ANATOMY &
PHYSIOLOGY

Nervous System:

Divided in two parts: Central and Peripheral

CNS (Central Nervous System): Is made up of the brain and the spine
Peripheral Nervous System: is made up of peripheral nerves and ganglia outside the CNS
 Neurons:

The neuron (or nerve cell) is the most important component of the nervous system. Its main
function is to rapidly process and transmit information. (Colm Treacy 2011). We are made up of
300-500 billion neurons (Mestecky at al 2011) that communicates with each other via chemical
synapses (neurotransmission).

Central Nervous System:

Main Protective Structures

The CNS is the most delicate organ of our body and therefore need particular protection.
THE SKULL:

This bony structure is made up of large flat bones that connect with each other via “sutures” all
around the brain.
The bones involved are:

 Frontal bone: (the anterior part of your head)

 Parietal bones (left and right side of your head)
 Occipital bone (back of the head)
 Temporal (below the parietal bone, at the level of your ear)
 Sphenoid bone (in the middle of the base of the skull, protecting a considerable number
of cranial nerves and major blood vessels)
 Ethmoid bone (Separate the nasal cavity from the cranial cavity)
The Meninges

The meninges are three layers of

connective tissue of different thickness just under the skull. Their main function is to protect the
brain acting as a cushion in case of traumatic impacts, as a barrier in case of external pathogen
that can otherwise cause infections, and as a source of CSF flow and re absorption.

Layers:
 Dura mater: The outer layer. Just under the skull. Defining the sub- Dural space.
 Arachnoid: The middle layer. Defining the Arachnoid space
 Pia mater: The inner layer. Protects the brain itself.

Cerebral Spinal Fluid (CSF)

CSF is another component of our nervous system involved in protection.
What you need to know!
 Where it is produced?: It is produced by ependymal cells in a leafy structure in the
middle of the brain called choroid plexus and it is absorbed by the arachnoid villi in the
arachnoid space. We produce about 400-500ml of CSF a day, and it is important that this
volume is maintained stable throughout the day, in order to maintain homeostasis.
 What it is?: It`s a clear/watery coloured fluid that flows in the arachnoid space, involved
in reducing friction and providing buoyancy to CNS protection. It`s made up of glucose,
protein, leucocytes.
 What is its main function?: It continuously helps the system to clear off waste
substances or any other organism that can affect the physiological function of the brain. It
also works as a cushion, providing protection from traumatic impacts.

Intracranial Pressure & Monroe Kelly Theory

Monroe Kelly hypothesis is a key concept in neuroscience! It helps us healthcare practitioners

to understand why it is important to keep a balanced pressure in our nervous system and how to
do so. Once this theory is understood, we are able to make informed decision about how to
managed patients with changed in their ICP (Intracranial Pressure).
Let`s concentrate on three main components:
1. Brain parenchyma(tissue)- 83% of intracranial volume
2. Cerebral blood volume(CBV)- 8% of intracranial volume
3. Cerebrospinal fluid( CSF)- 9% of intracranial volume (Mesteky 2011)

These components occupy a certain space in the intracranial vault, and this space should be
maintained stable. There is a minimal capacity left for them to change in quantity.
If there is an increase in volume of a single one of the components, one of the other two left has
to decrease accordingly, in order for the intracranial vault and the body, to preserve optimally
their physiological vital functions.
This is how our body maintains Homeostasis of ICP: Compensating any changes in the volume
of one of the components!
If this fails to happen, a healthcare needs to intervene to restore raised ICP.
Normal ICP values are between 0 and 10mmHg.

Cranial Nerves

Where They Are And How Are They Called?

What Is Their Function?

Summary of Cranial Nerves

No. Name Function
I OLFACTORY Sense of smell
II OPTIC Sense of sight
III OCULOMOTOR Eye Movements
 IV TROCHLEAR Eye Movement
V TRIGEMINAL Sense of touch to face & Muscles
of mastication

VI ABDUCENT Eye Movement

VII FACIAL Muscles of facial expression
VIII VESTIBULOCOCHULEAR Sense of Hearing & Balance
IX GLOSSOPHARYNGEAL Sensory to oropharynx & supplies
stylopharyngeal

X VAGUS Parasympathetics to body &

muscles to the palate

XI ACCESSORY Supplies sternoclavicularmastoid

& Trapezius

XII Hypoglossal Supplies muscles of the tongue

Functional Areas Of The Brain

ASSESSMENT OF CONSCIOUSNESS

Glasgow Coma Scale

 It is the gold standard in the assessment of consciousness.

 Developed to assess the impairment of consciousness and coma, primarily those who
have had a head injury and now used to assess LOC in patients with different
neurological problems.
 It is divided into 3 sections:
o Eye Opening
o Verbal Response
o Motor response
o
 

NEUROSURGICAL INVESTIGATIONS
Non-Invasive Procedure:
Conventional Radiography (X-Ray)
X-rays may be ordered to determine if the skull has been fractured following head trauma. The
need of x-rays has been dramatically reduced in the light of contemporary procedures such as
computed tomography (CT) and magnetic resonance imaging.
Indication:

-Trauma and fracture of the skull (especially in children)

-Tumours of the skull
-Older shunt model valve setting checks

Computed Tomography
CT is a technique that uses x-rays to produce a cross-sectional image of internal structures of the
body. CT images of the head can show the differences and boundaries between brain tissues,
bone, blood, cerebrospinal fluid (CSF) and air. CT is the most common form of neuroimaging
used. It is the method of choice to demonstrate intracranial haemorrhage and hydrocephalus.
Indications:
 Brain mass/tumour
 Fluid collection, such as an abscess
 Haemorrhage
 Hydrocephalus
 Ischemic process, such as stroke
 Trauma or fracture of skull

Magnetic Resonance Imaging (MRI)

MRI is considered a chief tool in neuroscience diagnostics. MRI scanning uses a powerful
magnetic field, pulses of radio waves and a computer to produce detailed images of the internal
structures of the body.

Indication:
 MRI provides more detailed images of soft tissue

Electroencephalogram (EEG)

EEG is where 10 to 12 electrodes are applied to the scalp to capture spontaneous electrical
activity from the brain. A trace in form of waves is registered.
Indication:
 Diagnose epilepsy
 Define the patient`s epilepsy syndrome
 Prior to epilepsy surgery in order to identify the epicentre of the epilepsy.
Invasive Procedure:

Angiography:
Cerebral angiography is an invasive procedure that provides images of the vasculature of the
brain. A catheter is inserted under local anaesthetic into the femoral artery and a contrast medium
is injected via the catheter to high-light cerebral blood vessels.
Indication:
 Angiography can provide detail of the anatomical structure of vascular malformation and
aneurysms.
Post-procedure:
 Pressure is applied to the groin site using manual pressure or with a pressure device such
as femostop.
 Patient remain supine in bed for 2 hours, with the head of the bed at 30 degrees or less to
reduce the risk of haemorrhage at the groin site.
 Neurological observations are completed quarter hourly for the first hour to detect any
neurological change and then reduced to half hourly. Bilateral pedal pulses and
monitoring of the colour, temperature and sensation of the lower limbs should be
undertaken, with neurological observations, to examine for vascular interruption.
 Groin site is checked for possible haemorrhage or haematoma formation every 15
minutes for at least the first hour, followed by half hourly checks.
 Fluids should be encouraged to aid removal of the contrast agent from the body more
speedily.
 Thereafter the patient can slowly be raised in bed and mobilised after 4 hours, if their
condition allows.
Please refer to policy about specific observation to be carried out for the above procedure.

Complications:
 Puncture site haematoma
 Transient or, in rare cases, permanent neurological deficit.
 Adverse reaction to the contrast medium
 Groin or cervical vessel dissection.

Lumbar Puncture (LP)

 Lumbar puncture is a medical procedure whereby a needle is inserted into the lumbar
subarachnoid space to attain CSF. The needle is usually inserted between the 3rd and 4th lumbar
vertebrae, to prevent accidental puncturing of the spinal cord, which terminates between L1 and
L2.
Indications:
 Performed for either diagnostic or therapeutic purposes.
 CSF analysis to diagnose different neurological conditions (i.e. polyneuropathies,
multiple sclerosis, subarachnoid haemorrhage, meningitis and encephalitis.)
 CSF pressure can be measured at the time of LP using a manometer.

Contraindications:

 Presence of raised ICP as herniation can occur.

 Non communicating CSF spaces such as a syrinx or obstructive hydrocephalu

Post-procedure:

 Patient can rest or mobilise after procedure

 Confinement to bed does not determine whether a patient complains of post lumbar
puncture headache.
 Headache following an LP is usually the result of CSF leakage and usually occurs within
48hrs of the procedure.
 A blood patch seals the puncture site to prevent CSF leak.
  Patient is encouraged to rest for 2hrs post LP.
 Monitor LP site for evidence of CSF leak and to assess the patient for post-lumbar puncture
headache.

MOST COMMON DRUGS USED IN

NEUROSURGERY

These are some of the common drugs that we use on the ward. It would be good for
you to familiarise yourself with them
Analgesia
Paracetamol
Codeine Phosphate
MST – MST &Oramorph
Diclofenac
Gabapentin

Anti-emetics
Cyclizine
Ondansetron
Metoclopramide

Anti-convulsant
Phenytoin
Sodium Valproate
Carbamazepine

Cortico-steroids
Dexamethasone
Hydrocortisone
 Prednisolone

Laxatives
Lactulose
Senna
Laxido
Glycerine suppositories & Phosphate enema

We would expect some knowledge in other common drug groups:

Anti-hypertensives, diuretics, muscles relaxants, antibiotics, and those for the control of
diabetes.

External Ventricular Drain

A device that allows the temporary relief of critically raised intracranial pressure or it can be
used to drain infected or bloodstained CSF, before definitive shunt surgery. It is inserted in the
lateral ventricles and connected to a closed connection system outside of the body.

Indications:
 Temporary drainage for infected or blocked shunts
 Short-term treatment of raised ICP
 Diversion of blood-stained or infected CSF
 Measurement of CSF pressure

Complications:
 Haemorrhage (from damage to vascular structures)
 Infection:
o Pyrexia
o Change in level of consciousness
o Evidence of meningism
o Neck stiffness or Kernig’s sign
o Headache, vomiting, photophobia, lethargy, irritability, confusion
 o Changes in CSF appearance
o Exudate at EVD insertion site

Lumbar Drain
A lumbar drain consists in a thin drain inserted in the dura compartment of your spine, with the
aim of draining CSF. Distally, the Lumbar drain is attached to a collection set. This set is made
up of a chamber that collects hourly CSF and needs to be monitored by the nurse. The CSF
collected in the chamber, is drained in a 500mls bag.
Usually is kept 3 to 5days for monitoring of CSF.

Indications:
 Hydrocephalus
 Dura leak repair
 Monitor CSF drainage

Nurse management and responsibilities:

 Check the look of the insertion site. Usually covered with tegaderm
 Make sure there is no oozing or bleeding
 Make sure the catheter is not obstructed
 Monitor GCS regularly
 Monitor amount of CSF drained according to surgeon instructions (can be hourly or less
often)
  Make sure the bag is changed with sterile technique when full

Ventriculoperitoneal shunt (VPS)

A ventriculoperitoneal shunt (VPS) is a catheter inserted in the lateral ventricle in our brain, all
the way down in our stomach. This allows the CSF produces in excess (Hydrocephalus) to be
drained and deviated into our stomach, where CSF is re absorbed.
The shunt comprehend also a reservoir valve, which is usually located at the back of one year.
This valve gives easy access to the doctor or specialist whenever a valve adjustment is needed, or
if a CSF Valve adjustment might be required if the CSF drained is not enough. To make sure the
shunt is working, GCS monitoring is required (in hospital settings).
This device can be inserted in new born for acquired hydrocephalus, or in adult age in case of
Indications:
 Hydrocephalous
Nursing management:
 Monitor GCS
 Monitor for sign of Sickness, headache, bladder dysfunction
 Monitor for fever, chills, confusion as might indicate infection

ICP bolt
In ventilated and unconscious patients is not possible to assess their level of consciousness with
non-invasive methods, therefore the use of invasive devices such as ICP bolt is required.
ICP bolts are placed in order to detect any increase in intracranial pressure in a timely manner.
This allows early interventions and a better recovery outcome.

Subdural drain (SDH drain)

A subdural drain is a gravity drain inserted post burr hole surgery in order to evacuate the Dural
space from excessive amount of blood. This can be life threatening as the blood compresses the
other brain components.
It consists in a soft silicone catheter made up of two different ends. The proximal end is inserted
in the subdural space, where the bleed is happening. This end is secure to the scalp with two or
three stiches. The other end has a plastic bag that can collect up to 500mls. This bag usually does
not need to be empty until the SDH can be removed.
Indications:
 Spontaneous blood collection post subdural haemorrhage
 The drain stays usually for 48hours
 The patient can mobilize independently
 Keep insertion site clean
 Monitor GCS and inform the doctor if there is any change in GCS : prevent re bleed
Following the drain removal there might be the need of a CT scan to check how much blood has
been removed.
Usually the doctor has to remove the drain and leave a single stitch on the patient `s scalp.
COMMON NEUROSURGICAL OPERATION

Craniotomy
Surgical removal of part of the bone from the skull to expose the brain. The bone flap is
temporarily removed, then replaced after the brain surgery has been done. The type of
craniotomy is named depending on the skull bone, which is opened. Typical skull bones targeted
for craniotomy include the frontal, parietal, temporal, and occipital bones.

Indications for a craniotomy:

 Removal of brain tumour

 Clipping or repairing an aneurysm
 Removing blood clots from a leaking vessel
 Removing an vascular malformation
 (AVM) or addressing an arteriovenous
 Fistula (AVF)
 Draining a brain abscess, which is an Infected pus-filled pocket
 Relieving pressure within the brain by removing damaged or swollen areas of the brain
 That may be caused by injury or stroke.
 Repairing skull fractures.

Transsphenoidal Surgery

Transsphenoidal
hypophysectomy is a procedure that aims to access the pituitary gland through the nasal cavity
via sphenoid sinus in order to remove tumours around the pituitary gland area.
Post op nursing care
 Monitor for CSF leak from nasal packs, pre and post removal
 Check for bleeding. Rational: accumulation of blood in the area can cause pressure on the
optic chiasm and affect visual field, which is another way of spotting bleeding with nasal
packs in situ.
 Check visual fields regularly
 Monitor GCS and vital sign according to post op instruction
 Monitor blood glucose regularly and check for any increase in its value
 Monitor intake and output and check for polyuria: we want to avoid diabetes insipidus
and therefore prolonged hospital stay. Excessive thirst is another red flag that can indicate
diabetes insipidus. This can be cause by the proximity of the gland that produces ADH to
the surgical incision site. It usually self-resolve within 12/36hours(Lindsay and Bone
2004)
Ventriculoperitoneal shunt insertion (see most common
neurosurgical devices)

A medical device that is inserted into the ventricles of the brain and allows passage of the CSF
into the peritoneal cavity to relieve pressure building up.
Indications
 Hydrocephalous

Post op nursing care

 Monitor GCS according to post op instruction
 Monitor any sign of infection (via blood result, new onset of confusion, temperature)

Common Spinal Procedures

Foraminotomy and Laminectomy.
  A procedure where a hole is drilled in the lamina of the spine (foraminotomy) or
the entire lamina is removed in order to relieve pressure on a nerve

(laminectomy).

Anterior Cervical Discectomy (ACD)

 This is the most common surgical procedure to treat damaged cervical discs. Its
goal is to relieve pressure on the nerve roots or on the spinal cord by removing
the ruptured disc. Called ‘anterior’ as the cervical spine is reached though a small
incision at the front of the neck.

Other spinal procedures:

These can include much more aggressive and risky treatment such as spinal fusion and
fixation with insertion of metalwork.
 Our patients can have fractured vertebrae and will therefore be treated very
cautiously.
 Unstable spinal fractures are immobilised and can only be positioned using a 4 –
5 man spinal turn.
- in order to communicate about patients, e.g., when making an urgent referral:
-assess patient with A-B-C-D-E approach, know the vital signs now & previously
-know the admission diagnosis
-have available vital signs chart, fluid chart, medical & nursing records, drug chart
-read the most recent progress notes in medical/nursing records (if possible)
-state: this is an SBAR call!

Situation
 My name is ……………………………………………………

S
 I am a ………………………... on …………………… ward.
 I am calling about ………………...…… … (patient name) in bed
……...
 I am calling because ………….
…………………………………………….
Background
 The patient was admitted with …………………...…, on ………..

B
(date).
 The patient’s relevant medical history is
………………………………….
 Their condition has changed in the last ……………...
minutes/hours.
 The patient is now ………………………………………. (current
status).
 I have done
…………………………………………………………………..
Assessment
I think the problem is …..……………………………..………………………
I’m unsure what the problem is, but the patient is deteriorating/unstable.
 Airway ……………………(clear/obstructed)

A 


Breathing
L/min O2
Circulation
hours
respiratory rate ………, SpO2 …… % on ……

pulse ………, BP ………, u/o ………… in last 2

 Disability AVPU/Glasgow Coma score ………

 Exposuretemperature ……………..
 anything else
………………………………………………………………
 Recommendation
 I would like …………………............…… (what you want to have
done)

R
 Ask: do you need me to do anything now?
 Agree timescale or review-and-call-back time.
 Ask: who’s an alternative contact/back-up if the situation gets
worse?
 Record name and number of contact and the recommendation
 If an urgent response is required: I NEED YOU TO COME NOW!
Don’t forget to document the call:
call made to ………………......, bleep/phone no. ………….., by ………………......,
what you want to have done …………….……….., date/time of call ……………….

Abbreviations:

E&D Eating and drinking

NBM Nil by Mouth

NGT Nasogastric tube

PEG Percutaneous endoscopic gastrostomy

JEJ Jejunostomy tube

PEJ Percutaneous endoscopic Jejunostomy

TOP Trans oesophageal puncture

TOF Trans oesophageal fistula.

Ryle’s enteral feeding tube

tube.

Soft soft consistency

Puree puree consistency

Thickened fluids

Bolus bolus feeding

SALT Speech and language therapist

VDF Videofluroscopy

FEES Functional endoscopic evaluation of

 swallowing

SCC Squamous cell carcinoma

EUA examination under Anaesthetic

GBM Glioblastoma

EVD External ventricular drain

LD Lumbar Drain

SOL Space occupying Lesion

ROC Removal of Clips

ROS Removal of stitches

HTN Hypertension

VP Shunt Ventriculoperitoneal

T2DM Type 2 Diabetic

CBG Capillary Blood Glucose

IV Intravenous

LVF Left ventricular failure

CCF Congestive cardiac failure

RRT Rapid response team

PERT Patient emergency response team

MI Myocardial infarction

RUA Routine urinalysis

MSU Midstream specimen of urine

EMU Early morning urine

NPU Not passed urine

FBC Full blood count

ABG Arterial blood gas

DDU Drug dependency unit

IVDU Intravenous drug user

NFA No fixed abode

ETOH Ethanol (Alcohol)

SOB Shortness of breath

GCS Glasgow coma scale

PEARL Pupils equal and reacting to light

LOC Loss of consciousness

HI Head injury

C/O Complains of

CT Computerised tomography

NIDDM Non-insulin dependent diabetic

IDDM Insulin dependent diabetic

PT Physiotherapist

SW Social worker

NH Nursing home

OT Occupational therapist

TTA / TTO Tablets to take away or take out

GI Gastro-intestinal

AF Atrial Fibrillation

TDS Three times a day

BD Twice daily

OD Once daily

QDS Four times a day

PO Per Orally

PV Per Vaginal

PR Per Rectal
 IM Intra-muscular

S/C Subcutaneous

COPD Chronic Obstructive Pulmonary Disease

NG Naso-gastric

Top Topical

NKDA No Known Drugs and Allergy

BO Bowels Open

BNO Bowels Not Open

FBR Flat Bed Rest

CONFIDENTIAL DATA

STUDENT CONTACT DETAILS:

NAME..
……....................................................................................................................

UNIVERSITY.………………………………………………………………………………….

TEL/MOBILE NO..……………………………………………………………………………..

NAME OF PERSON TO CONTACT IN AN EMERGENCY………………………………

RELATIONSHIP.………………………………………………………………………………
TEL/MOBILE NO..……………………………………………………………………………..

I hereby give permission to UCLH NHS Foundation Trust to contact the above person in
the case of emergency only.

PRINT NAME..…………………………………………………………………………………

Signature.………………………………………………………………………………………

Medical information:

I have a medical condition that I would like my placement area to be aware of

Yes

No

Please provide details below – please contact the Practice Education Team should you
rquire any additional support or have any concerns

……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………

Note:
Please store in a safe place for duty manager/ person in charge
Destroy when student completes their placement