The unreachable thing in tending to care for Neurosurgery patients: Can that ‘fingerspitzengefühl’ be learned?
Patients that under go neurosurgery are usually labeled as complex patients. These patients cannot tell the nurse adequately how they feel or how they are faring. Clinical observations are therefore very important. Sometimes you see that the state of the patient had changed or sometimes you feel that ‘something’ has changed in/with the patient. Usually it is the feeling of the nurse.

What is the difference between the nurse that ‘sees’ the almost undetectable signals and the nurse that doesn’t? In other words; what exactly is the essence of ‘fingerspitzengefühl’ ?

Through this article i will try to make the unreachable of tending to neurosurgery patients, reachable. I don’t have the illusion that it will be a complete story, but that it will be a start for the reading nurse to become a Neurosurgical Nurse. Just see it as a way to ….

What makes tending to Neurosurgery Patients so different and special?

Neurosurgery is something different and special at the same time. Patients with the same disease can be different every time. Except for the typical post-op nursing care, neurosurgical patients often have the same problems as the patients from an internal medicine ward. For example altered blood sugar levels, disturbed electrolytes or disturbed hormones. Furthermore, neurological deficits in the brain can cause disfunction in motor and/or sensory skills. Even behavior, character and personality of the person can change and therefore the border between physical and psychological pain becomes fuzzy. Except for the physical part of patient care, you also have to take care of the psychological and the social part of the patient.

What is needed to give excellent and complete neurosurgery care?

Because you often have patients that can’t or will not react appropriately,you have to rely on your nursing skills and observations to obtain an accurate picture. As a neurosurgical nurse you have to learn to think and feel for your patient. But for most you must see the signals yourself !! Observation is the key to good patient assessment.

The brain is an amazing organ. It controls the whole patient. If there is  something amiss in the brain of the patient then they will notice this for example, by that an arm or a leg that doesn’t move, or because they laugh at different jokes than prior to the injury, or because they get mad out of the blue, or because they have lost the ability to speak coherently so that others can’t understand them anymore.

All symptoms are of sensorimotor, cognitive or emotional nature and this is what makes us all different. Physical, mental and social aspects are within the care for neurosurgery patients closely bound together. All this makes that we have to see the patient as a whole person (holistic).

To be a good and complete neuroscience nurse and to be able to give complete neurosurgery care you must have what the Germans call ‘Fingerspitzengefühl’. What I mean with this is: “The knowledge that you gained by learning and experience and the fact that you have learned to observe the neurosurgery patient in such a way that you notice and/or feel the subtle, and for others hardly noticable, change in physical and/or mental state of the patient.”

How do you gain that ‘Fingerspitzengefuhl’ as a nurse?

First you must have the attitude that you constantly want to learn, gather knowledge and question your more experienced colleagues. Further more you must have the ability to observe, interpret and make the right deductions to come to a correct conclusion. You also must have the most up-to-date knowledge about the neurology and neurosurgical diseases. And last but not least you must have lots of experience.

What is meant with adequate knowledge?

Knowledge about a specialty isn’t something that just happens. It’s something you have to gather. With adequate knowledge we mean that the nurse is not only up-to-date with certain diseases, treatment or operations, but also knows what the associate phenomena are and what one can expect of the different treatments and/or the different (behavioral) changes. But nurses who are already working for an extended period of time in neuroscience can’t lean backwards on gaining their knowledge. For gaining knowledge you have to actively do things like reading up on professional literature, attending focused education and by asking questions to physician and/or experienced colleagues.

How does a nurse observe correctly?

As a neuroscience nurse you often see that ‘something’ has changed with your patient. Often this is a certain kind of feeling (perhaps the fingerspitzengefühl?). The question you ask yourself is what has then actually changed in your patient? With the right knowledge the neuroscience nurse has to be able to observe correctly and also has to be able to correctly interpret this.
When you interpret your observations as a neuroscience nurse you have to use all your knowledge at your disposal about the anatomy, pathology and internal medicine. Everyone can observe. But observing correctly, interpreting and coming to conclusions is what experienced neruoscience nurses do.
But what is observing correctly as a neuroscience nurse? It is the correct knowledge at the correct way or time so that minimal changes can be detected within the patient on time. That this, change can be interpreted in the correct way so that one can reach the correct conclusion.
A few handy skills have been added as an appendix. This may help you with the answer to the question: “What has changed?”.

Finally….

Fingerspitzengefühl doesn’t originate with just one of these elements, but as a combination of all these elements.
Being experienced is just one of the elements. Experience, according to the dictionary is the process of getting knowledge or skill from doing, seeing or feeling things.
For me, the element of willing has to be added to this. So for me the definition of experience is: the process of willingly getting knowledge or skill from doing, seeing or feeling things.
The fact that one experiences something doesn’t automatically mean that one learns something if you look at change of behavior.

Appendix 1: Checklist for observation of the neuro surgery patient.
What is different in …?

• Behavior
• Reaction to surrounding
• Consciousness
• Movement
  • Physiognomy (the difference between left and right side of the face)
  • Arms / Legs (the difference between left and right)
  • Neglect of one side of the body
  • Involuntary movements / Spasms
  • Rhythmic / Non Rhythmic (Epileptic?)
  • Uncontrolled / Clumsy
  • Loss of Strength
  • Ataxia
• Too much sedation or herniation or sleeping or hyperglycemia or hypoglycemia or hyponatraemia.
  Search for the differences: in all cases the patient has ( or might have) a reduced consciousness.
• Pupil difference? Think about the following causes: Glass eye? / Cataract surgery? Atropine drops in the eye?

Appendix 2: Delirious behavior.

Delirious behavior is a name for a state of mind that characterized by awareness raising, disorientation, disordered surviving impulse, fear and the fear of incoherent thinking, spectacle-like disperception and delusions. It starts acute. At night it is at it’s top. The progress fluctuates during the day and the maximum time span is less then six months.

Symptoms that must be present to diagnose a delirium:

• Disorder of conciousness and concentration (on a continuum of a lowered conciousness till a coma; the inability to concentrate or to hold the concentration or to move the focus of the concentration).
• General disorder of cognitive functions: Perceptual distortion / illusions / hallucinations / disfunction of making new memories / memory disorder / desorientation in time, person and place.
• Movements disorders: hypo-activity / hyperactivity / longer reaction time / increased word flow / increased scare reactions / disorder of sleep watch rhythm / sleeping badly / sleepiness during the day / disturbing dreams / nightmares.
• Emotinal disorders: anxiety / fear / irritability / euphoria / apathy.

Appendix 3: Coping.

The coping mechanism of humans with a neurologic disorder or after neuro surgery is something that needs a lot of attention of the neuroscience nurse. ‘Coping’ is a conception that has been described in many books and is often related to the quality of life. Coping is the ability to adapt ones behavior , cognitive and emotional, to a (difficult) situation. Coping plays an important role in the ability to reduce the stress of life and the ability to function on a physical and psychic level.
This mechanism changes with every individual person and is also called the coping strategy.
These strategies affects how one experiences and handles stressful events

Appendix 4: ‘Searching’.

I, as a writer of this document, am still searching. Especially in what is the exact difference is for example the neurology. The difference can be that you have unstable neurological patients. Or the the internal problems puts the nurse on an incorrect conclusion so that the cognitive disorders aren’t predictable. This in term makes planning interventions less effective because the patient reacts different than that you predicted so that new intervention are necessary. Flexibility and maneuverability of your actual knowledge are the key words here. This issue has to be addressed in the education of the neuroscience nurse. But how…thats the question.

Final Thought ….

I see this article as a living piece of text and if you have any suggestion to improve this, please let me know, by making a comment below or e-mailing me, so we together can make it better.