You are on page 1of 221
Neurologic Disorders Elvin Gene B. Colcol, RN, MN, MAN
Neurologic
Disorders
Elvin Gene B. Colcol, RN, MN, MAN
UNCONSCIOUS CLIENT
UNCONSCIOUS
CLIENT
General Information  State of depressed cerebral functioning with unresponsiveness to sensory and motor function. 

General Information

  • State of depressed cerebral functioning with unresponsiveness to

sensory and motor function.

  • Not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness.

Terminologies  Coma – clinical state of unconsciousness in which the patient is unaware of self

Terminologies

  • Coma clinical state of unconsciousness in

which the patient is unaware of self or the environment for prolonged periods

  • Akinetic mutism state of unresponsiveness to the environment in which the patient makes no movement or sound but sometimes opens the eyes

 Persistent vegetative state – condition in which the patient is described as wakeful but devoid
  • Persistent vegetative state condition in which the patient is described as wakeful but devoid of conscious content, without cognitive/affective mental function.

  • Brain death irreversible loss of all functions of the entire brain, including the brain stem

Causes  Neurologic – head injury, stroke  Toxicologic – drug overdose, alcohol intoxication  Metabolic

Causes

  • Neurologic head injury, stroke

  • Toxicologic drug overdose, alcohol intoxication

  • Metabolic hepatic/kidney failure, diabetes ketoacidosis

Assessment Findings  Unarousable  No response to painful stimuli  Altered respirations  Decreased cranial

Assessment Findings

  • Unarousable

  • No response to painful stimuli

  • Altered respirations

  • Decreased cranial nerve and reflex activity

  • Pupillary changes

  • Decreased GCS

  • Initially restlessness and anxiety

Laboratory Tests  Blood glucose  Serum electrolytes  Serum ammonia  Clotting time  Serum

Laboratory Tests

  • Blood glucose

  • Serum electrolytes

  • Serum ammonia

  • Clotting time

  • Serum ketones

  • BUN / serum creatinine

  • Serum osmolality

  • Arterial blood gas (ABG)

  • Serum drug and alcohol level

Complications  Respiratory failure  Pneumonia  Pressure ulcers  Aspiration  Venous stasis / DVT

Complications

  • Respiratory failure

  • Pneumonia

  • Pressure ulcers

  • Aspiration

  • Venous stasis / DVT

  • Musculoskeletal deterioration

  • Disturbed GI functioning

Medical Management  Maintain a patent airway  Circulation – heart rate and blood pressure 

Medical Management

  • Maintain a patent airway

  • Circulation heart rate and blood pressure

  • Intravenous access

  • Nutritional support

Nursing Diagnoses  Ineffective airway clearance  Risk for injury  Deficient fluid volume  Impaired

Nursing Diagnoses

  • Ineffective airway clearance

  • Risk for injury

  • Deficient fluid volume

  • Impaired oral mucous membrane

  • Risk for impaired skin integrity

Nursing Interventions:  Airway, Breathing, Circulation, Disability  Place the client in a semi- Fowler’s position

Nursing Interventions:

  • Airway, Breathing, Circulation, Disability

  • Place the client in a semi-Fowler’s position

  • Change position of the client every 2 hours avoiding injury when turning

  • Protect patient at all times (side rails, restraints)

  • Assess for edema

  • Monitor for fluid and electrolyte imbalances

  • Monitor intake and output and daily weight

  • Maintain NPO status until consciousness returns

  • Provide intravenous or enteral feedings as prescribed

Continuation on interventions:  Assess bowel sounds  Maintain urinary output to prevent stasis, infection and

Continuation on interventions:

  • Assess bowel sounds

  • Maintain urinary output to prevent stasis, infection and calculus formation

  • Monitor the status of skin integrity

  • Provide frequent mouth care

  • Remove dentures and contact lenses

  • Assess for cerebrospinal fluid leakage

  • Assume that the unconscious client can hear

  • Initiate seizure precautions

  • Use footboard or high-topped sneakers to prevent footdrop

Increased ICP  Normal ICP is 10 – 20 mmHg  Brain tissue (1400g); blood (75mL);

Increased ICP

  • Normal ICP is 10 20 mmHg

  • Brain tissue (1400g); blood (75mL); CSF (75mL)

  • Impede circulation to the brain, impede the absorption of CSF, affect the functioning of nerve cells, and lead to brainstem compression and death

Assessment:  Altered LOC  Headache  Abnormal respirations  Increased BP with widening pulse pressure

Assessment:

  • Altered LOC

  • Headache

  • Abnormal respirations

  • Increased BP with widening pulse pressure

  • Slowing of pulse

  • Elevated temperature

  • Vomiting

  • Pupil changes

  • Changes in motor function

Complications:  Brain stem herniation  Diabetes Insipidus  SIADH

Complications:

  • Brain stem herniation

  • Diabetes Insipidus

  • SIADH

Medical Management  Goal  Decrease cerebral edema  Lower volume of CSF  Decrease cerebral

Medical Management

  • Goal

    • Decrease cerebral edema

    • Lower volume of CSF

    • Decrease cerebral blood flow while maintaining adequate perfusion

 Administer osmotic diuretic and cortecosteroids  Restricting fluids  Drain CSF  Control fever 
  • Administer osmotic diuretic and cortecosteroids

  • Restricting fluids

  • Drain CSF

  • Control fever

  • Maintain BP and oxygenation

  • Reduce cellular metabolic demand

Nursing Diagnoses  Ineffective airway clearance  Impaired breathing pattern  Altered cerebral tissue perfusion 

Nursing Diagnoses

  • Ineffective airway clearance

  • Impaired breathing pattern

  • Altered cerebral tissue perfusion

  • Deficient fluid volume

  • Risk for infection

Nursing Interventions:  Elevate the head of the bed 30 to 40 degrees as prescribed 

Nursing Interventions:

  • Elevate the head of the bed 30 to 40 degrees as prescribed

  • Avoid the administration of morphine

  • Maintain mechanical ventilation

  • Maintain body temperature

  • Prevent shivering

  • Decrease environmental stimuli

  • Monitor intake and output

  • Monitor electrolyte and acid base balance

  • Instruct client to avoid straining activities such as coughing and sneezing

  • Instruct the client to avoid valsalva’s manuever

Medications:  Anticonvulsants  Antipyretics and muscle relaxants  Blood pressure medication  Corticosteroids  Intravenous

Medications:

  • Anticonvulsants

  • Antipyretics and muscle relaxants

  • Blood pressure medication

  • Corticosteroids

  • Intravenous fluids

  • Hyperosmotic agents

Ventriculoperitoneal Shunt  Shunts cerebrospinal fluid from the ventricles into the peritoneum  Monitor infection 

Ventriculoperitoneal Shunt

  • Shunts cerebrospinal fluid from the ventricles into the peritoneum

  • Monitor infection

  • Monitor signs on increasing ICP

  • Position the client supine

Late signs of increased ICP:  Deteriorating LOC  Altered respiratory patterns  Projectile vomiting 

Late signs of increased ICP:

  • Deteriorating LOC

  • Altered respiratory patterns

  • Projectile vomiting

  • Hemiplegia and abnormal posturing

  • Loss of brain stem reflexes

CEREBRAL ANEURYSM
CEREBRAL
ANEURYSM
Cerebral Aneurysm  Dilation of the walls of a weakened cerebral artery  Aneurysm can lead

Cerebral Aneurysm

  • Dilation of the walls of a weakened cerebral artery

  • Aneurysm can lead to rupture

Assessment findings:  Headache  Irritability  Diplopia  Blurred vision  Tinnitus  Hemiparesis 

Assessment findings:

  • Headache

  • Irritability

  • Diplopia

  • Blurred vision

  • Tinnitus

  • Hemiparesis

  • Nuchal rigidity

  • Seizures

Assessment findings:  Headache  Irritability  Diplopia  Blurred vision  Tinnitus  Hemiparesis 
Nursing Interventions :  Maintain a patent airway  Administer oxygen as prescribed  Monitor vital

Nursing Interventions:

  • Maintain a patent airway

  • Administer oxygen as prescribed

  • Monitor vital signs and for hypertension or dysrhythmias

  • Avoid taking temperatures via the rectum

  • Initiate aneurysm precautions

Aneurysm Precautions:  Maintain bed rest on semi- Fowler’s or side lying position  Maintain a

Aneurysm Precautions:

  • Maintain bed rest on semi-Fowler’s or side lying position

  • Maintain a darkened room

  • Provide a quiet environment

  • Limit visitors

  • Maintain fluid restrictions

  • Avoid overstimulants in diet

  • Avoid valsalva’s maneuver

  • Administer care gently

 Limit invasive procedures  Maintain normothermia  Prevent hypertension  Provide sedation  Provide pain
  • Limit invasive procedures

  • Maintain normothermia

  • Prevent hypertension

  • Provide sedation

  • Provide pain control

  • Administer prophylactic anticonvulsant

  • Provide DVT prophylaxis as prescribed

MENINGITIS
MENINGITIS
Meningitis:  Inflammation of the meninges of the brain and spinal cord  Caused by bacteria,

Meningitis:

  • Inflammation of the meninges of the brain and spinal cord

  • Caused by bacteria, viruses, or other microorganisms

  • May reach CNS through:

    • Blood, CSF, lymph

    • Direct extension

    • Oral or nasopharyngeal route

Assessment findings:  Headache, photophobia, malaise, irritability  Chills, vomiting and fever  Possible seizure and

Assessment findings:

  • Headache, photophobia, malaise, irritability

  • Chills, vomiting and fever

  • Possible seizure and altered LOC

  • Lumbar puncture result

  • Signs of meningeal irritation

    • Nuchal rigidity

    • Kernig’s sign

    • Opisthotonos body arched forward

    • Brudzinki’s sign

Nursing Interventions:  Administer large doses of antibiotics IV as ordered (penicillin and cephalosporin)  Enforce

Nursing Interventions:

  • Administer large doses of antibiotics IV as ordered (penicillin and cephalosporin)

  • Enforce respiratory isolation for 24 hours after initiation of antibiotic therapy

  • Provide nursing care for increased ICP, seizures, and hyperthermia

  • Provide nursing care for delirious, or unconscious client as needed

  • Provide bed rest

  • Administer analgesic for headache

 Maintain fluid and electrolyte balance  Prevent complications of immobility  Monitor vital signs and
  • Maintain fluid and electrolyte balance

  • Prevent complications of immobility

  • Monitor vital signs and neuro checks frequently

  • Provide client teaching and discharge planning concerning

    • Importance of good diet

    • Rehabilitation program of residual deficits

ENCEPHALITIS
ENCEPHALITIS
Encephalitis  Inflammation of the brain caused by a virus  May be associated with other

Encephalitis

  • Inflammation of the brain caused by a virus

  • May be associated with other diseases such as measles, mumps, chickenpox

Assessment findings:  Headache  Fever, chills, vomiting  Signs of meningeal irritation  Possible seizures

Assessment findings:

  • Headache

  • Fever, chills, vomiting

  • Signs of meningeal irritation

  • Possible seizures

  • Alterations in LOC

Nursing Interventions:  Monitor vital signs and neuro checks frequently  Provide nursing measures for increased

Nursing Interventions:

  • Monitor vital signs and neuro checks frequently

  • Provide nursing measures for increased ICP, seizures, hyperthermia if they occur

  • Provide nursing care for confused or unconscious client as needed

  • Provide client teaching and discharge planning

BRAIN TUMOR
BRAIN TUMOR
Brain Tumor  Tumor within the cranial cavity; may be benign or malignant  Types: 

Brain Tumor

  • Tumor within the cranial cavity; may

be benign or malignant

  • Types:

    • Primary originates in brain tissue (glioma, meningioma)

    • Secondary metastasizes from tumor elsewhere in the body

Medical Management:  Craniotomy – remove tumor when possible  Radiation therapy and chemotherapy – for

Medical Management:

  • Craniotomy remove tumor when possible

  • Radiation therapy and chemotherapy for inaccessible and metastatic tumors

  • Drug therapy to manage increased ICP

Assessment findings:  Headache  Vomiting  Papilledema  Seizures  Changes in mental status 

Assessment findings:

  • Headache

  • Vomiting

  • Papilledema

  • Seizures

  • Changes in mental status

  • Neurologic deficitshemiparesis, sensory problem

  • Diagnostic tests

    • Skull x-ray, CT scan, MRI

    • EEG and brain biopsy

Nursing Interventions:  Monitor vital signs and neuro checks  Administer medications as ordered (corticosteroids, anticonvulsant,

Nursing Interventions:

  • Monitor vital signs and neuro checks

  • Administer medications as ordered (corticosteroids, anticonvulsant, analgesic)

  • Provide supportive care for neurologic deficit

  • Prepare client for surgery

  • Provide care for effects of radiation therapy or chemotherapy

  • Provide psychologic support

BRAIN ABSCESS
BRAIN ABSCESS
Brain Abscess  Collection of free or encapsulated pus within the brain tissue  Usually follows

Brain Abscess

  • Collection of free or encapsulated pus within the brain tissue

  • Usually follows an infectious process elsewhere in the body (ear, sinuses, mastoid bone, trauma)

Assessment findings:  Headache, malaise, anorexia  Vomiting  Signs of increased ICP  Hemiparesis 

Assessment findings:

  • Headache, malaise, anorexia

  • Vomiting

  • Signs of increased ICP

  • Hemiparesis

  • Seizures

Nursing Interventions:  Adminitster large doses of antibiotics as ordered (penicillin and chloramphenicol)  Monitor vital

Nursing Interventions:

  • Adminitster large doses of antibiotics as ordered (penicillin and chloramphenicol)

  • Monitor vital signs and neuro checks

  • Provide symptomatic and supportive care

  • Prepare client for surgery if indicated

  • Corticosteroids and antiseizure drugs

HEADACHE
HEADACHE
Headache  Diffuse pain in different parts of the head  Types:  Functional / primary

Headache

  • Diffuse pain in different parts of the head

  • Types:

    • Functional / primary

      • Tension - anxiety

      • Migraine recurrent throbbing headache

      • Cluster recurrent with remissions

  • Organic secondary to intracranial or systemic disease

  • Assessment findings:  Tension – pain usually bilateral; occurs at the back of the neck extending

    Assessment findings:

    • Tension pain usually bilateral; occurs at the back of the neck extending on top of head

    • Migraine severe, throbbing pain, often in temporal or supraorbital area, lasting several hours to days; N and V, irritability, pallor and sweating

    • Cluster intense, throbbing pain, usually affecting only one side of face and head; abrupt onset, lasts 30-90 minutes, skin reddens, teary eyes due to pain

    Nursing Interventions:  Carefully assess details regarding the headache  Provide quiet, dark environment  Provide

    Nursing Interventions:

    • Carefully assess details regarding the headache

    • Provide quiet, dark environment

    • Provide nonpharmacologic pain relief measures

    • Administer medication as ordered

      • Nonnarcotic analgesic

      • Fiorinal

      • Midrin

      • Sumatriptan

      • Ergotamine tartrate (migraine)

    CEREBROVASCULAR ACCIDENT
    CEREBROVASCULAR
    ACCIDENT
    Cerebrovascular Accident  Destruction or brain cells caused by a reduction in cerebral blood flow and

    Cerebrovascular Accident

    • Destruction or brain cells caused by a reduction in cerebral blood flow and oxygen

    • Interruption of cerebral blood flow for 5 minutes or more causes death of neurons in affected area with irreversible loss of function

    • Affects men more than women; incidence increases with age

    • Caused by thrombosis, embolism, hemorrhage

    Risk factors:  Hypertension, diabetes mellitus, arteriosclerosis, atherosclerosis, cardiac disease (valvular disease, atrial fibrillation, MI) 

    Risk factors:

    • Hypertension, diabetes mellitus, arteriosclerosis, atherosclerosis, cardiac disease (valvular disease, atrial fibrillation, MI)

    • Lifestyle: obesity, smoking, inactivity, stress, use of oral contraceptives

    Modifying factors:  Cerebral edema – develops around affected area causing further impairment  Vasospasm –

    Modifying factors:

    • Cerebral edema develops around affected area causing further impairment

    • Vasospasm constriction of cerebral blood vessel causing further decrease in blood flow

    • Collateral circulation help to maintain cerebral blood flow when there is compromise of main blood supply

    Stages of development:  Transient ischemic attack  Warning sign of impending stroke  Brief period

    Stages of development:

    • Transient ischemic attack

      • Warning sign of impending stroke

      • Brief period of neurologic deficit

      • Less than 24 hours

  • Stroke in evolution progressive symptoms over hours or days

  • Completed stroke neurologic deficit remains unchanged for a 2- to 3-day period

  • Assessment findings:  Headache  Generalized signs: vomiting, seizures, confusion, disorientation, decreased LOC, nuchal rigidity, fever,

    Assessment findings:

    • Headache

    • Generalized signs: vomiting, seizures, confusion, disorientation, decreased LOC, nuchal rigidity, fever, hypertension, slow bounding pulse, cheyne- stokes respirations

    • Focal signs: hemiplegia, aphasia, homonymous hemianopsia

    • Diagnostic tests:

      • CT scan

      • EEG

      • Cerebral arteriography

    Nursing Interventions:  Maintain patent airway and adequate ventilation  Monitor vital signs and neuro checks

    Nursing Interventions:

    • Maintain patent airway and adequate ventilation

    • Monitor vital signs and neuro checks

    • Provide complete bed rest

    • Maintain fluid and electrolyte balance and ensure adequate nutrition

    • Maintain proper positioning and body alignment

    • Promote optimum skin integrity

    • Provide a quiet, restful environment

    • Establish a means of communicating with the client

    • Rehabilitation care

    Medications:  Hyperosmotic agents  Anticonvulsants  Thrombolytics  Anticoagulant  Antihypertensive

    Medications:

    • Hyperosmotic agents

    • Anticonvulsants

    • Thrombolytics

    • Anticoagulant

    • Antihypertensive

    TRIGEMINAL NEURALGIA
    TRIGEMINAL
    NEURALGIA
    General Information  Disorder of cranial nerve V causing disabling and recurring attacks of severe pain

    General Information

    • Disorder of cranial nerve V causing disabling and

    recurring attacks of severe pain along the sensory distribution of one or more branches of the trigeminal nerve

    • A unilateral shooting and stabbing pain

    • Involuntary contraction of facial muscles caused twitching of the mouth (tic douloureux)

    • Incidence increased in elderly women

    • Cause unknown

    Medical Management  Anticonvulsant drugs : carbamazepine (Tegretol), Gabapentin (Neurontin), Baclofen (Lioresal), and phenytoin (Dilantin) 

    Medical Management

    • Anticonvulsant drugs: carbamazepine (Tegretol), Gabapentin (Neurontin), Baclofen (Lioresal), and phenytoin (Dilantin)

    • Nerve block: injection of alcohol or phenol into one or more branches of the trigeminal nerve; temporary effect, lasts 6-18 months

    • Surgery

      • Peripheral: avulsion of peripheral branches of trigeminal nerve

      • Intracranial: microvascular decompression

    Assessment Findings  Sudden paroxysms of extremely severe shooting pain in one side of the face

    Assessment Findings

    • Sudden paroxysms of extremely severe shooting pain in one side of the face

    • Attacks may be triggered by a cold breeze, foods/fluids with extreme temperature, toothbrushing, chewing, talking, or touching the face

    • During attack: twitching, grimacing, and frequent blinking/tearing of the eye

    • Poor eating and hygiene habits

    • Withdrawal from interactions with others

    • Diagnostic tests: X-rays of the skull, teeth, and sinuses may identify dental or sinus infection as an aggravating factor

    Nursing Interventions  Assess characteristics of the pain including triggering factors, trigger points, and pain management

    Nursing Interventions

    • Assess characteristics of the pain including triggering factors, trigger points, and pain management techniques

    • Administer medications as ordered; monitor response

    • Maintain room at an even, moderate temperature, free from drafts

    • Provide small, frequent feedings of lukewarm, semiliquid, or soft foods that are easily chewed

    • Provide the client with a soft washcloth and lukewarm water and perform hygiene during periods when pain is decreased

    Nursing Interventions  Prepare the client for surgery of indicated  Provide client teaching and discharge

    Nursing Interventions

    • Prepare the client for surgery of indicated

    • Provide client teaching and discharge planning concerning

      • Need to avoid outdoor activities during cold, windy, or rainy weather

      • Importance of good nutrition and hygiene

      • Use of medications, side effects, and signs of toxicity

      • Specific instructions following surgery for residual effects of anesthesia and loss of corneal reflex

    BELL’S PALSY
    BELL’S PALSY
    General Information  Disorder of cranial nerve VII resulting in the loss of ability to move

    General Information

    • Disorder of cranial nerve VII resulting in the loss of

    ability to move the muscles on one side of the face

    • Inflamed, edematous nerve becomes compressed to the point of damage or nutrient vessel is occluded producing ischemic necrosis

    • Cause unknown; may be viral or autoimmune

    • Complete recovery in 3-5 weeks in majority of clients

    Assessment Findings  Loss of taste over anterior two-thirds of tongue on affected side  Complete

    Assessment Findings

    • Loss of taste over anterior two-thirds of tongue on affected side

    • Complete paralysis of one side of face

    • Loss of expression, displacement of mouth toward unaffected side, and inability to close eyelid (all on affected side)

    • Painful sensations in the face, behind the ear, and in the eye

    Nursing Interventions  Assess facial nerve function regularly  Administer medications as ordered  Corticosteroids (prednisone)

    Nursing Interventions

    • Assess facial nerve function regularly

    • Administer medications as ordered

      • Corticosteroids (prednisone)

      • Mild analgesics as necessary

  • Provide soft diet with supplementary feedings as indicated

  • Instruct to chew on unaffected side, avoid hot fluids/foods, and perform mouth care after each meal

  • Provide special eye care to protect the cornea.

    • Dark glasses or eyeshield

    • Artificial tears to prevent drying of the cornea

    • Ointment and eye patch at night to keep eyelid closed

  • Provide support and reassurance

  • AMYOTROPHIC LATERAL SCLEROSIS
    AMYOTROPHIC
    LATERAL SCLEROSIS
    General Information  Progressive motor neuron disease, which usually leads to death in 2-6 years. 

    General Information

    • Progressive motor neuron disease, which usually leads to death in 2-6 years.

    • Onset usually between ages 40 and 70; affects men more than women

    • Cause unknown; overexcitation of the nerve cells by the neurotransmitter glutamate leads to cell injury and neuronal degeneration

    • There is no cure or specific treatment; death usually occurs as a result to respiratory infection secondary to respiratory insufficiency; RILUZOLE (RILUTEK) a glutamate antagonists

    Assessment Findings  Progressive weakness and atrophy of the muscles of the arms, trunk, or legs

    Assessment Findings

    • Progressive weakness and atrophy of the muscles of the arms, trunk, or legs

    • Dysarthria, dysphagia

    • Fasciculations (twitching)

    • Respiratory insufficiency

    • Diagnostic tests: EMG and muscle biopsy can rule

    out other diseases; MRI (motor neuropathy)

    Nursing Interventions  Provide nursing measures for muscle weakness and dysphagia  Promote adequate ventilatory function

    Nursing Interventions

    • Provide nursing measures for muscle weakness and dysphagia

    • Promote adequate ventilatory function

    • Prevent complications of immobility

    • Encourage diversional activities; spend time with the client

    • Provide compassion and intensive support to client/significant others

    • Provide or refer for physical therapy as indicated

    • Promote independence for as long as possible

    GUILLAIN BARRE SYNDROME
    GUILLAIN BARRE
    SYNDROME
    General Information  Symmetrical, bilateral, peripheral polyneuritis characterized by ascending paralysis  Can occur at any

    General Information

    • Symmetrical, bilateral, peripheral polyneuritis characterized by ascending paralysis

    • Can occur at any age; affects women and men equally

    • Cause unknown; may be an autoimmune process

    • Precipitating factors: antecedant viral infection, immunization

    • Progression of disease is highly individual; 90% of clients stop progression in 4 weeks; recovery is usually from 3-6 months; may have residual deficits

    Medical Management  Mechanical ventilation if respiratory problems present  Plasmapheresis to reduce circulating antibodies 

    Medical Management

    • Mechanical ventilation if respiratory problems present

    • Plasmapheresis to reduce circulating antibodies

    • Propanolol to prevent tachycardia

    • Atropine may be given to prevent episodes of bradycardia during endotracheal suctioning and physical therapy

    Assessment Findings  Mild sensory changes; in some clients severe misinterpretation of sensory stimuli resulting in

    Assessment Findings

    • Mild sensory changes; in some clients severe misinterpretation of sensory stimuli resulting in extreme discomfort

    • Clumsiness: usually the first symptom

    • Progressive motor weakness in more than one limb (ascending and symmetrical)

    • Ventilatory insufficiency if paralysis ascends to respiratory muscles

    • Absence of deep tendon reflexes

    • Autonomic dysfunction

    • Diagnostic tests:

      • CSF studies: increased protein

      • EMG: slowed nerve conduction

    Nursing Interventions  Maintain adequate ventilation  Check individual muscle group every 2 hours in acute

    Nursing Interventions

    • Maintain adequate ventilation

    • Check individual muscle group every 2 hours in acute phase to check for progression of muscle weakness

    • Assess cranial nerve function: gag reflex

    • Monitor vital signs and observe for signs of autonomic dysfunction such as acute periods of hypertension fluctuating with hypotension, tachycardia, arrhythmias

    • Administer corticosteroids to suppress immune reaction as ordered

    • Administer antiarrhythmic agents as ordered

    • Prevent complications of immobility

    • Promote comfort

    • Promote optimum nutrition

    • Provide psychologic support and encouragement

    MULTIPLE SCLEROSIS
    MULTIPLE
    SCLEROSIS
    General Information  Chronic, intermittently progressive disease of the CNS, characterized by scattered patches of demyelination

    General Information

    • Chronic, intermittently progressive disease of the CNS, characterized by scattered patches of demyelination within the brain and spinal cord

    • Incidence

      • Affects women more than men

      • Usually occurs from 20-40 years of age

      • More frequent in cool or temperate climates

  • Cause unknown; may be a slow-growing virus or possibly of autoimmune origin (sensitized T cells)

  • Signs and symptoms are varied and multiple, reflecting the location of demyelination within the CNS

  • Characterized by remissions and exacerbations

  • Assessment Findings  Visual disturbances: blurred vision, scotomas (blind spots), diplopia  Impaired sensation: touch, pain,

    Assessment Findings

    • Visual disturbances: blurred vision, scotomas (blind spots), diplopia

    • Impaired sensation: touch, pain, temperature, or position sense; paresthesias such as numbness, tingling

    • Euphoria or mood swings

    • Impaired motor function: weakness, paralysis, spasticity

    • Impaired cerebellar function: scanning speech, ataxic gait, nystagmus, dysarthria, intention tremor

    • Bladder: retention or incontinence

    • Constipation

    • Sexual impotence in the male

    Medical Management  MRI – primary diagnostic test for visualizing plaques, documenting disease activity and evaluating

    Medical Management

    • MRI primary diagnostic test for visualizing plaques, documenting disease activity and evaluating the effect of treatment

    • Medications (ABC and R drugs)

      • Interferon beta-1a (Avonex)

      • Interferon beta-1b (Betaseron)

      • Glatiramer acetate (Copaxone)

      • Rebif

      • Corticosteroids

    Nursing Interventions  Assess the client for specific deficits related to location of demyelinization  Promote

    Nursing Interventions

    • Assess the client for specific deficits related to location of demyelinization

    • Promote optimum mobility

    • Administer medications as ordered

    • Encourage independence in self-care activities

    • Prevent complications of immobility

    • Institute bowel program

    Nursing Interventions  Maintain urinary elimination  Prevent injury related to sensory problems  Prepare client

    Nursing Interventions

    • Maintain urinary elimination

    • Prevent injury related to sensory problems

    • Prepare client for plasma exchange if indicated

    • Provide psychological support to client and SO

    • Provide client teaching and discharge planning

    MYASTHENIA GRAVIS
    MYASTHENIA
    GRAVIS
    General Information  A neuromuscular disorder in which there is a disturbance in the transmission of

    General Information

    • A neuromuscular disorder in which there is a disturbance in the transmission of impulses from the nerve to muscle cells at the neuromuscular junction, causing extreme muscle weakness

    • Incidence

      • Highest between ages 15 and 35 for women, over 40 for men

      • Affects women more than men

  • Cause: thought to be autoimmune disorder whereby antibodies destroy acetylcholine receptor sites on the postsynaptic membrane of the neuromuscular junction

  • Voluntary muscles are affected, especially those muscles innervated by the cranial nerves

  • Assessment Findings  Diplopia, dysphagia  Extreme muscle weakness, increased with activity and reduced with rest

    Assessment Findings

    • Diplopia, dysphagia

    • Extreme muscle weakness, increased with activity and reduced with rest

    • Ptosis, masklike facial expression

    • Weak voice, hoarseness

    • Diagnostic tests:

      • Tensilon test IV injection of Tensilon provides spontaneous relief of symptoms (lasts 5-10 minutes)

      • EMG amplitude of evoked potentials decreases rapidly

      • Presence of antiacetylcholine receptor antibodies in the serum

    This is also called the Simpson test in which fatigue is observed on sustained lid and

    This is also called the Simpson test in which

    fatigue is observed on sustained lid and eye elevation.

    Animated picture of a patient with right Cogan's twitch sign on rapid up gaze. Note the

    Animated picture of a patient with right Cogan's

    twitch sign on rapid up gaze. Note the overshooting of the lid before settling down to the

    original ptotic level.

    Medical Management  Drug therapy  Anticholinesterase drugs: neostigmine, pyridostigmine (Mestinon)  Block the action of

    Medical Management

    • Drug therapy

      • Anticholinesterase drugs: neostigmine, pyridostigmine (Mestinon)

        • Block the action of cholinesterase and increase levels of acetylcholine at the neuromuscular junction

        • Side effects: excessive salivation and sweating, abdominal cramps, nausea and vomiting, diarrhea, fasciculations (muscle twitching)

    • Corticosteroids: prednisone

      • Used if other drugs are not effective

      • Suppress autoimmune response

  • Plasma Exchange

    • Removes circulating acetylcholine receptor antibodies

    • Use in clients who do not respond to other types of therapy

  • Surgery (thymectomy) see new neuro pics

    • Surgical removal of the thymus gland (involved in the production of acetylcholine receptor antibodies)

    • May cause remission in some clients especially if performed early in the disease

  • Nursing Management  Administer anticholinesterase drugs as ordered  Promote optimal nutrition  Monitor respiratory status

    Nursing Management

    • Administer anticholinesterase drugs as ordered

    • Promote optimal nutrition

    • Monitor respiratory status frequently: rate, depth, vital capacity, ability to deep breathe and cough

    • Assess muscle strength frequently; plan activity to take advantage of energy peaks and provide frequent rest periods

    • Observe for signs of myasthenic or cholinergic crisis

    • Provide nursing care for the client with a thymectomy

    • Provide client teaching and discharge planning

    ALZHEIMER’S DISEASE
    ALZHEIMER’S
    DISEASE
    General Information  In dementia, the elderly client is alert with a progressive decline in memory

    General Information

    • In dementia, the elderly client is alert with a progressive decline in memory and cognition accompanied by personality and behavioral changes

    • Alzheimer’s disease accounts for 60-75% of all dementias and is the number one reason for institutionalization of the elderly

    Medical Management  Rule out other conditions that might be causing symptoms. A definitive diagnosis of

    Medical Management

    • Rule out other conditions that might be causing symptoms. A definitive diagnosis of Alzheimer’s disease can only be made upon autopsy

    • Medications for treatment include tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), or galantamine (Reminyl)

    • Treatment goals are to minimize behavioral symptoms and maximize quality of life

    Assessment Findings  Early in the disease process  Depressed or anxious  Increased risk of

    Assessment Findings

    • Early in the disease process

      • Depressed or anxious

      • Increased risk of suicide

      • Early, mild impairment

        • Last 2-4 years

        • Short-term memory loss

        • Social withdrawal

        • Decreased interest in usual activities

        • Mood swings

        • Irritability

        • Insight is diminished

    Assessment Findings  Middle, moderate impairment  Last several years  Memory and math calculations faulty

    Assessment Findings

    • Middle, moderate impairment

      • Last several years

      • Memory and math calculations faulty

      • Disoriented to time and place

      • Can no longer drive

      • Needs assistance with complex ADLs

      • Personality changes

      • Incontinence begins

      • Late, severe impairment

        • Assistance with all ADLs

        • Nonverbal or communication is incoherent

        • Becomes nonambulatory

        • Requires total support in all activities

        • Incontinent in bowel and bladder

        • Indifference in food

        • Agitation and aggression seen

    Nursing Interventions  Provide a safe environment  Provide structured environment and simple routines  Enlist

    Nursing Interventions

    • Provide a safe environment

    • Provide structured environment and simple routines

    • Enlist caregiver’s assistance in assessing routine and establishing plan of care

    • Use touch and a calm, relaxed manner in approaching the client

    • Facilitate effective communication

    • Encourage orientation with use of calendars and clocks

    Nursing Interventions  Having family bring items that stimulate memory  Encourage mobility and provide opportunities

    Nursing Interventions

    • Having family bring items that stimulate memory

    • Encourage mobility and provide opportunities for exercise

    • Avoid isolating the client

    • Provide nutritious, high-fiber foods and adequate fluids to maintain weight and hydration

    • Promote bowel and bladder continence by toileting at regular intervals

    • Provide a simple bedtime routine that facilitates sleep, and encourage daytime activities to avoid excess napping

    PARKINSON’S DISEASE
    PARKINSON’S
    DISEASE
    General Information  A progressive disorder with degeneration of the nerve cells in the basal ganglia

    General Information

    • A progressive disorder with degeneration of the nerve cells in the basal ganglia resulting in generalized decline in muscular function; disorder of the extrapyramidal system

    • Usually occurs in the older population

    • Cause unknown, predominantly idiopathic, but sometimes disorder is postencephalic, toxic, arteriosclerotic, traumatic, or drug induced (reserpine, methyldopa, haloperidol, phenothiazines)

    Pathophysiology  Disorder causes degeneration of the dopamine-producing neurons in the substantia nigra in the midbrain

    Pathophysiology

    • Disorder causes degeneration of the dopamine-producing neurons in the substantia nigra in the midbrain

    • Dopamine influences purposeful movement

    • Depletion of dopamine results in degeneration of the basal ganglia

    Assessment Findings  Tremors: at the upper limb, “pill - rolling,” resting tremor; most common initial

    Assessment Findings

    • Tremors: at the upper limb, “pill-rolling,” resting tremor; most common initial symptom

    • Rigidity: cogwheel type

    • Bradykinesia: slowness of movement

    • Fatigue

    • Stooped posture; shuffling, propulsive gait

    • Difficulty rising from sitting position

    Assessment Findings  Masklike face with decreased blinking of eyes  Quiet, monotone speech  Emotional

    Assessment Findings

    • Masklike face with decreased blinking of eyes

    • Quiet, monotone speech

    • Emotional lability, depression

    • Increased salivation, drooling

    • Cramped, small handwriting

    • Autonomic symptoms: excessive sweating, seborrhea, lacrimation, constipation; decreased sexual capacity

    Nursing Interventions  Administer medications as ordered  Provide a safe environment  Provide measures to

    Nursing Interventions

    • Administer medications as ordered

    • Provide a safe environment

    • Provide measures to increase mobility

    • Encourage independence in self-care activities

    • Improve communication abilities

    Nursing Interventions  Refer for speech therapy when indicated  Maintain adequate nutrition  Avoid constipation

    Nursing Interventions

    • Refer for speech therapy when indicated

    • Maintain adequate nutrition

    • Avoid constipation and maintain adequate bowel elimination

    • Provide psychological support to client and SO

    • Provide client teaching and discharge planning concerning