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Neurologic
Disorders
Elvin Gene B. Colcol, RN, MN, MAN
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UNCONSCIOUS
CLIENT
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General Information
State of depressed cerebral
functioning with unresponsiveness tosensory and motor function.
Not oriented, does not followcommands, or needs persistent stimulito achieve a state of alertness.
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Terminologies
Coma – clinical state of unconsciousness inwhich the patient is unaware of self or
the environment for prolonged periods
Akinetic mutism – state ofunresponsiveness to the environment inwhich the patient makes no movement orsound but sometimes opens the eyes
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Persistent vegetative state – condition inwhich the patient is described as wakeful butdevoid of conscious content, withoutcognitive/affective mental function.
Brain death – irreversible loss of all
functions of the entire brain, including thebrain stem
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Causes Neurologic – head injury, stroke
Toxicologic – drug overdose, alcoholintoxication
Metabolic – hepatic/kidney failure, diabetes
ketoacidosis
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Assessment Findings
Unarousable No response to painful stimuli Altered respirations Decreased cranial nerve and reflex activity Pupillary changes Decreased GCS Initially – restlessness and anxiety
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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
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Complications
Respiratory failure
Pneumonia
Pressure ulcers
Aspiration
Venous stasis / DVT
Musculoskeletal deterioration
Disturbed GI functioning
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Medical Management
Maintain a patent airway
Circulation – heart rate and blood pressure
Intravenous access
Nutritional support
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Nursing Diagnoses
Ineffective airway clearance
Risk for injury
Deficient fluid volume
Impaired oral mucous membrane
Risk for impaired skin integrity
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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
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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
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Increased ICP
Normal ICP is 10 – 20 mmHg
Brain tissue (1400g); blood (75mL); CSF (75mL)
Impede circulation to the brain, impede theabsorption of CSF, affect the functioning of nerve
cells, and lead to brainstem compression and death
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Assessment: Altered LOC
Headache
Abnormal respirations
Increased BP with widening pulse pressure Slowing of pulse
Elevated temperature
Vomiting
Pupil changes
Changes in motor function
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Complications:
Brain stem herniation
Diabetes Insipidus
SIADH
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Medical Management
Goal
Decrease cerebral edema
Lower volume of CSF
Decrease cerebral blood flow while maintaining
adequate perfusion
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Administer osmotic diuretic andcortecosteroids
Restricting fluids Drain CSF
Control fever
Maintain BP and oxygenation Reduce cellular metabolic demand
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Nursing Diagnoses Ineffective airway clearance
Impaired breathing pattern
Altered cerebral tissue perfusion
Deficient fluid volume
Risk for infection
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Nursing Interventions:
Elevate the head of the bed 30 to 40 degrees asprescribed
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
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Medications:
Anticonvulsants
Antipyretics and muscle relaxants
Blood pressure medication
Corticosteroids
Intravenous fluids
Hyperosmotic agents
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Ventriculoperitoneal Shunt
Shunts cerebrospinal fluid from the ventricles
into the peritoneum
Monitor infection
Monitor signs on increasing ICP
Position the client supine
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Late signs of increased ICP: Deteriorating LOC
Altered respiratory patterns
Projectile vomiting
Hemiplegia and abnormal posturing
Loss of brain stem reflexes
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CEREBRAL
ANEURYSM
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Cerebral Aneurysm
Dilation of the walls of a weakened
cerebral artery
Aneurysm can lead to rupture
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Assessment findings:
Headache
Irritability
Diplopia Blurred vision
Tinnitus
Hemiparesis
Nuchal rigidity
Seizures
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Nursing Interventions:
Maintain a patent airway
Administer oxygen as prescribed
Monitor vital signs and for hypertension ordysrhythmias
Avoid taking temperatures via the rectum
Initiate aneurysm precautions
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Aneurysm Precautions:
Maintain bed rest on semi-Fowler’s orside 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
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Limit invasive procedures
Maintain normothermia
Prevent hypertension
Provide sedation
Provide pain control
Administer prophylactic anticonvulsant
Provide DVT prophylaxis as prescribed
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MENINGITIS
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Meningitis: Inflammation of the meninges of the brain
and spinal cord
Caused by bacteria, viruses, or othermicroorganisms
May reach CNS through:
Blood, CSF, lymph Direct extension Oral or nasopharyngeal route
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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
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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
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Maintain fluid and electrolyte balance
Prevent complications of immobility
Monitor vital signs and neuro checksfrequently
Provide client teaching and dischargeplanning concerning
Importance of good diet Rehabilitation program of residual deficits
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ENCEPHALITIS
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Encephalitis
Inflammation of the brain caused by
a virus
May be associated with other
diseases such as measles, mumps,chickenpox
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Assessment findings:
Headache
Fever, chills, vomiting
Signs of meningeal irritation
Possible seizures
Alterations in LOC
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Nursing Interventions:
Monitor vital signs and neuro checksfrequently
Provide nursing measures for increased ICP,seizures, hyperthermia if they occur
Provide nursing care for confused orunconscious client as needed
Provide client teaching and dischargeplanning
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BRAIN TUMOR
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Brain Tumor
Tumor within the cranial cavity; maybe benign or malignant
Types: Primary – originates in brain tissue
(glioma, meningioma)
Secondary – metastasizes from tumorelsewhere in the body
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Medical Management:
Craniotomy – remove tumor when possible
Radiation therapy and chemotherapy – forinaccessible and metastatic tumors
Drug therapy to manage increased ICP
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Assessment findings: Headache Vomiting Papilledema
Seizures Changes in mental status Neurologic deficits– hemiparesis, sensory
problem
Diagnostic tests Skull x-ray, CT scan, MRI EEG and brain biopsy
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Nursing Interventions: Monitor vital signs and neuro checks Administer medications as ordered
(corticosteroids, anticonvulsant, analgesic)
Provide supportive care for neurologicdeficit Prepare client for surgery Provide care for effects of radiation
therapy or chemotherapy Provide psychologic support
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BRAIN ABSCESS
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Brain Abscess
Collection of free or encapsulated puswithin the brain tissue
Usually follows an infectious processelsewhere in the body (ear, sinuses,mastoid bone, trauma)
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Assessment findings: Headache, malaise, anorexia
Vomiting
Signs of increased ICP
Hemiparesis
Seizures
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Nursing Interventions:
Adminitster large doses of antibiotics asordered (penicillin and chloramphenicol)
Monitor vital signs and neuro checks
Provide symptomatic and supportive care Prepare client for surgery if indicated
Corticosteroids and antiseizure drugs
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HEADACHE
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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 systemicdisease
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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 severalhours to days; N and V, irritability, pallor andsweating
Cluster – intense, throbbing pain, usually affecting
only one side of face and head; abrupt onset,lasts 30-90 minutes, skin reddens, teary eyesdue to pain
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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)
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CEREBROVASCULAR
ACCIDENT
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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 inaffected area with irreversible loss offunction
Affects men more than women; incidenceincreases with age
Caused by thrombosis, embolism, hemorrhage
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Risk factors:
Hypertension, diabetes mellitus,arteriosclerosis, atherosclerosis, cardiacdisease (valvular disease, atrial fibrillation,MI)
Lifestyle: obesity, smoking, inactivity,stress, use of oral contraceptives
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M dif i f t
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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 cerebralblood flow when there is compromise of main
blood supply
St f d l t
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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 overhours or days
Completed stroke – neurologic deficit remainsunchanged for a 2- to 3-day period
A t fi di
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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
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N i I t ti
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Nursing Interventions:
Maintain patent airway and adequateventilation
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 theclient
Rehabilitation care
M di ti
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Medications: Hyperosmotic agents
Anticonvulsants
Thrombolytics
Anticoagulant
Antihypertensive
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TRIGEMINALNEURALGIA
G l I f ti
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General Information Disorder of cranial nerve V causing disabling and
recurring attacks of severe pain along the sensorydistribution of one or more branches of thetrigeminal nerve
A unilateral shooting and stabbing pain
Involuntary contraction of facial muscles causedtwitching of the mouth (tic douloureux)
Incidence increased in elderly women
Cause unknown
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M di l M n m nt
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Medical Management Anticonvulsant drugs: carbamazepine
(Tegretol), Gabapentin (Neurontin), Baclofen(Lioresal), and phenytoin (Dilantin)
Nerve block: injection of alcohol or phenolinto one or more branches of the trigeminalnerve; temporary effect, lasts 6-18 months
Surgery Peripheral: avulsion of peripheral branches of
trigeminal nerve Intracranial: microvascular decompression
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Assessment Findings
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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 extremetemperature, 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 identifydental or sinus infection as an aggravating factor
Nursing Interventions
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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 fromdrafts
Provide small, frequent feedings of lukewarm, semiliquid, orsoft foods that are easily chewed
Provide the client with a soft washcloth and lukewarm waterand perform hygiene during periods when pain is decreased
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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 rainyweather
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
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BELL’S PALSY
General Information
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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 occludedproducing ischemic necrosis
Cause unknown; may be viral or autoimmune
Complete recovery in 3-5 weeks in majority ofclients
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Assessment Findings
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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 mouthtoward unaffected side, and inability to closeeyelid (all on affected side)
Painful sensations in the face, behind theear, and in the eye
Nursing Interventions
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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 performmouth 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
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AMYOTROPHICLATERAL SCLEROSIS
General Information
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General Information Progressive motor neuron disease, which usually
leads to death in 2-6 years.
Onset usually between ages 40 and 70; affectsmen more than women
Cause unknown; overexcitation of the nerve cellsby the neurotransmitter glutamate leads to cellinjury and neuronal degeneration
There is no cure or specific treatment; deathusually occurs as a result to respiratory infectionsecondary to respiratory insufficiency; RILUZOLE(RILUTEK) a glutamate antagonists
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Assessment Findings
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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 ruleout other diseases; MRI (motor neuropathy)
Nursing Interventions
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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
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GUILLAIN BARRESYNDROME
General Information
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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 usuallyfrom 3-6 months; may have residual deficits
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Medical Management
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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 bradycardiaduring endotracheal suctioning and physical therapy
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Assessment Findings
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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 andsymmetrical)
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
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Nursing Interventions
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Nu s g te ve t o s 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 hypertensionfluctuating 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
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MULTIPLESCLEROSIS
General Information
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Chronic, intermittently progressive disease of the CNS,characterized by scattered patches of demyelination within the brainand 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 locationof demyelination within the CNS
Characterized by remissions and exacerbations
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Assessment Findings
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g
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
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g
MRI – primary diagnostic test for visualizingplaques, documenting disease activity and evaluatingthe effect of treatment
Medications (ABC and R drugs)
Interferon beta-1a (Avonex)
Interferon beta-1b (Betaseron)
Glatiramer acetate (Copaxone)
Rebif
Corticosteroids
Nursing Interventions
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g
Assess the client for specific deficits related tolocation of demyelinization
Promote optimum mobility
Administer medications as ordered
Encourage independence in self-care activities
Prevent complications of immobility
Institute bowel program
Nursing Interventions
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g 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
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MYASTHENIAGRAVIS
General Information
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A neuromuscular disorder in which there is a disturbance in thetransmission of impulses from the nerve to muscle cells at theneuromuscular 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 antibodiesdestroy acetylcholine receptor sites on the postsynaptic membrane of the neuromuscular junction
Voluntary muscles are affected, especially those muscles innervatedby the cranial nerves
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Assessment Findings
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Diplopia, dysphagia
Extreme muscle weakness, increased with activity andreduced 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
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This is also called the Simpson test in which
fatigue is observed on sustained lid and eye
elevation.
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Animated picture of a patient with right Cogan'stwitch sign on rapid up gaze. Note the
overshooting of the lid before settling down to the
original ptotic level.
Medical Management
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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 earlyin the disease
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Nursing Management
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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
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ALZHEIMER’SDISEASE
General Information
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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 reasonfor institutionalization of the elderly
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Medical Management
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Rule out other conditions that might be causingsymptoms. A definitive diagnosis of Alzheimer’sdisease can only be made upon autopsy
Medications for treatment include tacrine (Cognex),donepezil (Aricept), rivastigmine (Exelon), orgalantamine (Reminyl)
Treatment goals are to minimize behavioralsymptoms and maximize quality of life
Assessment Findings
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Early in the diseaseprocess
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
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Middle, moderateimpairment
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
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Provide a safe environment
Provide structured environment and simple routines
Enlist caregiver’s assistance in assessing routine andestablishing plan of care
Use touch and a calm, relaxed manner in approaching theclient
Facilitate effective communication
Encourage orientation with use of calendars and clocks
Nursing Interventions
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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 tomaintain weight and hydration
Promote bowel and bladder continence by toileting at regularintervals
Provide a simple bedtime routine that facilitates sleep, andencourage daytime activities to avoid excess napping
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PARKINSON’S
DISEASE
General Information
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A progressive disorder with degeneration of thenerve cells in the basal ganglia resulting ingeneralized 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)
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Pathophysiology
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Disorder causes degeneration of thedopamine-producing neurons in the substantianigra in the midbrain
Dopamine influences purposeful movement
Depletion of dopamine results in degenerationof the basal ganglia
Assessment Findings
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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
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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
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Administer medications as ordered
Provide a safe environment
Provide measures to increase mobility
Encourage independence in self-care activities
Improve communication abilities
Nursing Interventions
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Refer for speech therapy when indicated
Maintain adequate nutrition
Avoid constipation and maintain adequate bowel elimination
Provide psychological support to client and SO