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NURSING MANAGEMENT OF PATIENT WITH
DEGENERATIVE DISORDERS
The brain, the more you use it, the more it keeps on being
active, less risk for degeneration. What disorder would
usually manifest postural problem which could be
categorized under degenerative disorder? PARKINSON’S
DISEASE
What disorder is characterized by memory deficit?
ALZHEIMER’S DISEASE
Alzheimer is what type of disorder? Dementia
Dementia is usually compared with delirium.
PARKINSON’S DISEASE
 Progressive neurologic disorder
Progressive means overtime, it continues to
deteriorate.
 Control and regulation of movement
The main problem with Parkinson’s disease is the
control and regulation of your movement.
 Deficiency of DOPAMINE
 Degenerative changes of SUBSTANTIA NIGRA
 Characterized by tremor, bradykinesia, rigidity, and
postural abnormalities
Signs and symptoms:
 Main manifestations: resting tremors, cogwheel
rigidity, bradykinesia, postural changes, shuffling
gait, small steps
o Mask facies- loss of facial expressions or
no expression
o Decreased blinking reflex
 Non-motor signs and symptoms: anosmia,
constipation, orthostatic hypotension, drooling of
saliva, pain
Anosmia means loss of smell, cranial nerve 1.
Orthostatic hypotension, how do we test? You
get blood pressure. Twice, not on the same
position. 1st, on the bed. 2nd, while sitting down or
standing up. 3 minutes interval. Decrease in SBP of
20 mmHg, diastolic 20 mmHg. Main nursing
diagnosis is risk for fall or injury. Bradykinesia,
very slow movement. Difference between resting
and intentional tremors? Resting tremors walang
ginagawa ang patient. If the patient walang tremors
ang patient pero pag nagsusulat, that’s your
intentional tremors.
Pharmacologic management:
 Anticholinergics
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 Amantadine
 Dopaminergic agonists
 Levodopa-carbidopa – main medication
Levodopa is the active medication unfortunately,
that is easily metabolized by the body. We add
carbidopa because it is bida-bida. As a
combination, pagmagkasama sila ng levodopa, it
would say ako na ako na. Carbidopa would put
itself on the frontline to be metabolized to give
enough time for your levodopa to go to your Central
Nervous System. And that is when your levodopa
would act on as your dopamine supplement.
Carbidopa would allow levodopa to enter CNS for
action.
Anticholinergics like your benztropine, they
reduces the transmission of cholinergic pathways
which are overactive during the time when
dopamine is deficient.
Amantadine is an antiviral mediciation. It is an
antiflu medication. We give amantadine because it
would block the reuptake of dopamine. Your
amantadine, even though it is an antiflu medication,
it blocks the reuptake of dopamine and it also
increases the release of your dopamine by the
neurons of the brain.
Complications:
 Dementia
 Aspiration
 Injury from falls
Aspiration is one complication because aspiration
is a result when the protective reflexes of your
airways are deficient or there are problems. What
are the protective reflexes of airways? We have gag
reflex, cough reflex. Parkinson’s disease, there is a
problem with your muscle movement. If there is
aspiration what is the sequelae? Aspiration
Pneumonia
Nursing Diagnosis:
 Impaired physical mobility related to bradykinesia,
rigidity, and tremor
They can no longer do their ADLs kasi nga because
of the symptoms of your Parkinson’s disease. What
is the possible sequela of impaired mobility?
Pressure ulcers
 Imbalanced nutrition: less than body requirements
related to motor difficulties with feeding chewing,
and swallowing
NGT only stays for a month. It must be replaced. If
the patient has Parkinson and the patient has
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already started tube feedings, it must stay for  Lack of mental activity- SO MGA ATE AND KUYA
lifelong na. we advise these patients for MAG BASA BASA NA PO TAYO!!!!
gastrostomy tube.  Head trauma
 Impaired verbal communication related to  Smoking
decreased speech volume and facial muscle  Hypertension
movement  Decreased social interaction
 Constipation related to diminished motor function,
inactivity, and medications Signs and symptoms:
 Ineffective coping related to physical limitations and  Indifference
loss of independence  Mood swings
 Risk for fall or injury  Inattention
 Caregiver role strain- as time goes by these  Disorganized thinking
patients became more dependent to their care
 Forgetfulness
giver. We also have to address the care-givers
 Sundowning- manifestation wherein forgetfulness,
burnout.
irritability would become more progressed during
Nursing Interventions: gabi hence the name sundown, as the sun would
come down, the manifestations would become
 Improving mobility more prominent because the acetylcholine are
By exercise, range of motion, facilitate referral to declined because the nagamit na hiya within the
rehab medicine, speech therapies, facilitate day, consumed na hiya
different mediums of communication.  Confabulation- one symptom that is one
 Optimize nutritional status compensatory for forgetfulness. Making up stories.
Always ensure patency of tube feedings when the They would try to mask na nakakaremember pa
patient is admitted. If for discharge, proper teaching hiya.
to the caregivers. X-ray is the best way to assess
NGT placement. Most feasible way, auscultation- Management:
gurgling sound/borborygmi
 no cure, goal is to slow progression:
 Maximize communication ability
o cholinesterase inhibitors- to increase
 Prevention of constipation acetylcholinesterase, stop the
 Strengthening coping ability consumption of acetylcholine
ALZHEIMER DISEASE o symptomatic management

 Progressive, irreversible, degenerative neurologic Nursing Responsibilities

disorder  Aims to promote function and independence
 Form of dementia- most common form if dementia o Support cognitive function: provide calm
among elderly and constant environment, use cues,
 Affects ADLs, behavior, cognition orient daily
 Most common cause of dementia Don’t try challenging the patient. Ex: sige
 Main problem: deposits of amyloid protein, tangles, daw hin o man ako?
plaques, neuronal damage o Promote safety: prevent falls, provide
 Neurotransmitter: ACETYLCHOLINE, decreased, adequate lighting
excitatory and inhibitory neurotransmitter, most o Promote self-care activities
numerous neurotransmitter o Reduce anxiety
Cholinergic, nicotinic, muscarinic – pathways under o Promote adequate nutrition
peripheral nervous system o Support family- at risk for caregiver
burnout
Risk Factors:
MULTIPLE SCLEROSIS
 Age- elderly
 Family history  Chronic, frequently progressive neurologic disease of
 Limited physical activity the CNS of unknown etiology and uncertain trajectory

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 Demyelination of the white matter of the optic nerve,
brain, and spinal cord (What is affected? What sense?
It’s vision and what organ? The eyes.
 Exacerbations and remissions of symptoms What does
this mean? Mayda times na they’re okay then mabalik it
sakit ngan mag e-exacerbate. Pero once you’re
diagnosed with sclerosis, diri na talaga it mawawara. It’s
always there kay there’s no cure.
CLASSIFICATION
The National Multiple Sclerosis Advisory Committee
recognizes four clinical forms of MS:
1. Relapsing Remitting (RR) – clearly defined
acute attacks evolve over days to weeks. Partial
recovery of function occurs over weeks to
months. Average frequency of attacks is once
every 2 years and neurologic stability remains
between attacks without disease progression. (At
the time of onset, 90% of cases of MS are
diagnosed as RR.
2. Secondary Progressive (SP) – always begins
as RR but clinical course changes with increasing
relapse rate, with a steady deterioration in
neurologic function unrelated to the original
attack. (50% of those with RR will progress to SP
within ten years, 90% will progress within 25
years.
3. Primary Progressive (PP) – characterized by
steady progression of disability from onset
without exacerbations and remissions. More
prevalent among males and older individuals.
Worst prognosis for neurologic disability. (10%
cases of MS are diagnosed as PP) Wala siyang
time for remissions. Always masakit.
4. Progressive Relapsing (PR) – the same as PP
except that patients experience acute
exacerbations along with a steadily progressive
course (rarest form).
Signs and Symptoms:
Symptoms of MS are often variable and pwede ring
unpredictable, varying from person to person and time to
time
 Fatigue and weakness
 Abnormal reflexes – absent or exaggerated
pwedeng hypo or hyper reflexia
 Vision disturbances – impaired and double vision,
nystagmus because your optic nerve is
demyelinated on top of the brain and spinal cord
 Motor dysfunction – weakness, tremor,
incoordination
 Sensory disturbances – paresthesias, impaired
deep sensation, impaired vibratory and position
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sense. What is the medical term for position sense?
It’s your proprioception.
 Impaired speech – slurring, scanning (dysarthria)
 Urinary dysfunction
 Neurobehavioral syndromes
Nursing Diagnoses:
 Impaired physical mobility related to muscle
weaknesses, spasticity, and incoordination
 Fatigue related to disease processes and stress of
coping
 Risk for injury related to motor and sensory deficits
 Risk for aspiration related to dysphagia
 Impaired urinary elimination related to the disease
process
 Interrupted family processes related to inability to
fulfill expected roles
 Sexual dysfunction related to disease process.
Usually talaga basta chronic disease,
neurodegenerative diseases, and progressive
diseases would also correlate to sexual
dysfunction.
Management:
Goals of treatment are to delay the progression of the
disease kay diba there’s no cure, manage chronic
symptoms, and treat acute exacerbations.
Diseases modifying therapies:
 Corticosteroids (example: prednisone,
dexamethasone), immunosuppressive agents
 Interferon, glatiramer, mitoxantrone (s/e:
cardiotoxic, it’s important to monitor your cardiac
function
Treating exacerbations:
1. A true exacerbation of MS is caused by an area of
inflammation in the CNS (How would you know that
there’s inflammation? We are going to use
diagnostic imaging techniques.
2. The treatment most commonly used to control
exacerbations is IV, high-dose corticosteroids.
Methylprednisolone is one of the most commonly
used corticosteroids in MS.
3. Plasmapheresis (plasma exchange) is only
considered for the 10% who do not respond well to
corticosteroid treatment. Your plasmapheresis is
like dialysis. When you are to give
immunoglobulins, you don’t give them before you
do plasmapheresis. Bakit? Anybody? Isip isip.
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What’s going to happen? Diba kay parang dialysis
siya, ginsasara it imo dugo. Ginsasara gihap an
IVIg. Hence, gin-pinagasto mo la an imo pasyente
hin thousands of pesos para la ig discard. So, you
give your IVIg after plasmapheresis.
Nursing Interventions:
 Promoting motor function
 Minimizing fatigue
 Preventing injury
 Managing dysphagia
 Maintaining urinary elimination
 Normalizing family processes
 Promoting sexual function
AMYOTROPHIC LATERAL SCLEROSIS
 Lou Gehrig disease
 Remember that this is an incapacitating, fatal
neuromuscular disease. But if you were to ask me about
my personal opinion. All degenerative diseases are fatal
especially if diri controlled and nama-manage.
 Progressive muscle weakness and progressive wasting
and paralysis of the muscles
 +lower motor neuron signs, such as atrophy or
fasciculations
 May present bulbar symptoms (dysphagia, dysarthria)
 Unknown cause; usually affects men (50-60 yo)
Management:
 Sadly, once you’re diagnosed, there is no cure,
most treatment is palliative and symptomatic
 Botox? What is this mga ate and kuya? It’s a toxin
coming from what microorganism? It’s your
Botulinum. So, this is used to decrease the
progression.
 Riluzole has been shown to prolong the survival
Complications:
 Respiratory failure (because of the paralysis of the
diaphragm)
 Aspiration pneumonia (Is this active or passive? It’s
passive movement. It would be dependent on
what? On lung recoil.
 Cardiopulmonary arrest (Remember that your heart
is also a muscle, so this would also be affected)
 Locked-in syndrome (fully conscious but unable to
respond in any way)
Nursing Diagnoses:
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Your nursing diagnoses would depend on your patient’s
manifestations
 Ineffective breathing pattern related to respiratory
muscle weakness
 Impaired physical mobility related to disease
process
 Imbalanced nutrition: less than body requirements
related to inability to swallow
 Fatigue related to denervation of muscles
 Social isolation related to fatigability and decreased
communication skills
 Risk for infection related to inability to clear airway
Manifested by what? Cough. If your patient is
unable to expectorate? What will you do? You do
chest physiotherapy or suctioning.
Nursing Interventions
 Maintaining respiration
 Optimizing mobility
 Meeting nutritional requirements
 Minimize fatigue
 Maintaining social interaction
 Preventing aspiration and infection
NURSING MANAGEMENT OF PATIENT WITH
NEUROMUSCULAR DISORDERS
GUILLAIN – BARRE SYNDROME
(POLYRADICULONEURIRITS)
 Acute, rapidly progressing, symmetric, ascending
inflammatory demyelinating polyneuropathy of the
peripheral sensory (meaning affecting the spinal cord)
and motor nerves and nerve roots – so if a patient
comes with weakness on just one side of the extremity,
it is not GBS since it is not symmetric. Ascending
meaning caudocephalic.
 Muscular weakness and distal sensory loss or
dysesthesias
 Following symptoms of a respiratory or GI viral infection
– usually preceded by an inflammatory or an infectious
disorder (such as respiratory or GI). Sometimes in a
patient with history of bilateral lower extremity
weakness, 2 weeks ago they usually have a history of
fever, colds, diarrhea, etc.
 Maximum weakness: 2 weeks after symptoms appear
 What microorganism is associated with GBS? (presents
with diarrhea) 30-40% of GBS is preceded by
Campylobacter infection – acute diarrheal disease
 Pathognomonic sign: Hyporeflexia
Management:
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 Plasmapheresis – temporary reduction of
circulating antibodies
 High-dose Ig therapy and corticosteroids – give
it AFTER plasmapharesis
 ECG monitoring and treatment of cardiac
dysrhythmias
 Analgesics and muscle relaxants, as needed
Intubation and mechanical ventilation – it is an
ascending paralysis, so do intubation and
mechanical ventilation with the respiration is
affected
Complications:
 Respiratory failure
 Cardiac dysrhythmia
 Complications of immobility and paralysis
 Anxiety and depression
Nursing Diagnosis:
 Ineffective Breathing Pattern related to
weakness/paralysis of respiratory muscles.
 Impaired Physical Mobility related to paralysis.
 Imbalanced Nutrition: Less Than Body
Requirements, related to CN dysfunction.
 Impaired Verbal Communication related to
intubation, CN dysfunction. Chronic Pain related to
disease pathology.
 Anxiety related to communication difficulties and
deteriorating physical condition
Nursing Interventions:
 Maintaining respiration
 Avoid complications of immobility
 Promoting adequate nutrition
 Maintaining communication
 Relieving pain
 Reduce anxiety
Nursing interventions and nursing diagnosis are almost the
same because they are symptomatic. We have to identify
first the diagnosis and so as the nursing intervention. As
priority, we have to keep a patent airway. If the respiratory
muscles are already depressed, we do mechanical
ventilation.
What is the primary drive for respiration? Hypoxemia or
hypercarbia or both? HYPERCARBIA because it is the
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carbon dioxide that initiates respiration. So what is the
nursing intervention for this? We avoid
hypooxygenation.
Additional input: The primary drive is an increasing carbon
dioxide. So if the body is already used to the increasing CO2
retention, let’s say for example in patients of COPD, that is
when your hypoxemia kicks in as a stimulus for respiratory
drive. Because it is already used to the CO2 retention, it no
longer initiates respiration.
Hypoxemia – second stimuli; decreasing level of oxygen will
be the one that increases respiration. So if you administer
10L of oxygen in a COPD exacerbation, there will no longer
be hypoxemia (because you are already oxygenating at that
level). That’s why in COPD, it is specified that we do not give
High Flow Oxygenation.
What is the best laboratory to assess respiration? ABG
MYASTHENIA GRAVIS
 Chronic autoimmune disorder affecting the
neuromuscular transmission of impulses in the
voluntary muscles of the body
 Weakness increased by exertion (during the day and
relieved by rest) – weakness is felt more in the morning
than in the afternoon
 Antibody-mediated attack against acetylcholine
receptors at the neuromuscular junction
 Idiopathic in most patients
 Autoimmune because you have receptor antibodies –
widen the scope of your diagnosis such as your thyroid
Diagnostics:
 Acetylcholine receptor antibodies
 EMG
 Edrophonium (Tensilon test) – an IV injection of a
very short acting regulation of an
anticholinesterase, would relieve weakness and
fatigue temporarily. If you inject then after 5
minutes, you will be able to stand again since your
acetylcholine will be consumed.
 Thyroid function tests
Anticholinesterase – increases the levels of acetylcholine
because it aggravates the breakdown of your acetylcholine.
Clinical Manifestations:
1. Extreme muscular weakness and easy
fatigability.
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2. Vision disturbances – diplopia and ptosis from
ocular weakness, Extraocular muscle weakness or
ptosis is present initially in 50% of patients and
occurs during the course of illness in 90%. Bulbar
muscle weakness is also common, along with
weakness of head extension and flexion.
3. Facial muscle weakness causes a mask-like facial
expression. Patients may present a snarling
appearance when attempting to smile.
4. Dysarthria and dysphagia from weakness of
laryngeal and pharyngeal muscles.
5. Proximal limb weakness, with specific
weakness in the small muscles of the hands.
Patients progress from mild to more severe disease
over weeks to months. Weakness tends to spread
from the ocular to facial to bulbar muscles and then
to truncal and limb muscles. The disease remains
ocular in only 16% of patients. About 87% of
patients generalize within 13 months after onset.
6. Respiratory muscle weakness can be life-
threatening. Intercurrent illness or medication can
exacerbate weakness, quickly precipitating a
myasthenic crisis and rapid respiratory
compromise.
7. Impending myasthenic crisis may be triggered by
respiratory infection, aspiration, physical/emotional
stress, and changes in medications. Symptoms
include:
a. Sudden respiratory distress.
b. Signs of dysphagia, dysarthria, ptosis, and
diplopia.
c. Tachycardia, anxiety.
d. Rapidly increasing weakness of extremities
and trunk.
2 Crisis to Watch Out for:
acetylcholinesterase which increases your
acetylcholinesterase inhibitors, which then increases your
acetylcholinesterase which combats your symptoms, hence,
the improvements. Whereas, in CHOLINERGIC CRISIS, it
worsens or there is no improvement.
Is ENDROPHONIUM used as a medication against
Myasthenia Gravis? NO – it is only used for diagnosis
because this is only a very short acting medication. So, what
is used is the ORAL ANTICHOLINESTERASE DRUGS (first
line treatment for MG)
Management:
 Oral anticholinesterase drugs, such as
neostigmine and pyridostigmine are first-line
treatments for mild MG
 Immunosuppressive medications – corticosteroid
 Plasmapheresis removes antibodies
 IV Ig – give after plasmapheresis
 Neostigmine IV for myasthenic crisis (lack of
medication)
 Airway management
Nursing Diagnosis:
 Fatigue related to disease process
 Risk for Aspiration related to muscle weakness of
face and tongue.
 Impaired Social Interaction related to diminished
speech capabilities and increased secretions.
Nursing Interventions:
 Minimizing fatigue
 Preventing aspiration
 Maintaining social interactions

 Myasthenic Crisis may result from disease

exacerbation or a specific precipitating event
(infection) or lack of medication – lack of
acetylcholine
 Cholinergic crisis caused by overmedication with
cholinesterase inhibitor – excess medication of
cholinesterase inhibitor

Myasthenic crisis and Cholinergic crisis may be

differentiated through the use of Tensilon test.

In myasthenic crisis, do you think with the use of your

endrophoniums, would there be an improvement or
worsening of symptoms? IMPROVEMENT – in MG, there
is lack of medication. Endrophonium is an short acting

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