a.

Parkinson’s Disease (PD)

The basal ganglia are a collection of nuclei deep to the white matter of
cerebral cortex.

The name includes: caudate, putamen, nucleus accumbens, globus

pallidus, & substantia nigra
rostral section: middle section: caudal section:
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.
therefore…
Parkinson’s Disease (PD) / Paralysis agitans

-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
(neural network located in the brain that is part of the motor system
involved in the coordination of movement)

-Usually occurs in the older population: sxs occur during the 5th decade of life
some diagnosed at age 30
-Affects men more frequently than women
Cause: UNKNOWN ; predominantly idiopathic
🡻but sometimes disorder is postencephalitic, toxic, arteriosclerotic,
traumatic, or drug induced ( reserpine, methyldopa [Aldomet], haloperidol
[Haldol], phenothiazines )

Dxtic tests: not helpful …PET used only for evaluating levodopa uptake
==diagnosed clinically from patient’s hx, presence of 2 of the 3 cardinal sxs,
neuro examinations
Assessment findings

▪Tremor:
-mainly of the upper limbs
-"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
▪Masklike face with decreased blinking of eyes
▪Quiet, monotone speech
▪Emotional lability, depression
▪Increased salivation, drooling
▪Cramped, small handwriting
▪Autonomic symptoms:
-excessive sweating -constipation
-seborrhea -decreased sexual capacity
-lacrimation
Nursing interventions

▪ Administer medications as ordered

1. Antiparkinsonian: Levodopa (Dopar, Larodopa)
-increases level of dopamine in the brain; relieves tremor, rigidity, and
bradykinesia
-side effects: anorexia; nausea and vomiting; postural hypotension; mental
changes such as confusion, agitation, and hallucinations; insomnia; renal
damage; cardiac arrhythmias; dyskinesias (purposeless involuntary
movements that may be hyperkinetic =rapid and repetitive)
-contraindications:
>avoid multiple vitamin preparations containing vitamin B6 (pyridoxine) and
foods high in vitamin B6 (tuna, pork, dried beans, salmon)
>avoid Tyramine rich foods ( cheese, yogurt, coffee, raisins, sausage, red
wine, beer)=may cause hypertensive crisis
>administer with food or snack to decrease GI irritation.

2. Carbidopa (Sinemet): prevents breakdown of dopamine in the periphery

and causes fewer side effects.
3. Antiviral: Amantadine (Symmetrel):
-used in early/mild cases to reduce rigidity, tremor, and bradykinesia
-act by releasing dopamine from neuronal storage sites

4. Anticholinergic: Benztropine mesylate (Cogentin), procyclidine

(Kemadrin)
-inhibit action of acetylcholine
-used in mild cases or in combination with Levodopa
-relieve tremor and rigidity
-side effects: dry mouth, blurred vision, constipation, urinary retention

5. Dopamine agonist: Bromocriptine mesylate (Parlodel)

-stimulates release of dopamine in the substantia nigra
-often employed when Levodopa loses effectiveness

6. Tricyclic antidepressants given to treat depression

7. Antihistamines have mild central anticholinergic & sedative effects &

may reduce tremors
▪Provide a safe environment.

-Side rails on bed; rails and handlebars in toilet, bathtub, and hallways;
no scatter rugs
-Hard-back or spring-loaded chair to make getting up easier
▪ Provide measures to increase mobility.

-Physical therapy: active and passive ROM exercises; stretching

exercises; warm baths
-Assistive devices
If client "freezes," suggest thinking of something to walk over.
▪ Improve communication abilities: instruct client to practice reading aloud,
to listen to own voice, and enunciate each syllable clearly.
▪ Maintain adequate nutrition.

-Cut food into bite-sized pieces.

-Provide small, frequent feedings.
-Allow sufficient time for meals, use warming tray.
 b. Multiple Sclerosis (MS)

= results in impaired transmission of nerve impulses

therefore…
Multiple Sclerosis (MS)
-An immune-mediated progressive demyelinating disease of
the CNS which results in impaired transmission of nerve
impulses

-Typically present in young adults 20-40

-Affects women more than men

-More frequent in cool or temperate climates

-Cause UNKNOWN; may be a slow-growing virus

or possibly of autoimmune origin

-Characterized by remissions and exacerbations

 Pathophysiology

Sensitized T cells that would typically cross the

blood-brain barrier to check for antigens in the
CNS and then leave;
in MS would remain in the CNS
🡻
Promote infiltration of other agents that damage
the immune system
🡻
Immune system attack leads to inflamm that
destroys myelin and oligodenroglial cells
Major Types:
1. Relapsing-remitting MS (RRMS)=85%of cases
-relapses develop over 1-2 weeks & resolve over 4-8 months then
returns to baseline.
-50% may develop secondary progressive MS within 10 yrs; 90%
develop it within 25 yrs

2. Progressive-relapsing MS (PRMS)=5% of cases

-absence of remission & client’s condition does not return to baseline
-progressive, cumulative sxs & deterioration occur over several yrs

3. Primary progressive MS (PPMS)=onset tend to be bet 40&60 years

of age
-steady, gradual neurologic deterioration w/o remission of sxs
-progressive disability with no acute attacks

4. Secondary progressive MS (SPMS)

-begins with RRMS course that later becomes steadily progressive
-attacks & partial recoveries may continue to occur
Diagnostic tests:

CSF studies: increased protein and IgG (immunoglobulin)

EEG: abN

CT scan: increased density of white matter

MRI: shows areas of demyelination

Symptoms:

1st sx: visual disturbances: blurred vision, scotomas (patchy blindness),

diplopia

Impaired sensation: touch, pain, temperature, or position sense;

numbness, tingling

Impaired motor function: weakness, paralysis, spasticity

Impaired cerebellar function: scanning speech, ataxic gait, nystagmus,

dysarthria, intention tremor

Euphoria or mood swings

Bladder: retention or incontinence

Constipation

Sexual impotence in the male

Nursing interventions

▪ Promote optimum mobility.

Muscle-stretching and strengthening exercises
Walking exercises to improve gait: use wide-based gait
Assistive devices: canes, walker, rails, wheelchair as necessary

▪ Administer medications as ordered.

For acute exacerbations: corticosteroids (ACTH [IV], prednisone)
to reduce edema at sites of demyelinization
For spasticity: baclofen (Lioresal), dantrolene (Dantrium),
diazepam (Valium)
Beta interferon (Betaseron) for relapsing-remitting MS patients

▪ Prevent injury related to sensory problems.

Test bath water with thermometer.
Avoid heating pads, hot-water bottles.
Inspect body parts frequently for injury.
Make frequent position changes.

▪ Prepare client for plasma exchange (to remove antibodies) if indicated

Plasmapheresis

This treatment — also known as plasma exchange — is a type of

"blood cleansing" in which damaging antibodies are removed from
your blood.

Plasmapheresis consists of removing the liquid portion of your blood

(plasma) and separating it from the actual blood cells.
The blood cells are then put back into your body, which manufactures
more plasma to make up for what was removed.
It's not clear why this treatment works, but scientists believe that
plasmapheresis rids plasma of certain antibodies that contribute to the
immune system attack on the nerves
c. Myasthenia Gravis (MG)
Myasthenia Gravis (MG)

-A neuromuscular disorder in which there is a disturbance in the

transmission of impulses from nerve to muscle cells at the neuromuscular
junction (PNS), causing extreme muscle weakness

-Highest between ages 15-35 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.
The first noticeable symptoms of myasthenia gravis may be weakness of
the eye muscles, difficulty in swallowing, or slurred speech.
 Assessment findings

Ptosis, diplopia , dysphagia

Extreme muscle weakness, increased with activity and reduced with rest

(identifying characteristic)

Masklike facial expression

Weak voice, hoarseness

Diagnostic tests

Tensilon test: IV injection of Tensilon provides spontaneous relief of symptoms

(lasts 5-10 minutes)
Electromyography (EMG): amplitude of evoked potentials decreases rapidly
Presence of anti-acetylcholine receptor antibodies in the serum
TENSILON TEST

1. performed to diagnose myasthenia gravis

a. Tensilon (edrophonium chloride – anticholinesterase) 2mg are injected

IV, if no response after 30 secs, the remaining 8mg are injected
(+) test : reveals an ↑ in muscle strength (reduction of eyelid ptosis)
within 1min, weakness returns w/in 5-30 mins.
Tensilon(edrophonium)a medication that blocks the action of the enzyme that
breaks down the transmitter acetylcholine is given, muscle function may improve.

(-) test: client shows no improvement & strength may deteriorate

2. to differentiate myasthenic crisis and cholinergic crisis

myasthenic crisis: Tensilon is administered & if strength improves,

the client needs more medication
cholinergic crisis: Tensilon is administered & if weakness is more severe,
the client is overmedicated, administer atropine
sulfate
Medical management

Drug therapy

a. Anticholinesterase drugs:neostigmine bromide (Prostigmin),

pyridostigmine bromide (Mestinon), edrophonium chloride (Tensilon)
-block 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)

b. Corticosteroids: prednisone
used if other drugs are not effective
suppress autoimmune response
Nursing interventions

▪ Administer anticholinesterase drugs as ordered.

-Give medication exactly on time.
-Give with milk and crackers to decrease GI upset.
-Monitor effectiveness of drugs: assess muscle strength and vital
capacity before and after medication.
-Observe for side effects.

▪ Promote optimal nutrition.

-Mealtimes should coincide with the peak effects of the drugs:
give medications 30 minutes before meals.
-Check gag reflex and swallowing ability before feeding.
-Provide a mechanical soft diet.
-If the client has difficulty chewing and swallowing, do not leave alone
at mealtimes
-Keep emergency airway and suction equipment nearby.
▪ Monitor respiratory status frequently: rate, depth; vital capacity; ability to
deep breathe and cough
▪ Observe for signs of myasthenic or cholinergic crisis.

▪ Provide nursing care for the client with a thymectomy.