 Parkinson's Disease

 Mutliple Sclerosis
 Myasthenia Gravis
 Seizure and Epilepsy
 Alzheimer’s Disease and Dementia
 Cerebral Aneurysm
 Bell’s Palsy
 Corticosteroids
 immune response by:

 ing antibodies
 a progressive (chronic) degenerative disorder
 usually occurs in the older population
  due to degeneration of the

 exact cause is unknown*

 Dopamine enables people to

move smoothly and normally
 Parkinsonian manifestations may also develop in:
 long-term use of

to midbrain

from:
 carbon monoxide
 mercury
 manganese
 causes degeneration of the
neurons in the substantia nigra
in the midbrain
 blood dopamine levels

 dopamine influences
purposeful movement

 results in degeneration of
the basal ganglia
 manifestations:
 cardinal s/sx:

 Tremors at rest

 Rigidity, muscle tone,

stiffness at rest

 Bradykinesia
 manifestations:
 cardinal s/sx:

 Flexed posture of neck,

trunk, and limbs

 Loss of postural reflexes

 Freezing movement
 manifestations:

 MC initial symptom

 mainly of the upper

limbs

 “pill-rolling”
 manifestations:

 slow movement

 difficulty in performing
ADL

 “shuffling gait”

 lack of swinging of arms

while walking
 manifestations:

 difficulty rising from

sitting position

 severe cases can lead to

(total lack of
movement)
 client is literally
frozen to one spot
( )
 manifestations:

 words are poorly articulated

 quiet, monotonous speech

 salivation,
 manifestations:
 emotional lability, depression

 cramped, small handwriting

 fatigue
 ADL can take longer and require concentration
 medical management:
 manage

 sudden worsening of manifestations due to:

 emotional or

from medications
 medical management:
 manage

 respiratory and cardiac support

 place in a quiet room with subdued lighting

 Barbiturates
 Benztropine
 medical management:
 manage

 fluctuation of manifestations

 client may be mobile (“on”) then akinetic (“off”)

 managed medically by:

 dosage, or

 time interval
 nursing management:
 Provide a safe environment

on bed

 rails and handlebar in

toilet, bathtub, and
hallways

 no scattered rags
 nursing management:
 Provide a safe environment

 hard-back chair to make getting up easier

 nursing management:
 Provide measures to increase mobility

 Physical therapy:

 active and passive ROM

 stretching exercises

 warm baths

(walking canes, walker, rails, wheelchair)

 if client “freezes,”
 nursing management:
 encourage independence in self-care activities

for ease in dressing

client
 nursing management:
 improve communication abilities

 instruct client to:

 practice

each syllable
 nursing management:
 maintain adequate nutrition

 cut food into bite-sized pieces

 allow sufficient time for meals, use warming tray

 OFI, fiber in diet

 nursing management:
 avoid constipation and maintain

 provide to client / significant others

 depression is common due to changes in body image and

self-concept
 nursing management:
 provide client teaching and discharge planning concerning the
importance of daily exercise
 walking, swimming*, gardening are tolerated activities

 promotion of active participation in self-care activities

 nursing management:
 provide client teaching and discharge planning concerning the
importance of daily exercise
 activities/methods to

 firm mattress with a small pillow

 keep head and neck as erect as possible

 use broad-based gait

 raise feet while walking

 nursing management:
 administer medications as ordered

(L-dopa)
 s level of dopamine in the brain

 relieves tremor, rigidity and bradykinesia

 administer with food or snack to decrease GI irritation

 inform client that urine and sweat may be darkened

 nursing management:
 administer medications as ordered

(Sinemet)
 prevents breakdown of dopamine in the periphery and
causes fewer side effects

(Symmetrel)
 used in mild cases or in combination with L-dopa to
reduce rigidity, tremor, and bradykinesia
 nursing management:
 administer medications as ordered

:
 inhibit action of acetylcholine

 used in mild cases or in combinations with L-dopa

 relieves tremor and rigidity

 nursing management:
 administer medications as ordered

 decreases tremors and anxiety

 side effect: drowsiness

 stimulates release of dopamine in the substantia nigra

 often employed if L-dopa loses effectiveness
 nursing management:
 administer medications as ordered

(Selegilene)
 a MAO Inhibitor

 inhibits dopamine breakdown

 slows progression of disease

 given to treat depression which is commonly seen in

Parkinson’s disease
 a progressive (chronic)
degenerative disorder

 characterized by
within the
brain and spinal cord
 slows nerve conduction
 etiology:
 unknown

 maybe due to destruction

of oligodendrocytes by:
 a slow-growing

 an process
 manifestations:
and

 paresthesia such as
numbness, tingling

 visual disturbances
 blurred vision (optic

neuritis)
 manifestations:
 depression, euphoria, or

 weakness, fatigue
 paralysis
 spasticity
 incoordination
 manifestations:
 bowel and bladder dysfunction

 retention/constipation or incontinence

 impotence
 manifestations:

 scanning speech

 ataxia

 nystagmus

 dysarthria
 dxtics:
 history

 CSF studies
 protein and IgG

 Visual evoked response (VER)

 dxtics:
 CT scan / MRI

 shows areas of

demyelination and
MS plaques
 nursing management:
 promote optimum mobility

 muscle-stretching and strengthening

 avoid intense exercise

 exacerbates muscles fatigue
 nursing management:
 promote optimum mobility

 walking exercises to improve gait

 use

 canes, walker, rails, wheelchair as necessary

 nursing management:
 maintain urinary continence

 maintain fluid intake of 2400mL/day

 limited fluid intake after 6PM

 toilet every 3hrs while awake

 nursing management:
 maintain normal bowel movement

 fiber diet, OFI

 avoid routine use of enemas and laxatives

 suppositories or digital stimulation 45mins after breakfast

 manual disimpaction
 last resort
 nursing management:
 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 positioning changes

 nursing management:
 encourage independence in self-care activities

 prepare client for plasma exchange / plasmapharesis

 to remove antibodies
 nursing management:
 provide client teaching and discharge planning concerning

 general measures to ensure optimum health

such as walking, swimming, biking in mild

cases

 use of techniques
 nursing management:
 provide client teaching and discharge planning concerning

 general measures to ensure optimum health

 well-balanced

 fresh air and sunshine

 avoiding fatigue, overheating or chilling, stress, infection

 nursing management:
 provide client teaching and discharge planning concerning

 use of medication and side effects

 alternative methods for sexual gratification; refer to sexual

counseling if indicated
 nursing management:
 administer medications as ordered

 Corticosteroids (Prednisone)

 for acute exacerbations

 to reduce edema at sites of demyelinization

 to treat auto-immunity
 nursing management:
 administer medications as ordered

 β – interferon

 glatiramer acetate

 to alter immune response

 Baclofen, Dantrolene, Diazepam

 for spasticity
Myasthenia gravis (MG) is a chronic
autoimmune disorder in which
antibodies destroy the communication
between nerves and muscle, resulting
in weakness of the skeletal muscles.
Myasthenia gravis affects the voluntary
muscles of the body, especially those
that control the eyes, mouth, throat and
limbs.
 presents with and of skeletal
muscles
 worsens with exercise

 improves with rest

 etiology:
 exact etiology is unknown

 auto-immune disorder
 antibodies destroy ACh

receptors on the
postsynaptic membrane
of the NMJ
 manifestations:
with sustained muscle contraction
 weakness is greatest after sustained muscle contraction and
at the end of the day

and

 chewing and swallowing difficulties

 manifestations:
 mask-like facial expression

 tendency for the mouth to

hang open

 respiratory difficulties in
severe cases
 dxtics:

 anti-cholinesterase drug
 if with MG, IV injection

 lasts 5 to 10 minutes

 antidote:
 Atropine SO4 (anti-cholinergic)
 dxtics:
(EMG)
 confirmatory test

 Presence of ACh receptor antibodies in the serum

 ICE TEST
 It is quick and easy: An ice pack is applied to the ptotic lid for 2
minutes, and ptosis is measured with a ruler before and after
cooling. A rise of 2 mm is a positive result.

- has a sensitivity and specificity of 76.9% and 98.3%, respectively, for

the identification of MG
 medical management:
 no cure yet exists
 medical management:
 Drug therapy

and
 drugs of choice

 action:
 blocks cholinesterase*

 s levels of acetylcholine at the NMJ

 medical management:
 Drug therapy

 side effects:
 excessive salivation and sweating

 fasciculation (muscle twitching)

 medical management:
 Drug therapy

(Prednisone)
 s serum ACh antibodies

 used if other drugs are not effective

 medical management:
/
 removes ACh antibodies in the plasma

 Surgery ( )
 surgical removal of the thymus gland

 thought to be involved in the production of ACh

antibodies
 nursing management:
 encourage deep breathing and coughing

 oxygen inhalation

 when eating,:
 sit upright

 do not talk especially when mouth is full

 swallow only when chin is tipped downward towards chest

 nursing management:
 promote optimal nutrition

 give medications 30 minutes before meal

 check gag reflex and swallowing ability before feeding

 if the client has difficulty chewing and swallowing, do not

leave alone at meal times

 provide a soft diet

 nursing management:
 suction equipment at bedside

 plan activities
 to conserve energy and regain muscle strength

 instruct patient the need to avoid:

 fatigue, stress

 people with infections

 nursing management:
 administer anti-cholinesterase drugs as ordered

 Give medication exactly on time

 Give with milk and crackers to decrease GI upset

 avoid use of morphine and other strong analgesics

 respiratory depressant effect
 nursing management:
 observe for signs of complications*
 *complications:

 sudden worsening of manifestations due to:

or

 sudden of anti-cholinesterase meds

of anti-cholinesterase meds

factors
 *complications:

 symptoms improve temporarily with Tensilon test

 *complications:

 due to overmedication of anti-cholinesterase meds

 can cause:
 abdominal cramps

 diarrhea

 diaphoresis

 excessive pulmonary secretions

 paradoxical weakness
 *complications:

 symptoms worsen with Tensilon test

 keep atropine sulfate and emergency equipment on hand
 condition in which a person
has recurrent seizures due to a
chronic, underlying process

 two or more unprovoked

seizures*
 *abnormal, excessive,
hypersynchronous
discharges from an
aggregate of CNS neurons
 etiology:
 common:

 Cerebrovascular disease / infection / trauma

 Metabolic disturbances (hypoglycemia, hypocalcemia)

 Brain tumor

 Idiopathic
 etiology:
 infants and children:

 Hypoxia and ischemia

 Developmental / Genetic disorders

 Fever
 etiology:
 adults:

 Trauma

 Chronic alcoholism / Alcohol withdrawal

 Illicit drug use

 Degenerative CNS diseases

 precipitating factors:
 non-balanced diet

 caffeine or alcohol intake

 hours of sleep

 flashing lights

 emotional stress
 major categories of seizures:
 Partial seizures

 Simple

 Complex

 Generalized seizure
 madami
 partial seizures
 MC type of epilepsy

 types: with
 begins with of the upper limbs
 spreads to the face and lower limbs (Jacksonian march)
 on the affected area

in the field of vision

 speech disorders
 epigastric sensation
 pallor or flushing
 sweating
 piloerection
 pupillary dilation
 HR and RR
 begin with an
 may be a strange smell, noise, or sensation preceding a

seizure

 sense of “rising up” at the epigastric region

 visual distortions / deja vu

 partial seizures
 types:
 Complex partial seizures with Automatisms

 Partial seizures evolving into generalized seizures

 automatic behaviors with
 such as:
 lip-smacking

 chewing

 patting a part of the

body

 picking up clothes while

in a dreamy state
 inappropriate or anti-social behaviors

of any activities during seizure

 may be confused or drowsy afterwards

 lead to

 may or may not be convulsive

 types:
 Absence seizures

 Myoclonic seizures

 Clonic seizures

 Tonic seizures

 Tonic-clonic seizures

 Atonic seizures
 “ ” seizures

 common among children

and adolescents

 abrupt periods of
and
 unexplained “day-
dreaming”
 without loss of posture
 loss of contact with reality

 may lead to tonic-clonic

 sudden uncontrollable muscle jerking of one part or the whole
body

 client often falls

 LOC then confusion

 abrupt  in muscle tone and
contraction

 LOC

 autonomic manifestations
 rhythmic muscular
contraction and relaxation

 lasts for several minutes

 phases of tonic-clonic seizure
 phases of tonic-clonic seizure
 phases of tonic-clonic seizure
 phases of tonic-clonic seizure
 phases of tonic-clonic seizure
 phases of tonic-clonic seizure
 total loss of muscle tone
 dxtics:
 Electroencephalogram (EEG)

 CT scan / MRI

 PET
 measures cerebral blood flow

 history
 management:
 maintain airway

(after
tonic phase)

 eliminate precipitating
factors to seizures
 management:
 prevent injury

 place patient on the

of the way

especially at the neck

 management:
 prevent injury

 pillow / folded blanket on head

 prepare equipment
 management:
 administer anticonvulsant therapy

 Benzodiazepine

 Barbiturates

 Phenytoin

 Carbamazepine

 Valproic acid
 nursing management:
with clients with seizure history

should be up and padded

 IV insertion for meds

 prepare equipment
 nursing management:
 client should during seizure

 position the head to

until fully conscious

if seizure occurs in hospital

 nursing management:
 after seizure place patient
in
 to maintain airway

 to drain oral secretions

 stay with the patient until

he wakes up
 nursing management:
 take medications as prescribed

 identify precipitating factors

 nursing management:
 discuss lifestyle precautions:

 no driving allowed for 1 year

 never swim alone

 showers not bathtubs

 do not work at heights

 never cook alone

 never use power tools

 limit the use of knives

 loss of memory, reasoning, judgement, and language that
interferes with everyday life

 can cause:
 impaired cognitive functions

 changes in behavior and personality

 Alzheimer’s disease (MC) and CVA are common causes of dementia
 but exact etiology is unknown
 risk factors (Alzhemier’s)
 age

 Genetics 70%

 inflammation

 stroke
 pathophysiological changes:
 shrunken gyri

 widened sulci

 enlarged ventricles

 generalized atrophy
 manifestations:
 gradual memory loss
 obvious memory loss

 poor judgment and problem-solving skills

at work and at home

activities
 lacks the ability to adapt to new challenges

 becomes ,
 language disturbances
 impaired word-finding

 often “beats around the bush”

 Production of unintended syllables, words, or phrase

during effort to speak.
 repeats words or phrases spoken by:
 themselves (palilalia)

 others (echolalia)
 apraxia
 loss of the ability to execute or carry out learned purposeful

movements

 depression and irritability worsens

 becomes paranoid

 often wanders, gets lost

 cannot recognize family or friends

 cannot communicate in any way

 minimal voluntary movement

 limbs become rigid

 incontinence

 frequent aspiration
 dxtics:
 CT scan / MRI

 ventricular dilation

 enlarged sulci

 cerebral atrophy

 PET scan
 medical management:
 medications:

 Donepezil (Aricept)

 Tacrine (Cognex)

 Galantamine

 Rivastigmine

 Ginkgo Biloba

 improves memory but does not stop (or slow down) the

progression
 medical management:
 medications:

 Vitamin E and Omega-3 fatty acids

 as early preventive measures

 nursing management:
 nurse (and family) should be prepared to
of the patient
 tone should be calm and reassuring

 learn non-verbal communication applied by the patient

 nursing management:
 continuously reorient patient

 place clock and calendar

 allow to reminisce

 provide a calm non-threatening environment

 nursing management:
 ensure that the patient cannot leave without being noticed

 have the in-patient wear an ID badge just in case they become

lost

 have the doors and windows secured

 nursing management:
 at home, secure or remove sources of injury:

 electrical devices

 toxic substances

 loose rugs

 hot tap water

 unlocked doors
 nursing management:
 cooking and driving should be supervised

 have the patient have a routine bowel program for severe AD

 adult diapers

 teach the family adaptive measures

 “long good-bye”
 bleeding into the subarachnoid
space
 etiologies:
 cerebral aneurysm (MC)

 trauma

 arteriovenous malformation

 brain tumors

 blood dyscrasia

 anticoagulant therapy
 dilation of the walls of a
cerebral artery
 resulting in a sac-like, out-

pouching of the artery

 caused by:
 congenital weakness in the
vessel

 trauma

 arteriosclerosis

 hypertension
 Pathophysiology:
 Aneurysm nearby cranial nerves or brain substance,
producing dysfunction

 Aneurysm may , causing subarachnoid hemorrhage

 Initially a clot forms at the site of rupture, but fibrinolysis

(dissolution of the clot) tends to occur within 7 to 10 days and
may cause
 manifestations:
 cerebral aneurysm may be completely
 manifestations (SAH):

 “worst headache of my life”

 signs of meningeal irritation

 motor or sensory deficits, speech or CN deficits

 manifestations (SAH):
 signs of ICP

 vomiting

 headache

 seizures

 change in LOC

 confused

 lethargic

 coma
 dxtics:
 non-contrast (plain) CT scan

 lumbar puncture
 presence of blood in CSF

 c/i if ICP
 dxtics:
 non-contrast (plain) CT scan

 lumbar puncture
 presence of blood in CSF

 c/i if ICP
 medical management:
 medical emergency
 medical management:
 prevent rebleeding

 BP

 neuro exam especially LOC

 most sensitive and early indicator of neuro change

 note for lethargy or restlessness

 medical management:
 reduce vasospasm

 isotonic infusion

 maintain cerebral perfusion

 oxygen therapy

 maintain normal BP
 nursing management:
 monitor VS and neuro exam

 to note any deterioration

 maintain a patent airway and adequate ventilation

 instruct client to take deep breaths but to avoid coughing

 suction only with a specific order

 nursing management:
 observe for signs of:

 vasospasm (hypertension, pallor)

 ICP (vomiting, headache, convulsions)

 hyperthermia

 enforce strict bed rest and provide complete care

 keep head of bed flat or elevated to 20° to 30°C as ordered

 nursing management:
 maintain a quiet, darkened environment

 avoid taking temperature rectally

 s ICP

 instruct client to avoid sneezing, coughing, and straining at stool

 s ICP
 nursing management:
 Administer medications as ordered

 to maintain normotensive levels

 to prevent  in ICP

 to prevent seizures
 nursing management:
 Administer medications as ordered

 to prevent straining and  in ICP

 to  fibrinolysis of the clot (administered IV)

 dysfunction of the
of
 unilateral paralysis of the
facial muscles

 MC type of peripheral facial

paralysis

 self-limiting
 etiology:

 but thought to be due to:

 an

 leads to swelling of
the facial nerve

infection
 HSV, EBV, or Varicella
 manifestations:
 upward movement of
eyeball when closing the
eye

 slight lag in closing the eye

 causing the cornea to

dry up
 manifestations:
 facial drooping

 flattening of nasolabial fold

 widening of palpebral
fissure
 management:
 no cure, only palliative care

 reassure patient that this condition is self-limiting and not

stroke-related

 Steroids
 to inflammation

 Anti-viral medications*
 management:
 Analgesics

 Physical therapy
 moist heat

 massage

 nerve stimulation

 Surgery if paralysis becomes permanent