ABRA VALLEY COLLEGES

COLLEGE OF NURSING
BANGUED, ABRA

NCM 116

RESPONSES TO ALTERED
PERCEPTION

Prepared by:
Advincula, Jaynhard
Caldona, Athena
Duquinal, Darius Miguel
Inciong, Lawin
Luben, Vaness San chai
BSN - III

pg. 1
MULTIPLE SCLEROSIS (Irreversable)
(Mayo clinic, 2022) Multiple sclerosis is a
PROGNOSIS
potentially disabling disease of the brain and spinal
Although multiple sclerosis seems to be
cord. In MS, the immune system attacks the
rarely fatal, some or few complications
protective sheath (myelin) that covers nerve
may be developed due to the
fibers and causes communication problems between
progression of the disease, such as
your brain and the rest of your body. Eventually, the
bladder incontinence, urinary tract
disease can cause permanent damage or deterioration
infection bedsores and paralysis.
of the nerve fibers.

SIGN AND SYMPTOMS

 Numbness or weakness due to nerve damage
 Tingling sensation
 Lhermitte sign - a transient sensation of an electric shock that extends down the spine and
extremities upon flexion and/or movement of the neck
 Lack of coordination
 Unsteady gait or inability to walk
 Problems with sexual, bowel and bladder function
 Fatigue
 Slurred speech

CAUSES
The cause of multiple sclerosis is unknown. It's considered an immune mediated disease in
which the body's immune system attacks its own tissues. In the case of multiple sclerosis, this
immune system malfunction destroys the fatty substance that coats and protects nerve fibers
in the brain and spinal cord (myelin).

RISK FACTORS
These factors may increase your risk of developing multiple sclerosis:
 Age - can occur at any age, but onset usually occurs around 20 and 40 years of age.
 Sex - Women are more than 2 to 3 times as likely as men.
 Family history
 Certain infections. A variety of viruses have been linked to multiple sclerosis, including
Epstein-Barr, the virus that causes infectious mononucleosis – (is a viral infection that
causes fever, sore throat, and swollen lymph glands, most often in the neck.)
 Vitamin D Having low levels of vitamin D and low exposure to sunlight is associated
with a greater risk of multiple sclerosis.

pg. 2
  Certain autoimmune diseases. You have a slightly higher risk of developing MS if you
have other autoimmune disorders such as thyroid disease, pernicious anemia, psoriasis,
type 1 diabetes, or inflammatory bowel disease.
 Smoking

ASSESSMENT AND DIAGNOSTIC

a. Neurological examination
b. Blood tests - while there is no definitive blood test for multiple sclerosis, blood tests can
rule out other conditions that cause symptoms similar to those of multiple sclerosis,
including lupus erythematosus, Sjogren's syndrome, vitamin and mineral deficiencies,
some infections and rare hereditary diseases.
c. Spinal tap (lumbar puncture), in which a small sample of cerebrospinal fluid is removed
from your spinal canal for laboratory analysis. This sample can show abnormalities in
antibodies that are associated with the disease. (see figure a for reference)
d. MRI - which can reveal areas of multiple sclerosis (lesions) on your brain, cervical and
thoracic spinal cord. (see figure b for reference)
e. Evoked potential tests that record the electrical signals produced by the nervous system in
response to stimuli may be done. An evoked potential test may use visual stimuli or
electrical stimuli. In these tests, you watch a moving visual pattern, as short electrical
impulses are applied to nerves in your legs or arms. Electrodes measure how quickly the
information travels down your nerve pathways. (see figure c for reference)

Figure. a

Figure. B https://www.mdpi.com/2076-3417/12/10/4920
Figure C. https://oogziekenhuis.me/Visual_Evoked_Potential/Visual_Evoked_Potential.html

pg. 3
PHARMACOLOGICAL MANAGEMENT
(Mayo clinic, 2022) There is no cure for multiple sclerosis. Treatment typically focuses on
speeding recovery from attacks, reducing new radiographic and clinical relapses, slowing the
progression of the disease, and managing multiple sclerosis symptoms.
Treatments for MS attacks
 Corticosteroids, such as oral prednisone and intravenous methylprednisolone, are
prescribed to reduce nerve inflammation. Side effects may include insomnia, increased
blood pressure, increased blood glucose levels, mood swings and fluid retention.
 Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is
removed and separated from your blood cells. The blood cells are then mixed with a
protein solution (albumin) and put back into your body. Plasma exchange may be used if
your symptoms are new, severe and haven't responded to steroids.
 Interferon beta medications, such as Avonex and Betaferon. These drugs used to be the
most prescribed medications to treat multiple sclerosis. They work by interfering with
diseases that attack the body and may decrease inflammation and increase nerve growth.
They are injected under the skin or into muscle and can reduce the frequency and severity
of relapses.
 Glatiramer acetate (Copaxone, Glatopa). This medication may help block your immune
system's attack on myelin and must be injected beneath the skin. Side effects may include
skin irritation at the injection site.
 Monoclonal antibodies. Ofatumumab (Kesimpta, Arzerra) targets cells that damage the
nervous system. These cells are called B cells. Ofatumumab is given by an injection
under the skin and can decrease multiple sclerosis brain lesions and worsening
symptoms. Possible side effects are infections, local reactions to the injection and
headaches.

NURSING MANAGEMENT
 Assist and help the patient in managing fatigue. Plan an appropriate resting period to
conserve energy and help the patient’s body to relax.
 Encourage the patient and his/her significant other to build more communication
regarding his/her disease to lessen the development of depressive episodes.
 Provide emotional support and encourage the patient to enhance self-esteem.
 Educate the patient and their significant other about possible complication and ways to
prevent it (e.g. risk for fall)
 Educate and encourage the patient and significant other in preparing nutritious meals.

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PARKINSON’S DISEASE (Irreversable)
According to National Health Council, Parkinson’s disease is a neurodegenerative disorder that
affects predominately dopamine-producing (“dopaminergic”) neurons in a specific area of the
brain called substantia nigra. Symptoms generally develop slowly over the years. The
progression of symptoms is often a bit different from one
person to another due to the diversity of the disease.
Parkinson’s disease (PD) is a type of movement disorder that
can affect the ability to perform common, daily activities. It
is a chronic and progressive disease, meaning that the
symptoms become worse over time. It is characterized by its
most common of motor symptoms—tremors (a form of
rhythmic shaking), stiffness or rigidity of the muscles, and
slowness of movement (called bradykinesia)—but also
manifests in non-motor symptoms including sleep problems,
constipation, anxiety, depression, and fatigue, among others.
(American Parkinson’s Disease Association)

PROGNOSIS
According to the Michael J. Fox Foundation for Parkinson's Research, “patients usually live
between 10 and 20 years after diagnosis”. In spite of having normal to near normal life
expectancy, people diagnosed with Parkinson’s disease are more vulnerable for complications
such as infection and risk for falls.

SIGN AND SYMPTOMS

(Mayo clinic, 2022)
 Tremor - usually begins in a limb, often your hand or fingers, pill-rolling tremor.
 Bradykinesia - slow movement, making simple tasks difficult and time-consuming.
 Rigid muscles - Muscle stiffness may occur in any part of the body. The stiff muscles can
be painful and limit the range of motion.
 Impaired posture and balance - posture may become stooped.
 Loss of automatic movements - decreased ability to perform unconscious movements,
including blinking, smiling, or swinging your arms when you walk.
 Speech changes - speaking softly or quickly, slur, or hesitate before talking. Speech may
be more monotone rather than have the usual speech patterns.

CAUSES

pg. 5
In Parkinson's disease, certain nerve cells called neurons in the brain gradually break down or
die. Many of the symptoms of Parkinson's are due to a loss of neurons that produce a chemical
messenger in your brain called dopamine. When dopamine levels decrease, it causes irregular
brain activity, leading to problems with movement and other symptoms of Parkinson's disease.
The cause of Parkinson's disease is unknown. (Mayo clinic, 2022)

RISK FACTORS
 Age - begins in middle or late life, and the risk increases with age. People usually
develop the disease around age 60 or older.
 Heredity - having a close relative with Parkinson's disease increases the chances to
develop the disease.
 Sex - Men are more likely to develop Parkinson's disease than are women.
 Exposure to toxins - Ongoing exposure to herbicides and pesticides may slightly increase
your risk of Parkinson's disease.

ASSESSMENT AND DIAGNOSTIC

(Mayo clinic, 2022) Currently, there isn't a specific test to diagnose Parkinson's disease. A
diagnosis is made by a doctor trained in nervous system conditions, known as a neurologist. A
diagnosis of Parkinson's is based on your medical history, a review of your symptoms, and a
neurological and physical exam.
A member of your health care team may suggest a specific single-photon emission
computerized tomography (SPECT) scan called a dopamine transporter (DAT) scan.
Although this can help support the suspicion that you have Parkinson's disease, it is your
symptoms and results of a neurological exam that ultimately determine the correct diagnosis.
Most people do not require a DAT scan.
 Medical history – parkinson’s disease is hereditary and medical history can help to
determine the condition if one of the patient’s family has Parkinson’s disease.\
 Review of symptoms - if symptoms persisted or prolonged the health care provider can
use the patient’s symptoms to rule out the disease.
 Neurologic/physical examination – the health care provider may ask the patient to do task
such as standing, sitting, stand, or stretching; this is to determine the coordination of the
patient’s body.

pg. 6
  DaTscan - uses SPECT (Single Photon Emission Computed Tomography) imaging to
show how much DAT activity is happening around your striatum, a part of the brain
affected by Parkinson's. If the DaTscan image indicates the diminished activity of
DAT, this implies that there is a diminished level of dopamine.

To better understand Parkinson’s disease, refer to figure

d. and figure e.
In figure d. the Dopamine Active Transporter (DAT
Scan) will show the movement or the activity of the
Dopamine “neurotransmitter” – (a protein that is
responsible in transmitting signals or information from
one another up to the central nervous system). The red
color in figure d. represents the activity of dopamine,
larger red – increased activity of dopamine; smaller red
– decreased/diminished activity of dopamine.
In figure e. The image will show the mechanism of
dopamine in transmitting signals to the brain.

Figure e.

PHARMACOLOGICAL MANAGEMENT
Parkinson’s disease is irreversible, but there are few medications than can or may aid the patient
in managing possible complications; and to enhance activity such as walking, movements, and
even tremors. These medicines either substitute or increase dopamine.
 Carbidopa-levodopa (Rytary, Sinemet, Duopa, others). Levodopa, the most effective
Parkinson's disease medicine, is a natural chemical that passes into the brain and is
converted to dopamine. (Mayo clinic, 2023)

pg. 7
  Dopamine agonists (Apokyn) - unlike levodopa, dopamine agonists don't change into
dopamine. Instead, they mimic dopamine effects in the brain. (Mayo clinic, 2023)
 Monoamine oxidase B (MAO B) inhibitors (Zelapar, Azilect) - They help prevent the
breakdown of brain dopamine by inhibiting the brain enzyme monoamine oxidase B
(MAO B) – (this enzyme breaks down brain dopamine). (Mayo clinic, 2023)
 Anticholinergics (Cogentin) - antiparkinsonian effect is centrally mediated and that they
work by counteracting the imbalance between striatal dopamine and acetylcholine
activities caused by the degeneration of dopaminergic nigrostriatal neurons.
(Katzenschlager, 2022)

SURGICAL
Deep brain stimulation
(Mayo clinic, 2023) In deep brain
stimulation (DBS), surgeons implant
electrodes into a specific part of the brain.
The electrodes are connected to a
generator implanted in the chest near the
collarbone. The generator sends electrical
pulses to the brain and may reduce
Parkinson's disease symptoms.
(see figure f. for reference)
Figure f.

NURSING MANAGEMENT
 Provide support and education to patients and families about Parkinson’s disease,
treatment options, and lifestyle modifications.
 Facilitate physical therapy and occupational therapy to optimize mobility, balance, and
functional abilities.
 Monitor for and manage potential complications, such as falls, dysphagia, or cognitive
changes.
 Offer emotional support and counseling to patients and families to cope with the impact
of Parkinson’s disease.
 Coordinate care and referrals to specialists, such as neurologists or speech therapists.

TRAUMATIC LESIONS (Head injury & Spinal injury)

HEAD INJURY “Traumatic brain injury”

pg. 8
(Mayo clinic, 2021) Usually results from a violent blow or jolt to the head or body. An object
that goes through brain tissue, such as a bullet or shattered piece of skull, also can cause
traumatic brain injury.
Mild traumatic brain injury may affect your brain cells temporarily. More-serious traumatic brain
injury can result in bruising, torn tissues, bleeding, and other physical damage to the brain. These
injuries can result in long-term complications or death.

PROGNOSIS
(Agarwal et al., 2020) Patients with moderate head injuries fare less well. Approximately 60
percent will make a positive recovery and an estimated 25 percent left with a moderate degree of
disability. Death or a persistent vegetative state will be the outcome in about 7 to 10 percent of
cases. The remainder of patients will have a severe degree of disability.

SIGN AND SYMPTOMS

According to National Institute of Child Health and Human Development (NICHD, 2020) these
are the following sign and symptoms of head injury according to its severity.

Mild Head Injury Moderate – Severe Head Injury

 Headache  Headache that gets worse or will not

 Confusion go away.
 Lightheadedness  Loss of vision in one or both eyes
 Dizziness  Repeated vomiting or continued
 Blurred vision nausea
 tinnitus  Slurred speech
 Tiredness or sleepiness  Convulsions or seizures
 A bad taste in the mouth  An inability to wake up from sleep
 Loss of consciousness lasting a few  Enlargement of the pupil (dark center)
seconds to minutes of one or both eyes
 Sensitivity to light or sound  Loss of consciousness lasting a few
 Nausea or vomiting minutes to hours

CAUSES
The most common cause of head injuries are:

1. Vehicular accident

pg. 9
 2. Falls
3. Assault

RISK FACTORS
(Mayo clinic, 2021) The people most at risk of traumatic brain injury include:
 Children, especially newborns to 4-year-olds
 Young adults, especially those between ages 15 and 24
 Adults aged 60 and older
 Males in any age group

ASSESSMENT AND DIAGNOSTIC

(Mayo clinic, 2021)
 Glasgow Coma Scale
This 15-point test helps doctor or other emergency medical personnel assess the initial
severity of a brain injury by checking a person's ability to follow directions and move
their eyes and limbs. (see figure g. for reference)
 Information about the injury and symptoms
If you saw someone sustain an injury or arrive immediately after an injury, you may be
able to provide medical personnel with information that's useful in assessing the injured
person's condition.
Answers to the following questions may be beneficial in judging the severity of injury:
How did the injury occur?
Did the person lose consciousness?
How long was the person unconscious?
Where was the head or other parts of the body struck?
 Imaging tests
 Computerized tomography (CT) scan.
 Magnetic resonance imaging (MRI).
 Intracranial pressure monitor

pg. 10
 Tissue swelling from a traumatic brain injury can increase pressure inside the skull and
cause additional damage to the brain. Doctors may insert a probe through the skull to
monitor this pressure. (see figure h. for reference)

Figure h. Image NHS Foundation Trust

Figure g.
https://www.firsta
coma-scale-gcs-fi

PHARMACOLOGICAL MANAGEMENT
(Mayo clinic, 2021) Medications to limit secondary damage to the brain immediately after an
injury may include:
 Anti-seizure drugs. People who've had a moderate to severe traumatic brain injury are at
risk of having seizures during the first week after their injury.
 Coma-inducing drugs. Doctors sometimes use drugs to put people into temporary comas
because a comatose brain needs less oxygen to function. This is especially helpful if
blood vessels, compressed by increased pressure in the brain, are unable to supply brain
cells with normal amounts of nutrients and oxygen.
 Diuretics. These drugs reduce the amount of fluid in tissues and increase urine output.
Diuretics, given intravenously to people with traumatic brain injury, help reduce pressure
inside the brain.

SURGERY
Emergency surgery may be needed to minimize additional damage to brain tissues. Surgery may
be used to address the following problems:
 Removing clotted blood (hematomas). Bleeding outside or within the brain can result in
a collection of clotted blood (hematoma) that puts pressure on the brain and damages
brain tissue.
 Repairing skull fractures. Surgery may be needed to repair severe skull fractures or to
remove pieces of skull in the brain.
 Bleeding in the brain. Head injuries that cause bleeding in the brain may need surgery to
stop the bleeding.
 Opening a window in the skull. Surgery may be used to relieve pressure inside the skull
by draining accumulated cerebrospinal fluid or creating a window in the skull that
provides more room for swollen tissues.

NURSING MANAGEMENT

pg. 11
(Shaikh et al., 2023) The most important goal is to prevent secondary brain injuries. This can be
achieved by the following:
 Maintain airway and ventilation.
 Maintain cerebral perfusion pressure.
 Prevent secondary injuries (by recognizing and treating hypoxia, hypercapnia, or
hypoperfusion)
 Evaluate and manage for increased intracranial pressure (ICP)
 Obtain urgent neurosurgical consultation for intracranial mass lesions.
 Identify and treat other life-threatening injuries or conditions.

pg. 12
SPINAL INJURY

(Mayo clinic, 2023) A spinal cord injury

involves damage to any part of the spinal
cord. It also can include damage to nerves at
the end of the spinal cord, known as the
cauda equina (see figure i. for reference).
The spinal cord sends and receives signals
between the brain and the rest of the body. A
spinal cord injury often causes permanent
changes in strength, feeling and other body
functions below the site of the injury.

PROGNOSIS Figure i. – Image from Medline Plus

(Beutler, 2024) Patients with a complete spinal cord
injury have a less than 5% chance of recovery. If complete paralysis persists at 72 hours after
injury, recovery is essentially zero. If some sensory function is preserved, the chance that the
patient will eventually be able walk is greater than 50%. Ultimately, 90% of patients with spinal
cord injury return to their homes and regain independence.

SIGN AND SYMPTOMS

(Mayo clinic, 2023) The lowest part of the spinal cord not damaged after an injury is known as
the neurological level of the injury. "The completeness" of the injury refers to how much
feeling, known as sensation, is lost. Completeness is classified as:
 Complete. If all feeling and all ability to control movement are lost below the spinal cord
injury, the injury is called complete.
 Incomplete. If some feeling and control of movement remain below the affected area, the
injury is called incomplete. There are varying degrees of incomplete injury.
 Paralysis - there are two types of paralysis to categorize:
o Tetraplegia - also known as quadriplegia. This means that your arms, hands,
trunk, legs, and pelvic organs are all affected by your spinal cord injury.
o Paraplegia - This paralysis affects all or part of the trunk, legs, and pelvic organs
but not the arms.
 Loss of movement.
 Loss of or a change in sensation. This includes a change in the ability to feel heat, cold
and touch.
 Loss of bowel or bladder control.
 Exaggerated reflex activities or spasms.
 Changes in sexual function, sexual sensitivity, and fertility.
 Pain or an intense stinging sensation caused by damage to the nerve fibers in the spinal
cord.

CAUSES
(Mayo clinic, 2023) e most common causes of spinal cord injuries in the United States are:

pg. 13
  Motor vehicle accidents - Auto and motorcycle accidents are the leading cause of spinal
cord injuries. They account for almost half of new spinal cord injuries each year.
 Falls - A spinal cord injury after age 65 is most often caused by a fall.
 Acts of violence - About 12% of spinal cord injuries result from violent encounters,
usually from gunshot wounds. Knife wounds are also common.
 Sports and recreation injuries - Athletic activities, such as impact sports and diving in
shallow water, cause about 10% of spinal cord injuries.
 Diseases - Cancer, arthritis, osteoporosis, and inflammation of the spinal cord also can
cause spinal cord injuries.

RISK FACTORS

A spinal cord injury usually results from an accident and can happen to anyone. But certain
factors can increase the risk of having a spinal cord injury, including:
 Being male Spinal cord injuries largely affect men. In fact, women account for only
about 20% of traumatic spinal cord injuries in the United States.
 Being 65 and older Another spike in spinal cord injuries occurs at age 65. Falls cause
most injuries in older adults.
 Alcohol use Alcohol use is involved in about 25% of traumatic spinal cord injuries.
 Engaging in risky behavior. Motor vehicle crashes are the leading cause of spinal cord
injuries for people under 65. Other risky behaviors include diving into shallow water and
playing sports without wearing safety gear or taking proper precautions.
 Having certain diseases, A minor injury can cause spinal cord damage if you have a
condition that affects your joints or bones, such as osteoporosis.

ASSESSMENT AND DIAGNOSTIC

 X-rays can reveal damage to the bone surrounding the spinal cord, known as the
vertebrae.
 CT scan can provide a clearer image compared with an X-ray. This scan uses computers
to form a series of cross-sectional images that can define bone, disk, and other changes.

pg. 14
  MRI uses a strong magnetic field and radio waves to produce computer-generated
images. This test is helpful for
looking at the spinal cord to
find herniated disks, blood
clots or other masses that
might compress the spinal
cord.

Figure j. Shows the difference

between a healthy spinal cord with Figure j. Image from informedhealth.org.

comparison to
a fractured spinal cord

MEDICAL MANAGEMENT
PHARMACOLOGICAL
 GABA analogue is a compound which is an analogue or derivative of the
neurotransmitter gamma-Aminobutyric acid (GABA) (the IUPAC of which is 4-
aminobutanoic acid). Many GABA analogues are used as drugs, especially as
anticonvulsants, sedatives, and anxiolytics.
Acamprosate (Campral)
Gabapentin (Gralise, Neurontin)
Gabapentin enacarbil (Horizant)

SURGERY
(Mayo clinic, 2022) Laminectomy is surgery that
creates space by removing bone spurs and tissues
associated with arthritis of the spine. It usually
involves removing a small piece of the back part
(lamina) of the small bones of the spine (vertebrae).
Laminectomy enlarges the spinal canal to relieve
pressure on the spinal cord or nerves. Laminectomy
is often done as part of decompression surgery.

TRACTIONS

pg. 15
(Armstrong, 2019) Spinal traction stretches the spine to take pressure off compressed discs. This
straightens the spine and improves the body’s ability to heal itself.

https://www.thespinecentre.com.au/spinal-decompression/

SPLINT, BRACES, OR HALO DEVICE

Like traction, these keep the area around your SCI stable.
But unlike traction, you can wear these and move around
with them on.

NURSING MANAGEMENT
 Promote effective airway clearance.
 Assist the patient in managing and pain control using nonpharmacological methods such
as quiet and peaceful environments.
 Promote safety measures in the surrounding area to prevent complications related to falls.
 Encourage the patient to enhance self-esteem and provide entertainment to prevent self-
pity or depressive episodes.
 Monitor all vital signs to ensure the stability of the patient, especially in severe spinal
cord injury.

pg. 16
 MYASTHENIA GRAVIS
1. 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.
Myasthenia Gravis is a
neuromuscular disease
characterized by considerable weakness and abnormal fatigue of the voluntary muscles.
2. A defect in the transmission of nerve impulses at the myoneural junction occurs.
3. Causes include insufficient secretion of acetylcholine, excessive secretion of cholinesterase,
and unresponsiveness of the muscle fibers to acetylcholine.

SIGN AND SYMPTOMS

Common Sign and symptoms of myasthenia gravis include:
 droopy eyelids.
 double vision.
 difficulty making facial expressions.
 problems chewing and difficulty swallowing.
 slurred speech.
 weak arms, legs or neck.
 shortness of breath and occasionally serious breathing difficulties.

CAUSES
Myasthenia gravis is caused by a problem with the signals sent between the nerves and the
muscles. It's an autoimmune condition, which means it's the result of the immune system (the
body's natural defence against infection) mistakenly attacking a healthy part of the body.

pg. 17
 RISK FACTORS
 Being a woman between the ages of 20 to 30.
 Being a man between the ages of 60 to 70.
 Having specific genetic markers called HLA-B8 or DR3.
 Neonates (newborn infants) with mothers who have abnormal antibodies that have entered the
baby's body via the placenta during pregnancy.

ASSESSMENT AND DIAGNOSIS

1. The main test for myasthenia gravis is a blood test to look for a type of antibody (produced
by the immune system) that stops signals being sent between the nerves and muscles. A high
level of these antibodies usually means you have myasthenia gravis. Weakness and fatigue
2. Difficulty chewing
3. Dysphagia
4. Ptosis
5. Diplopia
6. Weak, hoarse voice
7. Difficulty breathing
8. Diminished breath sounds
9. Respiratory paralysis and failure

PHARMACOLOGICAL TREATMENT
Medicines such as pyridostigmine (Mestinon, Regonal) improve communication between nerves
and muscles. These medicines aren't a cure, but they can improve muscle contraction and muscle
strength in some people. Possible side effects include gastrointestinal upset, diarrhea, nausea, and
too much salivation and sweating.

NURSING MANAGEMENT

1. Monitor respiratory status and ability to cough and deep breathe adequately.
2. Monitor for respiratory failure.
3. Maintain suctioning and emergency equipment at the bedside.
4. Monitor vital signs.
5. Monitor speech and swallowing abilities to prevent aspiration.
6. Encourage the client to sit up when eating.
7. Assess muscle status.

pg. 18
 8. Instruct the client to conserve strength.
9. Plan short activities that coincide with times of maximal muscle strength.
10. Monitor for myasthenic and cholinergic crises.
11. Administer anticholinesterase medications as prescribed.
12. Instruct the client to avoid stress, infection, fatigue, and over-the counter medications.
13. Instruct the client to wear a Medic-Alert bracelet.
14. Inform the client about services from the Myasthenia Gravis Foundation.

PATHOPHYSIOLOGY
MG is caused by antibodies against the acetylcholine receptor (AChR), which produce a
compromise in the end-plate potential, reducing the safety factor for effective synaptic
transmission. It is clear that AChR antibody destruction of the postsynaptic surface is dependent
on complement activation.

PROGNOSIS
In one study, the disease of approximately 38% of individuals with MG went into remission.
Stabilization or even regression of symptoms at 3 years after disease onset is typical in patients
with MG. Approximately 50% of deaths occur during the first 3 years, when the symptoms are
most severe.

Cleveland Clinic Main Campus

Medical center in Cleveland, Ohio

pg. 19
CEREBROVASCULAR DISEASE
The word cerebrovascular is made up of two parts- “cerebro” which refers to the large part of the
brain, and “vascular” which means arteries and veins. Cerebrovascular disease is a term for
conditions that affect the blood vessels that supply blood to the brain. This decreases the amount
of oxygen that reaches the brain causing damage. The most common is stroke. This disease
includes all disorders in which an area of the brain is temporary or permanently affected by
ischemia or bleeding and one or more of the cerebral blood vessels are involved in the pathologic
process.

RISK RACTORS
 Diabetes- excessive blood glucose can result in increased fatty deposits or clots in the
blood vessels.
 High blood pressure- can damage blood vessels that supply blood to the brain
 High cholesterol- high cholesterol levels can contribute to thickening or hardening of the
arteries caused by build-up plaque
 Obesity- increases the risk of high blood pressure, high cholesterol and diabetes.
 Consuming too much salt- salt is the major factor that increases blood pressure and
therefore, responsible for many strokes and heart attack
 Stress- can cause the heart to work harder, increase blood pressure and increase sugar
and fat levels in the blood.

SYMPTOMS
 Loss of vision
 Paralysis or weakness on the one side of your body or face
 Sudden, severe headache
 Loss of balance
 Trouble speaking
 Sensory changes in one side of the body or face

CAUSES
 Blood clots- spontaneously forms in the blood vessels in the brain
 Blood vessels ruptured- this usually occurs in conjunction with uncontrolled high blood
pressure.
 Plaque- build-up in the arteries in the brain
 Structural problems in the brain blood vessels

PATHOPHYSIOLOGY
-Narrowed cerebral arteries can cause ischemic stroke, however constantly accelerated
blood strain also can purpose tearing of vessels, main to a hemorrhagic stroke when a
discount in blood go with the drift lasting seconds takes place, the mind tissue suffers
ischemia or insufficient blood deliver.

pg. 20
DIAGNOSTIC TEST
 Cerebral angiography- it helps in diagnosing blockage or other abnormalities in the
blood vessels of head and neck. A catheter is inserted into an artery in the wrist or groin
area. then they inject a contrast material through the catheter to show the structure of the
blood vessels.
 CT Coronary angiography- an imaging test to view the coronary arteries.
 Electrocardiogram (ECG)- is a test to records the heart electrical activity. To show if it
has any irregular hearth rhythms that may cause stroke. It uses temporary electrodes on
the chest and limbs to monitor, track and document the heart electrical activity.
 Magnetic resonance imaging- an imaging test to help in detecting early stage- stroke. A
provider uses a large magnet, radio waves and a computer to produce detailed images.

MANAGEMENT
 Control high blood pressure
 Eat a hypertensive diet low in;
o salt ( any fresh vegetables, fruits, most dairy products, unsalted nuts..)
o Fats ( tuna, peas, egg whites, beans, tofu, leafy green veg..)
o calories ( oats, yogurt, berries, eggs, potatoes..)

 Exercise- for a healthy lifestyle

 Limit alcohol intake- alcohol also caused heart attack. It can inhibit coagulation or liver
damage for too much alcohol can stop making substances that help blood clot.
 Maintain healthy weight- will help reduce risk of stroke
 Manage use of sugar and cholesterol levels
 Quit smoking – it narrows the blood vessels and can lead to plaque and clot formation.

PHARMACOLOGICAL MANAGEMENT
 Antiplatelet agent; ( aspirin/ clopidogrel)
They work by stopping the platelets from sticking together, that caused heart attack.
 Anticoagulant; (warfarin)
It help prevent blood clot formation by targeting clotting factors

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  Ace inhibitors, beta-blockers, calcium channel blockers
To manage hypertension and reduce the risk of stroke

SURGICAL MANAGEMENT
 Carotid endarterectomy
- Is a surgery to remove plaque and clots from the carotid arteries. During the
procedure, an incision is made the neck, at the location of the blockage the surgeon
then makes a length- wise incision along the portion of the artery containing the
plaque.
 Carotid artery angioplasty
- A balloon catheter is put inside a blood vessel. The doctor will uses an x-ray to guide
the catheter to the blocked or narrowed area of the carotid artery. Once in place, the
balloon tip is inflated for few seconds to open or widen artery. The filter collects any
debris that may break off the blockages.
 Carotid stenting
- A stent is place in the artery and opens to fit the size of the artery. The stent stays in
place permanently and acts as scaffold to support the artery walls and keep the artery
open.
 Catheter- directed mechanical thrombectomy
- A catheter is inset in the artery along with a device to suck out the blood clot.

PROGNOSIS
- Stroke continues to carry high morbidity and mortality. One year-survival for stroke
varies from 60 to 80 % . the recovery is prolonged and the risk of another stroke is
high. Most patients following a stroke remain disabled or have partial neurological
deficits that prevent them from being active.

American Association of Neurological Surgeons,(2022). Cerebrovascular

Disease (https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/
Cerebrovascular-Disease).

pg. 22
NEUROPATHIES
According to Health Direct website, neuropathy is when nerve damage leads to pain, weakness,
numbness or tingling in one or more parts of your body. The nerve damage may be because of
disease, infection, injury, medicines, long-term alcohol abuse or another reason. Sometimes no
cause is found.

(Moawad, 2021) There are four types of neuropathy: peripheral, autonomic, proximal, and
focal. There are many causes of neuropathy and you can also have more than one type.
Neuropathy can cause paresthesias (unusual sensations), discomfort, or pain. Usually, the
unpleasant sensations can be treated with medication. Sometimes, treating the underlying
condition can stop the progression of neuropathy.
Peripheral Neuropathy

This type of neuropathy affects the nerves that control the movement and sensation of your
limbs. Peripheral neuropathy is often described as having a “stocking-glove” pattern because it
usually affects the hands and feet more severely than other areas of the body.

Peripheral neuropathy stems from problems that affect the entire body. It also often affects
nerves on both sides of the body symmetrically. Common causes include diabetes (especially if
blood sugar levels are not well controlled), high amounts of alcohol use, medications such as
chemotherapy, and immune disorders.2
Autonomic Neuropathy

This type of neuropathy affects the involuntary nerves that control the organs of your body.
These nerves control movement of the intestines, heart rate, strength of heart contraction, blood
pressure, urination, and more.3

Autonomic neuropathy is associated with severe diabetes and systemic illnesses, such as kidney
failure and cancer.
Proximal Neuropathy

Proximal neuropathy is neuropathy that affects nerves of the limbs closer to your torso, such as
nerves of the upper arm, shoulder, or thighs. It is less common than other types of neuropathy
and can occur on its own or with peripheral neuropathy. Sometimes severe peripheral neuropathy
can involve proximal nerves as it progresses.

This type of neuropathy is usually asymmetric (not affecting both sides of the body equally).
Causes can include cancer1 and inflammatory diseases such as Guillain-Barré syndrome (acute
demyelinating polyneuropathy), Miller Fisher syndrome, and chronic inflammatory
demyelinating polyneuropathy.

Guillain-Barré is also known to involve the muscles that control breathing, which can cause a
respiratory emergency.

Focal Neuropathy
Focal neuropathy is common. It includes conditions like carpal tunnel syndrome and ulnar
neuropathy, which are caused by compression of different specific nerves (both affect the hand
and wrist). Compression can occur due to pressure, often from prolonged positions, or from
overusing the limb in a way that causes inflammation.

pg. 23
Bell’s palsy, which is neuropathy of the motor portion of the facial nerve, can occur due to a
viral infection or inflammation, and it is also described as a focal neuropathy.
Trigeminal neuralgia, another type of focal neuropathy, is a painful condition caused by
inflammation or irritation of the trigeminal nerve, which controls sensation of the face.

SIGN AND SYMPTOMS

 Temporary or permanent numbness
 Tingling, prickling, or burning sensation
 Increased sensitivity to touch
 Pain
 Muscle weakness or wasting
 Paralysis
 Dysfunction in organs or glands
 Impairment to urination and sexual function

PROGNOSIS

(Moawad, 2021) Some neuropathies are not expected to improve. Diabetic neuropathy and
alcoholic neuropathy, for example, can stabilize with treatment, but the damage is not likely to
heal. Focal neuropathy can improve with treatment, often with complete resolution of symptoms.

ASSESSMENT AND DIAGNOSIS

(Salomon, 2023) There are a number of ways in which neuropathy can be diagnosed, says
Williams. Generally the process will start with your physician taking down a patient history that
includes a description of your complaints, as well as a physical examination to check the
functioning of the area in question.

Electrodiagnostic Testing, This includes nerve conduction testing, where nerves are stimulated
and their responses are recorded and analyzed for abnormalities, and electromyography where
small needles are inserted into individual muscles to get audio and visual information on how the
nerves supplying that muscle are functioning.

Blood Tests, These can be ordered to check for elevated blood sugar (as seen in type 2 diabetes),
toxins, vitamin deficiencies, hereditary disorders, and evidence of an abnormal immune
response.

Skin Biopsies, A small incision is made to remove a sample of skin for examination. It may
help to distinguish certain disorders affecting the small nerve fibers, such as painful sensory
neuropathies affecting nerve fibers called axons.

Quantitative Sensory Testing (QST) Used to assess damage to the nerve endings involved in
sensing temperature and vibrations, QST uses computer testing to measure how the nerves in
question react to these stimuli.

PHARMACOLOGICAL TREATMENT

pg. 24
  amitriptyline – also used for treatment of headaches and depression

 duloxetine – also used for treatment of bladder problems and depression

 pregabalin and gabapentin – also used to treat epilepsy, headaches or anxiety

 Tramadol is a powerful painkiller related to morphine that can be used to treat

neuropathic pain that does not respond to other treatments a GP can prescribe.

 Physiotherapy helps to restore movement and function when someone is affected by

injury, illness or disability. It can also help to reduce your risk of injury or illness in the
future.

NURSING MANAGEMENT

1. Educate the patient and family member/s about safety precautions to prevent injuries.

2. Encourage the patient to do light exercise to improve muscle strength

pg. 25