Nursing Care of

Clients
with
Neurologic
Ma. Tosca Cybil A. Disorders
Torres, RN, MAN
 Outline
• Autoimmune Disorders
• Multiple Sclerosis (MS)
• Myasthenia Gravis (MG)
• Guillen-Barré syndrome
(GBS)
• Degenerative
disorders
• Parkinson’s Disease
• Huntington’s Disease
Multiple Sclerosis
M u lt ip le S c le r o s is

Chronic demyelinating
disease of the CNS
associated with abnormal
immune response to
environmental factor
 Multiple Sclerosis
• Periods of exacerbations and remissions
• Progression of disease with increasing
loss of function
• Incidence is highest in young adults
(20
– 40); onset between 20 – 50
• Affects females more than males
• More common in temperate climates
• Occurs mainly in Caucasians
 Manifestations
• Fatigue
• Optic nerve involvement: blurred
vision, haziness
• nystagmus, dysarthria,cognitive
dysfunctions, vertigo,
deafness
• Weakness, numbness in leg(s), spastic
paresis, bladder and bowel
dysfunction
• ataxia
• Spasticity
 STRESS
AGGRAVATES
SYMPTOMS.
Collaborative Care

Focus is on retaining
optimum functioning
and limiting disability
 Diagnostic Tests
• Neurological exam, careful history
• Lumbar puncture with CSF analysis: increased
number of T lymphocytes; elevated level of
immunoglobulin G (IgG)
• Cerebral, spinal optic nerve MRI: shows
multifocal lesions
• Evoked response testing of visual, auditory,
somatosensory impulses show delayed
conduction
• CT scan shows density of white matter or
plaque formation
NO CURE EXISTS
FOR MS
 Medications
• Biologic response modifiers
• Interferon beta-1a
• Interferon beta-1b
• Glatiramer acetate
• Glucocorticosteroids
• Immunosuppressants
• azathioprine (Imuran)
• cyclophosphamide (Cytoxan)
• methotrexate
• Muscle relaxants to treat muscle spasms
• diazepam
• Medications to deal with bladder problems:
anticholinergics or cholinergics depending on
problem experienced by client
 Nursing Diagnoses
• Self care deficit
• Impaired physical mobility
• Risk for injury
• Impaired urinary and bowel elimination
• Impaired verbal communication
• Risk for aspiration
• Disturbed thought processes
• Ineffective individual coping
• Potential for sexual dysfunction
 Nursing Care
• Monitor motor movements for
interference with ADLs
• Encourage activity balanced with rest
periods
• Assess cognitive function
• Explain:
• Bladder training
• Positioning
• Avoid temperature extremes
• Medication compliance
 Health Promotion
• Client needs to develop strategies
to deal with fatigue, exacerbations
• Prevention of respiratory and
urinary tract infections
 Home Care
• Education
• Referral to support group and
resources
• Referral to home health agencies
when condition requires
 Myasthenia
gravis (MG)
M y a s t h e n ia g r a v
(M G ) is

Chronic autoimmune
neuromuscular disorder
affecting the
neuromuscular
joint
M y a s t h e n ia g r a v
is (M G )
• characterized by fatigue and
severe weakness of skeletal
muscles
• Occurs with remissions and
exacerbations
• Occurs more frequently in females,
with onset between ages 20 – 30
 Manifestations
Seen in the muscles that are affected:
• Ptosis (drooping of eyelids), diplopia
(double vision)
• Weakness in mouth muscles resulting in
dysarthria and dysplagia
• Weak voice, smile appears as snarl
• Head juts forward
• Muscles are weak but DTRs are normal
• Weakness and fatigue exacerbated by
stress, fever, overexertion, exposure
MG is purely a MOTOR
disorder with no
effect on sensation or
coordination
 Complications
Pneumonia
Myasthenic Crisis
• Sudden exacerbation of motor
weakness putting client at risk for
respiratory failure and aspiration
• Manifestations: tachycardia,
tachypnea, respiratory distress,
dysphasia
 Complications
Cholinergic Crisis
• Occurs with overdosage of medications
(anticholinesterase drugs) used to treat
MG
• Develops GI symptoms, severe muscle
weakness, vertigo and respiratory
distress
Both crises often require
ventilation assistance
 Diagnostic Tests
• Physical examination and history
• Tensilon Test: edrophonium chloride (Tensilon)
administered and client with myasthenia will
show significant improvement lasting 5 minutes
• EMG: reduced action potential
• Antiacetylcholine receptor antibody serum
levels: increased in 80% MG clients; used to
follow course of treatment
• Serum assay of circulating acetylcholine
receptor antibodies: if increased, is diagnostic
of MG
 Medications
• Anticholinesterase medications
• Pyridostigmine bromide (Mestinon)
• Immunsuppression medications
including glucocorticoids
• Cyclosporineor azathioprine
(Imuran)
 Surgery
• Thymectomy is recommended in
clients <60
• Remission occurs in 40 % of clients,
but may take several years to
occur
 Plasmapheresis
• Used to remove antibodies
• Often done before planned
surgery, or when respiratory
involvement has occurred
 Nursing Care
• Teaching interventions to deal with
fatigue
• Importance of following medication
therapy
 Nursing Diagnoses
• Ineffective Airway Clearance
• Impaired Swallowing: plan to take
medication to assist with
chewing activity
 Home Care
• Avoid fatigue and stress
• Plan for future with treatment
options
• Keep medications available
• Carry medical identification
• Referral to support group,
community resources
Guil lain-Bar
é
Syndrome
(GBS)
G u i l la in -B a r r é S y n d r o m
e (G B S )
Acute autoimmune
inflammatory demyelinating
disorder of peripheral
nervous system
characterized by acute
onset of ascending motor
paralysis
 G u i l la in -B a r r
é S yndro m e
(G B S )
• Cause is unknown but precipitating
events include GI or respiratory
infection, surgery, or viral
immunizations
• 80 – 90% of clients have spontaneous
recovery with little or no disabilities
• 4 – 6% mortality rate, and up to 10%
have permanent disabling weakness
• 20 % require mechanical ventilation
due to respiratory involvement
M a n if e s t a t io n
s
• Most clients have symmetric weakness beginning in
lower extremities
• Ascends body to include upper extremities, torso, and
cranial nerves
• Sensory involvement causes severe pain, paresthesia and
numbness
• Paralysis of intercostals and diaphragmatic muscle
• Autonomic nervous system involvement: blood pressure
fluctuations, cardiac dysrhythmias, paralytic ileus,
urinary retention
• Weakness usually plateaus or starts to improve in the
fourth week with slow return of muscle strength
 Diagnostic Tests
• diagnosis made thorough history
and clinical examination; there is
no specific test
• CSF analysis: increased protein
• EMG: decrease nerve conduction
• Pulmonary function test reflect
degree of respiratory involvement
 Medications
• supportive and prophylactic care
• Antibiotics
• Morphine for pain control
• Anticoagulation to prevent
thromboembolic complications
 Medical management
• Tracheostomy
• Plasmapheresis
• Enteral feeding
• IVIG
 Nursing Diagnoses
• Ineffective breathing pattern
• Impaired bed and physical mobility
• Imbalanced nutrition
• Acute Pain
• Risk for Impaired Skin Integrity
• Impaired Communication
• Fear
 Nursing Care
• Maintain respiratory function
• Enhancing physical mobility
• Providing adequate nutrition
• Improving communication
• Decreasing fear and anxiety
 Home Care
• Clients will usually require
hospitalization, rehabilitation, and
eventually discharge to home
• Client and family will need support;
support groups
Degenerative
Disorders
P a r k in s o n
’ s
D is e a s e
 P a r k in s o n ’ s
D is e a s e
Associated with decreased levels of
dopamine resulting from
destruction of pigmented neuronal
cells in the substantia nigra in the
basal ganglia.
 P a r k in s o n ’ s
D is e a s e
• characterized by tremor at rest,
muscle rigidity and akinesia (poor
movement); cause unknown
• Affects older adults mostly, mean
age 60 with males more often than
females
• Parkinson-like syndrome can occur
with some medications,
encephalitis, toxins; these are
 Manifestations
Tremor
• at rest with pill rolling motion of thumb
and fingers
• Worsens with stress and anxiety
• Progressive impairment affecting ability
to write and eat
Rigidity
• Involuntary contraction of skeletal
muscles
•
 Manifestations
Akinesia
• Slowed or delayed movement that affects
chewing, speaking, eating
• May freeze: loss of voluntary movement
• Bradykinesia: slowed movement
Posture instability
• Involuntary flexion of head and shoulders,
stooped leaning forward position
• Equilibrium problems causing falls, and short,
accelerated steps
• Shuffling gait
 Manifestations
• Autonomic nervous system
• Constipation and urinary hesitation or
frequency
• Orthostatic hypotension, dizziness with
position change
• Eczema, seborrhea
• Depression and dementia; confusion,
disorientation, memory loss, slowed thinking
• Inability to change position while sleeping,
sleep disturbance
• Mask-like face
 Complications
• Impaired communication
• Falls
• Infection related to immobility and
pneumonia
• Malnutrition related to dysphagia
• Skin breakdown
• Depression and isolation
 Prognosis
• Slow progressive degeneration
• Eventual debilitation
 Diagnostic Tests

• No specific test for disease

• Drug screens to determine
medications or toxins causing
parkinsonism
• EEG: slowed and disorganized
pattern
 Medications
• Antiparkinsonian- Levodopa (Larodopa)
• antiviral therapy- amantadine (Symmetrel)
• anticholinergics- benztropine
mesylate (Cogentin)
• Bromocriptine (Parlodel) pergolide (Permax)
inhibit dopamine breakdown
• MAOI- selegiline (Eldepryl)
• Antihistamine- diphenhydramine
hydrochloride (Benadryl)
• Medications may lose their efficacy;
response to drugs fluctuates: “on-off”
 Treatments
Deep brain stimulation
Stereotactic procedures
• Pallidotomy: destruction of involved
tissue
• thalamotomy: destroys specific
tissue involved in tremor
 Nursing Diagnoses
• Impaired Physical Mobility
• Impaired Verbal Communication
• Impaired Nutrition: Less than body
requirements
• Self care deficit
• Constipation
• Disturbed Sleep Patterns
• Ineffective coping
 Nursing Care
• Improve mobility
• Enhance self care activities
• Improving bowel elimination
• Improving nutrition
• Enhancing swallowing
• Improving communication
supporting coping abilities
 Home Care
• Medication education
• Adaptation of home environment
• Gait training and exercises
• Nutritional teaching
H u n t in g t o n ’ s
D is

e
 H u n t in g t o n ’ s
D is e a s e (c h o r e a )

Progressive, degenerative
inherited neurologic
disease characterized by
increasing
dementia and chorea
 H u n t in g t o n ’ s
D is e a s e (c h o r e a )
• Cause unknown
• Autosomal dominant genetic
disorder
• No cure
• Usually asymptomatic until age of
30 – 40
• a significant reduction (volume and
activity) of acetylcholine
 Manifestations
• Abnormal movement and progressive dementia
• Early signs are personality change with severe
depression, memory loss; mood swings, signs of
dementia
• Increasing restlessness, worsened by
environmental stimuli and emotional stress;
arms and face and entire body develops
choreiform movements, lurching gait;
difficulty swallowing, chewing, speaking
• Slow progressive debilitation and total
dependence
• Death usually results from aspiration
 Diagnostic Tests
• Genetic testing of blood
• CT scan shows cerebral atrophy
 Medications
• Antipsychotic (phenothiazines and
butyrophenones) to block dopamine
receptors
• Antidepressants
 Nursing Diagnoses
• Risk for injury
• Risk for Aspiration
• Imbalanced Nutrition: Less than
body requirements
• Impaired Skin Integrity
• Impaired Verbal Communication
• Disturbed thought processes
 Nursing Care
• Very challenging: physiological,
psychosocial and ethical problems
• Genetic counseling
 Home Care
• Referral to agencies to assist
client and family, support group and
organization
 A m y o t r o p h ic
L a t er a l
S c le r o s
is (A L S
) Ge hrig’ s
Lou
e
diseas
Am yo tro ph La te ra
ic S c le r o s l
is (A L S )
Disease of unknown cause in
which there is a loss of motor
neurons in the anterior
horns of the spinal cord and
the motor nuclei in the
lower brain stem.
Am yo tro ph La te ra
ic S c ler o s l
is (A L S )
• Progressive, degenerative neurologic disease
characterized by weakness and wasting of muscles
without sensory or cognitive changes
• Several types of disease including a familial type
• onset is usually between age of 40 – 60
• higher incidence in males at earlier ages but equally
post menopause
• Physiologic problems involve swallowing, managing
secretions, communication, respiratory muscle
dysfunction
• Death usually occurs in 2 – 5 years due to
respiratory failure
 Manifestations

• Initial: spastic, weak muscles with increased

DTRs; muscle flaccidity, paresis, paralysis,
atrophy; clients note muscle weakness and
fasciculations; muscles weaken, atrophy; client
complains of progressive fatigue; usually involves
hands, shoulders, upper arms, and then legs
• Atrophy of tongue and facial muscles result in
dysphagia and dysarthria; emotional lability and
loss of control occur
• 50% of clients die within 2 – 5 years of diagnosis,
often from respiratory failure or aspiration
pneumonia
 Diagnostic Test
• Testing rules out other conditions that
may mimic early ALS such as
hyperthyroidism, compression of spinal
cord, infections, neoplasms
• EMG to differentiate neuropathy from
myopathy
• Muscle biopsy shows atrophy and loss of
muscle fiber
• Serum creatine kinase if elevated (non-
specific)
• Pulmonary function tests: to determine
 Medications
• Rilutek (Riluzole) antiglutamate
• Prescribed to slow muscle
degeneration
• Requires monitoring of liver
function, blood count,
chemistries, alkaline phosphatase
 Nursing Diagnoses
• Risk for Disuse Syndrome
• Ineffective Breathing Pattern: may
require mechanical ventilation and
tracheostomy
 Nursing Care
• Help client and family deal with
current health problems
• Plan for future needs including
inability to communicate
 Home Care
• Education regarding disease,
community resources for health
care assistance and dealing
with disabilities
 Creutzfeldt-Jakob
disease

(CJD, spongiform encephalopathy)

C r e u t z f e ld t - J a k o
b d is e a s e
Rapid progressive
degenerative neurologic
disease causing brain
degeneration
without
inflammation
 Description
• Transmissible and progressively fatal
• Caused by prion protein: transmission of
prion is through direct contamination with
infected neural tissue
• Variant form of CJD is “mad cow disease”:
believed transmitted by consumption of
beef contaminated with bovine form of
disease
• Pathophysiology: spongiform degeneration
of gray matter of brain
 No definitive
treatment.
Outcome is fatal.
 Manifestations
• Onset: memory changes,
exaggerated startle reflex, sleep
disturbances
• Rapid deterioration in motor,
sensory, language function
• Confusion progresses to
dementia
• Terminal states: clients are
comatose with decorticate and
 Diagnostic Tests

• Clinical pictures, suggestive

changes on EEG and CT
scan
• Similar to Alzheimers in early
stages
• Final diagnosis made on postmortem
exam
 Nursing Care
• Use of standard precautions with
blood and body fluids
• Support and assistance to client
and family
Trigeminal
neuralgia
(tic douloureux)
 Description
• Chronic disease of trigeminal nerve
(cranial nerve V) causing severe
facial pain
• The maxillary and mandibular
divisions of nerve are effected
• Occurs more often in middle and
older adults, females more than
males
 Manifestations
• Severe facial pain occurring for brief
seconds to minutes hundreds of times a
day, several times a year
• Usually occurs unilaterally in area of mouth
and rises toward ear and eye
• Wincing or grimacing in response to the
pain
• Trigger areas on the face may initiate the
pain
• Sensory contact or eating, swallowing,
talking may set off the pain
• Often there is spontaneous remission
 Diagnosis
• by physical assessment
 Medications
• Anticonvulsants
• carbamazepine (Tegretol)
• phenytoin (Dilantin)
• gabapentin (Neurotin)
 Surgery
• Intractable pain may be treated by
severing the nerve root:
rhizotomy
• Client may have lost facial
sensation and have loss of corneal
reflex
 Nursing Care
• Teaching client self-management of
pain
• Maintaining nutrition
• Preventing injury
Bell’s Palsy
 Description
• Disorder of seventh cranial nerve
and causes unilateral facial
paralysis
• Occurs between age of 20 – 60
equally in males and females
• Cause unknown, but thought to be
related to herpes virus
 Manifestations
• Numbness, stiffness noticed first
• Later face appears asymmetric:
side of face droops; unable to close
eye, wrinkle forehead or pucker
lips on one side
• Lower facial muscles are pulled to
one side; appears as if a stroke
 Prognosis
• Majority of person recover fully in
few weeks to months
• Some persons have residual
paralysis
 Diagnosis
• based on physical examination
 Collaborative Care
• Corticosteroids are prescribed in
some cases but use has been
questioned
• Treatment is supportive
 Nursing Care
• Teaching client self-care: prevent
injury and maintain nutrition
• Use of artificial tears, wearing eye
patch or taping eye shut at night;
wearing sunglasses
• Soft diet that can be chewed
easily, small frequent meals