care of patients with neurological disorders

CARE of PATIENTS with NEUROLOGICAL

DISORDERS

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MULTIPLE

SCLEROSIS

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DISEASES/ DISORDERS:

• Multiple Sclerosis

• Myasthenia Gravis

• Parkinsons DiseaseParkinsons Disease

• Guillain-Barré Syndrome


Multiple Sclerosis• Chronic, progressive degenerative disease

affecting the myelin sheath of the white matter of the brain & spinal cord

– Plaques form on myelin sheath causing inflammation, edema, & demyelination, eventually scarring nerve transmission becomes erratic, and slows down

– Age onset: 20 -40 yrs; affects women 2:1; whites are affected more often than Hispanics, blacks or Asians.

– More prevalent in colder climates: North America & Northern Europe. Norther Australia



Multiple Sclerosis

• Common affectation: – white matter of the spinal cord– optic nerve– brainstem– cerebrum– cerebellum

• Exacerbation and remissions.



Multiple SclerosisETIOLOGY

– Exact cause: unknown

– Theories: some evidence suggests that an infective agent causes a predisposition to MS

– Precipitating factors: Infection, pregnancy, physical activity, emotional stress.

– Hereditary



Multiple SclerosisCLINICAL MANIFESTATIONS

– weakness & fatigue: most common symptom– paresthesias– difficulty with coordination and balance – spastic weakness, ataxia, tremors, ↓ sensation to

temperature, foot dragging, staggering, or loss of balance

– Vision loss (optic neuritis) – Nystagmus– Bowel & bladder dysfunction: hesitancy, frequency,

loss of sensation, incontinence & retention; constipation.



Multiple SclerosisDIAGNOSTIC TESTS

– NO single test reliable in diagnosing MS

– Lumbar Puncture• presence of oligoclonal banding – presence of IgG

antibody in CSF (provides antibody –base immunity against invading pathogens)

– MRI of brain & spinal cord• presence of MS plaques



Multiple SclerosisNURSING DIAGNOSIS

– Impaired physical mobility related to fatigue & weakness

– Activity intolerance r/t weakness, dizziness, and unsteady gait

– Self-esteem disturbance r/t loss of health & lifestyle changes



Multiple SclerosisMEDICAL MANAGEMENT

• Tx: for acute relapses – IV or oral corticosteroids

• Methylprednisolone, followed by oral Prednisone taper• Azathioprine (Imuran)• Cyclophosphamide (Cytoxan) Chemo drug to destroy

the Tcells

• Tx: treating exacerbations– Interferon B (Betaseron) – reduces the

production of the T cells



Multiple SclerosisMEDICAL MANAGEMENT

• Symptomatic treatment:– Bladder dysfunction: Oxybutynin (Ditropan), Propantheline,

Urecholine, – Constipation: Psyllium hydromucilloid, Bisacodyl– Fatigue: Amantadine, Modafinil– Muscle spascity: Baclofen diazepam, Dantrolene– Tremors: Propranolol, Thenobarbial, Clonazepam– Trigeminal neuralgia: Carbamazepine, Phenytoin,

Amitriptyline– Dysesthesia: TENS (Transcutaneous Electrical Nerve

Stimulation)



Multiple SclerosisNURSING MANAGEMENT

1. Promotes physical mobility, activity and rest

– no vigorous physical exercise– frequent rest periods– walking and gait exercises– minimize spasticity and contractures

• (warm packs, daily muscle stretching)– activities: swimming, stationary bike,

progressive weight bearing




2. Minimize effects of immobility– skin integrity– cough and difficulty in breathing and expectoration

3. Promote bladder & bowel control– Urinal/bedpan readily available– PO fluids intake schedule/voiding schedule– increase fiber in diet– intermittent self-catheterization




4. Improve sensory and cognitive function:– Vision

• eye patch for diplopia; prism glasses for reading; talking books

– Speech• slurred, low volume, problems with phonation – speech therapist

– Cognitive & emotional responses• forgetfulness, easily distracted, emotionally labile

5. Development of coping strengths– education about diseases process– stress relief




6. Improve self care– assistive devices– raised toilet seat– shower bench– decrease physical and emotional stress– decrease exposure of extreme temperatures

7. Adapting to sexual dysfunction– counseling– plan sexual activity– willingness to experiment



Multiple SclerosisCOLLABORATIVE MANAGEMENT

– PT for:• instruction on assistive devices• conduct ROM exercise

– For vision impairment• scan the environment, remove sources of injury

– For urological control• drink 1500 cc q day of fluids and void q 3 hrs• intermittent catherization & clean technique• neurogenic bladder (most common in MS)




• Neurogenic bladder (most common in MS)– Refers to several bladder dysfunctions caused by

lesions of CNS/ PNS

– 5 types:• Uninhibited• Sensory paralytic (detrusor muscle hyperreflexia)• Motor paralytic (detrusor muscle areflexia)• Autonomous• Reflex




• Tx for constipation– High-fiber diet, bulk laxatives, stool softeners, fluids > 2000

cc/ day• Laxatives & enemas should be avoided lead to dependency• Bowel program should be performed every other day

– 45 min’s after largest meal (gastrocolic reflex) give suppository

• Keep environment cool– NO hot baths– Plan activity at peak energy level– Drugs

• Amantadine (symmetrel)• Modafinil (Provigil) may alleviate fatigue




• Require assistance with ADL’s– ADL nursing aides– assistive devices – raised toilet seat– reacher tongs

• Fear of loss of independence & fear of disability– Depressive episodes (short anti-depressant drug

therapy)




• Knowledge Deficit– unpredictable course– remissions & exacerbations– the role of stress– National Multiple Sclerosis Society

• Discharge & Home Health Care– Medications: be sure pt understands meds.

• dosage, route, action, & side effects



Multiple SclerosisEVALUATION

• The pt. with MS will:– Develop a realistic daily schedule that allows for

adequate rest– Achieve an activity level appropriate for the

extent of disability– Achieve bowel & bladder function– Demonstrate self-catheterization if prescribed– Verbalize and understanding of required lifestyle

changes, eg: ways to manage emotional stress, maintain a nutritious diet, avoid infection, etc



Myasthenia Gravis



Myasthenia Gravis• Autoimmune disorder affecting the

myoneural junction

• Antibodies directed at acetylcholine at the myoneural junction impair transmission of impulses

• Myasthenia gravis is a motor disorder



Myasthenia Gravis

ACh receptor site in myasthenia gravisNormal ACh

receptor site



Clinical Manifestations

– Initially, symptoms involve ocular muscles, causing conditions such as diplopia and ptosis

– Weakness of facial muscles, swallowing and voice impairment (dysphonia),

– Generalized weakness



Myasthenia Gravis• Chronic autoimmune neuromuscular

disease characterized by weakness of voluntary muscles

• Unknown etiology• Autoimmune • Causes:

– Decreased number of ACh receptors– Thymus gland

• Females > Males• Descending weakness



Myasthenia GravisInitial Diagnosis• Anticholinesterase test • Edrophonium chloride (Tensilon) IVAntidote• Atropine 0.4 mg should be available to

control the side effects of edrophonium:– Sweating– Cramping– Bradycardia



Myasthenia GravisNursing Diagnosis

• Ineffective breathing pattern related to respiratory muscle weakness.

• Impaired physical mobility related to weakness of voluntary muscles.

• Risk for aspiration related to the weakness of bulbar muscles.



Myasthenia GravisNURSING PROCESS

• Focus on patient and family teaching• Provide medication teaching and management• Implement energy conservation measures• Implement strategies to help with ocular

manifestations• Prevent and/or manage complications and avoid

crisis• Implement measures to reduce risk of aspiration• Avoid stress, infections, vigorous physical

activity, some medications, and high environmental temperatures



Myasthenia GravisMEDICAL MANAGEMENT

Pharmacologic therapy– Cholinesterase inhibitor: pyrostigmine

bromide (Mestinon)– Immunomodulating therapy

• Plasmapheresis - blood is removed and replaced to remove the antibodies

• Thymectomy –removal of the thymus gland



Myasthenic Crisis• Undermedication with cholinesterase

inhibitors• Result of disease exacerbation or a

precipitating event, most commonly a respiratory infection

• Severe generalized muscle weakness with respiratory and bulbar weakness (weakness of the facial and pharyngeal muscles)

• Patient may develop respiratory compromise failure



Cholinergic Crisis• Caused by overmedication with

cholinesterase inhibitors

• Severe muscle weakness with respiratory and bulbar weakness

• Patient may develop respiratory compromise and failure



Myastinic crisis Cholinergic crisis

Cause:Under medicationStressInfection

Manifestations:Unable to see – ptosis and diplopiaDysphagiaUnable to breathe

Management:Administer cholinesterase

Cause:Over medication

Manifestation:Flaccid ParalysisRespiratory failure

Management:Administer anticholinergic



Management of Myasthenic Crisis

• Ensuring adequate ventilation; intubation and mechanical ventilation may be needed

• Assessment and supportive measures include:– Ensure airway and respiratory support– Take ABGs, serum electrolytes, I&O, and daily weight– If patient cannot swallow, nasogastric feeding may be

required– Avoid sedatives and tranquilizers



Myasthenia GravisDRUG THERAPY

• Two groups of medications– Short-acting anticholinesterase

compounds• Mestinon (pyridostigmine)• Prostigmin (neostigmine)

– Corticosteriods (Prednisone)• assists in reducing the levels of serum Ach receptor

antibodies• Inform client that ther will be no immediate relief of

the symptoms



Myasthenia GravisDRUG THERAPY

• Immunosuppressive therapy

– ↓ the level of circulating Ach receptor antibodies

Examples– Imuran (azaathioprine)– Sandimmune (cycloporine)



Myasthenia GravisNURSING MANAGEMENT

• Improve respiratory function• Increase physical mobility• Improve communication• Provide eye care• Prevent aspiration



Parkinson’s Disease



Parkinson’s Disease• A progressively degenerative neurological disorder

affecting the brain centers (substantia nigra and basal ganglia) responsible for control & regulation of movement

• Occurs in 1% of pop.

• Over 50, affects men > women



Parkinson’s DiseasePATHOPHYSIOLOGY

• depletion of dopamine levels in the basal ganglia of the mid brain

– Dopamine promotes smooth, purposeful movements of motor function

– Dopamine depletion impairment of the extrapyramidal tracts with loss of movement coordination



Parkinson’s DiseaseETIOLOGY

• Cause: unknown– Some heredity causes

– Secondary iatrogenic PD – is drug or chemical related

• Dopamine depleting drugs: Reserpine. Phenothiazine, Metoclopromide, Butyrophenones (Droperidol & Haloperidol)



Parkinson’s DiseaseCLINICAL MANIFESTATIONS

• 3 cardinal signs – Bradykinesia / akinesia

• slowness of movement or complete or partial loss of movement difficulty with balance

– Involuntary tremors• course, rest tremor of the fingers & thumb (pill-rolling

movement) of one hand, occurs during rest, & intensifies w/ stress, fatigue, cold, disappears during sleep, the tremor can occur in tongue, lip, jaw, chin; eventually spreads to the foot on the same side




– Progressive muscle rigidity to antagonistic muscle groups, causing resistance to both extension & flexion

• Flexion contractures develop in the neck, trunk, elbows, knees & hip

• Face – expressionless, mask-like appearance, drooling & ↓ tearing ability

• Propulsive gait




• Speech: high-pitched monotone voice & parroting the speech of others (muscles of the voice box is affected

• Hypothalmic dysfunction: ↓ perspiration, heat intolerance, seborrhea, & oil production

• Psychosocial : does not affect intellectual ability– 20% of pts will end up having dementia (Alzheimer’s)



Parkinson’s DiseaseDIAGNOSTIC EVALUATION

• No specific tests

• History: progresses thru stages– Mild unilateral dysfunction– Mild bilateral dysfunction, expressionless face & gait

changes– Dysfunction w/ walking, initiating movements, and

maintaining equilibrium– Severe disability- difficulty in walking, & maintaining

balance & steady propulsion, rigidity



Parkinson’s DiseaseNursing Diagnosis

• Impaired physical mobility related to the stiffness and muscle weakness.

• Self care deficit related to neuromuscular weakness, decline in strength, loss of muscle control / coordination.

• Impaired Verbal Communication related to the decline in speech and facial muscle stiffness



Parkinson’s DiseaseDrug therapy

• Goal: enhance dopamine transmission

• Dopaminergics (Levodopa)• a synthetic metabolic precursor to dopamine• given in combination with Sinemet (Carbidopa)

– to allow more Levodopa to reach the brain – prevents peripheral metabolism of levodopa– beneficial first few years– on & off reactions




• Dopaminergics (cont.)• Sinemet

– most common drug (carbidopa-levodopa)– SE: Orthostatic hypotension, nausea,

hallucinations, dyskinesia– Nursing Considerations:

» Monitor B/P» Use TED hose to venous return» Monitor for urinary retention




• Dopaminergics (cont.)• Symmetrel (Amantadine)

– Action: causes release of dopamine in CNS– Indications: rigidity, bradykinesia– SE: dizziness, ataxia, insomnia, leg edema– Nursing Considerations:

» Monitor for postural hypotension» Do not administer at bed time




• Anticholinergic– to block the release of acetylcholine (balance

between dopamine & acetylcholine)

– to block the excitatory effects of the cholinergic system

– Examples:• Artane (trihexphenidyl)• Cogentin (benztropine)• Parsidol (ethopropazine)




• Anticholinergic – Indications: tremor, rigidity, drooling– SE: dry mouth, constipation, blurred vision,

confusion, hallucination– Nursing Considerations:

• Usually contraindicated in acute-angle glaucoma, & tachycardia

• Monitor pulse & B/P during dosage adjustments• Administer w/ meals• Do not withdraw meds suddenly




• Antihistamines• Benadryl

–Indications: tremor, rigidity, insomnia–SE: dry mouth, lethargy, confusion–Nursing Considerations:

»Use w caution in pts with seizures, hypertension, hyperthyroidism, renal disease, diabetes

»Administer w meals or antacids.




• Dopamine agonists– Parlodel (Bromocriptine)

• Action: activates dopamine receptor in the CNS, helpful for treatment of on-off reactions

• Indications: fluctuation of manifestations, dyskinesia, dystonia

• SE: hallucinations, orthostatic hypotension, confusion

• Nursing considerations: – monitor B/P & mental status




• COMT inhibitors [catechol-O-methyltransferase}– Tolcapone

• Action: enhance effect of dopamine• Indications: adjuvant treatment• SE: diarrhea• Nursing Considerations:

– Monitor liver enzymes




• MAO (Monoamine Oxydase) inhibitors– Deprenyl (Selegiline)

• Action: inhibit monoamine oxidase B, an enzyme that converts chemical byproducts in the brain into neurotoxins that prevent substantia nigra cell death

• Indications: adjuvant treatment• SE: nausea, dizziness, confusion, hallucinations, dry

mouth• Nursing considerations:

– Monitor for levodopa side effects



Parkinsonian Crisis• Sudden or inadvertent withdrawal of anti-PK drugs

or emotional trauma

• Severe exacerbation of tremor, rigidity and bradykinesia, along w/ acute anxiety, sweating, tachycardia.

• Interventions: respiratory & cardiac support, subdued lighting, mild barbiturates, anti PK drugs



Parkinson’s DiseaseNURSING MANAGEMENT

• Improve mobility • Exercise & stretch regularly (first thing in

morning)• Encourage daily ROM to avoid rigidity & contractures

• Enhance walking – walk erect, watch horizon, wide-based gait, heel-toe gait, long strides.

• Use cane or walker prevent falls




• Improve hydration & nutrition• Maintain fluid intake 2 L/24 hrs

• Monitor weight & ability to chew & swallow• Upright position to chew & swallow, offer small freq.

meals, soft foods & thick cold foods supplemental puddings

• Prevent aspiration think thru the steps of swallowing, keep lips closed, keep teeth together, chew, finish one bite before another




• Improve bowel elimination– Stool softeners, mild laxatives, regular routine,

fiber, raised toilet seat

• Improve communication– Speech therapy: speak slowly, use board,

mechanical voice synthesizer




• Enhance self-care– Extra time needed to perform ADL’s, use of side

rails, overhead trapeze.

– Reinforce occupational & physical therapy

– Sleep on firm mattress, prevent neck contractures




• Support coping abilities– Feel embarrassed, depressed, lonely, bored, more

muscle rigidity & unresponsive to verbal stimuli• treat w/ dignity• do not ignore clients

– Client to be active participant– Explore feelings– Education– Services: American Parkinson’s Disease Foundation



Parkinson’s DiseaseEvaluation

• The client is able to perform physical activity according to ability.

• The client is able to perform self care

• The client is able to maximize the ability to communicate.



Guillain-Barré

Syndrome



Guillain-Barré Syndrome

• Autoimmune disorder with acute attack of peripheral nerve myelin

• Rapid demyelination may produce respiratory failure and autonomic nervous system dysfunction with CV instability

• Most often follows a viral infection (respiratory/ GI: Campilobacter jejuni)

• Affects both men & women equally & of all ages.



Guillain –Barre’ Syndrome

• also known as acute demyelinating polyneuropathy or acute idiopathic polyneuritis

• results in a temporary, flaccid paralysis lasting 4-8 weeks

• ascending

• Medical emergency, 80% will recover



Guillain-Barré SyndromeCLINICAL MANIFESTATIONS

• variable and include: – Weakness– Paralysis– Paresthesias– Pain– diminished or absent reflexes starting with the lower

extremities and progressing upward– Cranial nerve symptoms– tachycardia, bradycardia,– hypertension, or hypotension



Guillain-Barré SyndromeNURSING PROCESS

• Conduct ongoing assessment with emphasis on early detection of life-threatening complications of respiratory failure, cardiac dysrhythmias, and deep vein thrombosis

• Monitor for changes in vital capacity and negative inspiratory force

• Assess VS frequently/continuously including continuous monitoring of ECG

• Encourage patient and family coping



Guillain-Barré SyndromeNURSING DIAGNOSIS

• Ineffective Breathing Pattern, related to respiratory muscle weakness or paralysis, decreased cough reflex, immobilization.

• Impaired Physical Mobility related to paralysis, ataxia.

• Risk for Impaired Skin Integrity related to muscle weakness, paralysis, impaired sensation, changes in nutrition, incontinence.



Guillain-Barré SyndromeMEDICAL MANAGEMENT

• Requires intensive care management with continuous monitoring and respiratory support

• Plasmapheresis and IVIG (Intravenous Immunoglobulin) are used to reduce circulating antibodies

• Recovery rates vary but most patients recover completely



Guillain-Barré SyndromeNURSING MANAGEMENT

• Enhance physical mobility and prevent DVT– Support limbs in a functional position– Perform passive ROM at least twice daily– Initiate position changes at least every 2 hours– Provide elastic compression hose and/or sequential

compression boots– Provide adequate hydration

• Administer IV and parenteral nutrition as prescribed• Assess swallowing and gag reflex and take measures

to prevent aspiration



Guillain-Barré SyndromeNURSING MANAGEMENT

• Develop a plan for communication individualized to patient needs

• Decrease fear and anxiety– Provide information and support– Provide referral to support group– Implement relaxation measures– Maintain positive attitude and atmosphere to promote a

sense of well-being– Implement diversional activities



Amyotrophic Lateral Sclerosis (ALS)




• “Lou Gehrig’s disease”

• Loss of motor neurons in the anterior horn of the spinal cord and loss of motor nuclei in the brain stem

• Causes progressive weakness and atrophy of the muscles of the extremities and trunk; weakness of the bulbar muscles impairs swallowing and talking; and respiratory function is also impaired



Amyotrophic Lateral SclerosisCLINICAL MANIFESTATIONS




• Course of disease – Death from pneumonia in 3-5 yrs.

• Diagnosis: – clinical signs & symptoms– EMG changes– muscle biopsies– CSF analysis– CT– MRI



Amyotrophic Lateral Sclerosis MANAGEMENT

• Making the client as comfortable and independent as possible

• Slowing the progression of the disease: Riluzole (Rilutek)– Antibiotic– Breast-cancer drug– Antioxidant coenzyme



Amyotrophic Lateral Sclerosis NURSING MANAGEMENT

• Physical therapy• Speech therapy• Nutritional support• Respiratory support


care of patients with neurological disorders

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