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  1. Nursing Care of Clients with Neurologic Disorders Ma. Tosca Cybil A. Torres, RN, MAN
  2. Outline • Autoimmune Disorders • Multiple Sclerosis (MS) • Myasthenia Gravis (MG) • Guillen-Barré syndrome (GBS) • Degenerative disorders • Parkinson’s Disease • Huntington’s Disease • Amyotrophic Lateral Sclerosis (ALS)
  3. Multiple Sclerosis
  4. 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
  5. 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
  6. 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
  8. Collaborative Care Focus is on retaining optimum functioning and limiting disability
  9. 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
  11. 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
  12. 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
  13. 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
  14. Health Promotion • Client needs to develop strategies to deal with fatigue, exacerbations • Prevention of respiratory and urinary tract infections
  15. Home Care • Education • Referral to support group and resources • Referral to home health agencies when condition requires
  16. Myasthenia gravis (MG)
  17. g r a v is M y a s t h e n ia (M G ) Chronic autoimmune neuromuscular disorder affecting the neuromuscular joint
  18. 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
  19. 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 to
  20. MG is purely a MOTOR disorder with no effect on sensation or coordination
  21. Complications Pneumonia Myasthenic Crisis • Sudden exacerbation of motor weakness putting client at risk for respiratory failure and aspiration • Manifestations: tachycardia, tachypnea, respiratory distress, dysphasia
  22. 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
  23. 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
  24. Medications • Anticholinesterase medications • Pyridostigmine bromide (Mestinon) • Immunsuppression medications including glucocorticoids • Cyclosporineor azathioprine (Imuran)
  25. Surgery • Thymectomy is recommended in clients <60 • Remission occurs in 40 % of clients, but may take several years to occur
  26. Plasmapheresis • Used to remove antibodies • Often done before planned surgery, or when respiratory involvement has occurred
  27. Nursing Care • Teaching interventions to deal with fatigue • Importance of following medication therapy
  28. Nursing Diagnoses • Ineffective Airway Clearance • Impaired Swallowing: plan to take medication to assist with chewing activity
  29. Home Care • Avoid fatigue and stress • Plan for future with treatment options • Keep medications available • Carry medical identification • Referral to support group, community resources
  30. Guillain-Bar é Syndrome (GBS)
  31. G u illa 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
  32. G u illa in -B a r r é S y n d r o 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
  33. 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
  34. 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
  35. Medications • supportive and prophylactic care • Antibiotics • Morphine for pain control • Anticoagulation to prevent thromboembolic complications
  36. Medical management • Tracheostomy • Plasmapheresis • Enteral feeding • IVIG
  37. Nursing Diagnoses • Ineffective breathing pattern • Impaired bed and physical mobility • Imbalanced nutrition • Acute Pain • Risk for Impaired Skin Integrity • Impaired Communication • Fear
  38. Nursing Care • Maintain respiratory function • Enhancing physical mobility • Providing adequate nutrition • Improving communication • Decreasing fear and anxiety
  39. Home Care • Clients will usually require hospitalization, rehabilitation, and eventually discharge to home • Client and family will need support; support groups
  40. Degenerative Disorders
  41. P a r k in s o n ’ s D is e a s e
  42. 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.
  43. 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 usually reversible
  44. 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 • Cogwheel rigidity: jerky motion
  45. 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
  46. 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
  47. Complications • Impaired communication • Falls • Infection related to immobility and pneumonia • Malnutrition related to dysphagia • Skin breakdown • Depression and isolation
  48. Prognosis • Slow progressive degeneration • Eventual debilitation
  49. Diagnostic Tests • No specific test for disease • Drug screens to determine medications or toxins causing parkinsonism • EEG: slowed and disorganized pattern
  50. 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”
  51. Treatments Deep brain stimulation Stereotactic procedures • Pallidotomy: destruction of involved tissue • thalamotomy: destroys specific tissue involved in tremor
  52. Nursing Diagnoses • Impaired Physical Mobility • Impaired Verbal Communication • Impaired Nutrition: Less than body requirements • Self care deficit • Constipation • Disturbed Sleep Patterns • Ineffective coping
  53. Nursing Care • Improve mobility • Enhance self care activities • Improving bowel elimination • Improving nutrition • Enhancing swallowing • Improving communication supporting coping abilities
  54. Home Care • Medication education • Adaptation of home environment • Gait training and exercises • Nutritional teaching
  55. H u n t in g t o n ’ s D is e a s e (c h o r e a )
  56. 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
  57. 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
  58. 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
  59. Diagnostic Tests • Genetic testing of blood • CT scan shows cerebral atrophy
  60. Medications • Antipsychotic (phenothiazines and butyrophenones) to block dopamine receptors • Antidepressants
  61. Nursing Diagnoses • Risk for injury • Risk for Aspiration • Imbalanced Nutrition: Less than body requirements • Impaired Skin Integrity • Impaired Verbal Communication • Disturbed thought processes
  62. Nursing Care • Very challenging: physiological, psychosocial and ethical problems • Genetic counseling
  63. Home Care • Referral to agencies to assist client and family, support group and organization
  64. A m y o t r o p h ic La t e r a l S c le r o s is Lou Gehrig’ s (ALS e ) diseas
  65. A m y o t r o p h ic S c le r o s is La t e r a l (ALS ) 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.
  66. A m y o t r o p h ic S c le r o s is La t e r a l (ALS ) • 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
  67. 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
  68. 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
  69. Medications • Rilutek (Riluzole) antiglutamate • Prescribed to slow muscle degeneration • Requires monitoring of liver function, blood count, chemistries, alkaline phosphatase
  70. Nursing Diagnoses • Risk for Disuse Syndrome • Ineffective Breathing Pattern: may require mechanical ventilation and tracheostomy
  71. Nursing Care • Help client and family deal with current health problems • Plan for future needs including inability to communicate
  72. Home Care • Education regarding disease, community resources for health care assistance and dealing with disabilities
  73. Creutzfeldt-Jakob disease (CJD, spongiform encephalopathy)
  74. 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
  75. 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
  76. No definitive treatment. Outcome is fatal.
  77. 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
  78. Diagnostic Tests • Clinical pictures, suggestive changes on EEG and CT scan • Similar to Alzheimers in early stages • Final diagnosis made on postmortem exam
  79. Nursing Care • Use of standard precautions with blood and body fluids • Support and assistance to client and family
  80. Trigeminal neuralgia (tic douloureux)
  81. 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
  82. 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
  83. Diagnosis • by physical assessment
  84. Medications • Anticonvulsants • carbamazepine (Tegretol) • phenytoin (Dilantin) • gabapentin (Neurotin)
  85. Surgery • Intractable pain may be treated by severing the nerve root: rhizotomy • Client may have lost facial sensation and have loss of corneal reflex
  86. Nursing Care • Teaching client self-management of pain • Maintaining nutrition • Preventing injury
  87. Bell’s Palsy
  88. 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
  89. 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
  90. Prognosis • Majority of person recover fully in few weeks to months • Some persons have residual paralysis
  91. Diagnosis • based on physical examination
  92. Collaborative Care • Corticosteroids are prescribed in some cases but use has been questioned • Treatment is supportive
  93. 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