Characteristics of Normal CSFAppearance clear and colorlessPressure 9-14mmHgRed blood cells None White blood cells OccasionalProtein 15-45 mg/dlGlucose 45-75 mg/dlSodium 140 mEq/literPotassium 3 mEq/literSpecific gravity 1.007pH 7.32-7.35Volume in the System at one time 125-150 ml Volume formed in 24h 500-800 ml

CONCEPT OF PERCEPTION AND COORDINATION

NERVOUS SYSTEM

P A R T O N E

Anatomically CNS PNSBrain Cranial Nerves Spinal Cord Spinal Nerves

Functionally SNS ANS(Voluntary Sympathetic activities) Parasympathetic

(involuntary activities )

A. ANATOMY AND PHYSIOLOGY OF THE BRAIN AND SPINAL CORD

A. CEREBRUM B. CEREBRAL CORTEXC. BASAL GANGLIA D. DIENCEPHALONE. BRAINSTEM F. CEREBELLUM G. SPINAL CORDH. MENINGESI. CEREBROSPINAL FLUID- Is a clear and colorless fluid with sp gravity of

1.007- Secreted in the ventricles and circulates

through the ventricles to the subarachnoid layer of the meninges where it is reabsorbed

- Circulates in the subarachnoid space- Choroid plexus – responsible for CSF production- Normal pressure is 50-175 mmH20- Normal volume is 125-150 ml- Acts as a protective cushion- Aids in the exchange of nutrients and wastes J. VENTRICLESK. BLOOD SUPPLY L. NEUROTRANSMITTERSM. NEURONS N. AXONS AND DENDRITESO. SPINAL NERVESP. AUTONOMIC NERVOUS SYSTEM

B. LABORATORY / DIAGNOSTIC TEST

A. Lumbar puncture- Measures CSF pressure (N: 60-150 mmH20) - Obtain specimen for lab

analysis - Check color of CSF ( N:

clear) and check for blood

- Inject air, dye or drugs into the subarachnoid space at the level of L3-L4

- Contraindication: clients with IICP, may lead to brain herniation

B. X-ray of skull and spine - Used to detect atrophy, erosion, or fractures of

bones; calcifications

C. Computerized tomography (CT scan)

- Used to detect intracranial bleeding, space occupying lesions, cerebral edema, infarction, hydrocephalus, cerebral atrophy and shifts of brain structures

- May or may not require an injection of dye - Check for shellfish / iodine allergy - Assess disorientation- Contraindication: Obesity > 300 lbs

Pregnancy Unstable vital signs Claustrophobia

D. Magnetic resonance imaging (MRI)

- Used to identify types of tissues, tumors and vascular abnormalities

- Similar to CT scan but provides more detailed pictures and does not expose the client to ionizing radiation

- Remove all metals - C/I same with CT scan

E. Cerebral angiography - Injection of radiopaque substance into the

cerebral circulation via carotid, vertebral, femoral or brachial artery ffd by x-ray

- Used to visualize cerebral vessels and detect tumors, aneurysms, occlusions, hematomas, abscesses

- Pressure dressing / ice

- Report bleeding / swelling at the site - Rest for 12-24 hrs after

F. Electroencephalography (EEG) - Used to detect foci of seizure activity and to

quantitatively evaluate level of brain function

III.NEUROLOGICAL ASSESSMENT

A. Neurological examination 1. Mental status exam (cerebral function)

a. General appearance and behavior b. Level of consciousness

i. Orientation to time, place and person

ii. Speech: clear, garblediii. Ability to follow commandsiv. Abnormal posturing ( may

occur spontaneously or in response to stimulus)

1. Decorticate posturing: damage to corticospinal tracts; cerebral hemisphere

2. Decebrate posturing: damage to upper brainstem, midbrain or pons

Glasgow Coma Scale

Definition: Technique of objectifying a client’s level of responses; client’s best response in each area is given a numerical value, and three values are totaled for a score ranging from 3-15.

A score of 15 indicates client is awake and oriented. A score of 7 to 4 is considered coma . The lowest score is 3, client is considered in deep coma

MOTOR RESPONSE, UPPER LIMB (M) o Obeys commands - 6o Localizes to pain -

5o Flexor withdrawal - 4o Abnormal flexion (decorticate) 3o Extension ( decebrate) - 2o Flaccid - 1

VERBAL RESPONSE (V)o Oriented - 5o Confused conversation - 4o Inappropriate words - 3o Incomprehensible sounds -

2o None - 1

EYE OPENING ABILITY (E) o Spontaneous - 4o To voice / speech -

3o To pain - 2o None - 1

c. Intellectual function: memory (recent and remote) , attention span, cognitive skills

d. Emotional status e. Thought content f. Language / speech

i. Expressive aphasia : inability to speak / frontal lobe problemBrocas area “motor speech

cortex” aka BROCAS APHASIA

ii. Receptive aphasia: inability to understand spoken words / temporal lobe problem

Sensory speech area aka WERNICKE’S APHASIA

iii. Dysarthria: difficult speech due to impairment of muscles involved with speech production

2. Cranial nerves 3. Cerebellar function : posture, gait, balance ,

coordination a. Romberg’s Test – stand with eyes

closed and feet together b. Heel-toe-walk in a straight line

4. Motor function : muscle size, tone, strength, abnormal or involuntary movements

5. Sensory function : light touch, superficial pain, temperature, vibration and position

6. Reflexesa. Deep tendon : grade from 0 (no

response) to 4 ( hyperactive); 2 is normal

b. Pathologic: babinski’s reflex indicates damage to corticospinal tracts Babinski (+) : dorsiflexion of great toe & fanning of other toes

Neurologic Disorders

A. INCREASED INTRACRANIAL PRESSURE - A condition in which the pressure of the CSF,

blood or brain volume within the skull exceeds the upper limits for normal pressure

- Can impede circulation to the brain, absorption of CSF, affect the functioning nerve cells and lead to brainstem compression and death

- Etiology : trauma, hemorrhage, tumors, hydrocephalus, edema or inflammation

NURSING ASSESSMENT o Infants : bulging fontanel, high pitch cry, poor

feeding, separated sutures o Older children and adults o Progressive decreased LOC, Projectile

vomiting , headache, changes in behavior, seizures , ipsilateral pupillary dilatation, contralateral hemiparesis

o Initial signs among adults: change in LOC , headache, lethargy, inc dizziness and bradypnea

o LATE SIGNS IICP: widening pulse pressure, inc BP, slowed HR

Nursing Care: Priority : Maintain patent airway & ventilation

Prevent hypoxia and hypercarbia Maintain fluid balance ( 1200-1500 ml/ day) Elevate HOB to 30-45 degrees & neck on

neutral position Prevent further inc in ICP Quiet and comfortable environment No straining: give stool softeners Prevent vomiting : antiemetic Prevent excessive coughing Administer medications as ordered

o Hyperosmotic agents (mannitol) o Corticosteroids ( dexamthesaone) o Diuretics ( furosemide) o Anticonvulsants ( phenytoin) o Analgesics

B. HYDROCEPHALUS

- An imbalance of CSF absorption or production, caused by malformations, tumors, hemorrhage, infections or trauma

- Results in head enlargement and increased ICP

NURSING ASSESSMENT o Infant : increased head circumference, anterior

fontanel tense(bulging), scalp veins dilated, frontal bossing, sunset eyes

o Child : behavior changes such as irritability and lethargy, headache upon awakening, nausea and vomiting, nystagmus

o LATE SIGNS: HIGH, SHRILL CRY AND SEIZURE ACTIVITIES

Nursing Care Teach the family about the management

required for the disordero Treatment is surgical by direct removal

of the obstruction and insertion of

shunts to provide primary drainage of CSF to peritoneum

o Ventriculostomy is a new nonshunting procedure

Provide pre-operative nursing care o Assess head circumference, fontanel’s,

cranial sutures and LOC o Firmly support head and neck when

holding the child o Provide skin care for the head to

prevent breakdown o Give small frequent feedings to

decrease the risk of vomiting Provide post operative nursing care

o Assess for signs of inc ICP and check the ffg: head circumference, ant. fontanel for size and fullness and behavior

o Administer prescribed medications: antibiotics, analgesics

o Provide shunt care Monitor for shunt infection and

malfunction which may be char. By a rapid onset of vomiting, severe headache, irritability, lethargy, fever, redness along the shunt tract and fluid around the shunt valve

Prevent infection Teach home care

o Encourage parents to provide as normal lifestyle as possible

o Explain how to recognize s/sx of inc ICP and shunt malfunction: headache and lack of appetite ( earliest common sign of shunt malfunction)

o Explain importance of routine medical check ups

C. HEAD INJURIES - Most commonly due to vehicular accidents

- Concussion : severe blow on the head/ a jarring of the brain within the skull with temporary loss of consciousness

- Contusion: a bruising type of injury to the brain, it may occur with subdural or extradural collections of blood

- Hemorrhage : 1. Epidural 2. Subdural 3. Subarachnoid 4. Intracerebral

- Fracture : 1. Linear 2. Comminuted 3. Depressed 4. Basilar

NURSING ASSESSMENT

Leakage of blood or CSF from nose/ ears

Battle’s sign

Raccoon eyes

Diagnosis : Skull X-ray, CT Scan, MRI

Nursing Care

o Maintain patent airway and adequate ventilation

o Observe for CSF leakage o (+) Testape or Dextostix Testt for glucose,

bloody spot encircled by watery pale ring o Never clean the ears or nose, suction nose

unless ordered by doctor o If SCF leak is present

o Never blow nose; HOB elevated 30 degrees as ordered

o Place cotton ball in the ear to absorb otorrhea, replace frequently

o Gently place sterile gauze pad at the bottom of the nose for rhinorrhea

o Observe signs of meningitis and give antibiotics as ordered

o Prepare client for surgery as indicated o Depressed skull fracture: removal or

elevation of splintered bone; debridement and cleansing of area; repair of dural tear if present ; cranioplasty ( if necessary for large cranial defect)

o Epidural, subdural hematoma: evacuation of hematoma

D. BRAIN ABSCESS - Collection of free & encapsulated pus in the

brain , occurs when there is an infection in another region on the body that spreads to the brain or after a penetrating head wound

NURSING ASSESSMENT Headache Malaise and anorexia Fever Nausea and vomiting Weight loss Focal deficits based on site: vision loss, paresis,

seizures, personality changes

Nursing Careo Encourage nutrient – dense diet to compensate

for antibiotic impact on nutritional status o Provide care for the client requiring brain

surgery o Explain the need to complete prescribed

therapy of antibiotics and continue anticonvulsant therapy

o Instruct client to seek prompt treatment for otitis media, sinusitis and dental and other infections

Treatmento Large doses of antibiotics

o In severe cases, a craniotomy may be performed to allow removal of abscess

o Anticonvulsants to control seizures

E. INTRACRANIAL TUMORS

- Abnormal growths within the cranium - Benign or malignant - Primary or secondary

NURSING ASSESSMENT

Headache is the most common Papilledema Nausea & vomiting, dizziness / vertigo Seizures, motor / sensory loss

Diagnosis: CT scan, MRI, Angiography

Nursing Care

o Medications as orderedo Psychological support o Preparation for surgery

o Craniotomy – surgical opening into the skull

o Cranioplasty- repair of a cranial defect with a metal or plastic plate

o Craniectomy – excise portion of the skull and removed permanently

Post Op: Check ABC Supratentorial incision :

Semi fowlers InFrantentorial Incision:

Flat o No straining o WOF seizures, decrease LOC, signs of IICPo Rehabilitation for residual deficits

F. SPINAL CORD INJURY

- Par tial or

complete disruption of nerve tracts and neurons resulting in paralysis , sensory loss, altered reflex activity and autonomic nervous system dysfunction

- Etiology: MVA, falls, sporting and industrial accidents

NURSING ASSESSMENT Spinal shock – absence of reflexes below the

lesion, flaccidity, hypotension, bradycardia, retention

Diagnosis : Spinal X-ray

CLASSIFICATION OF CORD INVOLVEMENT a. FUNCTIONAL DEFICIENCIES :

1. Quadriplegia (C1-C8) injury – paralysis of all four extremities; lesions above C6 causes respiratory depression

2. Paraplegia (T1-L4) injury – paralysis of the lower half of the body involving both legs

EXTENT OF INJURY a. Complete cord transaction

a. Loss of all voluntary movement and sensation below the level of injury

b. Reflex activity may return to normal after the spinal shock resolves and if blood supply to cord below injury is intact

b. Incomplete lesions: varying degree or motor or sensory loss below the level of the lesion depending on which neurologic tracts are damaged and which are spared.

Autonomic dysreflexia – occurs in clients with lesions above T6, most often those with cervical injuries, after spinal shock has resolved

- Acute emergency – results in exaggerated autonomic responses to stimuli ( most often distended bladder or impacted rectum) – treat immediately to prevent stroke

Nursing Care ACUTE CARE

Assess ABC: suction, tracheostomy set; jaw thrust maneuver

Immobilize and maintain spinal alignment : cervical tongs, cervical collar, spinal board or halo traction

Prevent pneumonia and atelectasis turn q2hours; cough and DBE q1hr.

Maintain fluid and electrolyte balance and nutrition

Check bowel sounds before feeding (paralytic ileus) : clear liquids to RD

Prevent complication of immobility footboard/high topped sneakers to prevent footdrop; splint for quadriplegic clients to prevent wrist drop

Maintain urinary catheterization; increase fluid intake

Maintain bowel elimination stool softeners, suppositories to prevent fecal impaction

Surgery: decompression laminectomy & spinal fusion LEVEL OF INJURY

FUNCTIONAL ABILITY

SELF-CARE CAPABILITY

C5,c4,c3 and above

Inability to control muscles of breathing, no upper extremity muscle

Unable to care for self, life sustaining ventilator support essential

functionsC6 Muscle functions in

C5 level; partial strength in pectoralis major

May self propel a light weight wheelchair, may feed self with devices, can write and care for self, can transfer from chair to bed

C7 Muscle function in C6 level, no finger muscle power

Can dress lower extremities, minimal assistance needed, independence in wheelchair, can drive car with hand controls

C8 Muscle function in C7 level, finger muscle power

Same as C7; in general, activities easier

T1-T4 Good upper extremity muscle strength

Some independence from wheelchair, long leg braces for standing exercises

T5-L2 Balance difficulties Still requires wheelchair, limited ambulation with long leg braces and crutches

L3-L5 Trunk pelvis muscle function intact

May use crutches or canes for ambulation

L5-S3 Waddling gait Ambulation

G. BELLS PALSY ( FACIAL PARALYSIS)

- It is caused by a lower motor neuron lesion of the seventh cranial nerve that may result from infection, trauma, hemorrhage, meningitis or a tumor

- It results in paralysis of one side of the face- Recovery usually occurs in few weeks without

residual effects

NURSING ASSESSMENT

o Flaccid facial muscleso Inability to raise the eyebrows, frown, smile,

close the eyelids and puff out the cheekso Upward movement

of the eye when attempting to close the eyelid

o Loss of taste

Nursing Care Encourage facial exercises to prevent the loss

of muscle tone ( a face sling may be prescribed)

Protect the eyes from dryness and prevent injury

Promote frequent oral care Instruct the client to chew on the unaffected

side

H. TRIGEMINAL NEURALGIA

-It is a sensory disorder of the 5th cranial nerve

-It results in severe, recurrent, sharp, facial pain along the trigeminal nerve

NURSING ASSESSMENT o Client has pain on the lips, gums, or nose or

across the cheeks o Situations that stimulate the symptoms

o Coldo Washing the

faceo Chewing o Food or

fluids of extreme

temperatures

Nursing Care

Instruct the client to avoid hot or cold foods and fluids

Provide small feedings of liquid and soft foods Instruct the client to chew food on the

unaffected side Administer medications as prescribed

o Elavil, tegretol, valium, dilantin,

Surgery An alcohol injection along the affected portion

of the nerve to produce anesthesia of the nerve may provide relief of pain for up to 16 hours

Janetta procedure surgically relocates the artery that is compressing the trigeminal nerve

I. SEIZURES

-Episodes of abnormal motor, sensory or autonomic due to abnormal discharge from brain cells.

-Epilepsy – chronic recurrent seizures

- Etiology : infantile fever, head injury,

hypertension, CNS infection, brain tumor or metastasis, drug withdrawal, stroke

Types of Seizure1. Generalized seizures(bilaterally symmetric;

without local onset) a. Major motor seizure (grand mal) : aura;

usually starts with tonic or stiffening phase ffd by clonic or jerking phase; may have bowel/bladder incontinence; in posticatal phase, sleeps hard to arouse

b. Absence seizure (petit mal) : sudden onset, with twitching or rolling of eyes; lasts a few seconds, brief lapse of consciousness

c. Myoclonic: a seizure that presents a brief generalized jerking or stiffening of

extremities; the victim may fall to the ground from the seizure

d. Atonic or Akinetic ( drop attacks): a sudden momentary loss of muscle tone; the victim may fall to ground as a result of the seizure

e. Febrile seizure : common under 5 years of age; seizure occurs only when fever is rising. EEG is normal 2 weeks after a seizure

2. Partial seizures (seizure beginning locally) a. Psychomotor seizure : may follow

trauma, hypoxia, drug use; purposeful but inappropriate repetitive motor acts; aura present, dreamlike state

b. Simple partial seizure : seizure confided to one hemisphere of the brain. NO LOSS OD CONSCIOUSNESS; maybe motor , sensory or autonomic symptoms

c. Complex partial seizure : begins in focal area but spreads to both hemispheres; impairs consciousness; maybe preceded by an aura

d. Jacksonian seizure: twitching begins at distal end of extremity, eventually involving entire extremity and possibly entire side of the body; no loss of consciousness, not commonly seen in children

3. Status epilepticus : usually refers to grand mal seizures; prolonged (repeated seizures without regaining consciousness) and unresponsive to treatment; can result in hypoxia and possible cardiac arrest

NURSING ASSESSMENT (tonic-clonic seizure) o Aura or warning sensation ( seeing spots or

feeling dizzy) o Loss of consciousness during seizureo Lethargy often follows return to consciousness

(postictal phase)o Pupils become fixed and dilatedo Often the client cries out as seizure begins or

as air is exhaled forcefullyo Tonic clonic movement of the muscleso Incontinence and abnormal EEG

Nursing Care

During seizure activity Protect form injury;

prevent falls, support head, decrease external stimuli, do not restrain, do not use tongue blade, loosen clothing

Keep airway open: side lying position, suction excess mucus

Observe and record seizure

o Note any pre-ictal phase:

fear, anxiety, hallucinations, de javu symptoms

o Note nature of the ictal phase: symmetry of movement, response to stimuli, LOC, respiratory pattern

o Note post-ictal phase : amount of time it takes to orient to time and place ; sleepiness

Provide client teaching and discharge planning Need to drug therapy Wear a medic-alert identification bracelet or

carry ID Availability of support group and community

agencies

Drug Therapy (Anticonvulsants)

Phenytoin (Dilantin)- most commonly used can only be administered within normal saline and levels are monitored; therapeutic level is 10-20 mg / dl; side effects include gum hyperplasia, hirsutism, ataxia, gastric distress, nystagmus, anemia and sedation

Phenobarbital – reduce emotional stress Carbamazepine ( Tegretol) is use in tonic-clonic

, complex partial seizure Diazepam (Valium) used for status epilepticus

Surgery To remove tumor, hematoma or epileptic focus

J. CEREBROVASCULAR ACCIDENT (STROKE)

- Destruction / infarction of brain cells caused by reduction in cerebral blood flow & oxygen

- Loss of brain functions caused by loss of blood circulation to areas of the brain. The specific neurologic deficits may vary depending on the location, extent of the damage, and cause of the disorder.

- CVA is a syndrome in which the cerebral circulation is interrupted causing neurological deficits. Cerebral anoxia lasting longer than 10 minutes causes cerebral infarction with irreversible change.

- Etiology : embolism, thrombosis , hemorrhage, TIA

Stages of Development

TIA Stroke in Evolution Completed Stroke <24 hrs hrs-days deficits for 2-3 days

Manifestations of Right Brain and left Brain StrokeRight Brain Damage ( stroke on right side of the brain)

Left Brain Damage ( stroke on left side of the brain)

Paralyzed left side : hemiplegia Left – sided neglect Spatial –perceptual deficits Tends to deny or minimize problemsRapid performance, short attention span Impulsive, safety problems

Paralyzed right side: hemiplegia Impaired speech / language aphasia Impaired right / left discrimination Slow performance, cautionsAware of deficits: depression, anxiety Impaired

Impaired judgment Impaired time concepts

comprehension related to language, math

Neurological Assessment in CVA Changes in LOC Signs of IICP Assessment of Cranial Nerves

o V – difficulty with chewing o VII – facial paralysis or paresis o IX and X – dysphagia; absent

gag reflexo XII – impaired tongue

movement Order in which function may return : FACIAL- SWALLOWING, LOWER LIMB, SPEECH AND ARM

NURSING ASSESSMENT o Decrease LOC, cognitive changeso Weakness or paralysis o Speech deficits ( dysphonia, dysarthria,

aphasia) o Urinary / bowel incontinence o Agnosia o Apraxia o Hemianopsiao Homonymous hemianopsiao Neglect syndrome (unilateral negect0 o Proprioception alterations

Nursing Care

Priority: Patent airway and ventilation

Proper positioning and body alignment Head of bed elevated at 30-45 degrees Position change q 2 hrs Passive ROM exercises q 4 hrs Promote nutrition Maintain adequate elimination Provide quiet and restful environment Prevent injury Establish means of communication with patient Promote self care activities Administer ,medications as ordered

Rehabilitation

Hemiplegia o Support paralyzed arm on pillow or use

sling o Elevate extremities to prevent

dependent edema o Provide active and passive ROM

regularly o Institute safety measures at all times

Homonymous Hemianopsia o Approach client on UNAFFECTED sideo Place food, personal belonging on the

UNAFFECTED sideo Teach client to compensate by

SCANNING Receptive Aphasia

o Give simple, slow and clear directionso Stand within 6 feet and face client

directlyo Give 1 command at a time, gradually

shift topicso Use non-verbal techniques o Talk without pressing a response

Expressive Aphasiao Listen and watch carefully when client

attempts to speak o Anticipate client’s needs to decrease

frustration o Allow sufficient time for the client to

answero Begin with simple words then progress

later

K. CEREBRAL ANEURYSM

- Cerebral aneurysm is dilation of the walls of the weakened cerebral artery

- Aneurysm can lead to rupture

NURSING ASSESSMENTo Headache o Paino Diplopiao Blurred vision o Tinnituso Nauseao Hemiparesis o Nuchal rigidity o Irritability o Seizure

Nursing Care Maintain a patent airway Administer oxygen as prescribed Monitor vital signs and for hypertension or

dysrhythmias Avoid taking temperatures via the rectum Initiate aneurysm precautions

o Maintain bed rest in semi fowler or side lying position

o Maintain a darkened room without stimulation

o Limit visitorso Maintain fluid restrictionso Avoid stimulants in the diet

Figure 38-10 Types of aneurysms. (A) A berry aneurysm is a small sac on a stem or stalk. (B) A saccular aneurysm is formed from a distended small portion of the vessel wall. (C) A fusiform aneurysm is an enlarged area of the entire blood vessel. (D) A dissecting aneurysm is formed when blood fills the area between the tunica media and the tunica intima.

L. CNS INFECTIONS

- MENINGITIS: bacterial infection of pia, arachnoid & CSF leading to inflammation of meninges

- ENCEPHALITIS: inflammation of the brain , caused by a virus, may occur as a sequala of measles, mumps, chickenpox

NURSING ASSESSMENT o Headache – most common o Fever & chillso Dizziness, vomiting, malaise

o Photophobia, irritability o Signs of meningeal irritation

o Nuchal rigidity: stiff neck o Opisthotonos: head and heels bent

backward and body arched forward

o Kernig’s sign: supine position, thigh and knee flexed to right angle, .extension of leg causes spasm of hamstring, resistance and pain

o Brudzinki’s sign: flexion of head causes flexion of both thighs at hips and knee flexion

DIAGNOSIS : Lumbar puncture – measurement and analysis of CSF shows increased pressure, elevated WBC and protein, decrease glucose and culture positive for specific microorganism

Nursing Care Give large doses of antibiotics as ordered Isolation precaution for 24 hours after initiation

of treatment Provide nursing care for increase ICP, seizures

and hyperthermia

Bedrest in quiet and dark room Dirt: high protein, high carbohydrates, small

frequent meals Administer medications as ordered Maintain fluid and electrolyte balance Prevent complications of immobility VS and neuro checks regularly Rehabilitation for residual deficits

P A R T T W O

A. MULTIPLE SCLEROSIS- Multiple sclerosis is a chronic,

progressive, non-contagious, degenerative disease of the CNS characterized by demyelinization of the neurons.

- Multiple sclerosis usually occurs between the ages of 20 and 40 and consists of periods of remissions and exacerbations.

- The causes are unknown, but the disease is thought to be a result of an autoimmune response or vital infection.

- Precipitating factors include pregnancy, fatigue, stress, infection and trauma.

- Electroencephalogram findings are abnormal.

- A lumbar puncture indicates increased gammaglobulin, but the serum globulin level is normal.

NURSING ASSESSMENT o Fatigue and weakness o Ataxia and vertigoo Tremors and spasticity of the lower

extremitieso Parasthesiaso Blurred vision and diplopiao Nystagmuso Dysphasiao Decreased perception to pain, touch

and temperatureo Bladder and bowel disturbances,

including urgency, frequency, retention and incontinence

o Abnormal reflexes, including hyperreflexia, absent reflexes and a positive Babinski’s reflex

o Emotional changes such as apathy, euphoria, irritability and depression

o Memory changes and confusion

Nursing Care Provide bed rest during exacerbation. Protect the client from injury by

providing safety measures. Place an eye patch on the eye for

diplopia.

Monitor for potential complications such as urinary tract infections calculuses decubitus ulcers respiratory tract infections and contractures.

Promote regular elimination by bladder and bowel training.

Encourage independence. Assist the client to establish a regular

exercise and rest program. Instruct the client to balance moderate

activity with rest periods. Assess the need for and provide

assistive devices. Initiate physical and speech therapy. Instruct the client to avoid fatigue,

stress, infection, overheating and chilling.

Instruct the client to increase fluid intake and eat a balanced diet, including low-fat, high-fiber foods and foods high in potassium.

Instruct the client in safety measures related to sensory loss, such as regulating the temperature of bath water and avoiding heating pads.

Instruct the client in safety measures related to motor loss, such as avoiding the use of scatter rugs and using assistive devices.

Instruct the client in the self-administration of prescribed medication

B. MYASTHENIA GRAVIS

- Myasthenia gravis is a neuromuscular disease characterized by considerable weakness and abnormal fatigue of the voluntary muscles.

- A defect in the transmission of nerve impulses at the myoneural junction occurs.

- Causes include insufficient secretion of acetylcholine, excessive secretion of cholinesterase and unresponsiveness of the muscle fibers to acetylcholine.

NURSING ASSESSMENT o Weakness and fatigueo Difficulty chewingo Dysphagiao Ptosiso Diplopiao Weak, hoarse voiceo Difficulty breathingo Diminished breath soundso Respiratory paralysis and failure

Nursing Care Monitor respiratory status and ability to

cough and deep breathe adequately. Monitor for respiratory failure. Maintain suctioning and emergency

equipment at the bedside.

Monitor vital signs. Monitor speech and swallowing abilities

to prevent aspiration. Encourage the client to sit up when

eating. Assess muscle status. Instruct the client to conserve strength. Plan short activities that coincide with

times of maximal muscle strength. Monitor for myasthenic and cholinergic

crises. Administer anticholinesterase

medications as prescribed. Instruct the client to avoid stress,

infection, fatigue and over the counter medications.

Instruct the client to wear a Medic-Alert bracelet.

Anticholinesterase medications1. Action: Increase levels of acetycholine

at the myoneural junction.2. Medications

a. Neostigmine bromide (Prostigmin)

b. Pyridostigmine bromide (Mestinon, Regonol)

c. Edrophonium chloride (Tensilon)

3. Side effectsa. Sweatingb. Salivationc. Nausead. Diarrhea and abdominal

crampse. Bradycardiaf. Hypotension

4. Interventionsa. Administer medications on

time.b. Administer medication 30

minutes before meals with milk and crackers to reduce gastrointestinal upset.

c. Monitor and record muscle strength.

d. Note that excessive doses lead to cholinergic crisis.

e. Have the antidote (atropine sulfate) available.

Myasthenic crisis1. Description

a. Myasthenic crisis is an acute exacerbation of the disease.

b. The crisis is caused by a rapid, unrecognized progression of the disease, an inadequate amount of medication, infection, fatigue or stress.

2. Assessmenta. Increased pulse, respirations

and blood pressure.b. Anorexia and cyanosis

c. Bowel and bladder incontinence

d. Decreased urine outpute. Absent cough and swallow

reflex3. Interventions

a. Assess for signs of myasthenic crisis.

b. Increase anticholinesterase medication.

Cholinergic crisis1. Description

a. Cholinergic crisis results in depolarization of the motor end plates.

b. The crisis is caused by overmedication with anticholinesterase.

2. Assessment a. Abdominal crampsb. Nausea, vomiting and diarrheac. Blurred visiond. Pallore. Facial muscle twitchingf. Hypotensiong. Pupillary miosis

3. Interventionsa. Hold anticholinesterase

medication.b. Prepare to administer the

antidote, atropine sulfate, if prescribed.

Tensilon Test

1. Description: The Tensilon Test is performed to diagnose myasthenia gravis and to differentiate between myasthenic crisis and cholinergic crisis.

2. To diagnose myasthenia gravisa. Edrophonium (Tensilon)

injection is administered to the client.

b. Positive for myasthenia gravis: Client shows improvement in muscle strength after the administration of Tensilon.

c. Negative for myasthenia gravis: Client shows no improvement in muscle strength and strength may even deteriorate after injection of Tensilon.

3. To differentiate crisis:a. Myasthenic crisis: Tensilon is

administered, and if strength improves, the client needs more medication.

b. Cholinergic crisis: Tensilon is administered and if weakness is more severe, the client is overmedicated; administer atropine sulfate, the antidote as prescribed.

C. PARKINSON’S DISEASE

- Parkinson’s disease is a degenerative disease caused by the depletion of dopamine, which interferes with the inhibition of excitatory impulses.

- Parkinson’s disease results in a dysfunction of the extrapyramidal system.

- Parkinson’s disease is a slow, progressive disease that results in a crippling disability.

- The debilitation can result in falls, self-care deficits, failure of body systems and depression.

- Mental deterioration occurs late in the disease.

NURSING ASSESSMENT o Bradykinesia, abnormal slowness of

movement and sluggishness of physical and mental responses

o Akinesiao Monotonous speecho Handwriting that becomes

progressively smallero Tremors in hands and fingers at rest

(pill rolling)o Tremors increasing when fatigued and

decreasing with purposeful activity or sleep

o Rigidity with jerky interrupted movements

o Restlessness and pacingo Blank facial expression-mask –like

faces o Droolingo Difficulty swallowing and speakingo Loss of coordination and balanceo Shuffling steps, stooped position and

propulsive gait

Nursing Care Assess neurological status. Assess ability to swallow and chew. Provide high-calorie, high-protein, high-

fiber soft diet with small, frequent feedings.

Increase fluid intake to 2000 mL/day. Monitor for constipation. Promote independence along with

safety measures. Avoid rushing the client with activities. Assist with ambulation and provide

assistive devices. Instruct the client to rock back and

forth to initiate movement. Instruct the client to wear low-heeled

shoes. Encourage the client to lift feet when

walking and to avoid prolonged sitting. Provide firm mattress and position the

client prone, without pillow to facilitate proper posture.

Instruct in proper posture by teaching the client to hold the hands behind the back to keep the spine and neck erect.

Promote physical therapy and rehabilitation.

Administer anticholinergic medications as prescribed to treat tremors and rigidity and to inhibit the action of acetylcholine.

Administer antiparkinsonian medications to increase the level of dopamine in the CNS.

Instruct the client to avoid foods high in vitamin B6 because they block the effects of antiparkinsonian medications.

Instruct the client to avoid monoamine oxidase inhibitors because they will precipitate hypertensive crisis.

D. GUILLAIN-BARRE SYNDROME

- It is an acute infectious neuronitis of the cranial and peripheral nerves

- The immune system overreacts to the infection and destroys the myelin sheath

- The syndrome usually is preceded by a mild upper respiratory infection or gastroenteritis

- The recovery is a slow process and can take years

- The major concern is difficulty breathing

NURSING ASSESSMENT o Paresthesiaso Weakness of lower extremitieso Gradual progressive weakness of

upper extremities and facial muscles

o Possible progression to respiratory failure

o Cardiac dysrhythmiaso Cerebrospinal fluid that reveals an

elevated protein levelo Abnormal EEG Nursing Care Care is directed toward the treatment

of symptoms Monitor respiratory status Provide respiratory treatments Prepare to initiate respiratory support Monitor cardiac status Assess for complications of immobility Provide the client and family with

support

E. AMYOTROPHIC LATERAL SCLEROSIS

- Also known as Lou Gehrig’s disease- It is a progressive degenerative disease

involving the motor system

- The sensory and autonomic systems are not involved and mental status changes does not result from the disease

- Cause of the disease is related to increase glutamate, a chemical responsible for relaying messages between the motor neurons

- As the disease progresses, muscle weakness and atrophy develop until a flaccid quadriplegia develops

- Eventually the respiratory muscle become affected leading to respiratory compromise, pneumonia and death

- No cure is known and the treatment is symptomatic

NURSING ASSESSMENT o Fatigue o Fatigue while talking o Muscle weakness and atrophy o Tongue atrophy o Dysphagia o Weakness of the hands and armso Fasciculation of the faceo Nasal quality of voiceo Dysarthria

Nursing Care Care is directed toward the treatment

of symptoms Monitor respiratory status Provide respiratory treatments Prepare to initiate respiratory

support Assess for complications of

immobility Provide the client and family with

support