Chapter 34

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Transcript Chapter 34

Chapter 27
Neurologic Disorders
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Learning Objectives
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Identify common neurologic changes in the older person and the implication of these
for nursing care.
Describe the diagnostic tests and procedures used to evaluate neurologic function
and the nursing responsibilities associated with each.
Identify the uses, side effects, and nursing interventions associated with common
drug therapies employed in patients with neurologic disorders.
Describe the signs and symptoms associated with increased intracranial pressure
and the medical therapies used in treatment.
List the components of the nursing assessment of the patient with a neurologic
disorder.
Describe the pathophysiology, signs and symptoms, complications, and medical or
surgical treatment for patients with selected neurologic disorders.
Assist in developing a nursing care plan for the patient with a neurologic disorder.
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Anatomy and Physiology of the
Nervous System
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Neuron (Nerve Cell)
• Functional unit of the nervous system that
conducts electrical impulses from one area of
the brain to another
• Sensory neurons
• Transmit information from distal parts of the body or
environment toward the central nervous system
• Motor neurons
• Carry motor information from the CNS to the
periphery
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Axons and Dendrites
• Branch off the main cell body
• Axons conduct impulses away from the cell
body
• Dendrites convey impulses toward the cell
body
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Myelin
• Material that covers many axons and dendrites
• Enhances conduction along nerve fibers
• Gives the axons a white appearance; cell
bodies without myelin are gray
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Figure 27-1
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Central Nervous System (CNS)
• Made up of the brain and spinal cord
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Peripheral Nervous System
• Comprises all the nerves of the peripheral
parts of the body, including spinal and cranial
nerves
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Brain
• Divided into the cerebrum, cerebellum, and
brainstem
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Cerebrospinal Fluid (CSF)
• Composed of water, glucose, sodium chloride,
and protein
• Acts as a shock absorber for the brain and
spinal cord
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Figure 27-2
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Spinal Cord
• Extends from the border of the first cervical
vertebra (C1) to the level of the second lumbar
vertebra (L2)
• Thirty-one pairs of spinal nerve roots exit the
spinal cord, each consisting of a posterior
sensory (afferent) root and anterior motor
(efferent) root
• These roots, along with the 12 cranial nerves,
make up the peripheral nervous system
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Autonomic Nervous System
• Controls the involuntary activities of the viscera,
including smooth muscle, cardiac muscle, and
glands
• Two major subdivisions: sympathetic nervous
system and the parasympathetic nervous
system
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Age-Related Changes
• The number of nerve cells decreases
• Brain weight is reduced; ventricles increase in size
• Lipofuscin: aging pigment deposited in nerve cells with
amyloid, a type of protein
• Increased plaques and tangled fibers in nerve tissue
• Eye pupil often smaller; may respond to light more
slowly
• Reflexes intact except for Achilles tendon jerk, which is
often absent
• Reaction time increases, especially complex reactions
• Tremors in the head, face, and hands are common
• Some develop dizziness and problems with balance
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Pathophysiology of
Neurologic Diseases
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Types of Disorders
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Developmental and genetic
Trauma
Infections and inflammation
Neoplasms
Degenerative processes
Vascular disorders
Metabolic and endocrine disorders
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Nursing Assessment of
Neurologic Function
• Health history
• Note speech, behavior, coordination, alertness,
comprehension
• Chief complaint and history of present illness
• Document what prompted the patient to seek medical attention
• Describe any injuries
• If patient has pain, note the onset, severity, location, and
duration
• Past medical history
• Head injury, seizures, diabetes mellitus, hypertension, heart
disease, and cancer
• Record dates and types of immunizations
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Nursing Assessment of
Neurologic Function
• Family history
• Have immediate family members had heart disease,
stroke, diabetes mellitus, cancer, seizure disorders,
muscular dystrophy, or Huntington’s disease?
• Review of systems
• Fatigue or weakness, headache, dizziness, vertigo,
changes in vision/hearing, tinnitus, drainage from
ears or nose, dysphagia, neck pain or stiffness,
vomiting, bladder or bowel function, sexual
dysfunction, fainting, blackouts, tremors, paralysis,
incoordination, numbness or tingling, memory
problems, mood changes
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Nursing Assessment of
Neurologic Function
• Functional assessment
• Document whether present symptoms interfere with
the patient’s usual activities and occupation
• Explore sources of stress, usual coping strategies,
and sources of support
• Physical examination
• Level of consciousness, pupillary evaluation,
neuromuscular response, and vital signs
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Diagnostic Tests and Procedures
• Advanced neurologic examination
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Cranial nerves
Coordination and balance
Neuromuscular function
Sensory function
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Pain
Temperature
Light touch
Vibration
Position
Tactile discrimination
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Figure 27-5
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Figure 27-6
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Figure 27-7
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Diagnostic Tests and Procedures
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Lumbar puncture
Electroencephalography
Electromyography
Radiologic studies
• Brain scan
• Cerebral angiography and digital subtraction
angiography
• Computed tomography
• Magnetic resonance imaging
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Figure 27-8
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Figure 27-9
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Figure 27-10
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Figure 27-11
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Common Therapeutic Measures
• Drug therapy
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Antimicrobials
Analgesics
Anti-inflammatory
Corticosteroids
Anticonvulsants
Diuretics
Chemotherapeutic agents
Dopaminergics
Anticholinergics
Cholinergics
Antihistamines
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Common Therapeutic Measures
• Surgery
• Craniotomy
• Surgical opening of the skull
• Craniectomy
• Excision of a segment of the skull
• Cranioplasty
• Any procedure done to repair a skull defect
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Disorders of the Nervous System
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Migraine Headache
• Intracranial vasoconstriction followed by vasodilation
• Triggered by menstruation, ovulation, alcohol, some
foods, stress
• Pain usually unilateral, often begins in the temple or
eye area and is very intense
• Tearing and nausea and vomiting may occur
• Hypersensitive to light and sound; prefers dark, quiet
environment
• Mild migraines treated with acetaminophen or aspirin;
severe ones with ergotamine (Cafergot) or sumatriptan
(Imitrex) tablet or autoinjector for self-injection
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Cluster Headache
• Occur in a series of episodes followed by a
long period with no symptoms
• Intensely painful and seem to be related to
stress or anxiety
• Usually have no warning symptoms
• Treatment may include cold application,
indomethacin (Indocin), and tricyclic
antidepressants
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Tension Headache
• Result from prolonged muscle contraction from
anxiety, stress, or stimuli from other sources,
such as a brain tumor or an abscessed tooth
• Pain location may vary; may have nausea and
vomiting, dizziness, tinnitus, or tearing
• Treatment: correction of known causes,
psychotherapy, massage, heat application, and
relaxation techniques
• Analgesics, usually nonopioid, may be
prescribed to reduce anxiety
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Seizure Disorder
• Electrical impulses in the brain are conducted
in a highly chaotic pattern that yields abnormal
activity and behavior
• Related to trauma, reduced cerebral perfusion,
infection, electrolyte disturbances, poisoning,
or tumors
• Medical diagnosis
• Accurate history of the seizure disorder
• Electroencephalogram (EEG)
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Seizure Disorder: Classification
• Partial seizures
• Simple
• Part of one cerebral hemisphere; consciousness not
impaired
• Complex
• Consciousness impaired; may exhibit bizarre behavior
• Generalized seizures
• Involve the entire brain from the onset
• Consciousness lost during the ictal (seizure) period
• Types: tonic-clonic, absence, myoclonic, and atonic
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Seizure Disorder
• Status epilepticus
• Medical emergency: continuous seizures or repeated
seizures in rapid succession for 30 minutes or more
• Aura
• Dizziness, numbness, visual or hearing disturbance,
noting an offensive odor, or pain may precede a
seizure
• Medical treatment
• Resolution of the underlying condition
• Anticonvulsant drug therapy
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Seizure Disorder
• Surgical treatment
• Removal of seizure foci in the temporal lobe and
pallidotomy or vagal nerve stimulator
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Seizure Disorder: Nursing Care
• Assessment
• Describe the seizure episode, including the postictal
period (following the seizure), and document drug
therapy
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Seizure Disorder:
Nursing Care
• Risk for Injury
• Side rails of bed up and padded, suction machine
readily available, bed maintained in the low position
• Quickly move objects away from the patient
• Do not attempt to restrain the patient
• Ineffective Coping and Deficient Knowledge
• Teach family and patient about the seizure disorder
and the therapy
• Teaching must be directed toward helping the
patient and family adjust to a chronic condition
• Encourage questions and concerns
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Head Injury: Types
• Scalp injuries
• Lacerations, contusions, abrasions, and hematomas
• Concussion
• Trauma with no visible injury to the skull or brain
• Contusion
• Bruising and bleeding in the brain tissue
• Hematoma
• Subdural hematoma or epidural hematoma
• Intracerebral hemorrhage
• From lesions within the tissue of the brain itself
• Penetrating injuries
• Sharp objects penetrate the skull and brain tissue
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Head Injury
• Surgical treatment
• Directed at evacuating hematomas and débriding
damaged tissue
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Head Injury: Nursing Care
• Interventions
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Ineffective Tissue Perfusion
Ineffective Breathing Pattern
Risk for Injury
Risk for Infection
Impaired Physical Mobility
Disturbed Body Image and Ineffective Role
Performance
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Brain Tumors
• Etiology and risk factors
• Some congenital; others may be related to heredity
• Drug/environmental factors may play a role in development
• Signs and symptoms
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Directly related to area of brain invaded by the tumor
Visual disturbances and headache
New-onset seizure activity
Difficulties with balance and coordination
• Medical treatment
• Surgery often followed by radiation with or without
chemotherapy
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Brain Tumors: Nursing Care
• Interventions
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Acute Pain
Disturbed Thought Processes
Disturbed Sensory Perception
Impaired Physical Mobility and Self-Care Deficit
Ineffective Coping
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Meningitis
• Etiology and risk factors
• Inflammation of the meningeal coverings of the
brain and spinal cord caused by either viruses or
bacteria
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Signs and symptoms
• Headache, nuchal rigidity (stiffness of the back of
the neck), irritability, diminished level of
consciousness, photophobia (sensitivity to light),
hypersensitivity, and seizure activity
• Positive Kernig’s sign and Brudzinski’s sign
• Medical diagnosis
• Lumbar puncture to obtain CSF for lab analysis
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Figure 27-16A
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Figure 27-16B
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Meningitis
• Medical treatment
• Bacterial infections usually respond to antimicrobial
therapy, but no specific drugs effective against most
viral infections
• Anticonvulsants used to control seizure activity if
necessary
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Meningitis: Nursing Care
• Assessment
• Assess vital signs and neurologic status frequently
to determine further deterioration or onset of
complications
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Meningitis: Nursing Care
• Interventions
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Ineffective Tissue Perfusion
Ineffective Breathing Pattern
Acute Pain
Risk for Injury
Deficient Fluid Volume
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Encephalitis
• Etiology and risk factors
• Inflammation of brain tissue caused by virus
• Signs and symptoms
• Fever, nuchal rigidity (stiff neck), headache,
confusion, delirium, agitation, and restlessness
commonly seen
• Comatose or exhibit aphasia, hemiparesis, facial
weakness, and other alterations in motor activity
• Medical treatment
• Enhance patient comfort and increase strength
• Because seizure activity is a potential problem, take
appropriate safety precautions
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Encephalitis: Nursing Care
• The nursing plan of care parallels that of the
patient with meningitis
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Guillain-Barré Syndrome
• Etiology and risk factors
• Although specific cause unknown, it is believed to
be an autoimmune response to a viral infection
• Patients often report some recent viral infection or
vaccination
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Guillain-Barré Syndrome
• Initial phase
• Symmetric muscle weakness: begins in lower
extremities; ascends to trunk and upper extremities
• Visual and hearing disturbances, difficulty chewing,
and lack of facial expression
• Mild paresthesias or anesthesia in feet and hands in
a glove or stocking distribution pattern
• Hypertension, orthostatic hypotension, cardiac
dysrhythmias, profuse sweating, paralytic ileus, and
urinary retention
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Guillain-Barré Syndrome
• Plateau phase
• Remains essentially unchanged
• No further neurologic deterioration, but no
improvement either
• Recovery phase
• Remyelinization; muscle strength returns in a
proximal-to-distal pattern (head to toes)
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Guillain-Barré Syndrome
• Medical diagnosis
• Characteristic onset and pattern of ascending motor
involvement
• Elevated protein level in the CSF
• Nerve conduction velocity studies reveal slowed
conduction speed in the involved nerves
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Guillain-Barré Syndrome
• Medical treatment
• Preserve vital function, particularly respiration
• Respiratory status is closely monitored and
mechanical ventilation initiated if vital capacity falls
to 15 mL/kg of body weight
• Massive doses of corticosteroids prescribed to
suppress the inflammatory process
• Plasmapheresis
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Guillain-Barré Syndrome: Nursing
Care
• Assessment
• Health history describes the progression of
symptoms
• Note fears, coping strategies, and sources of
support
• Physical examination focuses on cranial nerve,
motor, respiratory, and cardiovascular function
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Guillain-Barré Syndrome: Nursing
Care
• Interventions
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Ineffective Breathing Pattern
Decreased Cardiac Output
Risk for Disuse Syndrome
Imbalanced Nutrition: Less Than Body
Requirements
• Anxiety
• Deficient Knowledge
• Rehabilitation
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Parkinson’s Syndrome
• Etiology and risk factors
• Progressive degenerative disorder of the basal
ganglia: an eventual loss of coordination and control
over involuntary motor movement
• Signs and symptoms
• Tremor, rigidity, and bradykinesia
• Loss of dexterity and power in affected limbs,
aching, monotone voice, handwriting changes,
drooling, lack of facial expression, rhythmic head
nodding, reduced blinking, and slumped posture
• Depression common; dementia may develop
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Figure 27-17
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Parkinson’s Syndrome
• Medical diagnosis
• From health history and physical examination
• MRI to rule out other causes of the symptoms
• Medical treatment
• Control symptoms: physical therapy and drug
therapy
• Massage, heat, exercise, and gait retraining
• Dopamine receptor agonists pramipexole (Mirapex) or
ropinirole (Requip); L-dopa (L-dihydroxyphenylalanine);
carbidopa/levodopa (Sinemet); anticholinergic drugs such
as trihexyphenidyl (Artane) and benztropine (Cogentin)
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Parkinson’s Syndrome: Nursing Care
• Assessment
• Weakness, fatigue, muscle cramps, sweating, dysphagia,
constipation, difficulty voiding, and unusual movements
• Note lack of facial expression, eyes fixed in one direction,
drooling, slurred speech, tearing, tremors, muscle stiffness,
and poor balance and coordination
• Interventions
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Impaired Physical Mobility
Risk for Injury
Imbalanced Nutrition: Less Than Body Requirements
Ineffective Coping
Deficient Knowledge
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Multiple Sclerosis
• Etiology
• Chronic, progressive degenerative disease
• Attacks the protective myelin sheath around axons
and disrupts the conduction of impulses through the
CNS
• Chronic, progressive MS: progresses steadily
• Exacerbating-remitting MS: exacerbations and remissions
• Relapsing-progressive MS: less stable periods than
exacerbating-remitting
• Stable MS: stable; no active disease for a year
• Exact cause of MS is unknown; viral infections and
autoimmune processes have been implicated
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Multiple Sclerosis
• Signs and symptoms
• Fatigue, weakness, and tingling in one or more
extremities; visual disturbances; problems with
coordination; bowel and bladder dysfunction;
spasticity; and depression
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Figure 27-18
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Multiple Sclerosis
• Medical diagnosis
• Based on the physical examination and history of
cyclic remission-exacerbation periods
• Magnetic resonance imaging of the brain and spinal
cord may reveal plaques characteristic of MS
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Multiple Sclerosis
• Medical treatment
• Corticosteroids (ACTH, prednisone,
methylprednisolone)
• Interferon  1b (Betaseron) and interferon 1a
(Avonex)
• Glatiramer acetate (Copaxone)
• Immunosuppressants: mitoxantrone (Novantrone)
• Amantadine (Symmetrel)
• Urinary retention treated with cholinergics, such as
bethanechol (Urecholine) or neostigmine
(Prostigmine)
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Multiple Sclerosis: Nursing Care
• Assessment
• Onset and progression of symptoms, especially
those that affect mobility, vision, eating, and
elimination
• Range of motion and strength, gait abnormalities,
tremors, and muscle spasms
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Multiple Sclerosis: Nursing Care
• Interventions
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Impaired Physical Mobility
Disturbed Sensory Perception
Self-Care Deficit
Functional Urinary Incontinence
Risk for Infection
Ineffective Coping
Deficient Knowledge
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Amyotrophic Lateral Sclerosis (ALS)
• Etiology
• Also known as Lou Gehrig’s disease; a
degenerative neurologic disease
• Virus suspected, but exact cause unknown
• Pathophysiology
• Degeneration of the anterior horn cells and the
corticospinal tracts, so patient exhibits upper and
lower motor neuron symptoms
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ALS
• Signs and symptoms
• Weakness of voluntary muscles of the upper
extremities, particularly the hands
• Difficulty swallowing and speaking
• Eventually, respirations shallow; difficulty clearing
airway of pulmonary secretions
• Death results from aspiration, respiratory infection,
or respiratory failure
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ALS
• Medical diagnosis
• History and physical examination findings
• Electromyography
• Medical treatment
• Because no known cure or treatment, therapy is
supportive; focuses on preventing complications
and maintaining maximum function
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ALS: Nursing Care
• Assessment
• Dyspnea, dysphagia, muscle cramps, weakness,
twitching, joint stiffness, muscle atrophy, abnormal
reflexes and gait, and paralysis
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ALS: Nursing Care
• Interventions
• Ineffective Airway Clearance
• Impaired Physical Mobility
• Imbalanced Nutrition: Less Than Body
Requirements
• Impaired Verbal Communication
• Impaired Skin Integrity
• Anticipatory Grieving
• Situational Low Self-Esteem
• Interrupted Family Processes
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Huntington’s Disease
• Inherited degenerative neurologic disorder
• Usually begins in middle adulthood with
abnormal movements, emotional disturbance,
and intellectual decline
• Symptoms progress steadily: increasing
disability and death in 15 to 20 years
• Medical and nursing care are supportive only;
there is no cure
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Myasthenia Gravis
• Etiology
• May have an autoimmune basis
• Pathophysiology
• Insufficient receptor sites at the junction of the motor
nerve with the muscle
• With repeated stimulation, muscle becomes
exhausted; eventually unable to contract at all
• If respiratory muscles involved, death from
respiratory insufficiency or arrest possible
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Myasthenia Gravis
• Signs and symptoms
• Weakness of voluntary muscles, particularly those
of chewing, swallowing, and speaking
• Partial improvements of strength with rest
• Dramatic improvement with the use of
anticholinesterase drugs
• Ptosis and diplopia commonly seen
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Myasthenia Gravis
• Medical diagnosis
• Administering edrophonium (Tensilon)
• Muscle tone is markedly improved within 1 minute of
injection; persists for 4 to 5 minutes
• Medical treatment
• Anticholinesterase drugs
• Neostigmine and pyridostigmine (Mestinon)
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Corticosteroids
Cytotoxic therapies
Thymectomy
Plasmapheresis
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Myasthenia Gravis: Nursing Care
• Assessment
• Health history describes the onset of symptoms:
muscle weakness, diplopia, dysphagia, slurred
speech, breathing difficulties, and loss of balance
• Interventions
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Ineffective Breathing Pattern
Impaired Physical Mobility and Self-Care Deficit
Impaired Swallowing
Deficient Knowledge
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