Characteristics of Thrombotic CVA

● Slow in progression, evolving over minutes to

hours
● Signs/symptoms include confusion, dizziness,
ataxia, dysphagia, syncope, numbness/tingling,
Transition to Neurological Nursing in the United vertigo, hemiparesis/hemiplegia, changes in vision
States of America or speech.

Characteristics of Hemorrhagic
CVA
● Signs/symptoms can include
hemiparesis/hemiplegia, dizziness, ataxia,
nystagmus, aphasia, numbness/tingling, unilateral
neglect.
Subarachnoid Hemorrhage (SAH)
● If aneurysmal, will present with “the worst
headache of my life”.
● If AVM, will often present with either seizures,
headache, nausea/vomiting. Pulsatile tinnitus may
also be noted upon exam.

Assessment Tools Assessment Tools (cont.)

● Glasgow_coma.gif ● MMSE.gif
● Refer to neuro flow sheet information here.
● Ranchos Scale-- ● Braden Skin Scale .htm
− Level I: No response
− Level II: Generalized response
− Level III: Localized response
− Level IV: Confused/agitated
− Level V: Confused and inappropriate
− Level VI: Confused and appropriate
− Level VII: Automatic response
− Level IX: Purposeful/appropriate
Diagnostic Tests
● Head CT-- gives a two-dimensional reconstruction
from multiple x-rays. May use IV contrast for
further definition.
Medications
● If nonhemorrhagic, may use rt-PA (in ED) within
three hours of onset of signs/symptoms to reduce
the extent of neurological damage-- watch for ICH
after administering!
● Anticoagulation for nonhemorrhagic CVA's-- wait
10-14d before starting if infarct is large or HTN
noted (will see Plavix, Coumadin, ASA)
Treatments (Medical)
● Laxatives-- decrease strain during defecation, risk
of constipation
● Deep vein thrombosis prophylaxis-- for prolonged
bedrest (Lovenox, Heparin)
● Blood glucose monitoring-- if this is too high or
too low, can extend an infarct
● If febrile-- fevers can worsen prognosis by
increasing metabolic needs. Treat!
● Prophylaxis for seizures-- not recommended
Diagnostic Tests (cont.)
● MRI-- provides a three-dimensional view using a
static magnetic field, thus more detailed than a CT.
● MRI/MRA-- MRI with angiogram, using contrast
to show more detail in vasculature
● CT angiogram-- considered the “gold standard”
when evaluating for either AVM or aneurysms
Medications (cont.)
● Antihypertensive meds-- establish a regimen with
the patient before discharge from the hospital!
● Compliance is an issue because of cost, side
effects.
Treatments (Surgical)
● Insertion of external ventricular drain
● Neurosurgery– operative procedures to stop further
bleeding or relieve increased pressure
Treatments (surgical)
● Neurosurgery (radiology)-- can use interventional
radiology services to place small coils in a cerebral
aneurysm (will block blood flow to weakened
area) or embolize an AVM by cauterizing its
supplying vessels, therefore preventing increased
pressure within the AVM
● Endovascular.jpg
Nursing Management:
Assessment
● After stabilization: Continue neuro checks and
vital signs as directed, assess for nutrition (by
mouth vs. tube feeding) and aspiration risk prior to
feeding, assess ability to mobilize and safety
indications for this as well.
Patient Teaching
● When to notify physician– give client written
instructions, including follow-up appointments.
● Offer written materials on smoking cessation,
HTN, diabetes, CVA, meds.
● Give information on support groups, websites
Diet
● If unable to swallow, start tube feeds within 72
hours of admission
● Low Sodium Diet
− Low Sodium Diet.jpg
Nursing Management:
Interventions
Refer to physician for future removal of trach or
gastrostomy tubes. Review all labwork and vital
signs for any abnormalities before discharging.
Review and discuss all discharge education and
instruction with client and family-- address any
questions/concerns.
Referrals
● Internist (or primary care provider)-- can continue
to manage HTN, diabetes, labwork, on an
outpatient basis
● Neurology/neurosurgery (if operative)-- for
specific brain-related issues
● Physical/occupational/speech therapy-- can assess
home environment for safety, evaluate for return to
driving or work, maximize independence,
mobilizing, swallowing, prevent complications of
immobility
Referrals (cont.)
● Chaplain-- can assist with any spiritual needs or
help provide care specific to one's religious
preference
● Social Work-- will work with the client and the
family to anticipate future needs (living
arrangements, financial considerations, disability)
and be of support to the family and the client
during this time of transition/illness
What causes seizures?
● 2/3 of all seizure cases have an unknown etiology
(idiopathic)-- are considered a primary seizure
disorder.
● 1/3 of all seizure cases are caused by a known
disease or have a known diagnosis (examples
include traumatic brain injury, neurologic disease,
various medical diseases, genetic tendency).
Diagnostic tests
● Electroencephalogram-- records electrical
impulses from the brain's surface through scalp
electrodes. You are looking for an alteration or
localization of electrical activity.
Seizures
● A seizure is classified as an abnormal discharge of
cerebral neurons, causing a transient alteration in
brain function, which can lead to a temporary
decreased level of consciousness.
● Epilepsy is the general term for the primary
condition that causes seizures. This is a chronic
disorder for which there is no correctable cause.
Tools
● Seizure classification.gif
● epilepsyfoundation.cfm
Diagnostic tests (cont.)
● Positive electron tomography-- CT imaging with
injected radioactive substances; can see glucose
and O2 uptake in the brain, cerebral blood flow,
and drug effects using this test-- highly
specialized.
● EEG.jpg
● EEG(normal).gif
Medications (antiepileptic drugs)
● Dilantin (Phenytoin)-- the “gold standard”,
discovered in 1938; Fosphenytoin is a better form
of this drug to give I.V. It is less damaging to
peripheral vessels and has fewer side effects--
more soluble, preferred for status epilepticus
Medications (cont.)
● Keppra (Levetiracetam)-- can be used for control
of partial sz. Is increasing in favor with
prescribers.
Medications (cont.)
● These are medications commonly used to break
(stop) a seizure in progress:
− Valium (Diazepam)
− Ativan (Lorazepam)
− Klonipin (Clonazepam)
Medications (cont.)
● Tegretol (Carbamazepine)-- is the drug of choice
to treat partial seizures and can also be used to
treat generalized. Only available by mouth.
Medications (cont.)
● Other meds that can be used in adjunct therapy
with other drugs include the following:
− Lamictal (Lamotrigine)
− Neurontin (Gabapentin)
− Topamax (Topiramate)
− Depakote/Depakene/Depakane (all derivatives of
Valproic Acid)
− Trileptal (Oxycarbazepine)
Surgical Management
● Temporal Lobectomy-- this surgical procedure is
an option for those who experience intractable
temporal lobe seizures.
● Vagal Nerve Stimulation-- this is an outpatient
surgical procedure that might reduce the frequency
and severity of partial seizures refractory to
medications; stimulating electrodes are planted in
the left vagus nerve and can be activated with a
magnetic device when a seizure is in progress

Diet
● Know if there are any dietary restrictions with the
medications the client is taking.
● Ketogenic diet-- more commonly used with
children; can reduce severity/frequency of seizures
in certain populations
Nursing Management:
Interventions
● Immediately uncover patient to view activity fully.
May turn him/her on his/her side if level of
consciousness is decreased to prevent aspiration.
● Place oxygen on patient-- there is a 60% increase
in O2 use during a sz.
● Administer drug of choice per physician order if
applicable (Valium, Ativan)
● Do not stick anything in patient's mouth and do not
restrain in any way.
Patient Teaching
● Stress the importance of compliance with medical
regimen-- most recurrence is related to
noncompliance with medicines.
● Give activity orders and discuss return to
work/driving.
Nursing Management:
Assessment
● Be sure your client's room is equipped properly in
the event of seizure activity
− O2 set-up
− Wall suction
− Padded bedrails
− Call light within reach at all times
− Bed in low position
− Have an accurate watch or wall clock to time seizure
− Easily accessible crash cart
− Have patent IV access for emergency use prn
Activity
Driving-- the patient must be seizure-free for one
year before he/she can resume driving.
● Cannot operate heavy machinery/equipment on the
job if seizures are not controlled-- must have
physician order to return to work
Referrals
● Neurology-- continue management of medications
● Neurosurgery-- if surgical resection is a
possibility, also for vagal nerve stimulator if
seizures are not medically manageable
● Social Work-- for community resources, possible
disability issues, involvement with family and
transition back to home environment
Head Injury
● Closed head injuries are injuries that do not
penetrate the skull or the dura mater-- also called
“blunt” traumatic injury.
● Open head injuries involve penetration of the
skull. Also called “missile” traumatic injury.
Contusion (bruise)
● Contusions result in small tears that bleed, then
edema results around the damaged areas-- peak
effect of injury is noted between 18-36 hours.
● contusion(CT).jpg
Subdural Hematoma (SDH)
● Signs and symptoms of acute SDH include the
following: headache, drowsiness, slow to respond
to verbal cues, progressive confusion, ipsilateral
fixed/dilated pupil, hemiparesis
● SDH.gif
Concussion (“to shake violently”)
● Is the most common of head injuries
Signs/symptoms include the following: headache,
lethargy, confusion, dizziness, irritability, change
in vision, ataxia
Epidural Hematoma (EDH)
● Signs and symptoms include the following:
temporary loss of consciousness, then back to
baseline exam (this period of alertness can last
from minutes to a couple of days), headache,
drowsiness, confusion, may have ipsilateral dilated
pupil, can progress to rapid deterioration, possible
herniation-- must intervene (surgery) quickly!
Subdural Hematoma (cont.)
● Chronic SDH's are more common in the elderly
and alcoholic populations (associated atrophy of
the brain allows more space for blood to
accumulate).
● Signs and symptoms may present weeks/months
after injury.
Intracerebral Hematoma (ICH) Diagnostic Tests

● Will present with altered LOC, progressing to
coma. May see decorticate/decerebrate posturing,
hemiplegia on contralateral side, pupil changes
(dilation on ipsilateral side).
● Head CT-- quick and efficient way to assess for
increased hemorrhage, hydrocephalus, edema
● MRI of head-- provides more detail; will show
more in terms of ischemic change, edema, and
infarct.

Medications Medications (cont.)

● Mannitol (osmodiuretic) ● Seizure prophylaxis-- use for first seven days

● Hypertonic saline (3%) postinjury-- continue if patient experiences seizure
● Decadron (dexamethasone) activity.
● Pepcid (Famotidine)

Treatments Treatments (cont.)

● Medical– ● Surgical
− deep vein thrombosis prophylaxis, − Burr holes or craniotomy for evacuation of blood
− antibiotics only if cerebrospinal fluid is infected − Bone flap removal
(meningitis), − External Ventricular Drain
− control temperature
− control blood glucose
Diet
● If unable to swallow, start tube feeds within 72
hours of admission
● For motor impairment, may have special utensils
(strap on to hand, may have larger handles) to use.
● If visually impaired, place meals on unaffected
side.
Nursing Management:
Assessment
● Insert excerpt from Neuro ICU flowsheet here.
● Glascow Coma Scale– listed previously in stroke
section
● Rancho Los Amigos Scale– listed previously in
stroke section
Nursing Management:
Interventions
● Head of bed elevated at least 30 degrees
● Keep head in midline position, no flexion/turning
● If trach in place, do NOT fasten ties too tightly.
● Cervical collar if unresponsive until able to rule
out spine injury not visible on radiographs.
Activity
● Keep head of bed elevated at least 30 degrees
● Keep head in midline position to promote venous
return.
● Out of bed with assist to chair initially, then
advance as condition warrants.
Nursing Management:
Assessment
● Assess mental status (insert neuro ICU flowsheet
here)
● Assess pupils bilaterally (insert neuro ICU
flowsheet here)
● Assess motor response (insert neuro ICU
flowsheet here)
Patient Teaching
● Educate client and family on when to notify
physician.
● Reassure family that the client will not be better
“overnight”– will take time to recover.
● The client and his/her family need to know that
problems with concentration, focusing,
mood/affect, multitasking, being in crowds, are all
common with this diagnosis.
Referrals
● Physical/occupational/speech therapy
● Social Work
Diagnostic Tests
● X-rays determine bony involvement (fractures,
alignment of vertebrae)
● CT's and MRI's can be done either with or without
contrast to show the vertebral canal, the spinal
cord, the discs-- can see cord involvement here.
Medications (cont.)
● May need prophylactic antibiotics (like Bactrim) if
urinary tract infections become a chronic illness.
● Deep vein thrombosis prophylaxis-- Lovenox or
Heparin, but not until postoperative day #2 if
patient undergoes surgery.
Spinal Cord Injury (SCI)
● Incomplete quadriplegia-- function at or above the
level of C6 remains intact.
● Complete quadriplegia-- level of injury is above
C6. If injury involves C3-C5, there could be
phrenic nerve involvement-- may need ventilator.
● anatomy(spine).gif
● complications(SCI).htm
Medications
● Steroids (Solumedrol)
● Pain meds include morphine sulfate, Lortab,
Percocet, Demerol. If neuropathic pain is present,
can use Lyrica or Neurontin.
● Bowel routine-- can include Colace (stool
softener), Milk of Magnesia (laxative), or
Bisacodyl (laxative-- stimulant)
Treatments
● Halo vest-- can only be used if spine is stable and
in appropriate alignment.
● TLSO brace (thoracolumbar/sacral orthotic)--
looks like a “turtle shell”, plastic, in two pieces, to
prevent the patient from bending/leaning
backward.
Treatments (cont.)
● CTO (cervicothoracic) brace-- similar to TLSO,
only the brace extends all the way up to the chin
and up the back of the head. This prevents any
bending at the cervical level.
Diet
● High fiber diet with plenty of fluids is
recommended. Protein will need to be increased if
muscle wasting/atrophy are noted.
● If client has suffered a high cervical injury and is
on the ventilator, start tube feeds within 72 hours
of injury.
Activity (cont.)
● Forearm splints (on four hours, off two hours) can
help prevent contractures of the wrists/hands.
● Multipodus boots (on four hours, off two hours)
can help prevent foot drop and heel breakdown/
Treatments (cont.)
● Cervical collar-- for C3-C6 injuries, worn to
prevent any bending at these levels.
● Surgical fusion-- rods, screws, and/or plates are
inserted alongside/into the spine to stabilize and
prevent further injury to the spinal cord. May
wear collar or brace 6-12 weeks postoperatively
while bone is mending.
Activity
● If spine is stabilized with bracing or surgery, may
mobilize client to chair if hemodynamically stable.
● With an unstable spine, patient remains on flat
bedrest, log roll every two hours.
Nursing Management:
Assessment
● Watch for signs/symptoms of spinal shock. This
can last from 7-20 days-- assess for these
signs/symptoms.
 Nursing Management:
Nursing Management:
Interventions (autonomic
Assessment (cont.)
dysreflexia)
● Watch for signs/symptoms of autonomic ● Elevate head of the bed.
dysreflexia– will need emergent intervention to ● Locate and remove stimulant that is causing
prevent possible stroke. problem.
● Continue bowel/bladder routine to prevent
distention.

Patient Teaching Referrals

● Educate family on maximizing client's ● Inpatient rehabilitation-- discharge to facility for

independence and on how to care for him/her. further physical/occupational therapy.
Have them demonstrate various ● Skilled Nursing Facility-- facility used for long-
procedures/techniques (example: catheterization). term care
● Remind client to focus on what he/she has left,
educate on SCI and treatment, involve him/her in
care as much as possible.
● Acknowledge grief and be realistic about
outcomes.

Referrals (cont.) Review of Brain Anatomy

● Social Work-- will help client and family manage ● brain(function).gif

grief over loss of function, identify community ● brain(review).gif
resources, assist with possible disability
paperwork/financial issues, assist with client and
family coping with separation during rehabilitation
(can last four to twelve weeks)
Primary vs. Secondary Tumors
● Primary-- originate in or around the brain; can be
metastatic (spread to body). Primary intracerebral
tumors are called gliomas.
● Secondary-- originate from another site in the
body; can be found in or outside the brain.
Medications
● Chemotherapy-- limited efficacy in the treatment
of malignant gliomas. Listed below are examples
of alkylating agents commonly used
− Carmustine (BCNU)
− Lomustine (CCNU)
− Temozolomide (Temodar)
− Gliadel wafer-- surgically implanted in the brain to
deliver chemo directly to the tissue.
Medications (cont.)
● Antiepileptic drugs-- also refer to section on
seizures for further detail; tumor growth and
surgery can cause seizure activity
− Dilantin, Tegretol, and Keppra are the most commonly
used at this time.
Diagnostic Tests
● Head CT-- used initially to find any gross
abnormalities
● MRI with/without contrast-- specifically ordered
when a mass is found
Medications (cont.)
● Steroids-- used for anti-inflammatory effect, for
treatment of cerebral edema secondary to tumor
growth and during radiation therapy. Give Pepcid
(famotidine) or another drug to counter possible
stress ulcer formation.
− Decadron (dexamethasone)
Treatment
● Radiation-- used alone or as an adjunctive therapy
along with chemotherapy or surgery. Is used in
short, divided doses over a set period of time--
kills some tumor cells immediately, then damages
DNA in others by affecting their ability to divide.
Treatment (cont.)
● Surgery-- can be curative, cytoreductive, or
palliative.
− Curative: works with tumors having well-defined
margins (meningioma); all gross and microscopic
tumor is removed.
− Cytoreductive: debulking procedure-- part of the
tumor is removed, but part of it is knowingly left.
− Palliative: can be used to treat pain or obstructive
process (ventricular).
Activity
If hemiparetic/hemiplegic/visually impaired, will
need physical/occupational therapy to maximize
ability and recommend adaptive equipment.
● No driving until cleared by MD.
Nursing Management:
Assessment
● Add neuro flow sheet data-- need motor and LOC
exam here, plus pupils!
Diet
● High-protein/high-carbohydrate diets are often
ordered to help the client maintain weight.
● Radiation and chemotherapy can affect the sense
of taste-- may also cause n/v.
● Monitor weight on a regular basis.
Nursing Management:
Assessment
● Assess for signs/symptoms of increased
intracranial pressure or new hemorrhage.
● Assess incision for redness/edema/drainage.
Patient Teaching
● Educate client and family on when to notify
physician.
● Educate on side effects of drugs, treatments.
− Chemotherapy
− Radiation
Patient Teaching (cont.)
● If incision present, notify physician with any
redness/edema/drainage from site.
● Address advance directives, living will, durable
power of attorney.
● Educate about disease process, death, and dying.
Referrals (cont.)
● Radiation Oncologist-- specializes in radiation for
treatment of brain tumors
● Neuro Oncologist-- neurologist who can manage
drugs for treatment of seizures, chemotherapies.
● Neurosurgery-- available for resectable masses in
the brain and spinal cord
● Nutrition Services-- dieticians who will monitor
weight, obtain calorie counts if needed, and
recommend optimal dietary needs.
Multiple Sclerosis (cont.)
● Spinal type-- second most common form
− Patients will c/o stiffness, slowness, weakness, fatigue.
The most common finding is spastic paraparesis. With
increased spinal cord involvement, you will see
bowel/bladder dysfunction
Referrals
● Chaplain-- spiritual counseling, dealing with
anticipatory grief over terminal diagnosis
● Social Work-- identify community and financial
resources available, provide emotional support,
may explore family dynamics as well.
● Physical/occupational/speech therapy-- maximize
patient's abilities/independence, assess home for
safety/accessibility.
Multiple Sclerosis
● Mixed (general) type-- most common form
− Common signs/symptoms-- nystagmus, dysarthria,
deafness, vertigo, n/v, tinnitus, facial
weakness/numbness, depression, decreased cognition
(word-finding, impaired memory and concentration)
Multiple Sclerosis (cont.)
● Cerebellar type-- will initially present with
nystagmus and ataxia
● MS(course).jpg
Multiple Sclerosis (cont.) Diagnostic Tests

● Exacerbations can be caused by increased ● Head CT will show plaques diagnostic of MS

temperature, hypercalcemia, physical or emotional ● MS(head).htm
stress. ● Lumbar puncture
● Symptoms will usually remit at least partially or ● MRI-- will show brain stem, optic nerve, and
completely for weeks after the onset of early stage spinal cord lesions
MS. ● EMG (electromyogram) may be grossly abnormal
with advanced disease.

Medications Medications (cont.)

● Cytoxan (cyclophosphamide)
● Steroids-- reduce edema and the inflammatory ● Avonex (Interferon beta 1a)
response during acute exacerbation. ● Imuran
− ACTH (adrenocorticotropic hormone)
− Solu-Medrol (methylprednisolone)
− Prednisone

Medications (cont.) Treatments

● Baclofen (Lioresal), Valium (Diazepam), or ● Surgical intervention includes the following:

Dantrium (Dantrolene sodium) can be used to treat − Intrathecal pump insertion
muscle spasticity − Tendon release-- surgery if spasms keep client from
● Also consider intrathecal pump insertion if mobilizing
spasticity is severe.
● Inderal (Propanolol hydrochloride) and Klonopin
(clonazepam)
● Symmetrel (amantadine hydrochloride)
Diet
● Can have regular diet
● Monitor blood glucose if on steroids for a
prolonged period.
● If bowel/bladder issues are present,
− Can increase fluid intake to 2000 ml/day unless
contraindicated.
− High-fiber diet
− Vitamin C can be used as a supplement
Activity (cont.)
● Consult physical/occupational/speech therapies to
maximize function
● Use eye patch-- alternate from eye to eye every
few hours to relieve diplopia.
● Keep environment free of clutter, no rugs that
could cause slipping/falling-- assess home prior to
discharge from hospital or rehab.
Referrals
● Social Work-- can identify community and
financial resources.
● Neurologist-- will manage symptoms with
medications (steroids, immunosuppressants).
● Opthalmologist-- MD who will continue to
evaluate vision for further changes.
Activity
● Range-of-motion exercises, stretching, and
strength training.
● May require adaptive equipment/assistive devices
as disease progresses (cane, walker, wheelchair).
● Avoid strenuous activity that could increase body
temperature, which could lead to fatigue,
decreased motor skills, decreased visual acuity.
Nursing Management:
Interventions
● Educate client and family about how disease can
be exacerbated.
● Client must be informed about obtaining adequate
rest to avoid fatigue.
● Educate client and family about how to discern
between side effects of medicines and symptoms
of disease.
● Refer to support groups
Parkinson's Disease
● Signs/symptoms include tremor (first symptom to
appear) that is asymmetric, regular, rhythmic,
initially. Rigidity is another symptom that
impedes active and passive movment. Initially,
hand and toe cramps will present, then with
progression, the patient will complain of
stiff/heavy/tired/achy extremities.
Parkinson's Disease (cont.)
● This disease has an insidious onset-- to diagnose,
the patient must present with two out of four
symptoms: resting tremor, bradykinesia, cogwheel
rigidity, or postural instability.
Medications
● Dopaminergics (precursors to dopamine) treat
rigidity-- most effective during the first three to
five years of use. Long-term use can bring about
side effects such as tardive dyskinesia,
hallucinations, and orthostatic hypotension.
− Sinemet (carbidopa/levodopa)
Medications (cont.)
● Catechol O-methyltransferase (COMT) inhibitors
are drugs that block enzymes that inactivate
dopamine. This increases the efficacy of
levodopa.
− Comtan (entacapone) is used in conjunction with
Sinemet.
Diagnostic Tests
● Cerebrospinal fluid may show decreased levels of
dopamine.
● Diagnosis is made based on what is found during
assessment. Remember that two of four symptoms
(tremor, rigidity, akinesia, postural instability)
must be present to confirm diagnosis.
Medications (cont.)
● Anticholinergic drugs work particularly well for
patients with tremor. They enhance/extend the
effects of levodopa.
− Artane (trihexyphenidyl)
− Cogentin (benztropine.
Medications (cont.)
● Dopamine agonists activate the release of
dopamine-- can be used alone or in conjunction
with Sinemet.
− Parlodel (bromocriptine mesylate)
− Pergolide
Treatments
● DBS.jpg
Activity
● Consult physical/occupational therapy for active
and passive range-of-motion exercises, stretching.
● Speech therapy can prescribe exercises for the face
and tongue to aid in swallowing and speech.
● Respiratory therapy can direct patient in practicing
abdominal and diaphragmatic exercises.
Nursing Management:
Assessment
● Assess for hallucinations, confusion (acute), and
orthostatic hypotension-- could be side effects of
medications.
● Assess for depression/anxiety.
● Assess respiratory ability
Diet
● Dysphagia is a common finding as the disease
progresses
− May need to thicken liquids for easier swallowing.
− Weigh weekly
− Elevate head of bed at least 60 degrees.
− Time medications with meals so client will have
maximum mobility/independence.
− Allow plenty of time for feeding-- no rushing!
− May also offer smaller, more frequent meals to offset
fatigue, increase calories.
Activity
● Change positions slowly if orthostatic hypotension
is an issue.
● Patients will complain of being “frozen”
− Assist with repositioning q2hrs.
− Allow for time in the am for meds to begin working.
Do not schedule anything while patient begins to
regain function. Give plenty of time for ADL's and
feeding.
Nursing Management:
Interventions
● May use communication board or other device if
patient is unable to speak.
● Schedule meds so that peak effect occurs during
activity or therapy to maximize independence.
● Keep patient moving-- out of bed with assist at
least three-four times/day.
● After home assessment, remove throw rugs,
provide adequate lighting, add safety bars to
tub/toilet to assist when mobilizing.
Patient Teaching
● Educate client and family on when to notify
physician.
● Take plenty of time during meals to avoid
aspiration/choking.
● Change positions slowly to avoid symptoms of
orthostatic hypotension– out of bed with assistance
as needed.
Myasthenia Gravis
● Signs/symptoms include exertional fatigue,
weakness that increases with activity/decreases
with rest, recurrent upper respiratory infections
− Ocular palsies, diplopia, ptosis usually present early
on, followed by affected facial expression (will see
droop, no expression, or “snarl” when trying to smile),
decreased ability in chewing/swallowing/speech
(resulting in weight loss, choking, aspiration).
Medications
● Cholinesterase inhibitor (ChE) drugs are first-line
management for MG (also known as
anticholinesterase drugs). They prevent
breakdown of acetylcholine (A-Ch) by inhibiting
the enzyme ChE.
− Mestinon (pyridostigmine)
Referrals
● Physical/occupational/speech therapy
● Social Work-- may be used to help find long-term
placement, to locate community resources, aid in
financial planning (may need disability)
● Neurologist-- will manage medications,
tremor/rigidity issues
● Neurosurgeon-- can place a deep brain stimulator,
if medical regimen is failing.
Diagnostic Tests
● Tensilon test
● Repetitive single-fiber EMG
● CT/MRI-- rule out thymoma
● Test for acetylcholine receptor antibodies (AchR)--
80-90% of patients have elevated levels.
Medications (cont.)
● Immunosuppression-- can use Prednisone, Imuran,
or Cytoxan.
− Predisone
− Cytoxan
− Can also use IV immunoglobulins for acute
management of symptoms or when clients do not
respond to other treatments.
Treatments
● Plasmapheresis-- “dialysis” of the plasma
● Ventilator-- may need to rest patient on ventilator
if crisis ensues
● Other respiratory treatments include chest
physiotherapy (CPPD), assisted cough techniques,
suctioning.
Surgical Management
● Thymectomy is an alternative method of treatment
that may or may not be effective at facilitating
remission. Those having surgery within two years
of the onset of symptoms experience more
improvement.
Nursing Management:
Interventions
● Notify physician with any new weakness,
difficulty breathing, inability to swallow/clear
secretions.
● Offer small, frequent meals-- give small bites and
encourage client to chew slowly.
● Head of bed elevated at least 60 degrees
● Administer ChE drugs 30-60 minutes prior to
meals.
● Schedule activity/rest periods around medication
schedule.
Treatments (cont.)
● Eye patch-- alternate eyes every 2-3 hrs. to
alleviate diplopia.
● If unable to close eyes, use artificial tears,
lubricants, eye shields, to prevent corneal
abrasions.
Nursing Management:
Assessment
● Differentiate between myasthenic and cholinergic
crises.
● MG(furtherinfo).cfm
● Assess respiratory status regularly
● Assess during mealtimes for choking, gagging,
aspiration, nasal regurgitation.
● Weigh daily
● Monitor serum albumin, transferrin levels.
Nursing Management:
Interventions
● Encourage client to speak slowly, use alternate
communication methods if client unable to speak
(communication board, eye blinks).
● Assist with ambulation/transfers as needed when
client is in exacerbation. Provide range-of-motion
exercises and turn every two hours while in bed if
client unable to reposition self.
Patient Teaching
● Identify factors that predispose the client to an
exacerbation of MG and how to avoid them.
● Plan activities along with rest periods to save
energy.
● Do not miss medications or deviate from time they
are scheduled.
● Encourage family to become familiar with
respiratory equipment (mask, ambu bag, suction
apparatus) in case of crisis.
Referrals
● Physical/occupational/speech therapy
● Social Work-- can identify community resources if
needed, assist with finances (file for disability if
needed)
● Neurologist-- will manage medications and
exacerbations of disease.