RESPONSES TO ALTERED PERCEPTION

Neurologic Disturbances: Degenerative

 MUTIPLE SCLEROSIS

• Multiple sclerosis (MS) is a potentially disabling disease of the brain and

spinal cord (central nervous system).
• Multiple sclerosis is a central nervous system disorder that can create a
variety of symptoms ranging from visual disturbances to paralysis.
• It is characterized by damage to myelin, the insulatory material that
surrounds neurons.
• This damage is linked to disruptions in healthy neuronal function, which are
thought to lead to the symptoms of the disease.
• Most researchers believe the myelin damage that occurs in multiple sclerosis
is due to the cells of the immune system targeting myelin. Thus, most of the
treatments for multiple sclerosis involve drugs that suppress the immune
response in some way.
• In MS, the immune system attacks the protective sheath (myelin) that covers
nerve fibers and causes communication problems between your brain and
the rest of your body.
• Eventually, the disease can cause permanent damage or deterioration of
the nerve fibers.

• There's no cure for multiple sclerosis. However, there are treatments to help
speed the recovery from attacks, modify the course of the disease and
manage symptoms.
In multiple sclerosis, the protective coating on the
nerve fibers (myelin) is damaged and may
eventually be destroyed.

Depending on where the nerve damage occurs, MS

can affect vision, sensation, coordination,
movement, and bladder or bowel control.
 CAUSES
• The cause of multiple sclerosis is unknown.
• It's considered an immune mediated disease in which the body's immune
system attacks its own tissues.
• In the case of MS, this immune system malfunction destroys the fatty
substance that coats and protects nerve fibers in the brain and spinal cord
(myelin).
• Myelin can be compared to the insulation coating on electrical wires. When
the protective myelin is damaged and the nerve fiber is exposed, the
messages that travel along that nerve fiber may be slowed or blocked.

It isn't clear why MS develops in some

people and not others. A combination of
genetics and environmental factors
appears to be responsible.
 RISK FACTORS
• Age. MS can occur at any age, but onset usually occurs around 20 and 40
years of age. However, younger and older people can be affected.
• Sex. Women are more than 2 to 3 times as likely as men are to have
relapsing-remitting MS.
• Family history. If one of your parents or siblings has had MS, you are at higher
risk of developing the disease.
• Certain infections. A variety of viruses have been linked to MS, including
Epstein-Barr, the virus that causes infectious mononucleosis.
• Race. White people, particularly those of Northern European descent, are at
highest risk of developing MS. People of Asian, African or Native American
descent have the lowest risk. A recent study suggests that the number of
Black and Hispanic young adults with multiple sclerosis may be greater than
previously thought.
• Climate. MS is far more common in countries with temperate climates,
including Canada, the northern United States, New Zealand, southeastern
Australia and Europe. Your birth month may also affect the chances of
developing multiple sclerosis, since exposure to the sun when a mother is
pregnant seems to decrease later development of multiple sclerosis in these
children.
• Vitamin D. Having low levels of vitamin D and low exposure to sunlight is
associated with a greater risk of MS.
• Your genes. A gene on chromosome 6p21 has been found to be associated
with multiple sclerosis.
• Obesity. An association with obesity and multiple sclerosis has been found in
females. This is especially true for female childhood and adolescent obesity.
• Certain autoimmune diseases. You have a slightly higher risk of developing
MS if you have other autoimmune disorders such as thyroid disease,
pernicious anemia, psoriasis, type 1 diabetes or inflammatory bowel disease.
• Smoking. Smokers who experience an initial symptom that may signal MS are
more likely than nonsmokers to develop a second event that confirms
relapsing-remitting MS.
 SIGNS AND SYMPTOMS
• Multiple sclerosis signs and symptoms may differ greatly from person to
person and over the course of the disease depending on the location of
affected nerve fibers.
• Numbness or weakness in one or more limbs that typically occurs on one
side of your body at a time
• Tingling
• Electric-shock sensations that occur with certain neck movements,
especially bending the neck forward (Lhermitte sign)
• Lack of coordination
• Unsteady gait or inability to walk
• Partial or complete loss of vision, usually in one eye at a time, often with pain
during eye movement
• Prolonged double vision
• Blurry vision
• Vertigo
• Problems with sexual, bowel and bladder function
• Fatigue
• Slurred speech
• Cognitive problems
• Mood disturbances
 DISEASE COURSE
• Most people with MS have a relapsing-remitting disease course. They
experience periods of new symptoms or relapses that develop over days or
weeks and usually improve partially or completely. These relapses are
followed by quiet periods of disease remission that can last months or even
years.

• Small increases in body temperature can temporarily worsen signs and

symptoms of MS. These aren't considered true disease relapses but
pseudorelapses.
• 20% to 40% of those with relapsing-remitting MS can eventually develop a
steady progression of symptoms, with or without periods of remission, within
10 to 20 years from disease onset. This is known as secondary-progressive MS.

• The worsening of symptoms usually includes problems with mobility and gait.
The rate of disease progression varies greatly among people with secondary-
progressive MS.

• Some people with MS experience a gradual onset and steady progression of

signs and symptoms without any relapses, known as primary-progressive MS.
 MEDICAL MANAGEMENT
Goals of medical management for multiple sclerosis
• It is important to keep in mind the 4 main goals of MS management:
• (1) modifying/reducing relapses and delaying progression to disability
• (2) treating relapses
• (3) managing symptoms
• (4) maintaining an acceptable QOL.
 MEDICATIONS
• Interferon Beta (Avonex, Betaseron, Extavia, Plegridy, Rebif)

• These are lab-made versions of body's infection-fighting protein.

• They're a type of drug called biologics, which are made with living cells
 NURSING MANAGEMENT
• PROMOTE REST, COMFORT AND SLEEP
• PROMOTE OPTIMUM FUNCTION,AVOID STRESS
A. RELAXATION AND COORDINATION EXERCISE
B. ROM
• WARM BATH AND PACKS
• ADMINISTRATION OF DRUGS
• WIDE-BASED WALK, USE CANE AND WALKER
• USE OF WEIGHTED BRACELETS AND CUFFS TO STABILIZE UPPER EXTREMETIES
• BLADDER AND BOWEL TRAINING (care of Fcath if necessary)
• Self-help devices
• Eye patch for diplopia
• Occupational therapy
• Nutritional therapy
• Provide emotional support
• Referrals – National Multiple Sclerosis Society
 MANAGING MS PATIENTS
• Here are some tips that can make it easier for patients and caregivers alike
to deal with MS.
• Eat for optimal health. Everyone can benefit from a good diet, but especially
people with chronic diseases such as MS.
• Commit to regular exercise.
• Address sleep issues.
• Customize your environment.
• Reach out and get involved.
• Watch video
 PARKINSON’S DISEASE
• a progressive disorder that affects the nervous system and the parts of the
body controlled by the nerves.
• Symptoms start slowly.
• The first symptom may be a barely noticeable
tremor in just one hand. Tremors are common,
but the disorder may also cause stiffness
or slowing of movement.
 CAUSES
• In Parkinson's disease, certain nerve cells (neurons) in the brain gradually
break down or die.
• Many of the symptoms are due to a loss of neurons that produce a chemical
messenger in your brain called dopamine.
• When dopamine levels decrease, it causes atypical brain activity, leading to
impaired movement and other symptoms of Parkinson's disease.
 DOPAMINE
Dopamine is released when your brain is expecting a reward.
When you come to associate a certain activity with pleasure, mere
anticipation may be enough to raise dopamine levels.
It could be a certain food, sex, shopping, or just about anything else that you
enjoy.
 CAUSES
• The cause of Parkinson's disease is unknown, but several factors appear to
play a role, including:
• GENES - specific genetic changes that can cause Parkinson's disease, but
uncommon except in rare cases with many family members affected by
Parkinson’s disease.
• Environmental triggers - Exposure to certain toxins or environmental factors
may increase the risk of later Parkinson's disease, but the risk is small.
• Changes occur in patient with Parkinson’s disase:
• The presence of Lewy bodies - Clumps of specific substances within brain
cells, which are markers of PD.
• Alpha-synuclein found within Lewy bodies - found in all Lewy bodies in a
clumped form that cells can't break down.
 RISK FACTORS
• Age - Young adults are rare; begins in middle or late life, and the risk
increases with age. People usually develop the disease around age 60 or
older.
• Heredity - Having a close relative with Parkinson's disease increases the
chances
• Sex - Men are more likely to develop Parkinson's disease than women.
• Exposure to toxins - Ongoing exposure to herbicides and pesticides may
slightly increase your risk of Parkinson's disease.
 5 STAGES OF PD
• Stage One
During this initial stage, the person has mild symptoms that generally do not
interfere with daily activities. Tremor and other movement symptoms occur on
one side of the body only. Changes in posture, walking and facial expressions
occur.
• Stage Two
Symptoms start getting worse. Tremor, rigidity and other movement symptoms
affect both sides of the body or the midline (such as the neck and the trunk).
Walking problems and poor posture may be apparent. The person is able to
live alone, but daily tasks are more difficult and lengthier.
• Stage Three
Considered mid-stage, loss of balance (such as unsteadiness as the person
turns or when he/she is pushed from standing) is the hallmark. Falls are more
common. Motor symptoms continue to worsen. Functionally the person is
somewhat restricted in his/her daily activities now, but is still physically capable
of leading an independent life. Disability is mild to moderate at this stage.
• Stage Four
At this point, symptoms are fully developed and severely disabling. The person
is still able to walk and stand without assistance, but may need to ambulate
with a cane/walker for safety. The person needs significant help with activities
of daily living and is unable to live alone.
• Stage Five
This is the most advanced and debilitating stage. Stiffness in the legs may
make it impossible to stand or walk. The person is bedridden or confined to a
wheelchair unless aided. Around-the-clock care is required for all activities.
SIGNS
 COMPLICATIONS
• Thinking difficulties. Cognitive problems (dementia) and thinking difficulties.
These usually occur in the later stages of Parkinson's disease. Such cognitive
problems aren't usually helped by medications.
• Depression and emotional changes. Experience depression, sometimes in
the very early stages. Receiving treatment for depression can make it easier
to handle the other challenges of Parkinson's disease.
• Swallowing problems. Develop difficulties with swallowing as your condition
progresses. Saliva may accumulate in your mouth due to slowed swallowing,
leading to drooling.
• Chewing and eating problems. Late-stage Parkinson's disease affects the
muscles in the mouth, making chewing difficult; lead to choking and poor
nutrition.
• Sleep problems and sleep disorders. People with Parkinson's disease often
have sleep problems, including waking up frequently throughout the night,
waking up early or falling asleep during the day.
• Bladder problems. Parkinson's disease may cause bladder problems,
including being unable to control urine or having difficulty in urinating.
• Constipation. Many people with Parkinson's disease develop constipation,
mainly due to a slower digestive tract.
• Blood pressure changes. You may feel dizzy or lightheaded when standing
due to a sudden drop in blood pressure (orthostatic hypotension).
• Smell dysfunction. You may experience problems with your sense of smell.
You may have difficulty identifying certain odors or the difference between
odors.
• Fatigue. Many people with Parkinson's disease lose energy and experience
fatigue, especially later in the day. The cause isn't always known.
• Pain. Some people with Parkinson's disease experience pain, either in
specific areas of their bodies or throughout their bodies.
• Sexual dysfunction. Some people with Parkinson's disease notice a decrease
in sexual desire or performance.
 PREVENTION
• Because the cause of Parkinson's is unknown, there are no proven ways to
prevent the disease.

• Some research has shown that regular aerobic exercise might reduce the risk
of Parkinson's disease.
• Some other research has shown that people who consume caffeine —
which is found in coffee, tea and cola — get Parkinson's disease less often
than those who don't drink it.
• Green tea is also related to a reduced risk of developing Parkinson's disease.
However, it is still not known whether caffeine protects against getting
Parkinson's or is related in some other way.
 NURSING MANAGEMENT
• Promote rest, comfort and sleep
• Keep patient as functional and productive as possible
1. Encourage finger exercise such as typing, piano-playing
2. ROM
3. Teach patient ambulation modification.
a. Goose-stepping walk
b. Walk with wider base
c. Concentrate on swinging arms while walking
d. Turn around slowly, using small steps
e. Look ahead and not down
• Promote family understanding of the disease
1. Patient intellect is not impaired
2. Sight and hearing is intact
3. Disease is progressive but slow
• Refer to speech therapy
• Administer meds for symptomatic therapy such as Permax, Cogentin,
Levodopa, Parlodel, Sinemet, Amantadine
• New drugs include: Requip, Mirapex
• Antihistamine (Benadryl) may also be used to manage tremors
• Complentary/Alternative therapy
a. co-enzyme Q10 supplements
-made naturally by the body; used by cells to produce energy and as
antioxidant
 MYASTHENIA GRAVIS
• It is a rare long-term condition that causes muscle weakness.
• It most commonly affects the muscles that control the eyes and eyelids,
facial expressions, chewing, swallowing and speaking. But it can affect most
parts of the body.
• It can affect people of any age, typically starting in women under 40 and
men over 60.
 TYPES OF MG
• Generalized
• more severe form of the disease and may experience weakness in other
muscle groups.
• develops in about 50–80% of those who develop eye symptoms.
• Patients gradually develop difficulty speaking, problems chewing and
swallowing, and trouble performing everyday tasks, such as combing their
hair or climbing stairs, caused by weakness in the arm and leg muscles.
• Congenital
• differs from other forms of MG because it is caused by a genetic defect
rather than an abnormal immune system response.
• is usually inherited in an autosomal recessive pattern, meaning a person must
receive a copy of the defective gene from both parents to develop the
disease.
• If a person has only one copy of the defective gene, they will be a carrier
but not show any symptoms.
• Juvenile
• most common of the three types of myasthenia gravis seen in children and
adolescents.
• Juvenile MG, which usually begins before age 18, is a rare, chronic condition
that requires lifelong management.
• Its symptoms — muscular weakness and fatigue — are treatable. And
children with the condition — especially those who develop the disease
before puberty — may have long stretches without relapses.
• Ocular
• For about 15% of patients with myasthenia gravis, the muscles controlling eye
and eyelid movement remain the only muscles affected.
• People with symptoms of ocular myasthenia gravis for five years that have
not affected other muscles in their body are unlikely to develop weakness
elsewhere.
• Transient Neonatal
• a rare form of MG that typically affects 10–15% of babies born to mothers
who have myasthenia gravis, including those who are symptomatic.
• During pregnancy, the mother’s autoantibodies can be transferred to her
unborn child, resulting in the destruction of fetal acetylcholine receptors.
However, symptoms usually resolve.
 CAUSE
• Myasthenia gravis is caused by a problem with the signals sent between the
nerves and the muscles.
• It's an autoimmune condition, which means it's the result of the immune
system (the body's natural defence against infection) mistakenly attacking a
healthy part of the body.
• In myasthenia gravis, the immune system damages the communication
system between the nerves and muscles, making the muscles weak and
easily tired.
• It's not clear why this happens, but it's been linked to issues with the thymus
gland (a gland in the chest that's part of the immune system).

• Many people with myasthenia gravis have a thymus gland that's larger than
normal. Around 1 in 10 people have an abnormal growth of the thymus
called a thymoma.
 RISK FACTORS
• Age of Onset. The disease has a female predominance in patients under 40
years of age and a male predominance in those over 50 years of age.
Childhood MG is uncommon in Western nations, but it is common in Asian
countries where roughly half of MG patients are under the age of 15 years
• Genetics. Most people with MG have no family history of the disease, and it
is sporadic with no known cause in these patients. However, up to 5% of
patients have relatives with MG or other autoimmune diseases. Some
genetically determined human leukocyte antigens (HLAs) are more
common in people with MG, suggesting that genetic susceptibility may
contribute to the development of MG.
• Immune Dysregulation. Myasthenia gravis occurs due to an abnormal
immunological reaction in the form of an antibody-mediated autoimmune
response, in which antibodies inappropriately target particular proteins in
muscles that receive nerve impulses.

• Drug-Induced Myasthenia Gravis and Other Factors. D-penicillamine has

been reported to cause MG. Clinical symptoms of drug-induced MG may
resemble those of typical acquired autoimmune MG, and antibodies to
AChR may be detected. After discontinuing the drug, the disease usually
clears. Curare, aminoglycosides, quinine, procainamide, and calcium
channel blockers are other drugs that might cause myasthenia-like weakness
or aggravate weakness in patients with MG
 RISK FACTORS FOR MYASTHENIC CRISIS
• potentially fatal condition that affects 10% to 20% of patients with MG.
Precipitating factors include aspiration pneumonitis;
• physical, environmental and emotional stressors; infection; surgery;
pregnancy; perimenstrual state; sleep deprivation; extremes of temperature;
pain; tapering of immune-modulating drugs; and some medications,
including beta blockers, quinidine gluconate, quinidine sulfate, quinine
(Qualaquin®), phenytoin, specific anesthetics, and some antibiotics.
• The most common precipitating factor is believed to be infection.
• Postoperative myasthenic crisis (PMC).
-Progressively worsening function after thymectomy can lead to PMC, which is
caused by respiratory muscle paralysis and manifests as prolonged
mechanical ventilation or reventilation after extubation.
-It is a fatal complication and a significant condition following thymectomy
 SYMPTOMS
• Muscle weakness caused by myasthenia gravis worsens as the affected
muscle is used.
• Because symptoms usually improve with rest, muscle weakness can come
and go.
• However, the symptoms tend to progress over time, usually reaching their
worst within a few years after the onset of the disease.
Eye muscles
• In more than half of people who develop myasthenia gravis, their first signs
and symptoms involve eye problems, such as:
• Drooping of one or both eyelids (ptosis)
• Double vision (diplopia), which may be horizontal or vertical, and improves
or resolves when one eye is closed
Face and throat muscles
• 15% of people with myasthenia gravis, the first symptoms involve face and
throat muscles, which can:

• Impair speaking - speech might sound soft or nasal, depending on which

muscles have been affected.
• Cause difficulty swallowing- might choke easily, making it difficult to eat,
drink or take pills. In some cases, liquids trying to swallow come out the nose.
• Affect chewing - muscles used for chewing might tire halfway through a
meal, particularly if been eating something hard to chew, such as steak.
• Change facial expressions - For example, smile might look like a snarl.
Neck and limb muscles
• Myasthenia gravis can also cause weakness in neck, arms and legs.
• Weakness in legs can affect how you walk.
• Weak neck muscles make it hard to hold up your head.
 WARNING SIGNS
• When to see a doctor
• Talk to your doctor if you have difficulty:

• Breathing
• Seeing
• Swallowing
• Chewing
• Walking
• Using your arms or hands
• Holding up your head
 DIAGNOSTIC TEST
• Tensilon test
 MANAGEMENT
• MEDICAL

Plasmapheresis (plasma exchange) is a

type of treatment for autoimmune
diseases such as myasthenia gravis.
During the treatment, the plasma
compartment of the blood is exchanged
with substitute plasma to ensure that the
immune system does not attack the
body's own tissues.
• NURSING
a. Promote rest, comfort and sleep; balanced diet
b. Relieve symptoms (anticholinesterase, corticosteroids,
immunosuppressants)
c. Teach patients
1. Use med alert
2. Aware of the factors that may precipitate myasthenia crisis e.g. infections,
emotional stress, use of streptomycin, neomycin (produce muscle
weakness), surgery
3. Be alert of myasthenia crisis – sudden inability to swallow, speak, or
maintain a patient airway.