NEURODEGENERATIVE DISORDER

Ma’am Anabelle S. Santos → Medical-Surgical Nursing

PARKINSON’S DISEASE ● Drooling
● Dysarthria
● Associated with decreased levels of dopamine due to ● Mood swings
destruction of cells in the substantia nigra in the basal ● Cognitive impairment (dementia)
ganglia ● Progressive difficulty with ADLs
● affects the neurotransmission of impulses ● PARKINSONIAN GAIT: Stooped posture ; slow, shuffling
PATHOPHYSIOLOGY and propulsive gait
● TREMORS: Pill-rolling
CLINICAL DIAGNOSIS
● Diagnosis is made based on symptoms, their progression,
and by ruling out other diseases
● LABORATORY TESTS: No definitive diagnostic tests
COMPLICATIONS
● ASPIRATION PNEUMONIA: as PD advances in severity,
alterations in chewing and swallowing will worsen,
increasing the risk for aspiration.
○ Use swallowing precautions to decrease the risk for
aspiration
○ Develop individual dietary plan based on the speech
therapist's recommendations.
○ Have a nurse in attendance when the client is eating.
○ Encourage the client to eat slowly and chew thoroughly
before swallowing.
DOPAMINE ○ Feed the client in an upright position and have suction
equipment on standby.
● Neurotransmitter
● ALTERED COGNITION (dementia, memory deficits): Clients
● BASAL GANGLIA: balance between acetylcholine (Ach) and
in advanced stages of PD may exhibit altered cognition in
dopamine (DA) levels has been considered of main
the form of dementia and memory loss.
importance for the control of motor activity.
○ Acknowledge the client's feelings.
Acetylcholine (excitatory) = Dopamine (inhibitory) ○ Provide for a safe environment.
○ Develop a comprehensive plan of care with the
STAGES OF PARKINSON’S DISEASE family, client, and interprofessional team.
NURSING PROCESS
STAGE 1 ● Unilateral shaking or tremor of one limb
ASSESSMENT
STAGE 2 ● Bilateral limb involvement occurs, making ● Focus on the degree of disability and function of the patient
walking and balance difficult including ADLS, IADLs, and cognitive function
● Medications and responses to medications
STAGE 3 ● Physical movements slow down significantly, ● Emotional responses and individual coping
affecting walking more. ● Family processes and coping
● Home care and teaching needs
STAGE 4 ● Tremors may decrease but AKINESIA and ● Fall risk assessment
RIGIDITY make day-to-day tasks difficult. ● Manifestations and potential complications related to the
specific disorder
STAGE 5 ● Client unable to stand or walk, is dependent NURSING DIAGNOSIS
for all care, and may exhibit dementia.
● Impaired physical mobility and risk for activity intolerance
RISK FACTORS ● Impaired verbal. communication
● Disturbed thought processes
● Onset of symptoms between age 40-70 ● Self-care deficits
● More common in men ● Imbalanced nutrition
● Genetic predisposition ● Ineffective coping and compromised family coping
● Exposure to environmental toxins and chemical solvents ● Deficient knowledge
● Chronic use of antipsychotic medication ● Risk for injury
SUBJECTIVE DATA ● Constipation
● Reports of fatigue
● Report of decreased manual dexterity over time PLANNING
PHYSICAL ASSESSMENT FINDINGS MAJOR GOALS:
● Slow, monotonous speech ● Improved functional ability
● Muscle rigidity ● Maintaining independence in ADLs
● Bradykinesia/akinesia ● Achieving adequate bowel elimination
● Masklike expression ● Attaining and maintaining acceptable nutritional status
● Autonomic symptoms (orthostatic hypotension, flushing, ● Achieving effective communication
diaphoresis) ● Developing positive individual and family coping skills
● Difficulty chewing and swallowing

BSN 3A - Marjorie D. Solayao

 INTERVENTIONS
● Administer the client's medications at prescribed times.
○ Monitor medication effectiveness and make
recommendations for changes in dosage and time of
administration to provide best coverage.
● Monitor swallowing and maintain adequate nutrition.
● Consult speech and language, Therapist to assess swallowing
if the client demonstrates a risk for choking.
○ Consult the client's dietitian for appropriate diet.
○ Document the client's weight at least weekly.
● Keep a diet intake log.
● Encourage fluids and document intake.
● Provide smaller, more frequent meals.
● Add commercial thickener to thicken food.
● Provide supplements as prescribed.
MAINTAIN CLIENT MOBILITY FOR AS LONG AS POSSIBLE.
● Encourage exercise, such as yoga (may improve mental status
as well)
● Encourage use of assistive devices as disease progresses.
● Encourage range-of-motion (ROM) exercises.
● Teach the client to stop occasionally when walking to slow
down speed and reduce risk for injury.
● Pace activities by providing rest periods.
● Assist the client with ADLs as needed (hygiene, dressing).
PROMOTE CLIENT COMMUNICATION FOR AS LONG AS
POSSIBLE.
● Teach the client facial muscle-strengthening exercises.
● Encourage the client to speak slowly and to pause frequently.
● Use alternate forms of communication as appropriate.
● Refer client to a speech-language pathologist.
dosage form of medication and administration times
must be adjusted to avoid periods of poor mobility.
○ Monitor for the "WEARING-OFF" PHENOMENON and
DYSKINESIA (problems with movement) → indicates the
need to adjust the dosage or time of administration or the
need for a medication holiday.
● DOPAMINE AGONISTS: bromocriptine (Parlodel), ropinirole
(Requip), and pramipexole (Mirapex)
○ activate release of dopamine.
○ May be used in conjunction with a dopamine for better
results
● ANTICHOLINERGICS: benztropine (Cogentin) and
trihexyphenidyl (Artane)
○ Help control tremors and rigidity
● CATECHOL O-METHYLTRANSFERASE (COMT) INHIBITORS:
entacapone (Comtan)
○ decrease the breakdown of levodopa making more
available to the brain as dopamine.
○ Can be used in conjunction with a dopaminergic and
dopamine agonist for better results.
● ANTIVIRALS: amantadine (Symmetrel)
○ stimulate release of dopamine and prevent its reuptake.
EVALUATION
Client Outcomes
● The client’s medication will be scheduled so the “wearing-off”
phenomenon does not occur
● The client will ambulate safely through the use of assistive
devices.
● The client will maintain adequate hydration and nutrition via
an appropriate diet and thickened liquids.

MONITOR CLIENT'S MENTAL AND COGNITIVE STATUS.

● Observe for signs of depression and dementia.
● Provide a safe environment (no throw rugs, encourage the use
of an electric razor)
● Assess personal and family coping with the client's chronic,
degenerative disease.
● Provide a list of community resources (support groups) to the
client and the client's family.
● Refer the client to a social worker or case manager as
condition advances (financial issues, long-term home care,
and respite care)

ENHANCE SELF-CARE ABILITY

● Encourage, teach and support independence
● Implement environmental modifications
● Use assistive and adaptive devices
● Arrange consultation with occupational therapy

SUPPORT OF COPING
● Set achievable, realistic goals
● Encourage socialization, recreation and independence
● Plan programs of activity
● Make referrals to support groups and services: counselors,
social workers, and home care providers
MEDICATIONS
DOPAMINERGICS
● when given orally, medications such as LEVODOPA, are
converted to dopamine in the brain, increasing dopamine
levels in the basal ganglia.
● May be combined with CARBIDOPA (SINEMET) to decrease
peripheral metabolism of levodopa requiring a smaller dose to
make the same amount available to the brain. Side effects
are subsequently less.
● NURSING CONSIDERATIONS
○ Due to medication tolerance and metabolism, the client's

BSN 3A - Marjorie D. Solayao

AUTOIMMUNE NEUROLOGICAL DISORDERS
Ma’am Anabelle S. Santos → Medical-Surgical Nursing
MULTIPLE SCLEROSIS NURSING PROCESS
● Autoimmune disorder characterized by development of ASSESSMENT
PLAQUE in the white matter of the CNS that damages the
myelin sheath and interferes with impulse transmission ETIOLOGY
between the CNS and the body ● Unknown
● A progressive immune-related demyelination disease of the ● autoimmune
CNS RISK FACTORS
● Often, the disease relapses and remits, exacerbates, and ● ONSET: between 20- 404.0
symptoms recur including fatigue, weakness, numbness,
● 2x as often in women
difficulty in coordination, loss of balance, pain, and visual
● Family hx (first-degree relative)
disturbances
● SALTATORY CONDUCTION → jumping of electrical impulse TRIGGERING FACTORS
from one node to another ; makes electrical impulses faster ● Viruses and infectious agents
● Living in a cold climate
TYPES AND COURSES OF MULTIPLE SCLEROSIS ● Physical injury
● Emotional stress
CLINICALLY ISOLATED SYNDROME (CIS) ● Pregnancy
● refers to a first episode of neurologic symptoms caused by ● Fatigue, overexertion
inflammation and demyelination of the central nervous ● Temperature extremes (hot shower/bath)
system, SUBJECTIVE DATA
● Symptoms of CIS vary from person to person but commonly ● Fatigue → especially of the lower extremities
include; ● Pain or paresthesia
○ Vision problems (optic neuritis) ● Diplopia, changes in peripheral vision, decreased visual
○ Vertigo acuity, nystagmus
○ Loss of sensation in the face ● Tinnitus, vertigo, decreased hearing acuity
○ Weakness in the arms and legs, with one side of-the ● UHTHOFF'S SIGN → a temporary worsening of vision and
body affected than the other other neurological functions commonly seen in clients who have
○ Loss of control of bodily movements (ataxia) or are predisposed to MS, just after exertion or in situations
○ Bladder problems where they are exposed to heat
RELAPSING-REMITTING MS (RRMS)
● Most common disease course OBJECTIVE DATA
● shows clearly defined attacks of new ● Dysphagia
or increasing neurologic symptoms → ● Dysarthria (slurred and nasal speech)
also called relapses or exacerbations ● Muscle spasticity, ataxia and/or muscle weakness
● followed by periods of partial or ● Bowel dysfunction (areflexia, urgency, nocturia)
complete recovery, or remission. ● Cognitive changes (memory loss, impaired judgment)
● In remissions, all symptoms may ● Sexual dysfunction
disappear or some symptoms may
continue and become permanent: However, during those LABORATORY TESTS
periods, the disease does not seem to progress. ● Cerebrospinal fluid (CSF) analysis
PRIMARY-PROGRESSIVE MS (PPMS) → elevated protein level and a
slight increase in WBCs)
● Neurologic function worsens or
disability accumulates as soon as DIAGNOSTIC PROCEDURES
symptoms appear, without early ● magnetic resonance imaging (MRI)
relapses or remissions → reveals plaques of the brain
and spine [most diagnostic]
SECONDARY-PROGRESSIVE MS DIAGNOSIS
(PPMS)
● Impaired physical mobility
● follows the initial relapsing-remitting
● Risk for injury
course
● Impaired bowel and bladder function
● Some people diagnosed with RRMS
eventually go on to have a secondary ● Impaired verbal communication
progressive course ● Disturbed thought processes
● Neurologic function worsens ● Ineffective coping
progressively or disability accumulates ● Impaired home maintenance
over time ● Potential sexual dysfunction
PROGRESSIVE-RELAPSING MS (PPMS) PLANNING
● rare form of MS ● Promotion of physical mobility
● causes steady damage to nerves ● Improvement in cognitive function
when symptoms first appear and ● Avoidance of injury
continues to cause progressive ● Achievement of bowel and bladder continence
worsening. ● Promotion of speech and swallowing mechanisms
● relapses occur, followed by full or ● Development of coping strengths
partial recovery, but nerve damage ● Improved home maintenance
continues and symptoms become increasingly disabling. ● Adaptation to sexual function

BSN 3A - Marjorie D. Solayao

INTERVENTION NURSING PROCESS
● Instruction or administration of prescribed medications ASSESSMENT
● MONITOR: visual acuity, speech patterns (fatigue with
talking), swallowing, activity tolerance, skin integrity ETIOLOGY
● MAINTAIN TEMPERATE ENVIRONMENT: air conditioning to ● Caused by coexisting autoimmune disorder
avoid excessive heat and avoidance of exposure to extreme ● Frequently associated with hyperplasia of the thymus gland
cold
● Monitor cognitive changes and plan interventions to promote TRIGGERING FACTORS
cognitive function ● infection
○ Reorient the client ● stress
○ Place objects used daily in routine places ● Emotional upset
○ Memory aids ● Fatigue
○ Structured environment & daily routine to enhance ● Pregnancy
cognitive function ● Increases in body temperature (fever, sunbathing, hot
● Implement measures to minimize stress shower/tub)
● Use assistive devices and modify home care management
and independence in ADLS SUBJECTIVE DATA
● Discuss and support coping mechanisms and sources of ● Progressive muscle weakness
support ● Diplopia
MEDICATIONS ● Difficulty chewing and swallowing
● Bowel and bladder dysfunction
● IMMUNOSUPPRESSIVE AGENTS such as azathioprine ● Poor posture
(Imuran) and cyclosporine (Sandimmune) → used to reduce ● Fatigue after exertion
the frequency of relapses ● Respiratory dysfunction
● ANTISPASMODICS such as dantrolene (Dantrium), tizanidine
(Zanaflex), baclofen (Lioresal), and diazepam (Valium) → OBJECTIVE DATA
used to treat muscle spasticity. ● Impaired respiratory status (difficulty managing secretions,
● CORTICOSTEROIDS such as prednisone → used to reduce decreased respiratory effort)
inflammation in acute exacerbations. ● Decreased swallowing ability
● IMMUNOMODULATORS → prevent or treat relapses (eg, ● Decreased muscle strength, especially of the face, eyes, and
interferon beta) proximal portion of major muscle groups
● ANTICONVULSANTS → for paresthesia (e.g., ● Incontinence
carbamazepine [Tegretol]) ● Drooping eyelids (PTOSIS) → unilateral or bilateral
● STOOL SOFTENERS → for constipation (e.g., docusate ● Initial symptoms involve ocular muscles, causing conditions such
sodium [Colace]] as diplopia and ptosis
● ANTICHOLINERGICS → for bladder dysfunction (e.g., ● Weakness of facial muscles, swallowing and voice impairment
propantheline) (dysphonia), generalized weakness
● BETA-BLOCKERS → for tremors (e.g., primidone [Mysoline]
and clonazepam [Klonopin]] TENSILON TEST
MYASTHENIA GRAVIS ● baseline assessment of the cranial muscle strength is done
● EDROPHONIUM (TENSILON) is administered.
● Progressive Autoimmune disorder affecting the MYONEURAL ○ Medication that inhibits the breakdown of
JUNCTION → produces severe muscle weakness acetylcholine, making it available for use at the
● Antibodies directed at acetylcholine at the myoneural junction neuromuscular junction.
impair transmission of impulses ● POSITIVE TEST → results in marked improvement in
● A MOTOR disorder muscle. strength that lasts approximately 5 minutes.
● Characterized by periods of exacerbation and remission
● Muscle weakness improves with rest and worsens with increased DURING TENSILON TEST
activity ● Assist physician in administering this test.
● Observe for complications such as FASCICULATIONS
around the eyes and face, as well as cardiac arrhythmias.
● Have ATROPINE available → antidote for edrophonium
(bradycardia, sweating, and abdominal cramps)

COMPLICATIONS
● MYASTHENIC CRISIS
○ Result of disease exacerbation or a precipitating event,
most commonly a respiratory infection
○ Severe generalized muscle weakness with respiratory
and bulbar weakness
○ Patient may develop respiratory compromise failure
● CHOLINERGIC CRISIS
○ Caused by overmedication with cholinesterase inhibitors
○ Severe muscle weakness with respiratory and bulbar
weakness
○ Patient may develop respiratory compromise and failure

BSN 3A - Marjorie D. Solayao

 MEDICAL MANAGEMENT
● PHARMACOLOGIC THERAPY - Cholinesterase inhibitor:
Pyrostigmine bromide (Mestinon)
● Immunomodulating therapy
● PLASMAPHERESIS – similar to dialysis ; cleans blood by
removing autoimmune antibodies, hence decreasing
destruction of acetylcholine receptors
● THYMECTOMY – removal of thymus gland; to decrease
autoimmune activity caused by the thymus gland
INTERVENTION
● Patient instruction in signs and symptoms of myasthenic crisis
and cholinergic crisis
● Ensuring adequate ventilation; intubation and mechanical
ventilation may be needed
● Assessment and supportive measures include:
○ Ensure airway and respiratory support
○ Take ABG's, serum electrolytes, I&O, and daily weight
○ If patient cannot swallow, nasogastric feeding may be
required
○ Avoid sedatives and tranquilizers

BSN 3A - Marjorie D. Solayao