NCMB316 LECTURE:
10
Introduction to Nervous System
Bachelor of Science in Nursing 3YB
Professor: Maria Sheila Mujemulta, RN, MAN
INTRO TO NERVOUS SYSTEM
Assessment of the Nervous System
Health History
- An important aspect of the neurologic assessment is the
history of the present illness.
- The initial interview provides an excellent opportunity to
systematically explore the patient’s current condition and
related events while simultaneously observing overall
appearance, mental status, posture, movement, and affect.
- Neurologic disease may be stable or progressive,
characterized by symptom-free periods as well as
fluctuations in symptoms.
- The health history therefore includes details about the:
• Onset, character, severity, location, duration, and
frequency of signs and symptoms
• Associated complaints.
• Precipitating, aggravating, and relieving factors
• Progression, remission, and exacerbation; and
• The presence or absence of similar symptoms among
family members.
- Common signs and symptoms associated with
neurologic disease:
• Pain
• Seizures
• Dizziness & vertigo
• Visual disturbances
• Muscle weakness
• Abnormal sensation
- Past Health, Family, and Social History
• The nurse may inquire about any family history of
genetic diseases.
• A review of the medical history, including a system-by-
system evaluation, is part of the health history.
• The nurse should be aware of any history of trauma or
falls that may have involved the head or spinal cord.
• Questions regarding the use of alcohol, medications,
and il- licit drugs are also relevant.
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Midterm Week
- The history-taking portion of the neurologic assessment is
critical and, in many cases of neurologic disease, leads to
an accurate diagnosis.
Physical Assessment
- 5 Components of Neurologic Assessment:
consciousness and cognition, cranial nerves, motor
system, sensory system, and reflexes.
Diagnostic tests
Radiographic examinations
1) X-ray Examinations of the Skull and Spine
- used to determine
- bony fractures
- curvatures
- bone erosion
- bone dislocation
- possible calcification of soft tissue w/c can damage the
nervous system
• you will be asked to lie on the x-ray table or sit in a
chair
• your head may be placed in a number of positions
• several views are taken: anteroposterior, lateral,
oblique & when necessary, special views of the
facial bones
- Nursing responsibilities before:
• Explain that it is similar to that for a chest x-ray
procedure
• Need to remain still during the procedure
• Exposure to radiation is minimal
• Remove hairpins, glasses, hearing aids
• Patient in traction & no portable x-ray= accompany
patient to assist in positioning
• Patient who cannot walk & transfer fr wheelchair to
x-ray table = stretcher
- Nursing responsibilities after: follow up care is not
required
2) Cerebral Angiography (Arteriography/ Arteriogram)
- used to visualize cerebral vessels & detect tumors,
aneurysms, occlusions, hematomas, abscesses
- injection of radiopaque substance into the cerebral
circulation via carotid, vertebral, femoral, brachial
artery followed by x-rays
- DSA – Digital Subtraction Angiography
• x-ray images of the area are obtained b4 and after
the injection of the contrast agent
• images obtained before contrast injection are
digitized and subtracted from post - contract images,
thus removing bones and other background
structures from the final digital images
- Nursing responsibilities before:
• signed consent (after explaining the procedure,
usually the radiologist)
 316 LECTURE: WK10 – INTRO TO NERVOUS SYSTEM
• check for allergy to iodinated contrast agents
o =infreq. pt may have an immediate or delayed
allergic rxn to the iodine contained in the
contrast agent
o Manifestations: dyspnea, n&v, sweating,
tachycardia & numbness of extremities
o Int: report to physician at once
o Tx: adm of epinephrine, antihistamines, or
corticosteroids
o Addtnal risks: vessel injury, bleeding & CVA
• necessity for not moving during the procedure
• NPO 4-6 hours before the test – well hydrated, clear
liquids permitted up to the time of regular
angiography
• remove hairpins & jewelries
• record neuro & v/s
• empty bladder
- Nursing responsibilities after:
• v/s, neuro signs & neurovascular checks as ordered;
compare with pre-angiography signs
• restricted to bedrest for several hours
• monitor VS & neuro checks
• extremity used is kept straight & immobilized for the
duration of the bedrest – if w/ hematoma, (localized
collection of blood), ice bag may be applied,
intermittently to the puncture site
• check for the extremity’s skin color & temp, pulses
distal to the injection site, capillary refill
• inspect injection site for evidence of bleeding
• increase oral or IV fluids if not contraindicated
3) Computed Tomography/ Computed Axial Tomography
(CT/ CAT scan)
- used to detect intracranial & spinal cord lesions
- used to monitor effects of surgery or other therapy
- uses ionizing radiation
- skull & spinal cord are scanned in successive layers by
a narrow beam of x-rays
- computer construct a picture of the internal structure of
the brain
- contrast media may or may not be used
- Nursing responsibilities before:
• signed consent
• if w/ contrast agent: notify physician if client has risk
factor & food is withheld for 4-6 hours; fluids are
generally not withheld
• patients must remove all metallic materials (may be
required to change into a hospital gown)
• remove hairpins, hairpieces or wigs
• to provide clear images: patients must remain as
still as possible
• the technician is able to see the patient and
communicate through an intercom system
throughout the procedure
- Nursing responsibilities after: If w/ contrast agent:
• check for delayed allergic response to contrast
medium if used
• increase fluid intake if contrast medium was used
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• check I & O, resultant diuresis may require
replacement of fluids
4) Positron Emission Tomography (PET)
- provides information about the function of the brain
- specifically glucose, O2 metabolism and cerebral blood
flow
- it can be used to image what the brain is doing
- A PET scan can show patterns in the brain which aid the
physician in diagnosing and treating Parkinson's
Disease
• Client is placed on a stretcher
• IV line is started to inject isotope (deoxyglucose)
• isotope emits activity in the form of positron which
are scanned & converted into a color image by
computer
• more active a given part of the brain = the greater the
glucose uptake
• client may be blindfolded with earplugs
• client is asked to perform certain mental functions
to activate different areas of the brain
- Nursing responsibilities before:
• signed consent form
• instruct the client to withhold caffeine, alc &
tobacco for 24 hrs (accdg to agency policy)
• NPO for 6-12 hours (if diabetic=no insulin before the
test)
• no glucose solution nor any drugs that alter glucose
metabolism
- Nursing responsibilities after:
• increase fluid intake (radioisotope is eliminated in
the urine)
• ff-up care is not required
5) Single-Photon Emission Computed Tomography
(SPECT)
- limitation of PET may be overcome.
- less expensive than PET but resolution of images is
limited
- particularly useful in studying:
• Cerebral blood flow
• Head trauma
• Stroke
• Seizures
• Dementia
• Persistent Vegetative state
• AIDS
• Brain death
• Amnesia
• Psychiatric disorders
• Neoplasms
- uses a radiopharmaceutical agent that enables
radioisotopes to cross the blood-brain barrier via IV
injection (1hr before the scan)
- positioned on an x-ray table in a quiet dark room
- gamma cameras scan the head
- images are downloaded to a computer
- it is able to provide true 3D information
 316 LECTURE: WK10 – INTRO TO NERVOUS SYSTEM
2) Lumbar puncture/ Spinal tap
- Left: SPECT scans of the brain of a three year old male near
drowning patient shown shortly after the accident showing
decreased brain activity. The patient presented in a
persistent vegetative state, and was pronounced blind with
severe spasticity.
- Right: SPECT scans of the same child taken 9 months later
demonstrating increased brain activity and blood flow
following 120 hyperbaric oxygen treatments. The child was
now alert, responsive, laughing, eating and drinking
normally, walking, speaking bi-lingually, and had regained
normal vision.
Other diagnostic tests
1) Magnetic Resonance Imaging (MRI)
- produces images superior to CT scan computer-drawn,
detailed pictures of structures of the brain & body
through the use of large magnet, radio waves
- used to detect intracranial & spinal cord
- abnormalities assoc with disorders such as:
• cerebrovascular diseases
• tumors
• abscesses
• cerebral edema
• hydrocephalus
• multiple sclerosis
- for enhancement of images, may use gadolinium = a
non-iodine-based contrast
- Nursing responsibilities before:
• signed consent form
• remove jewelry, glasses & other metals
• contraindicated to:
o anyone with orthopedic hardware
o IUDs, tattoos
o Pacemaker
o internal surgical clips
o other fixed metallic objects in the body
• warn client of normal audible humming & thumping
noises during the scan = may wear earplugs
• instruct to remain still, lasts for 45-60 mins
• help prevent claustrophobia = offer open MRI
• void before the test
- Nursing responsibilities after:
• Follow-up care is not required.
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- the insertion of a spinal needle into the subarachnoid
spacebetween the 3rd & 4th (sometimes L4/L5, L5/S1)
lumbar vertebrae
- used to do the ff:
• obtain pressure readings with a manometer.
• Normal: 60-150 mmH2O
• obtain CSF for analysis protein, sugar, cytology, C/S,
color
• significance of CSF findings
• check for spinal blockage attributable to spinal cord
lesion
• inject contrast medium or air for diagnostic study
• inject spinal anesthetics
• inject certain medications
• reduce mild to moderate increased ICP in certain
conditions
- Nursing responsibilities before:
• signed consent form
• void before the test
• position in lateral recumbent with head & neck
flexed onto the chest & knees pulled up; “fetal
position”
• explain the need to remain still during the procedure
- Nursing responsibilities after:
• label specimens
• keep client flat for 4-8 hours or 12-24 hours as
prescribed by physician or as determined by hospital
policy – to prevent CSF leakage
• check puncture site for bleeding or CSF leak
• increase fluid intake (to 3000ml unless
contraindicated) – facilitate CSF production
• assess sensation and movement in lower
extremities
• monitor VS
• analgesics for headache – a ↓ in CSF may cause
severe, throbbing headache =spinal headache
• If LP is done to ↓ ICP, perform rapid neuro check
 316 LECTURE: WK10 – INTRO TO NERVOUS SYSTEM

3) Electroencephalography (EEG) • head position depends on the dye used:

- graphic recording of electrical activity of the brain by o oil-based or water-soluble =elevated
several electrodes placed on the scalp o air =positioned lower than the trunk
- used to: • administer analgesics for headache or backache as
• Detect focus or foci of seizure activity prescribed
• used to quantitatively evaluate level of brain • encourage fluids to help excrete the contrast
function (determine brain death) material
• diagnose sleep disorders (sleep EEG) • monitor I & O to ensure adeq fluid intake, facilitate
- sleep EEG: excretion of contrast material and determine adeq
• You will be placed in a room that encourages urine output – at least 30mL/hr
relaxation
• asked to fall asleep
• while brain's electrical activity is recorded
• last about 2-3 hours / sometimes 6 hours
- Nursing responsibilities before:
• withhold sedatives, tranquilizers, stimulants for 2-3
days
• not to consume caffeine before the test.
• avoid using hair styling products (hairspray or gel) on
the day of the exam
• for sleep EEG, client may be asked to stay awake the
night before the exam
- Nursing responsibilities after:
• remove electrode paste with acetone & shampoo
hair
• any medications withheld are reinstituted
• may need a nap if sleep deprived
Radiographic or Non-radiographic?
1) Myelography / Myelogram
- injection of dye or air into the subarachnoid space to
detect abnormalities of the spinal cord and vertebrae
• procedure begins with a lumbar puncture radiologist
may remove some of the CSF from the spinal canal
• next, a portion of contrast dye will be injected into
the spinal canal through the hollow needle
• the needle will remain in place and will be placed in
prone position
• x-ray table will be tilted in various directions to allow
gravity to move the contrast dye to diff areas of the
spinal cord (patient is be held in place by a special
brace or harness)
• more contrast dye will be administered during this
process through the secured lumbar puncture
needle
• required x-rays or CT scan pictures will be taken
- Nursing responsibilities before:
• informed consent
• provide hydration for at least 12 hours before the
test
• solid foods are avoided
• assess for allergies to contrast agents, iodine or
shellfish
• if taking phenothiazine: hold medication -lowers the
seizure threshold
• premedicate for sedation as prescribed
- Nursing responsibilities after:
• assess v/s & neuro condn freq as prescribed

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 NCMB316 LECTURE: Midterm Week

Increased ICP, Head Injury, CVA, SCI & Seizures
Bachelor of Science in Nursing 3YB
Professor: Maria Sheila Mujemulta, RN, MAN
INCREASED ICP, HEAD INJURY, CVA, SCI AND SEIZURES
Increased ICP
- means, an ↑ in intracranial bulk due to an ↑ in any of the
intracranial
- Components: brain tissue, CSF or blood
- Causes: trauma, hemorrhage, abscesses, growths or
tumors, hydrocephalus, edema or inflammation
• Can impede circulation to the brain
• Can impede the absorption of CSF
• Affect functioning of nerve cells
• Lead to brainstem compression
• Death
- To understand intracranial pressure, think of the skull as a
rigid box.
- After brain injury, the skull may become overfilled with
swollen brain tissue, blood, or CSF.
- The skull will not stretch like skin to deal with these
changes.
- The skull may become too full and increase the pressure
on the brain tissue. This is called increased intracranial
pressure.
- ICP is usually measured in the lateral ventricles, with the
normal pressure being 0 to 10 mm Hg, and 15 mm Hg being
the upper limit of normal (Brunner & Suddarth’s Textbook
of MS 12th ed)
Monro-Kellie Principle
11
- Later: stupor then coma
• Pupillary dysfunction relative to size, shape, and
reaction to light
- Early: gradual dilation, a slightly ovoid shape, and a
sluggish response to light ipsilateral to the lesion
- Later: signs are dilation of the ipsilateral pupil and a
non-reactivity to light (from compression of CNIII)
- Final: bilateral dilation and fixation
• Motor weakness and sensory deficits
- Early: monoparesis, contralateral hemiparesis, and
decreased visual acuity, such as blurred vision &
diplopia
- Later: hemiplegia, decortication or decerebration
(either unilateral or bilateral)
• Headache, possible seizures, projectile vomiting, (+)
Babinski’s reflex
- Late sign: Changes in vital signs
o Hypertension systolic BP rises while diastolic
pressure remains the same (widening pulse
pressure-a difference of more than 50 mm Hg )
o Bradycardia
o abnormal respiratory pattern
o elevated temperature
• Cushing's triad – a very late presentation of brain stem
dysfunction

- This concept holds that the skull is a rigid compartment

that contains 3 components:
• brain tissue
• blood (arterial & venous)
• CSF
- These components are balanced in a state of dynamic
equilibrium.
- If an increase occurs in the relative volume of one
component, such as brain tissue = the volume of one or
more of the other components must decrease or an
elevation in ICP will result.
Assessment
• Earliest sign: Deterioration in the level of
consciousness
- Early: confusion, restlessness, lethargy, and
disorientation first to time, then to place, and then to
person
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Nursing interventions
1) Elevate head of bed to 30-40 degrees as prescribed.
2) Avoid Trendelenburg’s position.
3) Prevent flexion of the neck and hips.
4) Monitor respiratory status and prevent hypoxia. -leads to
brain swelling
5) Avoid the administration of morphine sulfate to prevent the
occurrence of hypoxia.
6) Maintain mechanical ventilation as prescribed.
- PaCO2 at 30-35 mmHg → vasoconstriction of cerebral
blood vessels → ↓ed blood flow = ↓ed ICP
- Hypercarbia=vasodilation= ↑ ICP;
- Hypocarbia=too much vasoconstriction
7) Maintain body temperature.
8) Prevent shivering –can ↑ICP
9) Decrease environmental stimuli.
10) Monitor electrolyte levels and acid-base balance.
11) Monitor I& O.
12) Limit fluid intake to 1200 mL/day.
13) Instruct client to avoid straining activities, such as
coughing and sneezing.
14) Instruct the client to avoid Valsalva’s maneuver.
Medications
1) Anticonvulsants
- as prophylactic to prevent seizures → ↑metabolic
requirements & cerebral blood flow & volume → ↑ing
ICP
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- phenytoin (Dilantin)
2) Antipyretics & Muscle Relaxants
- prevents temp elevation & shivering
- temp reduction → ↑metabolism, cerebral blood flow +
ICP
- acetaminophen (Tylenol), diazepam (Valium)
Blood Pressure Medications
- to maintain cerebral perfusion at a normal level
- notify physician if BP is <100 or >than 150mmHg systolic
- beta blockers (Propanolol)
3) Corticosteroids
- stabilize the cell membrane & reduce the leakiness in
the blood-brain barrier ↓ cerebral edema
- S/E: ↑gastric secretion (give histamine blocker) ;
adrenal crisis (withdrawn slowly from corticosteroid
therapy)
- dexamethasone (Decadron)
4) Hyperosmotic Agents
- Mannitol (Osmitrol) is a hyperosmotic agent that
↑intravascular pressure by drawing fluid from the
interstitial spaces & from the brain cells
- monitor renal function ; -diuresis is expected
5) Intravenous Fluids
- administered via infusion pump to control the amount
delivered
- hypertonic IVs are avoided bec of risk of promoting
addtnal cerebral edema
Surgical Intervention
Ventriculoperitoneal Shunt
- shunts CSF from the ventricles into the peritoneum
Post procedure interventions:
1) Position the client supine and turn from the back to the
nonoperative side.
2) Monitor for signs of ↑ing ICP resulting from shunt failure.
3) Monitor for signs of infection.
Head Injury
- trauma to the skull, resulting in mild to extensive damage
to the brain
- usually caused by car accident, falls & assaults
- immediate complications: cerebral bleeding, hematomas,
uncontrolled ↑ed ICP, infections and seizures
- changes in personality or behavior cranial nerve deficits &
any other residual deficits depend on the area of the brain
damage & the extent of the damage
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- Types of head injuries:

1) Open
• Scalp lacerations
• Fractures of the skull
• Interruption of the dura mater
2) Closed
• Concussion
• Contusions
• Fractures
Concussion Contusion
• widespread • localized (coup-contra
• microscopic coup)
• jarring of the brain • macroscopic
within the skull • bruising type of injury to the
• temporary loss of brain
consciousness • noticeable loss of functions

Assessment
- Assessment findings depend on the injury
- Clinical manifestations usually result from ↑ed ICP
• Changes in LOC
• visual disturbances, pupillary changes & papilledema
• airway & breathing pattern changes
• headache, n&v
Fractures
Types of skull fracture include: • weakness & paralysis
• posturing
• Linear or hairline: a break in a cranial bone resembling a
thin line, without splintering, depression, or distortion of • v/s changes
bone - CSF drainage: ears / nose
Nursing intervention
• Depressed: a break in a cranial bone (or "crushed" portion
1) Maintain patent airway & ventilation; V/S, neuro checks,
of skull) with depression of the bone in toward the brain
• Compound: a break in or loss of skin and splintering of the monitor signs of ↑ICP, seizures, hyperthermia
bone 2) Observe CSF leak
• Comminuted: a fracture of many relatively small fragments - check discharge for glucose (strip test); bloody spot
Hematoma encircled by watery, pale ring on pillowcase or sheet
- never attempt to clean the ears or nose; never use nasal
• Subdural Hematoma
suction unless ordered
- occurs under the dura as a result of tears in the veins
3) If a CSF leak is present:
crossing the subdural space
- instruct not to blow nose
- forms slowly
- elevate HOB 30 degrees
- results from a venous bleed
- observe for signs of meningitis, antibiotics as ordered
• Intracerebral Hematoma
- place cotton ball on ear to absorb otorrhea
- accumulation of blood within the cerebrum

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- gently place sterile gauze pad at the bottom of the nose
for rhinorrhea
4) Prevent complications of immobility
5) Prepare the client for surgery if indicated
- Depressed skull fracture-surgical removal or elevation
of splintered bone; debridement & cleansing; repair of
dural tear
- Epidural / subdural hematoma-evacuation of
hematoma
6) Monitor for signs of infection
Cerebrovascular Accident (CVA)
- Destruction (infarction) of brain cells caused by a
reduction in cerebral blood flow and oxygen
- Affects men more than women; incidence increases with
age
- Caused by thrombosis, embolism, hemorrhage
- Risk factors:
• Hypertension
• diabetes mellitus
• arteriosclerosis/atherosclerosis
• cardiac disease (valvular disease/replacement, chronic
atrial fibrillation, MI)
• life-style (obesity, smoking, inactivity, stress, use of oral
contraceptives)
- A stroke can happen when:
• A blood vessel carrying blood to the brain is blocked by
a blood clot.
• This is called an ischemic stroke.
• A blood vessel breaks open, causing blood to leak into
the brain. This is a hemorrhagic stroke.
• If blood flow is stopped for longer than a few seconds,
the brain cannot get blood and oxygen.
• Brain cells can die, causing permanent damage.
- Pathophysiology: interruption of cerebral blood flow for 5
minutes or more causes death of neurons in affected area
with irreversible loss of function
Stages of development:
1) Transient ischemic attack (TIA)
- warning sign of impending CVA
- brief period of neurologic deficit (visual loss,
hemiparesis, slurred speech, aphasia, vertigo)
- may last less than 30 seconds, but no more than 24
hours with complete resolution of symptoms
2) Stroke in evolution – progressive development of stroke
symptoms over a period of hours to days
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3) Completed stroke – neurologic deficit remains unchanged
for a 2- to 3-day period
Assessment
• Headache
• Generalized signs: vomiting, seizures, confusion,
disorientation, decreased LOC, nuchal rigidity, fever,
hypertension, slow bounding pulse, Cheyne-Stokes
respirations
• Focal signs (related to site of infarction): hemiplegia,
sensory loss, aphasia, homonymous hemianopsia
• Diagnostic tests
1) CT and brain scan: reveal lesion
2) EEG: abnormal changes
3) Cerebral arteriography: may show occlusion or
malformation of blood vessels
Nursing interventions
Acute stage:
1) Maintain patent airway and adequate ventilation.
2) Monitor VS, neuro checks, observe for signs of ed ICP,
shock, hyperthermia, and seizures.
3) Provide complete bed rest as ordered.
4) Maintain F& E balance and ensure adequate nutrition.
• IV therapy for the first few days
• NGT feedings - if unable to swallow
• Fluid restriction as ordered - to decrease cerebral
edema
5) Maintain proper positioning and body alignment.
• Head of bed may be elevated 30°-45° to  ICP
• Turn and reposition every 2 hours (only 20 minutes on
the affected side)
• Passive ROM exercises every 4 hours.
6) Promote optimum skin integrity: turn client and apply
lotion every 2 hours
7) Maintain adequate elimination.
• Offer bedpan or urinal every 2 hours, catheterize only if
absolutely necessary.
• Administer stool softeners and suppositories as
ordered to prevent
constipation and fecal impaction.
8) Provide a quiet, restful environment.
9) Establish a means of communicating with the client.
10) Administer medications as ordered.
• Hyperosmotic agents, corticosteroids to decrease
cerebral edema
• Anticonvulsants to prevent or treat seizures
• Thrombolytics given to dissolve clot (hemorrhage must
be ruled out)
a) tissue plasminogen activator (tPA, Alteplase)
b) streptokinase, urokinase = must be given within 2
hours of episode
• Anticoagulants - stroke in evolution or embolic stroke
a) heparin
b) warfarin (Coumadin) for long-term therapy
c) aspirin and dipyridamole (Persantin) – to inhibit
platelet aggregation in treating TIAs
• Antihypertensives - if indicated for elevated blood
pressure
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Rehabilitation Spinal cord injury

1) Hemiplegia: results from injury to cells in the cerebral - trauma to the spinal cord which causes partial or complete
motor cortex or corticospinal pathway disruption of the nerve tracts & neurons
a) Turn every 2 hours (20 minutes only on affected side) - Causes
b) Use proper positioning & repositioning to prevent • traumatic: motor vehicle accidents, diving in shallow
deformities water, falls, industrial accidents, sports injuries,
c) Support paralyzed arm on pillow or use sling while out gunshot or stab wound
of bed • non-traumatic: tumors, hematomas, aneurysms,
d) Elevate extremities to prevent dependent edema congenital defects
e) Provide active & passive ROM exercises every 4 hours - SCI is classified according to:
2) Susceptibility to hazards • Extent of injury
a) keep side rails up at all times • Level of injury
b) institute safety measures o Cervical
c) inspect body parts frequently for signs of injury o Thoracic
3) Dysphagia (inability to swallow or difficulty in swallowing) o Lumbar
a) check gag reflex before feeding the patient • Mechanism of injury
b) maintain calm, unhurried approach o Hyperflexion
c) place in upright position o Hyperextension
d) place food in unaffected side of mouth o Axial loading – force exerted straight up or down
e) offer soft foods spinal column (ex: diving)
f) give mouth care before and after meals - May affect the vertebral column.
4) Homonymous hemianopsia • Fracture
a) approach client on unaffected side • Dislocation
b) place personal belongings, food on unaffected side - May affect anterior & posterior ligaments
c) teach client by scanning
• compression of spinal cord
5) Emotional lability: mood swings, frustration
- May affect the spinal cord & its roots:
a) create a quiet, restful environment with a reduction in
• Concussion
excessive sensory stimuli
• Contusion
b) maintain a calm, nonthreatening manner
• Compression or laceration by fracture / dislocation
c) explain to family that the client behavior is not
purposeful • penetrating (ex. GSW, missile)
6) Aphasia – most common in R hemiplegics bec. Left- - Axial Loading
hemisphere dominance for language • Fall from a height, landing on one's feet is typical of this
a) Receptive: fracture
• give simple, slow directions • axial loading applied to intravertebral disc results in
• give one command at a time; gradually shift topics increased pressure and stresses
• use nonverbal techniques of communication • a large central posterior- superior fragment occurs as a
b) Expressive: result of these forces
• listen & watch very carefully when client attempts to - Pathophysiology: hemorrhage & edema → ischemia →
speak necrosis & destruction of cord
• anticipate clients need to decrease frustration & - Medical management: Immobilization & maintenance of
feelings of helplessness normal spine alignment – to promote fracture healing
• allow sufficient time & client to answer 1) Horizontal turning frame / Stryker frame
7) Sensory/ perceptual deficits – more common in left 2) Skeletal traction
hemiplegics – characterized by impulsiveness, unaware of a) cervical tongs (Crutchfield)
disabilities, visual neglect b) halo traction
a) assist with self-care - Surgery
b) provide safetty measures • Decompression laminectomy
c) initially arrange objects in env of unaffected side • Spinal fusion
d) gradually teach clients to take care of the unaffected Assessment
side & to turn frequently & look at affected side 1) Spinal Shock
- occurs immediately after the injury as a result of the
insult to the CNS
- temporary condition lasting from several days to 3
months
- characterized by:
• Absence of reflexes below the level of lesion
• Flaccid paralysis

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 316 LECTURE: WK11 – INCREASED ICP, HEAD INJURY, CVA, SCI AND SEIZURES
• Lack of temperature control
• Hypotension w/ bradycardia
• Retention of urine & feces
2) Level of Injury
a) Quadriplegia
- Cervical injuries (C1-C8) → paralysis of all 4
extremities
- respiratory paralysis → lesions above C6 (phrenic
nerve at C4-C5 level) =the nerve that governs
movement of the diaphragm during breathing
b) Paraplegia
- thoracolumbar injuries (T1-L4) → paralysis of the
lower half of the body involving both legs
3) Extent of Injury
a) Complete Cord Transection
- loss of all voluntary movement and sensation below
the level of injury
b) Incomplete lesions
- varying degrees of motor or sensory loss between
the level of the lesion depending on which
neurologic tracts are damaged & which are spared
Nursing Interventions
Emergency Care:
1) Assess ABC
- do not move patient during assessment
- if airway obstruction or inadequate ventilation exists; do
not hyperextend neck to open airway, use jaw thrust
2) Perform a quick head to toe assessment; check for LOC,
signs of trauma; check for leakage of fluid from ear
3) Immobilize client
4) Assist in immobilizing head and neck with cervical collar &
place on spinal board; avoid flexion of the spinal column
Acute Care:
1) Maintain optimum respiratory function
- observe for weak or labored respirations
- prevent pneumonia and atelectasis; turn every 2 hours;
cough and deep breathe
- tracheostomy & mechanical ventilation may be
necessary
2) Maintain optimal cardiovascular function
- monitor vital signs: observe for bradycardia, arrythmias,
hypotension
- apply thigh-high elastic stockings
- change position slowly & gradually elevate the head of
the bed to prevent postural hypotension
- observe for signs of DVT
3) Maintain fluid & electrolyte balance & nutrition
- NGT may be inserted until bowel sounds return
- maintain IV therapy as ordered
- check bowel sounds before feeding
- progress slowly from clear liquid to regular diet
- provide diet high in protein, CHO, calories
4) Maintain immobilization & spinal alignment always
- turn every hour on turning frame
- maintain cervical traction at all times if indicated
5) Prevent complications of immobility
6) Maintain urinary elimination
J.A.K.E 6 of 8
- provide intermittent catheterization or indwelling
catheter
- increase fluids to 3000ml/day
- provide acid-ash foods/ fluids to urine = a diet
consisting largely of meat or fish, eggs, and cereals with
a minimal quantity of milk, fruit, and vegetables, that
when catabolized leaves an acid residue to be excreted
in the urine.
7) Maintain bowel elimination
8) Monitor temperature control
9) Observe for & prevent infection
10) Observe for & prevent stress ulcers
Chronic care
1) Nonreflexive/ Areflexive or lower motor neuron bladder
/ LMN bladder
- spinal shock: when reflex arc is not functioning due to
initial trauma
- no reflex activity of the bladder occurs, resulting in
urine retention with overflow
- Failure to Empty
- lesion: Complete destruction of Sacral Micturition
Center (S2–S4) at S2 or below
- Management:
• intermittent catheterization every 6 hours
• Crede’s maneuver or rectal stretch
• regulate intake to 1800-2000 ml/day → to prevent
overdistention of bladder
2) Reflex or upper motor neuron bladder / UMN bladder
- reflex activity of the bladder may occur after spinal
shock resolves
- bladder is unable to store urine very long and empties
voluntarily
- Failure to Store (Incontinence)
- lesion: Above Sacral Micturition Center (above S2)
- Management:
• intermittent catheterization every 4 hours and
gradually progresses to every 6 hours
• regulate fluid intake to 1800-2000 ml/day
• bladder taps → to cause reflex emptying of the
bladder
Autonomic Dysreflexia
- rise in blood pressure, sometimes to fatal levels
- reflex response to stimulation of the sympathetic nervous
system
- occurs in clients with cord lesions above T6
- most commonly in clients with cervical injuries
- stimulus: overdistended bladder or bowel, decubitus ulcer,
chilling, pressure from bedclothes
- Symptoms: severe headache, hypertension, bradycardia,
sweating, goose bumps, nasal congestion, blurred vision,
convulsions
- Interventions:
• raise client to sitting position to decrease BP.
• check for source of stimulus (bladder, bowel, skin)
• remove offending stimulus (e.g. reposition client
catheterize client, digitally remove impacted feces,)
• monitor BP
 316 LECTURE: WK11 – INCREASED ICP, HEAD INJURY, CVA, SCI AND SEIZURES

• administer antihypertensives (e.g. hydralazine HCl - Related to organic brain damage.

[Apresoline]) as ordered Akinetic seizure Sudden brief loss of postural tone,
Medications (atonic) and temporary loss of
1) Dexamethasone (Decadron) consciousness.
- used for its anti-inflamm & edema reducing effects - Associated with brain damage, may
- may interfere with healing be precipitated by tactile or visual
2) Dextran (plasma expander) sensations.
- used to increase capillary blood flow within the spinal - May be generalized or local.
Myoclonic
cord and to prevent / treat hypotension Brief flexor muscle spasm; may
seizure
3) Dantrolene (Dantrium), Baclofen (Lioresal) have arm extension, trunk flexion.
- used for clients with upper motor neuron injuries to - Single group of muscles affected;
control muscle spasticity involuntary muscle contractions =
myoclonic jerks.
Seizures - Usually nonorganic brain damage
- An abnormal, sudden, excessive, uncontrolled electrical present; must be differentiated from
Absence seizure
discharge of neurons within the brain that may result in daydreaming.
(petit mal)
alteration of consciousness, motor or sensory ability, - Sudden onset, with twitching or
and/or behavior rolling of eyes; lasts a few seconds.
- Epilepsy – a chronic disorder characterized by recurrent, - Common in 5% of population under
unprovoked seizure activity. Cause unknown in 75% of 5, familial, nonprogressive; does not
epilepsy cases. generally result in brain damage.
- THEREFORE: Seizure is a symptom of epilepsy Febrile seizure Typically tonic-clonic.
Pathophysiology - Seizure occurs only when fever is
- Normally neurons send out messages in electrical rising.
impulses periodically, and the firing of individual neurons is - EEG is normal 2 weeks after seizure.
regulated by an inhibitory feedback loop mechanism. Status epilepticus
- With seizures, many more neurons than normal fire in a - Usually refers to generalized grand mal seizures.
synchronous fashion in a particular area of the brain; the - Seizure is prolonged (there are repeated seizures without
energy generated overcomes the inhibitory feedback regaining consciousness) and unresponsive to treatment.
mechanism. - Can result in decreased oxygen supply and possible
cardiac arrest.
II. Partial seizures
- Seizure confined to one hemisphere
of brain.
Simple partial - No loss of consciousness.
seizure - May be motor, sensory, or
autonomic symptoms.
- Begins in focal area (anterior
temporal lobe) but spreads to both
Complex partial
hemispheres.
seizure
- Impairs consciousness.
Type of Seizure Clinical Findings
- May be preceded by aura.
I. Generalized seizures
- May be preceded by aura
- tonic and clonic phases
- Tonic phase: limbs contract or
stiffen; pupils dilate and eyes roll up
and to one side; glottis closes,
causing noise on exhalation; may be
Major motor
incontinent; occurs at same time as
seizure (grand
loss of consciousness; lasts 20–40
mal)
seconds.
- Clonic phase: repetitive
movements, increased mucus
production; slowly tapers.
- Seizure ends with postictal period of
confusion, drowsiness.

J.A.K.E 7 of 8
 316 LECTURE: WK11 – INCREASED ICP, HEAD INJURY, CVA, SCI AND SEIZURES
Medical management (Drug therapy)
1) Phenytoin (Dilantin)
- It is one of the drugs of choice for :
• Generalized tonic-clonic seizures
• Partial seizures
- Phenytoin should not be used to treat absence seizures
or myoclonic seizures.
- Serum blood level determinations may be necessary for
optimal dosage
- adjustments – the clinically effective serum level is
usually 10-20 mcg/mL
- Common side effects of phenytoin include:
• swollen, tender gums – gum hyperplasia
• growth of facial and body hair
• enlarged or rough facial features
• acne
• skin rash
- Serum phenytoin level
• The therapeutic range is 10-20 mcg/mL.
• Plasma levels (mcg/mL) have an association with
acute neurological symptoms.
o Lower than 10 - Rare
o Between 10 and 20 - Occasional mild nystagmus
o Between 20 and 30 - Nystagmus
o Between 30 and 40 - Ataxia, slurred speech,
nausea, and vomiting
o Between 40 and 50 - Lethargy and confusion
o Higher than 50 - Coma and seizures
- Considerations:
• Phenytoin may decrease the effectiveness of
hormonal contraceptives (birth control pills, patches,
rings, injections, implants, or intrauterine devices).
Use another form of birth control while taking
Phenytoin.
• Phenytoin is listed in Pregnancy Category D. This
means that there is a risk to the baby, but the
benefits may outweigh the risk for some women.
• Often used with Phenobarbital for its potentiating
effect.
a) elevates the seizure
b) threshold and inhibits the
c) spread of electrical discharge
2) Carbamazepine
- It is used alone or in combination with other
medications to treat certain types of seizures in
patients with epilepsy.
- It is also used to treat trigeminal neuralgia (a condition
that causes facial nerve pain).
- It works by reducing abnormal excitement in the brain.
- Common side-effects:
• fatigue
• dizziness
• nausea & vomiting
- Carbamazepine can lower the white blood cells.
- Serious side effects:
• Fever
• sore throat
J.A.K.E 8 of 8
• headache with a severe blistering, peeling & red skin
rash
• pale skin
• easy bruising or bleeding
• jaundice (yellowing of the skin or eyes
3) Valium
- It slows the central nervous system and is used to treat
anxiety related disorders and conditions that cause
severe muscle spasms and convulsions.
- Valium is administered rectally. Liquid Valium is
absorbed fast from the rectum.
- The effect should take place 5-15 minutes after the
injection.
- Valium should not be used on a daily basis because it
can cause withdrawal.
Surgery
- to remove the tumor, hematoma, or epileptic focus
Diagnostic tests
• Blood studies to rule out lead poisoning, hypoglycemia,
infection, or electrolyte imbalances
• Lumbar puncture to rule out infection or trauma
• Skull x-rays, CT scan, or ultrasound of the head, brain scan,
arteriogram to detect any pathologic defects
• EEG may detect abnormal wave patterns characteristic of
different types of seizures
Nursing interventions (During seizure activity)
a) Protect from injury.
• prevent falling, gently support head.
• decrease external stimuli; do not restrain.
• do not use tongue blades (they add additional stimuli).
• loosen tight clothing.
b) Keep airway open.
• place in side-lying position.
• suction excess mucous.
c) Observe and record seizure.
• note any preictal aura.
- affective signs: fear, anxiety
- psychosensory signs: hallucinations
- cognitive signs: "déjà-vu" symptoms
• note nature of the ictal phase.
- symmetry of movement
- response to stimuli; LOC
- respiratory pattern
• note postictal response: amount of time it takes to
orient to time and place; sleepiness
 NCMB316 LECTURE:
PD, MS, MG
Bachelor of Science in Nursing 3YB
Professor: Dr. Potenciana A. Maroma
PARKINSON’S DISEASE, MULTIPLE SCLEROSIS, AND
MYASTHENIA GRAVIS
Parkinson’s Disease (PD)
- The basal ganglia are a collection of nuclei deep to the
white matter of cerebral cortex.
- The name includes: caudate, putamen, nucleus
accumbens, globus pallidus, & substantia nigra.
Pathophysiology
• Disorder causes degeneration of the dopamine-producing
neurons in the substantia nigra in the midbrain
• Dopamine influences purposeful movement
• Depletion of dopamine results in degeneration of the basal
ganglia.
Parkinson’s Disease (PD) / Paralysis agitans
- A progressive disorder with degeneration of the nerve cells
in the basal ganglia resulting in generalized decline in
muscular function; disorder of the extrapyramidal system
(neural network located in the brain that is part of the
motor system involved in the coordination of movement)
- Usually occurs in the older population: sxs occur during
the 5th decade of life some diagnosed at age 30
- Affects men more frequently than women
- Cause: UNKNOWN; predominantly idiopathic
- but sometimes disorder is postencephalitic, toxic,
arteriosclerotic, traumatic, or drug induced ( reserpine,
methyldopa [Aldomet], haloperidol [Haldol],
phenothiazine )
- Dxtic tests: not helpful …PET used only for evaluating
levodopa uptake = diagnosed clinically from patient’s hx,
presence of 2 of the 3 cardinal sxs, neuro examinations
J.A.K.E 1 of 3
Final Week
13
Assessment findings
• Tremor:
- mainly of the upper limbs
- "pill-rolling"
- resting tremor; most common initial symptom
• Rigidity: cogwheel type
• Bradykinesia: slowness of movement
• Fatigue
• Stooped posture; shuffling, propulsive gait
• Difficulty rising from sitting position
• Masklike face with decreased blinking of eyes
• Quiet, monotone speech
• Emotional lability, depression
• Increased salivation, drooling
• Cramped, small handwriting
• Autonomic symptoms:
- excessive sweating
- constipation
- seborrhea
- decreased sexual capacity
- lacrimation
Nursing interventions
• Administer medications as ordered
1) Antiparkinsonian: Levodopa (Dopar, Larodopa)
- Increases level of dopamine in the brain; relieves
tremor, rigidity, and bradykinesia
- Side Effects: anorexia; nausea and vomiting;
postural hypotension; mental changes such as
confusion, agitation, and hallucinations; insomnia;
renal damage; cardiac arrhythmias; dyskinesias
(purposeless involuntary movements that may be
hyperkinetic =rapid and repetitive)
- Contraindications:
o avoid multiple vitamin preparations containing
vitamin B6 (pyridoxine) and foods high in vitamin
B6 (tuna, pork, dried beans, salmon)
o avoid Tyramine rich foods ( cheese, yogurt,
coffee, raisins, sausage, red wine, beer)=may
cause hypertensive crisis
o administer with food or snack to decrease GI
irritation.
2) Carbidopa (Sinemet): prevents breakdown of dopamine
in the periphery and causes fewer side effects.
3) Antiviral: Amantadine (Symmetrel):
- used in early/mild cases to reduce rigidity, tremor,
and bradykinesia
- act by releasing dopamine from neuronal storage
sites
4) Anticholinergic: Benztropine mesylate (Cogentin),
procyclidine (Kemadrin)
- inhibit action of acetylcholine
- used in mild cases or in combination with Levodopa
 316 LECTURE: WK13 – PD, MS, MG
- relieve tremor and rigidity
- side effects: dry mouth, blurred vision, constipation,
urinary retention
5) Dopamine agonist: Bromocriptine mesylate (Parlodel)
- stimulates release of dopamine in the substantia
nigra
- often employed when Levodopa loses effectiveness
6) Tricyclic antidepressants given to treat depression
7) Antihistamines have mild central anticholinergic &
sedative effects & may reduce tremors
• Provide a safe environment.
- Side rails on bed; rails and handlebars in toilet, bathtub,
and hallways; no scatter rugs
- Hard-back or spring-loaded chair to make getting up
easier
• Provide measures to increase mobility.
- Physical therapy: active and passive ROM exercises;
stretching exercises; warm baths
- Assistive devices. If client "freezes," suggest thinking of
something to walk over.
• Improve communication abilities: instruct client to
practice reading aloud, to listen to own voice, and
enunciate each syllable clearly.
• Maintain adequate nutrition.
- Cut food into bite-sized pieces.
- Provide small, frequent feedings.
- Allow sufficient time for meals, use warming tray.
Multiple Sclerosis (MS)
- An immune-mediated progressive demyelinating disease of
the CNS which results in impaired transmission of nerve
impulses
- Typically present in young adults 20-40
- Affects women more than men
- More frequent in cool or temperate climates
- Cause UNKNOWN; may be a slow-growing virus or possibly
of autoimmune origin
- Characterized by remissions and exacerbations
Pathophysiology
1) Sensitized T cells that would typically cross the blood-brain
barrier to check for antigens in the CNS and then leave; in
MS would remain in the CNS
2) Promote infiltration of other agents that damage the
immune system
3) Immune system attack leads to inflamm that destroys
myelin and oligodenroglial cells
Major types
1) Relapsing-remitting MS (RRMS) = 85%of cases
- relapses develop over 1-2 weeks & resolve over 4-8
months then returns to baseline.
- 50% may develop secondary progressive MS within 10
yrs; 90% develop it within 25 yrs
2) Progressive-relapsing MS (PRMS) = 5% of cases
- absence of remission & client’s condition does not
return to baseline
- progressive, cumulative sxs & deterioration occur over
several yrs
J.A.K.E 2 of 3
3) Primary progressive MS (PPMS) = onset tend to be bet
40&60 years of age
- steady, gradual neurologic deterioration w/o remission
of sxs
- progressive disability with no acute attacks
4) Secondary progressive MS (SPMS)
- begins with RRMS course that later becomes steadily
progressive
- attacks & partial recoveries may continue to occur
Diagnostic tests:
• CSF studies: increased protein and IgG (immunoglobulin)
• EEG: abN
• CT scan: increased density of white matter
• MRI: shows areas of demyelination
Symptoms:
• 1st sx: visual disturbances: blurred vision, scotomas
(patchy blindness), diplopia
• Impaired sensation: touch, pain, temperature, or position
sense; numbness, tingling
• Impaired motor function: weakness, paralysis, spasticity
• Impaired cerebellar function: scanning speech, ataxic gait,
nystagmus, dysarthria, intention tremor
• Euphoria or mood swings
• Bladder: retention or incontinence
• Constipation
• Sexual impotence in the male
Nursing interventions
• Promote optimum mobility.
- Muscle-stretching and strengthening exercises
- Walking exercises to improve gait: use wide-based gait
- Assistive devices: canes, walker, rails, wheelchair as
necessary
• Administer medications as ordered.
- For acute exacerbations: corticosteroids (ACTH [IV],
prednisone) to reduce edema at sites of
demyelinization
- For spasticity: baclofen (Lioresal), dantrolene
(Dantrium), diazepam (Valium)
- Beta interferon (Betaseron) for relapsing-remitting MS
patients
• Prevent injury related to sensory problems.
- Test bath water with thermometer.
- Avoid heating pads, hot-water bottles.
- Inspect body parts frequently for injury.
- Make frequent position changes.
• Prepare client for plasma exchange (to remove antibodies)
if indicated
Plasmapheresis
- This treatment — also known as plasma exchange — is a
type of "blood cleansing" in which damaging antibodies are
removed from your blood.
- Plasmapheresis consists of removing the liquid portion of
your blood (plasma) and separating it from the actual
blood cells.
- The blood cells are then put back into your body, which
manufactures more plasma to make up for what was
removed.
 316 LECTURE: WK13 – PD, MS, MG
- It's not clear why this treatment works, but scientists
believe that plasmapheresis rids plasma of certain
antibodies that contribute to the immune system attack on
the nerves.
Myasthenia Gravis (MG)
- A neuromuscular disorder in which there is a disturbance
in the transmission of impulses from nerve to muscle cells
at the neuromuscular junction (PNS), causing extreme
muscle weakness
- Highest between ages 15-35 for women, over 40 for men.
- Affects women more than men
- Cause: thought to be autoimmune disorder whereby
antibodies destroy acetylcholine receptor sites on the
postsynaptic membrane of the neuromuscular junction.
- Voluntary muscles are affected, especially those muscles
innervated by the cranial nerves.
- The first noticeable symptoms of myasthenia gravis may be
weakness of the eye muscles, difficulty in swallowing, or
slurred speech.
Assessment findings
• Ptosis, diplopia , dysphagia, Extreme muscle weakness,
increased with activity and reduced with rest (identifying
characteristic)
• Masklike facial expression
• Weak voice, hoarseness
Diagnostic tests
• Tensilon test: IV injection of Tensilon provides
spontaneous relief of symptoms (lasts 5-10 minutes)
J.A.K.E 3 of 3
• Electromyography (EMG): amplitude of evoked potentials
decreases rapidly
• Presence of anti-acetylcholine receptor antibodies in the
serum
Medical management
• Drug therapy
a) Anticholinesterase drugs: neostigmine bromide
(Prostigmin), pyridostigmine bromide (Mestinon),
edrophonium chloride (Tensilon)
- block action of cholinesterase and increase levels of
acetylcholine at the neuromuscular junction
- side effects: excessive salivation and sweating,
abdominal cramps, nausea and vomiting, diarrhea,
fasciculations (muscle twitching)
b) Corticosteroids: prednisone.
- used if other drugs are not effective
- suppress autoimmune response
• Administer anticholinesterase drugs as ordered.
- Give medication exactly on time.
- Give with milk and crackers to decrease GI upset.
- Monitor effectiveness of drugs: assess muscle strength
and vital capacity before and after medication.
- Observe for side effects.
• Promote optimal nutrition.
- Mealtimes should coincide with the peak effects of the
drugs: give medications 30 minutes before meals.
- Check gag reflex and swallowing ability before feeding.
- Provide a mechanical soft diet.
- If the client has difficulty chewing and swallowing, do
not leave alone at mealtimes
- Keep emergency airway and suction equipment nearby.
• Monitor respiratory status frequently: rate, depth; vital
capacity; ability to deep breathe and cough
• Observe for signs of myasthenic or cholinergic crisis.
• Provide nursing care for the client with a thymectomy.
 NCMB316 LECTURE:
GBS, HD, ALS
Bachelor of Science in Nursing 3YB
Professor: Dr. Potenciana A. Maroma
GUILLAIN BARRE SYNDROME, AMYOTOPHIC LATERAL
SCLEROSIS, AND HUNTINGTON’S DISEASE
GUILLAIN BARRE SYNDROME (GBS)/ Polyradiculoneuritis
J.A.K.E 1 of 3
Final Week
14
Assessment findings
• Mild sensory changes; in some clients severe
misinterpretation of sensory stimuli resulting in extreme
discomfort
• Clumsiness: usually first symptom
• Progressive motor weakness in more than one limb
(classically is ascending and symmetrical)
• Cranial nerve involvement (dysphagia)
• Ventilatory insufficiency if paralysis ascends to respiratory
muscles
• Absence of deep tendon reflexes
• Diagnostic tests
- CSF studies: increased protein
- EMG: slowed nerve conduction
Medical Management
• Considered as medical emergency patient is managed in
the ICU
• Mechanical ventilation if respiratory problems present
• Plasmapheresis to reduce circulating antibodies
• Continuous ECG monitoring to detect alteration in heart
rate and rhythm
• Propranolol to prevent tachycardia
• Atropine may be given to prevent episodes of bradycardia
during endotracheal suctioning and physical therapy.
Nursing interventions
• Maintain adequate ventilation.
• Check individual muscle groups every 2 hours in acute
phase to check for progression of muscle weakness.
• Assess cranial nerve function: check gag reflex and
swallowing ability; ability to handle secretions; voice.
• Monitor vital signs and observe for signs of autonomic
dysfunction such as acute periods of hypertension
fluctuating with hypotension, tachycardia, arrhythmias.
• Administer corticosteroids to suppress immune reaction
as ordered.
• Administer antiarrhythmic agents as ordered.
• Prevent complications of immobility.
• Promote comfort (especially in clients with sensory
changes)
• Promote optimum nutrition.
- Check gag reflex before feeding.
- Start with pureed foods.
- Assess need for nasogastric tube feedings if unable to
swallow.
Amyotrophic Lateral Sclerosis (ALS)
- A disease of UNKNOWN cause in which there is loss of
motor neurons in the anterior horns of the spinal cord & the
motor nuclei of the lower brain stem
- Onset occurring usually in the 5th or 6th decade of life
 316 LECTURE: WK13 – PD, MS, MG
- Leading theory: overexcitation of nerve cells by
neurotransmitter glutamate leads to cell injury and
neuronal degeneration.
Pathophysiology
1) Motor neurons in the anterior horns of the spinal cord and
motor nuclei of lower brainstem dies.
2) Muscle fibers that they supply undergo atrophic changes.
3) Neuronal degeneration may occur in both upper and lower
neuron system
Diagnostic tests
• Diagnosed on the basis of the signs & sxs
• No clinical or lab test are specific for this disease
• EMG- may indicate reduction in the # of functioning motor
units
• MRI – may show high signal intensity in the corticospinal
tracts -differentiates it from a multifocal motor neuropahy
Symptoms
• Progressive weakness and atrophy of the muscles of the
arms, trunk, or legs
• Dysarthria, dysphagia
• Spasticity
• Fasciculations("muscle twitch") – a small, local,
involuntary muscle contraction visible under the skin
• DTRs becomes brisk and overactive
• Respiratory insufficiency
• 25% of patients: weakness starts in the muscles supplied
b the cranial nerves = difficulty talking, swallowing and
ultimately breathing
• Death usually occurs as a result of infection, respiratory
failure, or aspiration and generally occurs about 3 years
after the onset of the disease. Few patients survive for
longer periods.
Medical Management
• Drugs
- Riluzole (Rilutek)-glutamate antagonist; slows
deterioration of motor neurons
- Baclofen (Lioresal)/ Diazepam (Valium) -used to control
spasticity that interferes with ADL
- Quinine -relieve muscle cramps
• NGT feeding
J.A.K.E 2 of 3
• Cervical esophagostomy or gastrostomy to prevent
aspiration & for long-term nutritional support
• Mechanical ventilation if hypoventilation develops
Nursing interventions
• Provide nursing measures for muscle weakness and
dysphagia.
• Promote adequate ventilatory function.
• Prevent complications of immobility.
• Encourage diversional activities; spend time with the client.
• Provide compassion and intensive support to
client/significant others.
• Provide or refer for physical therapy as indicated.
• Promote independence for as long as possible.
Huntington’s Disease (HD) / Huntington’s Chorea (Dance)
- A chronic, progressive, hereditary disease of the nervous
system that results in slow progressive involuntary
choreiform movement and dementia
- Onset occurs between the ages of 35 & 45 years, though
10% of patients are children
- Affects men and women of all races
- Transmitted as an autosomal dominant genetic disorder:
each child of a parent w/ HD has a 50% risk of inheriting
the illness
Pathophysiology
1) Premature death of cells in the striatum, (caudate &
putamen) of the basal ganglia (for control of movts)
2) + loss of cells in the cortex (for thinking, memory,
perception & judgment)
3) + loss of cells in the cerebellum (for coordination)
4) Cells’ destruction results in lack of GABA & AcH
5) A ↓ in GABA & Ach (both excitatory neurotransmitters
leads to brisk, jerky, purposeless movements, particularly
the hands, face tongue and legs which the client is unable
to stop
- Accdg to researches, GLUTAMINE –building block for
protein abnormally collects in the cell nucleus, causing
cell death
- Reason that the protein destroys only certain brain cells is
UNKNOWN
Diagnostic tests
• clinical presentation of characteristic sxs
• (+) family hx
• CT & MRI - may show atrophy of the caudate nuclei once
the dse is well established
2 Main Symptoms
1) Progressive mental status changes leading to dementia
– significant loss of intellectual abilities such as memory
 316 LECTURE: WK13 – PD, MS, MG

capacity, severe enough to interfere with social or

occupational functioning
2) Choreiform movements (rapid, jerky movements) in the
limbs, trunk & facial muscles
- Other sxs: Emotional disturbance: fits of anger, suicidal
depression, impaired judgment & memory,
hallucinations, delusions & paranoid thinking
3 stages
• Onset of neurologic or psychological sxs
• ↑ng dependence on others for care
• Loss of independent functions
- Death follows from complications such as choking, fall,
infection, pneumonia or heart failure and generally
occurs 10-20 years after onset of the disease.
Medications
1) Phenothiazine – blocks dopamine receptors
2) Reserpine – depletes presynaptic dopamine
3) Tetrabenezine – reduces dopaminergic transmission
Nursing interventions
• Frequent assessment/ evaluation of patient’s motor signs
• Interact with the patient in a creative manner
• Learn how this particular patient expresses need and want

J.A.K.E 3 of 3