WEEK 10  Focal signs (related to site of infarction): hemiplegia, sensory

CVA AND SCI loss,

aphasia, homonymous hemianopsia

Cerebrovascular Accident (CVA) Diagnostic tests

- destruction (infarction) of brain cells caused by a reduction 1. CT and brain scan: reveal lesion
in cerebral blood flow and oxygen 2. EEG: abnormal changes
- affects men more than women; incidence increases with age 3.Cerebral arteriography: may show occlusion or malformation
- caused by thrombosis, embolism, hemorrhage of blood vessels

Risk factors:
-hypertension NURSING INTERVENTIONS:
-diabetes mellitus Acute stage
-arteriosclerosis/atherosclerosis 1. Maintain patent airway and adequate ventilation.
-cardiac disease 2. Monitor VS, neuro checks, observe for signs of increased ICP, shock,
(valvular disease/replacement, chronic atrial fibrillation, MI) hyperthermia, and seizures.
-life-style 3. Provide complete bed rest as ordered.
(obesity, smoking, inactivity, stress, use of oral 4. Maintain F& E balance and ensure adequate nutrition.
contraceptives)   IV therapy for the first few days
  NGT feedings - if unable to swallow
Every 45 seconds, someone in the United States has a stroke.   Fluid restriction as ordered - to decrease cerebral edema
A stroke can happen when: 5. Maintain proper positioning and body alignment.
•A blood vessel carrying blood to the brain is blocked by a   Head of bed may be elevated 30°-45° to decreased ICP
blood clot.   Turn and reposition every 2 hours (only 20 minutes on the
This is called an ischemic stroke. affected side)
  Passive ROM exercises every 4 hours.
6. Promote optimum skin integrity: turn client and apply lotion every 2
•A blood vessel breaks open, causing blood to leak into the
hours
brain.
7. Maintain adequate elimination.
This is a hemmorhagic stroke.
  Offer bedpan or urinal every 2 hours, catheterize only if
absolutely necessary.
If blood flow is stopped for longer than a few seconds, the brain
  Administer stool softeners and suppositories as ordered to
cannot get blood and oxygen.
prevent constipation and fecal impaction.
Brain cells can die, causing permanent damage.
8. Provide a quiet, restful environment.
9. Establish a means of communicating with the client.
Most common in…
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
PATHOPHYSIOLOGY: 
 interruption of cerebral blood flow for 5 minutes or more - Antihypertensives - if indicated for elevated blood pressure
causes death of neurons in affected area with irreversible loss
of function Rehabilitation
1. Hemiplegia: results from injury to cells in the cerebral motor cortex
STAGES OF DEVELOPMENT: or corticospinal
1. Transient ischemic attack (TIA) pathway
-warning sign of impending CVA a. Turn every 2 hours (20 minutes only on affected side)
-brief period of neurologic deficit b. Use proper positioning & repositioning to prevent deformities
(visual loss, hemiparesis, slurred speech, aphasia, vertigo) c. Support paralyzed arm on pillow or use sling while out of bed
-may last less than 30 seconds, but no more than 24 hours d. Elevate extremities to prevent dependent edema
with complete resolution of symptoms e. Provide active & passive ROM exercises every 4 hours
2. Susceptibility to hazards
2. Stroke in evolution a. keep side rails up at all times
-progressive development of stroke symptoms over a period b. institute safety measures
of hours to days c. inspect body parts frequently for signs of injury
3. Dysphagia (inability to swallow or difficulty in swallowing)
3. Completed stroke a. check gag reflex before feeding the patient
-neurologic deficit remains unchanged for a 2- to 3-day b. maintain calm, unhurried approach
period c. place in upright position
d. place food in unaffected side of mouth
e. offer soft foods
ASSESSMENT: f. give mouth care before and after meals
 Headache 4. Homonymous hemianopsia
 Generalized signs: vomiting, seizures, confusion, a. approach client on unaffected side
disorientation, b. place personal belongings, food on unaffected side
decreased LOC, nuchal rigidity, fever,hypertension, c. teach client by scanning
slow bounding pulse, Cheyne-Stokes respirations
5. Emotional lability : mood swings , frustration -fracture
a. create a quiet, restful environment with a reduction in -dislocation
excessive sensory stimuli 
b. maintain a calm, nonthreatening manner May affect anterior & posterior ligaments
c. explain to family that the client behavior is not purposeful -compression of spinal cord
6. Aphasia – most common in R hemiplegics bec. Left- 
hemisphere dominance for language May affect the spinal cord & its roots:
Receptive: -concussion
• give simple, slow directions -contusion
• give one command at a time; gradually shift topics -compression or laceration by fracture / dislocation
• use nonverbal techniques of communication -penetrating (ex. GSW, missile)
Expressive:
• listen & watch very carefully when client attempts to speak B. LEVEL OF
• anticipate clients need to decrease frustration & feelings of INJURY
helplessness Cervical
• allow sufficient time & client to answer Thoracic
7. Sensory/perceptual deficits- more common in left Lumbar
hemiplegics
-characterized by impulsiveness, unaware of disabilities, visual
neglect C. MECHANISM OF
a. assist with self-care INJURY
b. provide safetty measures Hyperflexion
c. initially arrange objects in env of unaffected side Hyperextension
d. gradually teach clients to take care of the unaffected side &
to turn frequently & look at affected side Axial loading
-force exerted straight up or down spinal column (ex. diving)
1. On admission, the patient’s vital signs were: temperature axial loading
99.4oF (37.4oC), pulse 97, respirations 27, blood pressure axial loading applied to intravertebral disc results in increased
240/120 mm Hg. Based on these assessments, what is the most pressure and stresses
probable cause of the CVA? a large central posterior- superior fragment occurs as a result of
A. Hypoglycemia B. Hypercholesterolemia C. Hypertension these forces
D. Kidney disease =fall from a height, landing on one's feet is typical of this fracture

2. In caring for patient during the acute phase of a cerebral PATHOPHYSIOLOGY

vascular accident. It is most important for the nurse to hemorrhage & edema  ischemia  necrosis & destruction of cord
maintain the patient’s...
A. respiratory function. C. musculoskeletal function. MEDICAL MANAGEMENT:
B. nutritional status. D. skin integrity  Immobilization & maintenance of normal spine alignment
-to promote fracture healing
3. The nurse is performing a neurological assessment on a
client post-right CVA. Which finding, if observed by the nurse, 1. Horizontal turning frame / Stryker frame
would warrant immediate attention? 2. Skeletal traction
A. loss of bladder control C. decrease in level of consciousness a. cervical tongs (Crutchfield)
B. altered sensation to stimuli D. emotional lability b. halo traction

4. A man who had a cerebral vascular accident develops Surgery

dysphagia. Before allowing the patient to eat, which of the 1. decompression laminectomy
following actions should the nurse take first? 2. spinal fusion
A. Check his gag reflex. C. Place him in high-Fowler’s position. -surgery is done to relieve pressure on the spinal cord
B. Order a soft diet. D. Offer to cut his food.

5. The bowel retraining program for a patient who has had a

CVA should include which of these measures?
A. checking for impaction daily
B. establishing a consistent time for elimination
C. utilizing incontinent pads until control is achieved
D. increasing the intake of milk products

SPINAL CORD INJURY

-trauma to the spinal cord which causes partial or
complete disruption of the nerve tracts & neurons ASSESSMENT:
1. Spinal Shock
Causes -occurs immediately after the injury as a result of the insult to the CNS
a. traumatic: motor vehicle accidents, diving in shallow water, -temporary condition lasting from several days to 3 months
falls, industrial accidents, sports injuries, gunshot or stab -characterized by:
wound  absence of reflexes below the level of lesion
b. non-traumatic: tumors, hematomas, aneurysms, congenital  flaccid paralysis
defects  lack of temperature control
 hypotension w/ bradycardia
SCI is classified according to:  retention of urine & feces
A. EXTENT OF INJURY
B. LEVEL OF INJURY
C. MECHANISM OF INJURY

May affect the vertebral column

 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
2. Level of Injury -change position slowly & gradually elevate the head of the bed to
prevent postural hypotension
a. quadriplegia -observe for signs of DVT
-cervical injuries (C1- 3. Maintain fluid & electrolyte balance & nutrition
C8)paralysis of all 4 -NGT may be inserted until bowel sounds return
extremities -maintain IV therapy as ordered
-respiratory paralysis -check bowel sounds before feeding
lesions above C6 -progress slowly from clear liquid to regular diet
(phrenic nerve at C4- -provide diet high in protein, CHO, calories
C5 level) =the nerve 4. Maintain immobilization & spinal alignment always
that governs -turn every hour on turning frame
movement of the -maintain cervical traction at all times if indicated
diaphragm during 5. Prevent complications of immobility
breathing 6. Maintain urinary elimination
b. paraplegia -provide intermittent catheterization or indwelling catheter
-thoracolumbar -increase fluids to 3000ml/day
injuries (T1- -provide acid-ash foods/ fluids to urine
L4)paralysis of the =a diet consisting largely of meat or fish, eggs, and cereals with a
lower half of the body minimal quantity of milk, fruit, and vegetables, that when catabolized
involving both legs leaves an acid residue to be excreted in the urine.
3. Extent of injury 7. Maintain bowel elimination
a. complete cord transection 8. Monitor temperature control
- -loss of all voluntary movement and sensation below the level 9. Observe for & prevent infection
of injury 10. Observe for & prevent stress ulcers
b. incomplete lesions
-varying degrees of motor or sensory loss between the level of Laboratory for Wellness and Motor Behavior
the lesion depending on which neurologic tracts are damaged &
which are spared

Chronic Care
NEUROGENIC BLADDER
a. 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
 intermittent catheterization every 4 hours and gradually
progresses to every 6 hours
NURSING INTERVENTION:  regulate fluid intake to 1800-2000 ml/day
Emergency Care  bladder taps  to cause reflex emptying of the bladder
1. Assess ABC
-do not move patient during assessment b. Reflex or upper motor neuron bladder / UMN bladder
-if airway obstruction or inadequate ventilation exists; do not -reflex activity of the bladder may occur after spinal shock resolves
hyperextend neck to open airway, use jaw thrust -bladder is unable to store urine very long and empties voluntarily
2. Perform a quick head to toe assessment; check for LOC, signs -Failure to Store (Incontinence)
of trauma; check for leakage of fluid from ear -lesion: Above Sacral Micturition Center (above S2)
3. Immobilize client
4. Assist in immobilizing head and neck with cervical collar &
place on spinal board; avoid flexion of the spinal column Chronic Care
AUTONOMIC DYSREFLEXIA
Acute Care:   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
  administer antihypertensives (e.g. hydralazine HCl
[Apresoline]) as ordered

MEDICATIONS:
1. Dexamethasone (Decadron)
Pathophysiology
-used for its anti-inflamm & edema reducing effects
-Disorder causes degeneration of the dopamine-producing neurons in
-may interfere with healing
the substantia nigra in the midbrain
2. Dextran (plasma expander)
-Dopamine influences purposeful movement
-used to increase capillary blood flow within the spinal cord
-Depletion of dopamine results in degeneration of the basal ganglia.
and to
prevent / treat hypotension
therefore…
3. Dantrolene (Dantrium) , Baclofen (Lioresal)
-used for clients with upper motor neuron injuries to control
Parkinson’s Disease (PD) / Paralysis agitans
muscle
-A progressive disorder with degeneration of the nerve cells in the
spasticity
basal ganglia resulting in generalized decline in muscular function;
disorder of the extrapyramidal system (neural network located in the
PRACTICE QUESTIONS:
brain that is part of the motor system involved in the coordination of
1. Most common cause of spinal cord injury
movement)
A. Sports B. Falls C. Violence related D. Vehicle crashes
-Usually occurs in the older population: sxs occur during the 5th
decade of life some diagnosed at age 30
2. Which of the following actions would a nurse take when
-Affects men more frequently than women
caring for a patient who is brought to the emergency
department with a potential spinal cord injury?
Cause: UNKNOWN ; predominantly idiopathic
A. Taping the patient’s eyelids closed
but sometimes disorder is postencephalitic, toxic, arteriosclerotic,
B. Elevating the head of the patient’s bed.
traumatic, or drug induced ( reserpine, methyldopa [Aldomet],
C. Placing the patient in a side-lying position
haloperidol [Haldol], phenothiazines )
D. Maintaining the patient’s neck in extension.
Dxtic tests: not helpful ...PET used only for evaluating levodopa uptake
3. Which assessment indicates that the spinal shock is
==diagnosed clinically from patient’s hx, presence of 2 of the 3 cardinal
resolving?
sxs, neuro examinations
A. flaccid paralysis C. return of sensations
B. atonic urinary bladder D. return of reflexes
Assessment findings
 Tremor:-mainly of the upper limbs -"pill-rolling"
4. A patient who has a spinal cord injury reports symptoms of
-resting tremor; most common initial symptom
autonomic dysreflexia to a nurse. Which of the following
 Rigidity: cogwheel type
assessments should the nurse make immediately?
 Bradykinesia: slowness of movement
A. pedal pulses B. pupillary response C. breath sounds D. skin
 Fatigue
inspection
 Stooped posture; shuffling, propulsive gait
 Difficulty rising from sitting position
5. A hospitalized patient who has a spinal cord injury reports
 Masklike face with decreased blinking of eyes
an acute, pounding headache. Which of the following actions
 Quiet, monotone speech
should the nurse take first?
 Emotional lability, depression
A. suction the patient C. raise the head of the bed
 Increased salivation, drooling
B. institute seizure precautions D. administer an analgesic as
 Cramped, small handwriting
ordered
 Autonomic symptoms:
-excessive sweating -constipation
-seborrhea -decreased sexual capacity
-lacrimation
a. Parkinson’s Disease (PD)
The basal ganglia are a collection of nuclei deep to the white Nursing interventions
matter of cerebral cortex.  Administer medications as ordered
The name includes: caudate, putamen, nucleus accumbens, 1. Antiparkinsonian: Levodopa (Dopar, Larodopa)
globus pallidus, & substantia nigra rostral section -increases level of dopamine in the brain; relieves tremor, rigidity, and
: caudal section:middle section: 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) -Cause UNKNOWN; may be a slow-growing virus or possibly of
-contraindications: autoimmune origin
>avoid multiple vitamin preparations containing vitamin B6 -Characterized by remissions and exacerbations
(pyridoxine) and
foods high in vitamin B6 (tuna, pork, dried beans, salmon) Pathophysiology
>avoid Tyramine rich foods ( cheese, yogurt, coffee, raisins, Sensitized T cells that would typically cross the blood-brain barrier to
sausage, red wine, beer)=may cause hypertensive crisis check for antigens in the CNS and then leave;
>administer with food or snack to decrease GI irritation. in MS would remain in the CNS

2. Carbidopa (Sinemet): prevents breakdown of dopamine in Promote infiltration of other agents that damage the immune system
the periphery and causes fewer side effects. 
Immune system attack leads to inflamm that destroys myelin and
3. Antiviral: Amantadine (Symmetrel): oligodenroglial cells
-used in early/mild cases to reduce rigidity, tremor, and
bradykinesia Major Types:
-act by releasing dopamine from neuronal storage sites 1. Relapsing-remitting MS (RRMS)=85%of cases
-relapses develop over 1-2 weeks & resolve over 4-8 months then
4. Anticholinergic: Benztropine mesylate (Cogentin), returns to baseline.
procyclidine -50% may develop secondary progressive MS within 10 yrs; 90%
(Kemadrin) develop it within 25 yrs
-inhibit action of acetylcholine
-used in mild cases or in combination with Levodopa 2. Progressive-relapsing MS (PRMS)=5% of cases
-relieve tremor and rigidity -absence of remission & client’s condition does not return to baseline
-side effects: dry mouth, blurred vision, constipation, urinary -progressive, cumulative sxs & deterioration occur over several yrs
retention
3. Primary progressive MS (PPMS)=onset tend to be bet 40&60 years
5. Dopamine agonist: Bromocriptine mesylate (Parlodel) of age
-stimulates release of dopamine in the substantia nigra -steady, gradual neurologic deterioration w/o remission of sxs
-often employed when Levodopa loses effectiveness -progressive disability with no acute attacks

6. Tricyclic antidepressants given to treat depression 4. Secondary progressive MS (SPMS)

7. Antihistamines have mild central anticholinergic & sedative -begins with RRMS course that later becomes steadily progressive
effects & may reduce tremors -attacks & partial recoveries may continue to occur

Provide a safe environment. Diagnostic tests:

-Side rails on bed; rails and handlebars in toilet, bathtub, and CSF studies: increased protein and IgG (immunoglobulin)
hallways; EEG: abN
no scatter rugs CT scan: increased density of white matter
-Hard-back or spring-loaded chair to make getting up easier MRI: shows areas of demyelination

Provide measures to increase mobility. Symptoms:

-Physical therapy: active and passive ROM exercises; stretching  1st sx: visual disturbances: blurred vision, scotomas (patchy
exercises; warm baths blindness), diplopia
-Assistive devices  Impaired sensation: touch, pain, temperature, or position sense;
If client "freezes," suggest thinking of something to walk over.  numbness, tingling
 Impaired motor function: weakness, paralysis, spasticity
Improve communication abilities: instruct client to  Impaired cerebellar function: scanning speech, ataxic gait,
practice reading aloud, nystagmus,
to listen to own voice, and enunciate each syllable clearly.  dysarthria, intention tremor
 Euphoria or mood swings
Maintain adequate nutrition.  Bladder: retention or incontinence
-Cut food into bite-sized pieces.  Constipation
-Provide small, frequent feedings.  Sexual impotence in the male
-Allow sufficient time for meals, use warming tray.
Nursing interventions
b. Multiple Sclerosis (MS)  Promote optimum mobility.
= results in impaired transmission of nerve impulses 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.
therefore...Multiple Sclerosis (MS) Avoid heating pads, hot-water bottles.
-An immune-mediated progressive demyelinating disease of Inspect body parts frequently for injury.
the CNS which results in impaired transmission of nerve Make frequent position changes.
impulses
-Typically present in young adults 20-40  Prepare client for plasma exchange (to remove antibodies) if
-Affects women more than men indicated
-More frequent in cool or temperate climates
Plasmapheresis
This treatment — also known as plasma exchange — is a type Assessment findings
of Ptosis, diplopia , dysphagia
"blood cleansing" in which damaging antibodies are removed Extreme muscle weakness, increased with activity and reduced with
from rest
your blood.
(identifying characteristic)
Plasmapheresis consists of removing the liquid portion of your Masklike facial expression
blood Weak voice, hoarseness
(plasma) and separating it from the actual blood cells.
The blood cells are then put back into your body, which Diagnostic tests
manufactures Tensilon test: IV injection of Tensilon provides spontaneous relief of
more plasma to make up for what was removed. symptoms
It's not clear why this treatment works, but scientists believe (lasts 5-10 minutes)
that Electromyography (EMG): amplitude of evoked potentials decreases
plasmapheresis rids plasma of certain antibodies that rapidly
contribute to the Presence of anti-acetylcholine receptor antibodies in the serum
immune system attack on the nerves
TENSILON TEST
c. Myasthenia Gravis (MG) 1. performed to diagnose myasthenia gravis
a. Tensilon (edrophonium chloride – anticholinesterase) 2mg are
injected IV, if no response after 30 secs, the remaining 8mg are
injected
(+) test : reveals an  in muscle strength (reduction of eyelid ptosis)
within 1min, weakness returns w/in 5-30 mins.

Tensilon(edrophonium)a medication that blocks the action of the

enzyme that breaks down the transmitter acetylcholine is given, muscle
function may improve.

(-) test: client shows no improvement & strength may deteriorate

2. to differentiate myasthenic crisis and cholinergic crisis

Myasthenia Gravis (MG)
-A neuromuscular disorder in which there is a disturbance in myasthenic crisis: Tensilon is administered & if strength improves,
the transmission of impulses from nerve to muscle cells at the the client needs more medication
neuromuscular junction (PNS), causing extreme muscle cholinergic crisis: Tensilon is administered & if weakness is more
weakness severe, the client is overmedicated, administer atropine sulfate
-Highest between ages 15-35 for women, over 40 for men.
-Affects women more than men Medical management
Drug therapy
-Cause: thought to be autoimmune disorder whereby a. Anticholinesterase drugs:neostigmine bromide (Prostigmin),
antibodies destroy acetylcholine receptor sites on the pyridostigmine bromide (Mestinon), edrophonium chloride (Tensilon)
postsynaptic membrane of the neuromuscular junction. -block action of cholinesterase and increase levels of acetylcholine at
-Voluntary muscles are affected, especially those muscles the neuromuscular junction
innervated by the cranial nerves. -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

Nursing interventions
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.
The first noticeable symptoms of myasthenia gravis may be
weakness of the eye muscles, difficulty in swallowing, or
slurred speech.
 (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

and patient is managed in the ICU
 Mechanical ventilation if respiratory
problems present
 Plasmapheresis to reduce circulating
antibodies
Promote optimal nutrition.
 Continuous ECG monitoring to detect
-Mealtimes should coincide with the peak effects of the drugs:
alteration in heart rate and rhythm
give medications 30 minutes before meals.
 Propranolol to prevent tachycardia
-Check gag reflex and swallowing ability before feeding.
 Atropine may be given to prevent
-Provide a mechanical soft diet.
episodes of bradycardia during
-If the client has difficulty chewing and swallowing, do not
endotracheal suctioning and physical
leave alone at mealtimes
therapy.
-Keep emergency airway and suction equipment nearby.
Nursing interventions
WEEK 11 -Maintain adequate ventilation.
GUILLAIN BARRE SYNDOME & -Check individual muscle groups every 2 hours in acute phase to check
POLYRADICULONEURITIS 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)

PATHOGENESIS
-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
-Affects more men than
women

Pathophysiology
Motor neurons in the anterior
horns of the spinal cord and
motor nuclei of lower brainstem
dies.


Muscle fibers that they supply

undergo atrophic changes.

Assessment findings
-Mild sensory changes; in some clients severe Neuronal degeneration may
misinterpretation of occur in both upper and lower
sensory stimuli resulting in extreme discomfort neuron system
-Clumsiness: usually first symptom
-Progressive motor weakness in more than one limb
Leading theory: overexcitation of nerve cells by
neurotransmitter glutamate leads to cell injury and neuronal HUNTINGTON’S DISEASE (HD) ; HUNTINGTON’S
degeneration.
CHOREA (dance)
Dxtic tests: -A chronic, progressive, hereditary disease of the nervous system that
diagnosed on the basis of the signs & sxs results in slow progressive involuntary choreiform movement and
no clinical or lab test are specific for this disease dementia
EMG- may indicate reduction in the # of functioning motor -Onset occurs between the ages of 35 & 45 years, though 10% of
units patients are children
MRI -may show high signal intensity in the corticospinal tracts -Affects men and women of all races
-differentiates it from a multifocal motor neuropahy -Transmitted as an autosomal dominant genetic disorder: each child of
a parent w/ HD has a 50% risk of inheriting the illness
Symptoms:
Pathophysiology
 Progressive weakness and atrophy of the muscles of the
Premature death of cells in the striatum, (caudate & putamen)
arms, trunk, or legs
of the basal ganglia (for control of movts)
 Dysarthria, dysphagia

 Spasticity
 Fasciculations("muscle twitch")
+ loss of cells in the cortex (for thinking, memory, perception &
-a small, local, involuntary muscle contraction visible under
judgment)
the skin

 DTRs becomes brisk and overactive
 Respiratory insufficiency
+ loss of cells in the cerebellum (for coordination)

25% of patients: weakness starts in the muscles supplied b the
cranial nerves Cells’ destruction results in lack of GABA & AcH
= difficulty talking, swallowing and ultimately breathing 

Death usually occurs as a result of infection, respiratory failure, A decreased in GABA & Ach (both excitatory neurotransmitters leads
or aspiration and generally occurs about 3 years after the onset to brisk, jerky, purposeless movements, particularly the hands, face
of the disease. Few patients survive for longer periods. tongue and legs which theclient is unable to stop

Accdg to researches, GLUTAMINE –building block for protein

Medical Management abnormally collects in the cell nucleus, causing cell death
-Drugs
> Riluzole (Rilutek)-glutamate antagonist; slows deterioration Reason that the protein destroys only certain brain cells is UNKNOWN
of motor neurons
> Baclofen (Lioresal)/ Diazepam (Valium) -used to control Dxtic tests:
spasticity that interferes with ADL clinical presentation of characteristic sxs
> Quinine -relieve muscle cramps (+) family hx
-NGT feeding CT & MRI - may show atrophy of the caudate nuclei once the dse is
-Cervical esophagostomy or gastrostomy well established
to prevent aspiration & for long-term nutritional support
-Mechanical ventilation if hypoventilation develops 2 Main Symptoms:
 progressive mental status changes leading to dementia
Nursing interventions =significant loss of intellectual abilities such as memory capacity,
 Provide nursing measures for muscle weakness and severe enough to interfere with social or occupational functioning
dysphagia.  choreiform movements (rapid, jerky movements) in the limbs, trunk
 Promote adequate ventilatory function. & facial muscles
 Prevent complications of immobility.
 Encourage diversional activities; spend time with the Other sxs:
client. -emotional disturbance: fits of anger, suicidal depression, impaired
 Provide compassion and intensive support to judgment & memory, hallucinations, delusions & paranoid thinking
client/significant others.
 Provide or refer for physical therapy as indicated. 3 stages:
 Promote independence for as long as possible. • Onset of neurologic or psychological sxs
• increase in dependence on others for care
===also called LOU GEHRIG’S DISEASE after the famous • Loss of independent functions
baseball player who suffered from it
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

FINAL STAGES
Deborah Martin is in the final stages of Huntington's Disease.
She is in a wheelchair and rarely leaves the nursing home.
She can't walk, talk or feed herself.

A feeding tube has been keeping her alive for the last three+
years.

Shana Martin with her Mom .

She chatted, laughed and held her mother's hand.

"She doesn't make eye contact," Shana Martin said.

"She doesn't talk. She does seem more alert when we're
around but the final stages of Huntington's. . . .you are very
rigid.
You're just kind of curled up in a ball basically.