Test 6: Intracranial / Emergency Nursing (Mod 11 & 12)

Infectious Neurological Disorders:

●​ Meningitis
○​ Inflamed meninges that cover the brain and spinal cord
○​ Caused by bacteria and viruses
●​ Encephalitis
○​ Inflammation of the brain tissue
○​ Caused by bacterial or viral, auto-immune, insect bites
○​ HSV or HIV infection
○​ infectious encephalitis
○​ Auto-immune encephalitis
○​ Tx:
■​ Antivirals, antibacterials, anti-inflammatory, anticonvulsants
●​ Brain abscess
○​ Caused by bacteria or fungus
●​ Creutzfeldt-jakob disease
○​ Rare disease caused by prions
○​ Infectious agents that have no DNA material

Meningitis: Inflammation of the meninges (Any pathogen that can affect these)
●​ Causes
○​ Types:
■​ Bacterial: from Strep pneumoniae, or Neisseria Meningitidis
●​ Usually SUDDEN in onset
●​ Usually septic in nature
●​ Non-modifiable risk factors:
○​ Seen in younger <1 or older >60 y.o
●​ Common risks:
○​ Diabetes, HIV, Cirrhosis, CKD, Spina bifida
○​ Sinusitis, Otitis, Mastoiditis, Neurosurgery or skull
fractures.
●​ Easily spread in crowded environments like college dorms
●​ Septic caused by bacteria (Strepto pneumoniae, Neisseria
meningitidis)
■​ Viral: Aseptic caused by viral infection secondary to cancer or a weak
immune system.
●​ S/S:
○​ Usually presents with a Triad of symptoms
■​ Fever, Headache, Neck stiffening (nuchal rigidity)
○​ Photophobia
○​ N/V , muscle pain
○​ Positive kernig's sign
■​ Flex leg at hip & knee, try to extend leg = pain, spasm
○​ Positive brudzinski sign
■​ Lying supine, flex neck towards chest = pain, will flex hip and knees
○​ Rash - for meningococcal
■​ Petechiae and purpura
○​ Complications can arise that cause Meningoencephalitis leading to. (VERY
SERIOUS)
■​ Change in LOC or behavior, may be accompanied by seizures

●​ Recap on S/S
○​ Meningitis usually presents with a triad of symptoms such as Fever, headache,
and Stiffening of the neck aka (Nuchal rigidity); Patients may also show signs
of Photophobia, N/V, Rashes and muscle pain. A doctor will do some physical
exam testing that includes a kernig's test this is done by taking the patients leg
and trying to flex the leg towards the chest at a 90 degree angle. A positive result
causes pain and muscle spasms. Another test is called the Brudzinski test. This
test is done by flexing the client's neck towards the chest, a positive result
causes the client extreme pain and the client will passively flex their hips and
knees to compensate for the pain.
○​ Patients may also show signs of Change in LOC or behavior and can be
accompanied by Seizures and this is because of complications by
meningoencephalitis

●​ Complications
○​ Stroke, Increased ICP, and Brain herniation (most common cause of death)
○​ Bacterial Meningitis is usually spread via homogeneous route and leads to septic
shock which can lead to DIC

●​ Labs​
○​ CBC (increased Neutrophils)
○​ Blood cultures (Important to check for sepsis)
○​ PT, INR (Coagulation studies)
○​ Electrolyte panel (Hyponatremia <135)
●​ DX:
○​ CT head, MRI brain
○​ CXR
 ○​ LP: Important diagnostics
■​ CSF shows
●​ Elevated WBC (neutrophils), Proteins
●​ Decreased Glucose
■​ Lumbar puncture may be contraindicated if the patient has cerebral
edema because it can further raise ICP
●​ Tx: IMPORTANT: we need meds that can pass through the blood brain barrier
○​ IV steroids to reduce inflammation
■​ Dexamethasone
○​ IV Antibiotics - start as soon as possible for better prognosis
■​ Penicillin G and a cephalosporin (rocephin)
■​ Or broad spectrum vancomycin
○​ Analgesics, antipyretics
○​ IV fluids for patients with a fever
○​ Increasing ICP can cause seizures patients will usually receive
■​ Anticonvulsants and Mannitol
○​ Anticoagulants for VTE prevention

○​ If shock occurs; Fluid boluses, and Ventilation

○​ Supportive care
■​ Low stimulation environment, limit visitors
■​ Padded side rails - seizure
○​ Immobility complications
■​ Atrophy, contractures, pressure sores

Brain Abscess
●​ Collection of pus in brain
○​ Bacteria is the most common cause
■​ Can occur from otitis media,
■​ Dental infection
■​ Rhinosinusitis
■​ Result of trauma to brain/face
●​ Location
○​ Frontal-temporal
○​ Parietal
○​ Cerebellar and occipital areas
●​ Characteristics
○​ Areas of brain become necrotic
●​ S/S:
○​ Headache (worse in the morning due to increased ICP during bedtime)
○​ Fever
○​ Mental status changes
○​ N/V
 ○​ Visual / speech problems
●​ Dx:
○​ CT head, MRI brain
○​ CBC, blood cultures, H&H, PLT, ESR, CRP
○​ CT guided aspirations is a biopsy that will identify exact organism, can drain
abscess at same time as bx
●​ Tx:
○​ Control ICP and drain abscess
○​ Broad spectrum abx
○​ Antifungals (if caused by fungal)
○​ Analgesics, antipyretics, steroids, anticonvulsants
○​ Watch for S/S of increased ICP due to more inflammation and growing abscess
●​ Nursing interventions:
○​ Frequent neuro assessments and reassessments to interventions
○​ Supportive measures

Encephalitis
●​ Severe and acute inflammation of brain tissue, A pathogen will spread to the brain and
once it reaches the brain it will multiply, after it multiplies the brain starts an inflammatory
response causing edema which decreases blood flow to the brain. Affecting movement,
move, and behavior.
○​ Most common from virus (HSV)
○​ Vector-borne (west nile)
○​ Rabies, Mumps, Measles
○​ Fungal infections
●​ Complications
○​ Brain abscess, Intracerebral hemorrhage
○​ Long term complications; Extensive brain damage
●​ Risk factors
○​ <1 or 55>y.o
○​ Immunocompromised, HIV, or places with tics
●​ S/S:
○​ Initial symptoms are in triad formation
■​ Fever, Fatigue, headache
○​ Signs of Increased ICP
■​ Vomiting
■​ Cushing's triad (Irregular respirations, Bradycardia, Wide PP)
○​ Signs of Meningeal irritation
■​ Stiff neck (Nuchal rigidity)
■​ Kernigs and Brudzinski signs
○​ Signs of LOC changes
■​ Confusion, Behavior, Mood, hallucinations
○​ Signs of Motor issues
 ■​ Tremors and muscle weakness
○​ Long term issues
■​ Seizures
■​ Neurological deficits (hemiparesis)

●​ Diagnostics: Starts with a History and Physical assessment

○​ Head CT or MRI
■​ To reveal Brain edema
■​ Also to reveal a brain abscess (Ring enhancing lesion, with central
necrosis)
■​ Used to rule out other conditions such as: Stroke or brain tumor
○​ LP: Done to check WBC, Protein, Glucose, and gram stain(follow table below)
Viral Infection encephalitis CSF Bacterial Infection encephalitis CSF

CSF is CLEAR CSF is CLOUDY

increased wbc and protein Increased wbc and protein

Normal glucose DECREASED glucose

○​ Polymerase Chain Reaction test (PCR) to identify the virus

○​ Fundoscopy of the eye to reveal papilledema (swelling of the optic disc)
○​ CBC, Blood Cultures, CMP
○​ EEG if the patient had a seizure
●​ Tx:
○​
Corticosteroids to decrease the brain edema
○​
Anti-Viral (Acyclovir) is also started
○​
If its fungal related (amphotericin)
○​
Additional treatment for relieving symptoms
■​ Analgesics: To reduce fever and headache
■​ Anticonvulsants (valproic acid) for seizures
■​ Osmotic diuretics (mannitol) for Increased ICP
■​ Antipsychotics for clients with Behavioral changes
●​ Nursing Care
○​ Closely monitor Neuro status
○​ Supportive care
■​ Quiet non stimulating environment
■​ Seizure precautions
■​ Supportive fluids for fever
■​ Administer medications
●​ Analgesics, Anti-Viral, Corticosteroids, and Anti-Seizure meds
○​ Report to HCP immediately if noticing (means condition is worsening)
■​ Decreased LOC, Confusion, or agitation
■​ Seizure, Vomiting, Blurred vision
○​ Positioning and Increased ICP medication
 ■​ HOB 30 degrees, keep the neck midline
■​ If ICP is increased, be prepared to administer mannitol
●​ Client and family teaching
○​ Explain the diagnosis
○​ Explain the treatment plan above
○​ Take prescribed medication EXACTLY as prescribed
○​ Rest and activity at home
■​ Increase activity slowly
■​ Stay AWAY from work and school until the HCP says its okay to return
○​ Important to go to all follow up appointments
○​ Preventative measures
■​ Protect from mosquitoes or tick bites (repellant when outdoors)
○​ Stay up to date on all vaccinations

Creutzfeldt-Jakob Disease & Variant

●​ Characteristics
○​ Degenerative infectious disorder
○​ TSE: transmissible spongiform encephalopathies
○​ Rapidly progressing, fatal, rare
○​ Caused by prions - resistant to tx
○​ Unknown cause - genetic mutations
○​ 4-5 mo life expectancy
○​ S/S:
■​ Muscle twitching
■​ Personality changes - poor judgement
■​ Visual probs, insomnia, depression
■​ As disease progresses - go blind, seizures, unable to speak, coma, death
●​ Variant disease
○​ Aka mad cow disease - due to ingesting contaminated beef products
○​ 13-14 mo life expectancy
○​ S/S:
■​ Psychiatric symptoms
■​ Persistent painful sensory symptoms
■​ After few months - dementia, poor coordination, muscle jerks
■​ Overactive reflex responses
●​ Dx:
○​ Brain biopsy, brain MRI, EEG
●​ Tx:
○​ No tx, is fatal
○​ Supportive & palliative care
○​ Standard precautions
■​ Handle spinal fluid with special care
Cranial Nerve Disorders:
●​ Trigeminal neuralgia (tic douloureux)
○​ Affects 5th cranial nerve
■​ More common in women, 50-60 yo
■​ Common in those with MS
○​ Symptoms
■​ Severe, disabling pain (typically unilateral)
■​ Paroxysmal - sudden onset, but then goes away.
■​ Occurs w/ stimulation
●​ washing face, eating, draft of air, brushing teeth, smiling
■​ Lasts 1-15 mins, becomes more frequent
■​ Important to note!!!
●​ Since patients often feel the pain from stimulation of eating,
brushing their teeth, or washing their face; they often will have
poor hygiene and their teeth may be discolored or have debris due
to not wanting to brush their teeth. They also may show signs of
decreased skin turgor and dry oral mucous membranes from not
wanting to drink.
○​ Causes
■​ Demyelination of compressed trigeminal nerve
○​ Diagnostics
■​ Usually just a history
■​ No lab or diagnostic can diagnose this
○​ Tx:
■​ Anticonvulsant Carbamazepine is the FIRST LINE
■​ May add phenytoin, gabapentin, baclofen
■​ Microvascular decompression surgery of trigeminal nerve
●​ Decreases inflammation of the nerve (crani sx)
■​ Radiofrequency thermal coagulation
●​ Heat that interferes with pain signals
■​ Percutaneous balloon microcompression
●​ Compress trig nerve to disrupt pathway that causes pain
●​ More seen in those w/ MS
○​ Nursing interventions
■​ Pain control and hygiene for normal daily living
●​ Education on decreasing triggers
●​ Eat small frequent meals high in calories and protein
○​ Select foods that are easy to chew
●​ Warm water on soft cotton to clean face
●​ Avoid hot and cold
●​ Education on regular oral hygiene is important
○​ Small soft bristled toothbrush instead
Bell's palsy
●​ Facial paralysis by inflammation of cranial nerve 7 - Facial
○​ Will subside 80-90%
○​ Sudden onset
●​ Risk factors
○​ Exact cause is Unknown
○​ Believed that HSV, FLU and Epstein barr virus plays a role
●​ Diagnostics
○​ History and physical
○​ MRI to rule out brain tumor
○​ EMG to test muscles
●​ S/S:
○​ Being SUDDENLY
○​ Unilateral paralysis of ALL muscles on that side
○​ Facial distortion
○​ Dryness of the eye and mouth of affected side
○​ Difficulty with speech and eating
○​ Since this is involving the facial CN
■​ Painful sensations in the face, numbness
■​ Loss of taste on the side of the tongue
●​ Treatment
○​ Most cases will resolve on their own with in 6 months
○​ Corticosteroids to reduce inflammation
○​ NSAIDs, artificial tears
○​ maybe antiviral (acyclovir) since HSV or flu could be involved

●​ Nursing interventions:
○​ Exercise facial muscles to maintain muscle
○​ Protect eye from injury, cover w/ shield
○​ Provide support for the client and encourage them to express any anxiety or
feelings
●​ Client and family teaching
○​ Explain the diagnosis
○​ Reassure in most cases the symptoms will resolve within several months
○​ Emphasize following up with scheduled appointments
○​ Patient can apply moist heat to help pain and discomfort
○​ Education for eating
■​ Chew on the NON-Affected side
■​ Choose soft foods, maintain good oral hygieen
○​ Importance of protecting the eyes and eye care
■​ Moisturizing medications and protective eyewear
■​ Client may close their eye manually throughout the day to mimic blinking
 ■​ At night, Apply moisturizing ointment, Tape eyelid shut, and apply a
patch/shield
■​ Contact HCP immediately if feelings of
●​ Itching, pain, vision loss, gritty feeling in the eyes

Peripheral Neuropathy:
●​ Refers to many conditions of peripheral nervous system
●​ s/s:
○​ Painful, burning pain
○​ Paresthesias numbness and tingling
○​ Starts in distal parts (of feet) first
●​ Diabetic neuropathy
○​ Due to poor glycemic control
○​ Diabetic education!! Control BG
○​ Neuropathy is irreversible
○​ High fall risk, risk for infection to unknown wounds
●​ Dx:
○​ EEG
○​ H & p

Neurological Autoimmune Disorders:

●​ Multiple sclerosis
●​ Myasthenia gravis
●​ Guillain-barre

Multiple Sclerosis:
●​ Immune-related demyelination of the CNS (VERY SLOW PROGRESSION)
○​ The below genetic and environmental risk factors cause the body's own immune
cells to activate, they travel to the the CNS and target the Myelin sheath of
neurons
○​ As inflammation increases it can start to affect the axon terminal itself and impair
nerve impulses causing issues with
■​ Sensory motor and cognitive problems
●​ Risks
○​ Exact cause is unknown
○​ Linked to Genetic and environmental factors
■​ Genetic
●​ Family history, more common in women
■​ Environmental
●​ Infections(epstein barre), smoking, cold climates, VIT D deficiency
 ●​ S/S:
○​ Initial symptoms are called Charcot's neurologic triad
■​ Dysarthria(slurred speech), Nystagmus, intention tremors
○​ Fatigue, Most disabling
○​ Numbness, weakness
○​ Loss of sensation and coordination
○​ Visual problems
○​ Impaired bowel and bladder function
○​ Lhermitte sign
■​ Electric shock like feeling going down spine, radiating to arms and legs
■​ Occurs when head flexes towards chest

Courses of MS and Relapses

Relapsing-Remitting Symptoms develop but resolve in weeks to months and the client goes into partial or complete
remission

Primary-progressive Steady neurologic deterioration occurs without any remission

Progressive-relapsing Relapses with continuous disabling progression between exacerbations

Relapse meaning Defined as neurologic symptoms that occur due to no other reasons than MS

Neurological disturbance lasts more than 24 hrs

●​ Complications (COME BACK TO THIS)

○​ Spinal cord injuries due to CSF drainage
○​ Aspiration (due to dysphagia)
○​ Incontinence, risk for falls
○​ Presbyopia, nystagmus
○​ Cognitive problems
 ○​ Osteoporosis
○​ UTI - bladder/bowel issues
○​ Pressure ulcers, contractures, pneumonia
●​ Deficits
○​ Clonus
○​ Babinski sign “upgoing toes”
○​ Cerebellar tremor (finger to nose)
○​ Spasticity (use baclofen)
●​ Dx:
○​ History and physical, along with neurological exam
○​ No definitive diagnostic tests can diagnose this
○​ MRI of the brain and spine- can see plaques in CNS
○​ Visual Evoked Potential (VEP) may be done for response to visual stimuli
○​ Electrophoresis of CSF
●​ Treatment: NO CURE
○​ Immunomodulators
■​ Interferon 1a injection
●​ Rebif
●​ Side effects: flu-like symptoms, hepatotoxic, fetal abnormalities
■​ Interferon 1b injection
●​ Betaseron
●​ Flu like side effects
■​ Glatiramer injection
■​ Fingolimod oral medication
●​ Used for relapses
●​ Contraindicated: MI < 6 mo, stroke, angina
●​ Side effects: bradycardia, elevated LFT
○​ Immunosuppressant
■​ Mitoxantrone
●​ Used in worsening RRMS
●​ Side effects: blue/green urine, bone marrow suppression,
infection, uti, nausea
○​ Tylenol and Ibuprofen can help manage side effects
○​ If spasticity occurs use baclofen
○​ Plasmapheresis to help get rid of antibodies if meds dont work
○​ Improve sensory, motor, and cognitive symptoms
■​ PT, OT, SLP
■​ Deep brain stimulation
■​ Dorsal column electrical stimulation
●​ Nursing interventions:
○​ Assess current level of Neuromuscular function
○​ Administer prescribed medications
○​ Prevention of complications of exacerbation
 ■​ Institute fall precautions and collaborate with Physical therapy on
Stretching and ROM exercises to strengthen muscles
○​ Assist patient to turn Q2 to prevent pressure ulcers
○​ To prevent aspiration implement swallow precautions and reach out to SLP for a
swallow assessment and individualized dysphagia diet
○​ Keep an eye bladder function; Intake and out
■​ If urinary retention perform a bladder scan and report to HCP
■​ Straight cath patient as ordered
○​ Keep an eye on bowel function
■​ Auscultate bowel sounds
■​ Monitor for distention
○​ Avoid hot temperatures: This is what mainly brings on fatigue

●​ Client and family teaching

○​ Review diagnosis
○​ Take prescribed meds EXACTLY as prescribed
○​ Decrease exacerbation by frequent hand washing, avoiding large crowds, and
people who are sick
○​ Moderate activity is a good thing to improve muscle spasticity and improve
coordination just don't do TOO much
■​ As discussed TOO much physical activity and exercise can increase body
temperature and cause a lot of fatigue and lead to an exacerbation
○​ Alternate Moderate activity with rest this is very important
○​ Adequate sleep each night is also very important
○​ Education on when starting ANY new medication OR supplement it is important
to discuss this with your HCP as some medications may trigger an exacerbation
○​ Avoid extremes of heat and cold
○​ Important to identify individual triggers
○​ Seek immediate medical care if the patient cannot move, becomes confused,
double vision or loss of vision occurs, or if they become depressed or having
thoughts of suicide

Myasthenia Gravis: Chronic progressive disease that worsens over time

●​ Acquired autoimmune disorder affecting myoneural junction
○​ The bodies own B cells produce Auto-antibodies causing a Type II
hypersensitivity reaction. These Auto-Antibodies bind to the Acetylcholine
receptors and cause a loss of function in Acetylcholine.
○​ This action from Auto-Antibodies triggers the COMPLEMENT system which
generates inflammation, damage to the postsynaptic membrane (the binding site)
and a decrease in Acetylcholine receptor sites since they are now damaged.
○​ A result of everything that has happened over time initiation of muscle contraction
becomes less effective over time
●​ S/S:
○​ Clients usually feel fine in the morning and throughout the day have progressive
muscle weakness
■​ Mainly from repetitive movements, REST improves the weakness
○​ Other symptoms relating to muscle weakness are
■​ Impaired facial expressions from muscle weakness
■​ trouble chewing, swallowing, and difficulty with speech
■​ Difficulty walking or climbing stairs
○​ Ocular weakness
■​ Diplopia and ptosis(lid drooping)
●​ Dx:
○​ IV tensin given over 30 mins
■​ This test injects an ACh inhibitor to block the break down of the ACh if this
test is positive it means the weakness should improve and it is in fact
myasthenia gravis
○​ Antibody blood test to detect AChR and MuSK antibodies
○​ Ice pack test over eyes, improvement in lid drooping from ice
○​ EMG to assess muscle contractions

●​ Medical treatment: NO CURE

○​ Medications
■​ First line- Anticholinesterase inhibitors
●​ End in -Stigmine
●​ Limit the break down of ACh
●​ GIVEN 30 MINS BEFORE meal time
■​ Immunosuppressants: Corticosteroids
●​ Prednisone
●​ Decreases the production of antibodies
■​ IVIG may help to neutralize Auto-Antibodies
○​ Non-Invasive and Invasive routes
■​ Noninvasive
●​ Plasmapheresis or therapeutic plasma exchange (TPE)
●​ Similar to hemodialysis
■​ Invasive
●​ Thymectomy
○​ Removes the thymus, which is what keeps producing
antibodies
●​ Cholinergic crisis
○​ This happens because the patient RECEIVES TOO MUCH OF THE MED
■​ Too much cholinesterase inhibitors
●​ Myasthenia crisis
○​ Worsening generalized weakness that Result in respiratory problems
■​ Report to HCP: Deterioration of speaking, chewing, swallowing, or
dyspnea
 ○​ This is because the patient DID NOT GET ENOUGH MEDS
○​ Nursing interventions:
■​ Respiratory support measures
●​ ET tube intubation
■​ Administer IVIG to neutralize antibodies
■​ If the patient cannot swallow, TPN may also be needed.
■​ Avoid sedatives & tranquilizers?????
●​ Fluoroquinolones, Macrolides, and Aminoglycosides
●​ B-Blockers (propranolol)
●​ Antiarrhythmics (Procainamide, and quinidine)

●​ Nursing Management
○​ Assess
■​ muscle weakness (onset, duration, frequency)
■​ Ability to cough and swallow, for aspiration risk
●​ Take small bites and eat soft foods
●​ Important to utilize SLP
■​ respiratory status (O2 and breath sounds)
●​ If patient is not Oxygenating well or absent of breath sounds make
sure Supplemental O2, Suction, and Ambu bag are available
■​ Keep items within reach due to muscle and ocular weakness and institute
fall precautions
●​ Client and family teaching
○​ Reinforce understanding of the disease process and that patients will feel fine
and energetic and then very tired as the day progresses and that symptoms can
be controlled with medication
○​ Emphasize!!!!
■​ taking prescribed medications as directed!!
■​ Alcohol and some OTC medications can make their symptoms worse!!
■​ Consult with their HCP before taking any new medications or
supplements
○​ Organize daily activities to conserve energy, while taking REGULAR rest periods
throughout the day!
○​ Institute safety measures at home to prevent falls
■​ Install grab bars in the shower or bathtub, and use a shower chair
○​ Eat several small meals throughout the day that are chopped, cooked, or
softened for easier chewing
○​ If experiencing double vision, talk to HCP about wearing an eye patch
○​ Make sure they understand a cholinergic and myasthenic crisis
○​ ALWAYS WEAR A MEDICAL ALERT ID
○​ Reminder to protect themselves from infection
■​ Wash hands, Avoid crowded areas, and get an annual flu shot
Guillain-Barre:
●​ Acute idiopathic polyneuritis
○​ Autoimmune disorder that attacks the peripheral nervous system
○​ Followed by viral infections (epstein barr, etc)
■​ May follow immunizations
○​ Onset is usually days to weeks
○​ Most clients recover over time usually 4m-2y as the myelin regenerate
■​ Some clients may experience residual muscle deficits
●​ S/S:
○​ Bilateral ascending paralysis
■​ Starts from the lower limbs and works its way up
○​ Muscle weakness rapidly progresses
○​ Difficulty with moving, walking or flaccid paralysis
○​ Difficulty with Talking, chewing, or swallowing.
○​ Lose sense of position (proprioception)
○​ Diminished or absent reflexes (areflexia)
○​ Tachycardia, bradycardia
○​ High or low BP
○​ Constipation - paralytic ileus
●​ Dx:
○​ Good History and Physical
○​ LP for CSF analysis
■​ Elevated protein
■​ Increased pressure
○​ Electromyography
●​ Tx:
○​ Aimed at symptom management
■​ Corticosteroids?
■​ IVIG to reduce antibodies
■​ Plasmapheresis to reduce antibodies
■​ Ventilatory support if difficulty breathing
■​ IV fluids for hypotension and hydration
●​ Nursing interventions:
○​ Respiratory Assessment
○​ Assess swallowing and gag reflex
■​ HOB 30 degrees to prevent aspiration
■​ Suction near by incase its needed
○​ Prevention of clots
■​ Q2 turns
■​ Anti embolism stockings for DVT
■​ ROM exercises
○​ Assess pain
■​ Administer prescribed pain medications
○​ Assess bowel and bladder for retention
Neurodegenerative diseases:
-​ Alzhemiers
-​ Parkinsons
-​ Amyotrophic lateral sclerosis (ALS)
-​ Loss of motor neuron system
-​ s/s: clumsiness, foot drop, slurred speech, dysphagia
-​ Friedreich's ataxia
-​ Degeneration of spinal cord
-​ Hereditary, starts in childhood, no cognitive dysfunction
-​ Huntington's disease
-​ Inherited, progressive degeneration of cells in brain
-​ Affects movement, dystonia, impulsive behaviors
-​ Spinal muscular atrophy
-​ Genetic defect in skeletal muscles
-​ Restless leg syndrome
-​ Problem with dopamine, serotonin
-​ Abnormal sensation in legs, urge to move them around, impairs sleep

Parkinsons:
●​ Risk factors
○​ Hereditary, older age
○​ Environmental, toxic chemical exposure
○​ Haldol-methyldopa
●​ Pathophysiology
○​ Slow, progressive movement disorder
○​ Decreased levels of dopamine
○​ Imbalance of dopamine and acetylcholine results in prob w/ voluntary muscle
movement
○​ Symptoms occur when 80% decrease of dopamine
●​ S/S:
○​ Tremors: Pill rolling tremor (will look like someones rolling a pill in between
fingers)
○​ Cogwheel-type rigidity (a ratchet, jerky, forceful movement)
○​ Rigidity of facial muscles (mask like expressions)
○​ Bradykinesia: Slowness of involuntary movements
○​ Akinesia: No involuntary movements
○​ Stooped posture; Postural instability
○​ Will have shoulder pain
○​ Sweating, drooling, flushing, orthostatic hypotension
○​ Constipation, urinary retention
 ○​ Dysphagia, dysphonia
○​ Depression, anxiety, dementia, delirium - later signs
●​ Diagnostics:
○​ Physical exam for Presence of 2 of the 4 cardinal manifestations
■​ Tremor, rigidity, bradykinesia, postural changes
○​ Administering Levodopa and if symptoms improve the diagnosis is confirmed
○​ ROM on wrist - see jerky cogwheel rigidity in arm
○​ Electromyography EMG
○​ PET scans, CT, DaT scan(imaging for visualizing dopamine in the brain)
●​ Complications:
○​ Thinking difficulties, depression, emotional changes
○​ Swallowing problems, chewing, swallowing
●​ Treatment: goal is to restore balance between dopamine & cholinergic neurons
○​ levodopa/carbidopa (this drug is important because Levodopa increases
dopamine in the brain while Carbidopa prevents Levodopa from breaking down
■​ Most effective first few years - effectiveness decreases
■​ Taking this medication can lead to Neuroleptic malignant syndrome -
emergency
●​ Occurs from stopping the med too quickly, or lowering the dose
too much
●​ NMS manifestations
○​ Change in behavior (confusion etc), stiff, rigid muscles,
enhanced bradykinesia, fever > 100.4, change in v/s
■​ Develop dyskinesia after 5-10 years
■​ Long term use can lead to bizarre movements of face, mouth, tardive
dyskinesia
○​ Botox is used for dystonia(muscle contraction disorder), eyelid spasms

Huntington Disease:
●​ Pathophysiology
○​ A Mutated HTT gene produces a defective huntingtin protein, this defective
protein causes neurons in the ganglia to atrophy affecting neurotransmitters in
the brain
○​ Chronic; progressive disease
○​ Results in choreiform movement and dementia
○​ Death can occur w/in 15 years of the onset
○​ Incurable
○​ 50% chance of getting if family history
●​ Classic triad huntington's symptoms
○​ Motor dysfunction - Chorea
○​ Cognitive impairment - Memory and eventually dementia
○​ Psychiatric/Behavioral - apathy, blunt affect
●​ Early stage S/S:
 ○​ Motor Dysfunction: Tongue smacking, grimacing, facial twitching
Bradykinesia(slow movement), unsteady gait
○​ Cognitive Impairment: Forgetful
○​ Behavior changes: Apathy, paranoia, irritability
●​ Later stage S/S:
○​ Motor Dysfunction: Hyperkinesia (Constant twitching and moving), Severe
chorea (Involuntary brief movements), Difficulty chewing and swallowing
○​ Dysarthria(Slurred speech, difficult to understand), Emaciation (very thin and
weak)
○​ Cognitive impairment: Disorientation, memory loss
○​ Behavior changes: Exhaustion, Depression
●​ Complications
○​ Malnutrition, Aspiration, Increased risk of suicide
●​ Diagnostics :
○​ PET scan - shows reduced glucose, reduced dopamine
○​ MRI - butterfly dilation in brain
○​ CT scan - atrophy and enlarged brain ventricles
○​ Clinical s/s are significant in the dx, family hx, genetic markers
●​ Treatment:
○​ Treat the symptoms, Supportive measures
○​ Tetrabenazine/Xenazine to treat chorea
○​ Antiparkinsonian meds to help w/ rigidity
○​ SSRIs, TCA for mental health
○​ Antipsychotics to control behavior, anxiety
●​ Nursing interventions:
○​ Maintain physically safety from falls
○​ Monitor Skin integrity
○​ Assess nutrition
■​ High calorie demand
■​ Work with the SLP for swallowing difficulties
■​ Work with a dietician to work on the clients needs
■​ Prevent aspirations
○​ Provide emotional and physiological support
○​ Important to promote sleep (quiet, comfortable and safe environment)
●​ Client and family teaching
○​ Discuss diagnosis in depth
○​ Go over meds and explain each one is specifically for managing symptoms, take
exactly a prescribed
○​ Genetic testing is crucial to anyone in the family or any plan on having children
○​ Important to modify homes to prevent falls
○​ Increased calorie demand, to maintain strength and well being
○​ Patients will experience forgetfulness, or anxiety this is normal
■​ Suicidal ideation is NOT
Amyotrophic lateral sclerosis (ALS): AKA Lou gehrig's disease
●​ Pathophysiology
○​ Affects upper motor neurons in brain, and lower motor neurons in the spinal cord
○​ Degeneration of the upper and lower motor neurons result in weakened ability to
transmit the impulses to the muscles
○​ Gradual onset, with no cure
○​ Spastic and atrophic changes
○​ Dies within 5-7 years of diagnosis
●​ Risk factors
○​ Non Modifiable
■​ White, male, family history
○​ Modifiable
■​ Smoking
■​ Participation in military wars
●​ Causes
○​ Thought to be caused by excess neurotransmitter glutamate
○​ Genetic
○​ Autoimmune
●​ S/S:
○​ Progressive weakness & atrophy of muscles, cramps, twitching, involuntary
contractions
○​ Difficulties with fine motor movements
○​ Spasticity, hyperreflexia (DTR brisk and overactive)
○​ Difficulty speaking , Dysphagia
○​ Respiratory insufficiency, trouble breathing
○​ Cognitive dysfunction, labile with emotions (mood swings)
●​ Diagnostics
○​ Good history and physical
○​ Typically does not have a definitive diagnostic test
■​ Blood, urine, spinal tap, and MRI to rule out other causes first
■​ EMG can help detect nerve impulses to the muscles

●​ Treatment:
○​ Primarily centered around relieving symptoms
○​ First line: Riluzole: Used to decrease levels of glutamate in the brain and delay
the disease progression
○​ Antidepressants, anxiolytics: for depression or anxiety
○​ Mucolytics (guaifenesin): helps to break up and thin secretions
○​ Nebulizer/Bronchodilators: To help open the airways and aid with breathing
○​ Atropine: May also be used for secretions
○​ Morphine: Used for dyspnea and to decrease the O2 Demand
 ○​ Muscle relaxers (baclofen): For spasticity
●​ Nursing interventions:
○​ Priority is supportive care and emotional support
○​ Assess respiratory status
■​ Elevate the HOB and use suction for secretion management or
medications
○​ Assess pain levels
○​ Assess nutrition and place a referral to a SLP and dietician
■​ High aspiration risk and nutritional deficits
○​ Institute Fall precautions
○​ Collaborate with PT, OT for ROM exercises and to help with strength
○​ VTE prophylaxis: due to immobility, muscle wasting
●​ Client and family teaching
○​ Teach about the diagnosis in depth
○​ Teach about prescribed medications and take as directed
○​ Teaching on nutrition
■​ Stay well hydrated
■​ Sit up while eating
■​ Eat a balanced diet with smaller more frequent meals
○​ Home and Lifestyle modifications
■​ Continue to work with PT and OT
■​ Continue to use mobility aids to stay as independent as possible
■​ Explain to to pace themselves when doing ADL’s and take rest breaks to
reduce fatigue
■​ Modify the home to prevent falls

Muscular Dystrophies:
●​ Incurable, progressive weakening and wasting of skeletal muscles
○​ Inherited disorders
○​ Duchenne muscular dystrophy is most common
●​ Management
○​ Supportive, prevent problems from occurring
○​ Maintain muscle tone and prevent contractures
○​ Risk for pulmonary issues - atelectasis & pneumonia
○​ Goal = enhance quality of life