Exam 3 Review

Parkinson’s Disease
 Progressively debilitating disease that affects motor function
o Tremor, muscle rigidity, bradykinesia (slow movement), and postural instability
o Occur due to overstimulation of the basal ganglia by acetylcholine
o This occurs because degeneration of the substantia nigra results in decreased
dopamine production
o TX of PD focuses on increasing the amount of DA or decreasing the amount of
ACh in the client’s brain
 R/F
o Onset of symptoms between 40 and 70
o More common in men
o Genetic predisposition
o Exposure to environmental toxins and chemical solvents
o Chronic use of antipsychotic medication
 Stage 1: Unilateral shaking or tremor of one limb
 Stage 2: Bilateral limb involvement occurs, making walking and balance difficult
 Stage 3: Physical movements slow down significantly, affecting walking more
 Stage 4: Tremors can decrease but akinesia and rigidity make day-to-day tasks more
difficult
 Stage 5: Client unable to stand to walk, is dependent for all care, and might exhibit
dementia
 Nursing Care
o Monitor swallowing, and maintain adequate nutrition and weight
 Speech and language therapist to assess swallowing if the client
demonstrates a risk for choking  Client with MS has been admitted due
to the quick acceleration in symptoms. Needs help with eating
 Occupational therapist for adaptive eating devices
o Provide safe environment
o Refer the client to a SW or case manager as condition advances
 Classic symptom of Parkinson’s Disease
o Tremors
 Priority concept to consider in planning care for a patient with stage 2 PD is
o Mobility
 As PD advances in severity, alterations in chewing and swallowing worsen, increasing
the risk for aspiration
o Use swallowing precautions to decrease risk
o Encourage client to eat slowly and chew thoroughly before swallowing
 Stage 3  provide a walker for ambulation because movement slows down significantly
and gait disturbances occur
  Stage 4  Record diet and fuid intake daily; offer nutritional supplements between
meals
o Client should be sitting upright for meals
 New prescription for bromocriptine
o Rise slowly when standing
o Orthostatic hypotension is a common A/E to this dopamine agonist
 Manifestations of PD
o Pill-rolling tremor of the fingers; Shuffling gait; Drooling; Lack of facial expression
o Decreased vision and bilateral ankle edema are NOT an expected finding
 Bradykinesia (abnormally slow movement)
o Give the client extra time to perform activities
 Underlying cause of PD: Certain nerve cells (neurons) in the brain gradually break down
or die. Many of the S/S are due to a loss of neurons that produce DA. When DA levels
decrease, it causes abnormal brain activity, leadings to symptoms of PD
 Impaired physical mobility related to bradykinesia
o Suggest that the patient rock from side to side to initiate leg movement
o Rocking the body from side to side stimulates balance and improves mobility
 Highest priority for a patient with PD who is unable to move facial muscles (7 th cranial
nerve)
o Imbalanced nutrition: less than body requirements
o The data about the patient indicate that poor nutrition will be a concern because
of decreased swallowing

“Do you recall if any of your relatives had difficulty holding on to things with their hands?”

“He may have trouble chewing, so I will offer bite-sized portions”

 Because chewing and swallowing can be problematic, small frequent meals and a
supplement are better for meeting the client’s nutritional needs

Keep the HOB at 30 degrees or higher

 Elevation of the HOB will help prevent aspiration

Bradykinesia: Suggest that the patient rock from side to side to initiate leg movement
 Rocking the body from side to side stimulates balance and improves mobility. The
patient will be encouraged to continue exercising because this will maintain functional
abilities. Maintaining a wide base of support will help with balance. The patient should
lift the feet and avoid shuffling gait

92/52 BP: Hypotension is an A/E of bromocriptine, and the nurse should check with the HCP
before giving the medication

The diagnosis of PD is made when two of the three characteristic manifestations of tremor,
rigidity, and bradykinesia are present
  The confirmation of the diagnosis is made on the basis of improvement when
antiparkinsonian drugs are administered

Dyskinesia (uncontrolled head movement) is an A/E of Sinemet, indicating a need for change in
medication or decrease in dose

Alzheimer’s Disease
 Nonreversible type of dementia that progressively develops over many years
 Dementia is defined as multiple cognitive deficits that impair memory and can affect
language, motor skills, and/or abstract thinking
 The percentage of dementia attributable to AD ranges from 60 to 90%
 AD is most likely to occur in clients in their 60s and 70s. But it can be diagnosed as early
as 40
 AGE is the number 1 known R/F for AD, which usually occurs after the age of 65
 AD is characterized by memory loss, problems with judgement, and changes in
personality
 Mini Mental State Examination (MMSE) is used to assess
 DOC is DONEPEZIL (ARCEPT)  prevents the breakdown of Ach, which increases the
amount of Ach available. This results in increased nerve impulses at the nerve sites
o Effective teaching: “This medication should help my husband’s daily function”
o Helps the progression of AD and can help improve behavior and daily functions
 Rivastigmine (Exelon); mild to moderate
 Galantamine (Razadyne); mild to moderate
 R/F
o Exposure to metal waste products
o Previous head injury
o History of herpes infection
 Primary focus for a patient with AD: Maintain patient safety
o Major goal of treatment for a patient with AD
 The early stage of AD is characterized by memory problems and mild confusion
 The early stages of Alzheimer’s disease are often characterized by disturbances of
attention; a selective decline in memory; changes in personality

Late manifestation of ALS: Impairment of respiratory muscles

“What would you like to be done if you begin to have difficulty breathing?”  If patient does
not want to be placed on a mechanical ventilator

Patient with ALS is hospitalized with pneumonia, the nurse should assist with active ROM

Medication will not improve dementia but can help control emotional responses
As AD progresses, the client experiences changes in emotional and behavioral affect. The nurse
should be alert to the client’s reaction to a change in environment, such as being hospitalized,
because the client may exhibit an exaggerated response, such as aggression, to the event

“I see you are still hungry. I will get you some toast”
 Use of validation therapy with clients who have AD involves acknowledgement of the
client’s feelings and concerns

Several strategies may be used to cope with restlessness and wandering. One strategy is to
engage the client in structured activities (scheduled activities throughout the day). Another is to
take the client for frequent walks.

Install deadbolt locks on all outside doors  Client’s with AD have a tendency to wander,
especially at night. If possible, alarms should be installed on all outside doors to alert family
members when the client leaves. At a minimum, all outside doors should have deadbolt locks
installed to prevent the client from going outdoors unsupervised

A diagnosis of AD is made only after other causes of dementia are ruled out
 The diagnosis of AD is usually one of exclusion
 Age is the most important risk factor for development of AD
 Drugs may slow the deterioration but do not reverse the effects of AD
 Brain atrophy is a common finding in AD, but it can occur in other diseases as well and
does not confirm a diagnosis of AD

A new cough after a meal in a patient with dementia suggests possible aspiration and the
patient should be assessed immediately

Providing a consistent routine will decrease anxiety and confusion for the patient

Migraine Headaches
 Phonophobia with migraine headaches
o Put the patient in a quiet room, tell the staff to minimize noise
 Ergotamine with caffeine for migraine headaches
o S/E: “My headache is initially relieved by the medication, but then it returns.”
 Propranolol hydrochloride
o Prescribed prophylactically to patient
 Migraines have a strong familial connection and affect females three to one over males
 What should you ask these patients?
o “Is there a pattern of headaches among family members”
o When do the headaches occur?
o How often do the headaches occur?
o Can you point to the place where your head hurts the worse?
o Do you experience other symptoms with your headaches?
 o Have there been any recent changes in your headaches?
 Avoid nuts because they contain thymine which can trigger migraine headaches
 Cluster Headache
o Unilateral ptosis (drooping or falling of the upper eyelid)
 Alcohol causes vasodilaton of blood vessels

Osteoarthritis
 A degeneration of articular cartilage in synovial joints
 Symptom onset is in the fifth and sixth decades
o OA is not considered a normal part of the aging process, but aging is one R/F for
disease development
 Patient is trying to manage the condition appropriately when the patient says they
maintain a regular exercise program of walking
o Regular low-impact exercise, such as walking, can help maintain joint mobility in
the patient with OA
 OA of the knees
o Eat a well-balanced diet to maintain a healthy body weight
o Because maintaining an appropriate load on the joints is essential to the
preservation of articular cartilage integiry, the patient should maintain an
optimal overall body weight or lose weight if overweight
 OA of the hip
o OA is more common with aging, but usually it remains confined to a few joints
and does not cause crippling
o OA can be prevented from progressing when well controlled with a regiment of
exercise, diet, and medication
 It is important to maintain a balance between rest and activity to prevent overstressing
joints with OA
 Joint pain worsens with use
o OA pain ranges from ild discomfort to significant disability. Joint pain is the
predominant symptom, and the pain usually worsens with joint use
 Or degenerative joint disease (DJD)
 Progressive deterioration of the articular cartilage
 R/F
o Aging: Majority of adults over age of 60
o Genetic factors
o Joint injury due to acute or repetitive stress on joints
o Obesity
o Metabolic disorders like DM, blood disorders (Sickle cell)
 Heberden’s nodes, enlarged joint size, limp when walking
o Heberden’s nodes are enlarged nodules on the distal interphalangeal joints of
the hands and feet of a client who has DJD
o A client can manifest enlarged joints due to bone hypertrophy
 o A client can manifest a limp when walking due to pain from inflammation in the
localized joint
 Apply heat to joints to alleviate pain, ice inflamed joints following activity, install an
elevated toilet seat, complete high-energy activities in the AM
o Applying heat to joints can provide temporary pain relief; applying ice to joints
following activity can decrease edema; installing an elevated toiler seat can help
decrease strain and pain of affected joints
 Capsaicin cream
o Inspect for skin irritation and cuts prior to application
o Because hot peppers in the cream can cause a painful burning sensation in areas
of skin breakdown
 DIP (Proximal interphalangeal joints) and DIJ (distal interphalangeal joints) 
Osteoarthritis
o About half of patients with hand involvement have Heberden’s nodes (bony
nodules at the DIP joints) and Bouchard’s nodes (bony nodes at the PIP joints
o Chronic joint pain and stiffness
o Early in the course of the disease, the pain diminishes after rest and worsens
after activity
o Later, impaired comfort occurs with slight motion or even when at rest
o Cartilage has no nerve supply; the pain is caused by joint and soft-tissue
involvement and spasms of the surrounding muscles
o Joint examination reveals tenderness and hard on palpation or when putting the
joint through ROM
 Crepitus may be felt or heard as the joint goes through ROM
 On inspection the joint is often enlarged because of bony hypertrophy

Rheumatoid Arthritis
 Positive Rh factor and positive antinuclear antibodies (ANA)
o Test results that would be the best diagnostic indicator for a patient with RA
 Arthritis: Type of rheumatic (rheumatism is non-specific term for disorders affecting
joints and connective tissue) disease, which involves inflammation of a joint or joints;
most common types are osteoarthritis, RA, and gout
 Rheumatoid Arthritis (RA): Chronic, systemic autoimmune disease characterized by
inflammation of connective tissue in the diarthrodial (synovial) joints, typically with
periods of remission and exacerbation; frequently accompanied by extraarticular
(systematic) manifestations.
o Women are likely to have RA
o Risk increases with age (30 to 50 is peak)
o Increased stress linked
o Family hx might be genetic link

RA vs. Osteoarthritis
 LOCAL:
 o OA (joint pain is predominated symptom; early morning stiffness usually resolves
in 30 minuets; joint affected asymmetrically)
o RA: Morning stiffness does not resolve easily; jointed affected symmetrically
 SYSTEMIC
o OA: N/A
o RA: Fatigue, fever, organ involvement

Plasmapheresis
 Process that filters the blood and removes harmful antibodies
 Similar to dialysis, but specifically removes antibodies from the plasma portion of the
blood
 NEVER CHOOSE QUESTIONS THAT START WITH NEVER OR ALWAYS
o “almost always”
 Should not use fresh frozen plasma
 Fresh frozen plasma is generally not used because of the associated risk for infection
and allergic pulmonary edema
 Should be done within several days after the onset of the illness, although patients
benefit up to 30 days after the onset of symptoms
 The patient usually receives 3-4 treatments, 1 to 2 days apart
 Providing information and reassurance, weighing the patient before and after the
procedure, caring for the shunt or venous access site
 IV Immunoglobulin (IVIG) has been shown to be as effective as plasmapheresis and is
immediately available in most settings
 EFFECTIVE TEACHING:
o

Methotrexate
 The patient has a decrease in joint pain
 It is given once a week
 If the patient reports severe bone pain after administration, the nurse should administer
ibuprofen to relieve bone pain in the patient
 Used for Rheumatoid Arthritis
 An immunosuppressive medication, in a low, once-a-week dose (generally 25 mg or less
per week orally)
 It is a slow-acting drug, taking 4-6 weeks to begin to control joint inflammation
 Observe for desired therapeutic drug effects such as decrease in joint discomfort and
swelling
 Disease Modifying Antirheumatic Drugs
 Prior to administering methotrexate, it is most important for the nurse to assess the
patient for latent tuberculosis


Seizures/Epilepsy
 EEG will be used to diagnose a possible seizure disorder
 A seizure is a single occurrence; whereas epilepsy is a neurological condition
characterized by two or more unprovoked seizures
o Seizure: Abrupt, abnormal, excessive, and uncontrolled electrical discharge of
neurons within the brain that can cause alteration in the LOC and/or changes in
motor and sensory ability and/or behavior
o Epilepsy: Chronic recurring abnormal brain electrical activity resulting in two or
more seizures. Seizures resulting from identifiable causes, such as substance
withdrawal or fever, are not considered epilepsy
 R/F
o Genetic predisposition; acute febrile state; head trauma; cerebral edema; abrupt
cessation of antiepileptic drugs (AEDs); infection; metabolic disorder
(hypoglycemia or hyponatremia); exposure to toxins; stroke; heart disease; brain
tumor; hypoxia; acute substance withdrawal; fluid and electrolyte imbalances
 Generalized seizures
o Involves both cerebral hemispheres
o Can begin with aura (alteration in vision, smell, hearing, or emotional feelings)
o Tonic-Clonic
 Lasting 2 to 5 minutes; stiffening or rigidity of the muscles in the arms
and legs; immediate LOC
 “I should call 911 if during the seizure”  MORE TEACHING
 Caregivers do not need to call an ambulance or send a person to
the hospital after a single seizure unless the seizure is prolonged,
another seizure immediately follows, or extensive injury has
occurred
 If breathing stops for more than 30 seconds, call 911
 No objects should be placed in the mouth
 Lethargy is common in the postictal phase of a seizure
 Jerking of the extremities occurs during the clonic phase of a
tonic-clonic seizure. The clonic phase may last 30 to 40 seconds
o Clonic or rhythmic: The patient may bite his or her tongue and may become
incontinent of urine or feces; fatigue, acute confusion, and lethargy may last up
to an hour after the seizure; lasts several minutes and causes muscle contraction
and relaxation
o Tonic: Abrupt increase in muscle tone, LOC, and autonomic changes lasting from
30 seconds to several minutes
o Myoclonic: Causes a brief jerking or stiffening of the extremities that may occur
singly or in groups; lasting for just a few seconds, the contractions may be
symmetric (both sides) or asymmetric (one side)
o Atonic (akinetic): The patient has a sudden loss of muscle tone, lasting for
seconds, followed by postictal (after the seizure) confusion; in most cases, these
 seizures cause the patient to fall, which may result in injury; this type of seizure
tends to be most resistant to drug therapy
 Partial or focal/local seizure
o Involves only one cerebral hemisphere
o A patient reports feeling numbness and tingling of the left arm before
experiencing a seizure  Focal seizure
o Complex partial: unaware of environment and may wander at the start of the
seizure; may cause LOC or black out for 1 to 3 minutes; may have amnesia
o Simple partial: Remains conscious throughout the episode; often has an aura
before seizure; déjà vu; one-siodes movement of extremity, experience unsual
sensations, or have autonomic symptoms (change in HR, skin flushing, and
epigastric discomfort) during the seizure
 Unclassified or idiopathic seizures
o Do not fit into either category
o Account for half of all seizure activity and occur for no reason
 During seizure
o Protect the client’s privacy and the client from injury (move furniture away, hold
head in lap if on floor)
o Position the client to provide a patent airway
o Be prepared to suction oral secretions
o Turn the client to the side to decrease risk of aspiration
o Loosen restrictive clothing
o Do not attempt to restrain client
o Do not attempt to open the jaw or insert airway during seizure activity
o Do not use padded tongue blades
o Document onset and duration and findings (LOC, apnea, cyanosis, motor activity)
prior, during, and following seizure
 After a Seizure
o Postictal phase of seizure episode
o Maintain client in a side-lying position to prevent aspiration and to facilitate
drainage of oral secretions
o Check vitals
o Assess for injuries
o Perform neurological checks
o Allow the client to rest if necessary
o Reorient and calm the client, who might be agitated or confused
o Determine if client experienced an aura, which can indicate the origin of seizure
in the brain
o Try to determine possible trigger (e.g., fatigue)
 Phenytoin (Dilantin)  AED (Antiepileptic drugs) is used to treat and reduce seizure by
decreasing the voltage, frequency, and spread of electrical discharge in the motor cortex
of the brain or both
o Increased pressure from the abscess can cause seizures
 o Even after the seizure stops, I will continue to take this drug
o Taken for 2 years, insepct the oral mucosa
o Therapeutic reference range is between 10 and 20 mg/mL
o Nystagmus frequently observed at the levels greater than 20 mg/mL
o Overdose?
 S/S; fast, uncontrolled eye movements or double vision
 Dizziness, drowsiness, confusion
 Lack of coordination of fingers, hands, arms, legs, body
 Slurred speech
 N/V
 Decreased activity, irregular and jerky movements
o In ER
 Vital signs
 Blood and urine tests
 Chest X-Ray
 CT Scan
 EKG
o TX
 Breathing support
 Fluids through IV
 Activated charcoal
 Laxative
 Client is about to have a seizure
o Provide privacy
o Ease the client to the floor if standing
o Move furniture away from client
o Loosen the client’s clothing
o Protect the client’s head with padding
 The greatest risk to the client is aspiration during the postictal phase. Therefore, the
priority intervention is to keep the client in a side-lying position so secretions can drain
from the mouth and keep the airway patent
 Prescribed phenytoin
o Take at the same time every day to enhance effectiveness
o Oral contraceptive effectiveness is decreased
o Periodic blood tests to determine the therapeutic level of phenytoin
 Trigger factors that can cause generalized seizures
o Avoid overwhelming fatigue
o Remove caffeinated products from the diet
o Limit looking at flashing lights
o Avoid vigorous physical activity
o Limit excess hyperventilation
o Avid using aerosol hairspray
 “Place a magnet over the implantable device when you feel an aura occurring”
 o As to decrease seizure activity

The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous.
Discontinuing the medication can predispose the client to seizure activity and status epilepticus.
The client should not drink alcohol while taking seizure medications. The client should wear a
medical alert bracelet and should make the doctor aware of all medications to prevent
complications of polypharmacy

A patient is being treated for a common neurological disease that is characterized by abnormal
cell firing to the brain  Seizures

Absence Seizure: Involves a blank stare, unresponsiveness to questions, smacking of the lips,
lasts less than a minute

Tonic-Clonic Seizure: Stiffening of the muscles of the arms and legs, followed by an immediate
LOC and jerking of all extremities
- Start fluids via a large-bore catheter
- Time and observe and record the details of seizure and postictal state
- Epilepsy usually can be well controlled with medications
- For a patient in the ED who is experiencing tonic-clonic seizures, FIRST administer
Lorazepam (Ativan) 4mg IV
o To prevent ongoing seizures, the nurse should administer rapidly acting
antiseizure medications
o Phenytoin will also be administered but it is not reapidly acting
o Patients who are experiencing tonic-clonic seizures are nonresponsive, although
the nurse should assess LOC after the seizure

Phenytoin (Dilantin)
- Consult HCP before administering if patient has minor elevations in the liver function
tests
- Many older patients (especially with compromised liver function) may not be able to
metabolize phenytoin
- The HCP may need to choose another antiseizure medication

Status Epilepticus (SE)

 A medical emergency associated with significant morbidity and mortality
 A continuous seizure lasting more than 30 minutes, or two or more seizures without full
recovery of consciousness between of them
 Administer Lorazepam (Ativan)

Fosamax
 Paget’s Disease
 It can treat or prevent osteoporosis. Also, it can treat Paget’s disease of the bone
  Paget’s disease of bone interferes with your body’s normal recycling process, in which
new bone tissue gradually replaces old bone tissue. Over time, the disease can cause
affected bones to become fragile and misshapen. Most common in the pelvis, skull,
spine, and legs
 Bone pain is one of the common early manifestations
 Increased bone mass
o Increases BMD and significantly reduces the risk of spine, hip, and wrist fractures
in women with osteoporosis or Paget’s disease
 Assist the patient to sit up at the bedside

Osteomalacia
 The softening of the bones caused by impaired bone metabolism primarily due to
inadequate levels of available phosphate, calcium, and vitamin D, or because of
resorption of calcium
 The impairment of bone metabolism causes inadequate bone mineralization
 Loss of bone due to Vit D deficiency
 Bone biopsy, DXA scan
 In children: Rickets malabsorption of Vit D
 Causes softening of the bones

Osteomyelitis
 A clinical state in which the bone has become infected, can be secondary to systemic
infection but more frequently occurs as a primary infection
 Bone infections can affect any bone in the body, but it most commonly affects the long
bones in the leg, upper arm, and spine
 If untreated, osteomyelitis can lead to chronic infection, loss of function and mobility,
amputation, and death
 Can arise from invasion of bacteria, viruses, or fungi in the body. The invasion can
include one or multiple microorganisms which produces inflammation
 Inflammation causes edema due to vascular leak
 The vessels then form clots which release exudate (pus) into body tissue
 The bone becomes necrotic due to ischemia of bone tissue
 Exogenous: Pathogens invade body from outside (can occur from an open fracture)
 Endogenous: Pathogens enter the body by the way of the bloodstream
 Contiguous: Skin infections from nearby tissues cause the bone to become infected

Myasthenia Gravis
 Activity intolerance is the priority in the care of a patient with MG
 Artificial tears throughout the day to decrease the risk of corneal abrasion
 Chronic disease characterized by remissions and exacerbation of fatigue and weakens
primarily in muscles innervated by the cranial nerves, as well as in skeletal and
respiratory muscles
 o Autoimmune disease of the NM junction in which Ach receptor sites are attacked
by the body
 Nutrition, eye care, respiratory care
 Acquired autoimmune disease characterized by muscle weakness
 Can preset at any age (high in men)
 Caused by infection, pregnancy, or anesthesia
 Ask the patient when symptoms worsen, specifically noting the affected muscle groups
and any limitation or inability in performing ADLs.
 Assess the patient about a hx of respiratory difficulty, choking, or voice weakness
 Assess about any difficulty holding up the head, brushing teeth, combing hair, or shaving
 Assess for the presence of paresthesia or aching in the weakened muscle
 Ptosis: Incomplete eyelid closure
 Diplopia
 Dysphagia
 Diagnosis is confirmed by electromyography (EMG)
 Keep a bag-valve-mask setup, equipment for oxygen administration, and suction
equipment at the bedside of the patient with MG in case of respiratory distress.
Ongoing assessment and maintenance of respiratory gas exchange are nursing care
priorities
 Myasthenic Crisis
o Severe generalized muscle weakness that may involve muscles of respiratory
o Treat with neostigmine
 Effective when increased muscle strength
o Impaired gas exchange related to respiratory failure
o Maintain adequate respiratory function to promote gas exchange
o Plasmapheresis is used for myasthenia crisis or for situations in which
corticosteroid therapy must be avoided
 It is not routinely scheduled
 MG presents with shorter transmission in the disease progressive
o Patient experience an increase of symptoms when exposure to sunlight, viral
illness, and emotional stress
o The onset of MG in women commonly occurs between 20 and 40 years old
 A patient with MG admitted to hospital for respiratory insufficiency and severe
weakness: diagnosis of cholinergic crisis
o Administration of edrophonium (Tensilon) increases muscle weakness
o The reduction of Ach effect in MG is treated with anticholinesterase drugs, which
prolong the action of Ach at the NM synapse, but too much of these drugs will
cause cholinergic crisis with symptoms very similar to those of MG
o To determine whether the patient’s manifestations are due to a deficiency of
Ach or too much anticholinesterase drug, the anticholinesterase drug
edrophonium chloride (Tensilon) is administered
 Perform physically demanding activities early in the day
 o Muscles are generally strongest in the morning, and activities involving muscle
activities should be scheduled then
 Most important for nurse to make:
o Respiratory effort
o Because respiratory insufficiency may be life threatening, it will be most
important to monitor respiratory function
 Thymectomy
o Removal of thymus gland
 Patient with MG who is reporting increased muscle weakness
o Increased muscle weakness may indicate the onset of a myasthenic crisis
 Activity intolerance is likely to be a priority in the care of a patient with MG
 Myasthenic = underdosing
 Cholinergic = overdsosing

ALS
 One of the most distressing problems experienced by a patient  Retention of cognitive
function with total degeneration of motor function
o In ALS, there is gradual degeneration of motor neurons with extreme muscle
wasting from lack of stimulation and use
o However, cognition function is not impaired and patients feel trapped in a dying
body
 Hospitalized with pneumonia
o Assist with active ROM
 ALS causes progressive muscle weakness, but assisting the patient to
perform active ROM will help maintain strength for as long as possible
 “This is a progressive disease that eventually results in permanent paralysis, though you
will not lose any cognitive function”
 Most important to help prevent a common cause of death for patients with ALS
o Reduce the risk for aspiration
 Respiratory support as the muscles of breathing fail, and managing secretions due to the
inability

Guillain-Barré syndrome (GBS)

 Respiratory assessment: the nurse’s priority
 (Body’s immune system mistakenly attacks park of its PNS)
 Priority is respiratory assessment
o Acute risk of respiratory failure requires vigilant monitoring of the patient’s
respiratory function
 Plasmapheresis
o A client with GB is scheduled for plasmapheresis. Before the procedure, which
clinical manifestation does the nurse use to determine patency of the client’s
arteriovenous shunt?
  The presence of a bruit
 The nurse checks for bruits every 2 to 4 hours for patency
o During plasmapheresis. Which complication does the nurse monitor for?
 Hypovolemia
 The nurse monitors fluid status, assesses vital signs, and administers
replacement fluid as indicated
o The patient will always need an albumin transfusion
o Removes circulating antibodies assumed to cause the disease; plasma selectivity
is separated from whole blood and blood cells are returned the patient without
plasma
o Plasma replaces itself or the patient is transfused with albumin
 IV fluid and supine position if no respiratory distress
 Increased CSF protein level correlates with this disease process

Bell’s palsy
 Condition in which the muscles on one side of your face become weak or paralyzed. It
affects only one side of the face at a time, causing it to droop or become stiff on that
side
 Some kind of trauma to the 7th cranial nerve (Facial Nerve)
 Prednisone
o Should be started immediately
o Patients have the best chance for full recovery if prednisone is initiated before
complete paralysis occurs. It will be tapered over the last 2 weeks of treatment.
Oral prednisone may be taken with food or milk to decrease GI upset. Patients
with Bell’s palsy usually begin recovery in 2 to 3 weeks and most patients have a
complete recovery in 3 to 6 months. No serious drug interactions between
prednisone and acetaminophen

Lupus Erythematosus
 Individual round discoid (coin-like) scarring like lesions are very evident
 Disorder of immune function, but it is extremely variable in its course, and there is no
way to predicts its progression
 Women are more at risk
 Prednisone (Deltasone) – monitor input and output
o Monitor renal function
 Social isolation related to embarrassment about the effects of SLE
 Anti-Smith antibody (Anti-Sm)
o Serum test result that is the most specific for SLE
o The anti-Sm is antibody found almost exclusively in SLE
 “I need to restrict my exposure to sunlight to prevent an acute onset of symptoms”
o Sun exposure associated with SLE exacerbation and patients should use
sunscreen
  Initial characteristic sign of system lupus erythematous
o Rash on the face across the bridge of the nose
o Skin lesions or rash on the face across the bridge of the nose and on the cheeks
is an initial characteristic of SLE

Fibromyalgia
 To assist with the diagnosis of fibromyalgia, the client must have pain upon palpation of
11 or more of the 18 standard tender points
 This disorder closely resembles chronic fatigue syndrome, with the exception of the
musculoskeletal pain typically associated with fibromyalgia
 Family history of fibromyalgia is a R/F for development
o Female is a risk factor
o Being between 20 and 50 years old
o Being diagnosed with another rheumatic disorder, such as RA (not OA) and
systemic lupus erythematosus
 A widespread pain index  used to properly diagnosis
 Duloxetine (Cymbalta)
o To increase levels of DA and Serotonin
 A program of regular, mild to moderate exercise
 Physical or emotional trauma can contribute to the development of fibromyalgia
 Viral illness usually precedes general symptom manifestations of fibromyalgia
 “I have had generalized pain throughout my body for at least 3 to 4 months”
 “The pain and tiredness are worse when I am very active”
o Symptoms follow a specific pattern that includes morning stiffness and acute
fatigue following increased activity

Lyme Disease
 LYMEEEE DISEASE

Huntington’s Disease
 Chorea manifested by writhing, involuntary movements
 Autosomal dominant genetic disease  has 50% change of being passed to each
offspring
 Option of genetic testing for the patient’s children to determine their own HD risks
o Genetic testing is available to determine whether an asymptomatic individual
has the HD gene

The nurse should monitor for jerky hand movements

 An imbalance between excitatory and inhibitory NTs lead to uninhibited motor
movements, such as brisk, jerky, purposeless movements of the hands, face, tongue,
and legs
“Tell me more specifically what information you need about family planning so that I can direct
you to the right information or HCP”

Option of genetic testing for the patient’s children to determine their own HD risks

Ewing’s Sarcoma
 Very rare type of cancerous tumor that grows in your bones or the soft tissue around
your bones, such as cartilage or the nerve
 Usually affects people from the ages of 10 to 20 and has a high rate of being cured
 Difficult to diagnosis and to treat
 Results from a molecular abnormality of the DNA in the tumor cell (usually caused by a
somatic mutation)
 Most occur in the long bones of the arms or legs
 Complications
o Bone fractures, anemia, osteomyelitis, A/E of chemotherapy, A/E of radiation
 Assessment/Physical findings
o Pain and swelling of the tumor site, pathologic fracture at site of tumor, fever,
bone tenderness, limping, unexplained weight loss, fatigue, symptoms related to
nerve compression, such as numbness, tingling and paralysis

Paralysis


Resting Leg Syndrome

 Willis-Ekbo Disease
 Causes unpleasant or uncomfortable sensations in the legs and an irresistible urge to
move them
 Symptoms commonly occur in the late afternoon or evening hours, and are often most
severe at night when a person is resting, such as sitting or lying in bed
 Cause is unknown but associated with: pregnancy, obesity, smoking, iron deficiency and
anemia, and nerve disease

Cranial Nerves

Multiple Sclerosis
 MS is  Inflammation that causes demyelination and axonal injury to the brain and the
spinal cord
 Unpredictable, often disabling disease of the CNS, in which the immune system eats
away the protective covering of the nerves
 Urinary tract problems with incontinence or retention are common symptoms of MS
 MS symptoms may be worse after the pregnancy
o During the postpartum period, women with MS are at greater risk for
exacerbation of symptoms
  Credé method can be used to improve bladder emptying
 You will have either periods of attacks and remissions or progression of nerve damage
over time
o Most patients with MS have remissions and exacerbations of neurologic
dysfunction or relapsing-remitting initial course followed by progression with or
without occasional relapses, minor remissions, and plateaus that progressively
cause loss of motor, sensory, and cerebellar functions
o Intellectual function generally remains intact but patients may experience anger,
depression, or euphoria
o A few people have chronic progressive deterioration and some may experience
only occasional and mild symptoms for several years after onset

Methylprednisolone (Medrol)
- Methylprednisolone is the DOC for acute exacerbations of MS
- Avoid crowds and people with colds
o The client should be taught to avoid people with any type of URD because the
medications are immunosuppressive

MS Symptoms may worsen after pregnancy

Which action will the nurse plan to take for a patient with MS who ha urinary retention caused
by a flaccid bladder? Teach the patient how to use the Credé method

Degenerative disease of the nervous system

Presence of multiple plaques on MRI

Blurred vision, intention tremor and urinary hesitancy are typical S/S of MS

When teaching the patient with MS how to reduce fatigue, the nurse should tell them to rest in
an air-conditioned room

Expect a CT scan