Chronic Neurologic Problems

Chronic Neurologic
Problems
Lecture by: M.K. Sastry
Headache
 The most common type of pain experienced by
humans
 Types
 Tension type headache
 Migraine headache
 Cluster headache
Tension-Type Headache
 Characterized by…
 Neck and shoulder muscle pain; Bilateral pain at the base
of the skull and in the forehead
 Etiology and Pathophysiology
 Exact cause is unknown
 Sometimes difficult to distinguish
 Precipitating factors may include: Stress; Hunger; Sleep
deprivation; Eyestrain; Withdrawal from caffeine
Migraine Headache
 …episodic familial disorder manifested by unilateral,
frontotemporal, throbbing pain in the head which is
often worse behind one eye or ear
 Clinical manifestations
 … often accompanied by sensitive scalp; Anorexia;
Photophobia; Nausea with (or without) vomiting
Migraine Headache
 Three classifications for migraine headache
 Migraines with aura
 Aura is a sensation that indicates the onset of a migraine or
seizure (develops over several minutes; does not last more
than an hour)
 Aura may consist of flashing lights; buzzing noises;
distorted vision (find out what triggers it)
 Migraines without aura
 Most are migraines without aura
Migraine Headache
 Atypical migraine (more assoc w/ teens & 20 yr olds)
 Less common
 Associated with menstrual periods
 Includes cluster headaches
 Neuro imaging recommended for persons older
than 50 years of age with new onset of headaches
When and Why? (worrisome… MRI might be test of choice)
 MRI is gold standard for migraine, but CT scan is
much cheaper.
Stages of a Migraine Headache
 Prodrome phase (specific symptoms including
food cravings; mood changes)
 Aura phase (visual changes; diplopia [double
vision]; flashing lights)
 Headache phase: few hours to a few days
 Termination phase (intensity decreases)
 Postprodrome phase (fatigue; muscle pain;
irritable)
Cluster Headache
 Less frequent than migraines
 More common in men between 20 and 50 years
of age
 Definitive cause of headache is unknown
 May be related to hypothalamic hyperactivity
 Onset is associated with relaxation, napping, or
rapid eye movement (REM) sleep
 Pain is unilateral, oculotemporal or oculofrontal;
Excruciating, boring and non-throbbing type
Cluster Headache
 Intense pain felt deep in and around the eye (may radiate
to the ear and neck)
 Ipsilateral (same side) tearing of the eye; runny rhinorrhea
(runny nose) or congestion; ptosis (drooping eyelid);
miosis (abnormal constriction of pupils)
 Headaches occur every 8 to 12 hours, up to 24 hours a day
at the SAME TIME for 6 to 8 weeks
 Remission follows for 9 months to 1 year
 Duration of headache is usually 10 to 45 minutes
 (tearing, runny nose might be the way to tell difference
between cluster 7 migraine)
Headaches – Other Types
 Can be first symptom of a more serious illness
 Can be accompany subarachnoid hemorrhage; brain
tumors; other intracranial masses; arteritis; vascular
abnormalities; trigeminal neuroalgia (intense pain
around the eyes, lips, nose, scalp, forehead and jaw);
diseases of the eyes, nose, and teeth; and systemic
illness
Headaches
 Collaborative Care for Headaches
 Drug therapy
 Tension-type headache
 Acetaminophen and NSAIDs
 Migraine headache
 Acetaminophen and NSAIDs (Naproxen) effective for mild
migraine pain
 Abortive therapy (aura phase) and Preventative therapy (with
history of migraines 2 to 3 times/month)
 Cluster headache
 Drug therapy same as for migraine headache
Headaches: Nursing Management
 Nursing assessment
 Nursing diagnoses
 Planning
 Nursing Implementation
 Evaluation
Headaches: Nursing Diagnoses
 Acute pain related to lack of knowledge of pain
control techniques or methods to prevent
headaches
 Disturbed energy field related to disharmony
 Ineffective management of therapeutic regimen
related to lack of knowledge, identification and
elimination of aggravating factors
Chronic Neurologic Disorders
Epilepsy
 “To be seized from a force within”
 Chronic condition characterized by recurrent paroxysmal
(sudden attack)episodes of disturbance in
 Skeletal muscle function
 Sensation
 Autonomic visceral function often lose bowel & bladder
control
 Behavior and consciousness: some have aura & may
have behavioral change… don’t lose consciousness, but
may become drowsy or stuporous
Epilepsy
 Amount of time between varies, usually there is repetition
of activity
 “pretty important”
 Can be primary disease or a symptom of a disease… learn
diff types of epilepsy & types of seizures
 Don’t say grand mal any more… it is generalized or tonic
clonic seizure.
Epilepsy
 A symptom of CNS irritation, excessive and
abnormal neuronal discharges
 Present as a manifestation of disease in
approximately 50 other diseases
 Epilepsy in a nutshell: Epilepsy is a common
neurological disorder characterized by recurrent
seizures
 Caused by a brief disruption of electrical activity
in the brain
Epilepsy
 Affects 2 – 4 million people*
 Not accurate*
 Not reportable
 Individuals not likely to admit to condition
Why?
Epilepsy
 Most common age groups:
 Birth to 2 years
 5-7 years
 Early puberty (especially girls)
 90% of all patients experience first seizure prior to
age 20
 Genetic tendency toward cerebral dysrrhythmias
Epilepsy
 Cerebral epilepsy-cerebral lesions account for
activity, usually due to…
 Birth injuries (Example: Cerebral palsy)
 Infectious disorders (Example: meningitis… once treated,
the seizure disorder will go away… takes a long time to treat… on
antiepileptic meds while treating for meningitis)
 Circulation disorders (Example: stroke)
 Cerebral trauma (Example: TBI)
 Neoplasms (Recall prior slide!)
Epilepsy
 Biochemical epilepsy – biochemical disorders
that include epilepsy as a clinical feature
 Alcohol ingestion/drug overdose (barbiturates, high doses, can be
a cause of a seizure disorder)
 Medications (Overdose or withdrawal. Examples: Antidepressants,
Antipsychotics, PNC in high doses, Lithium)
 Electrolyte imbalance (Example: Altered levels of sodium
magnesium; calcium)
 Vitamin deficiency
 Diabetes mellitus (Example: Hypoglycemia; Hypercalcemia)
 Pregnancy and/or menstruation
Epilepsy
 Post traumatic epilepsy – from previously
sustained cerebral injuries, few prior to 2 months
or after 5 years
 Head injuries
 Birth injuries
 Idiopathic epilepsy – no identifiable cause
Seizures: Terms to Remember
 Prodromal (Early warning of impending attack)
 Aura (Visual disturbances… can be any of the 5 senses…;
buzzing sounds)
 Ictus (The event; i.e., seizure)
 Tonus (Maintained contraction r/t bombardment of
motor impulses)
 Clonus (Contraction/relaxation of muscles, wild muscle
movement)
 Postictal (Exhaustion): confusion common
Seizure Classification
 Generalized – bilaterally symmetric and without
local onset
 Tonic-clonic seizures (Type most commonly associated
with epilepsy; Generalized seizure)
 Typical absence seizures (Stares into space without
twitching; Lasts for seconds)
 Atypical absence seizures (Stares but is somewhat
responsive)
 Other types of generalized seizures (Associated with
AIDS; Acute infection; Alcohol or drug use)
 Partial-focal in nature, may become generalized
 Simple/partial: No loss of consciousness
 Focal (or local) motor or sensory: can begin in one part
of the cebrum & spread. Pt usually maintains level of
consciousness… may report aura or feeling of déjà vu.
Odd movement, twitching of hand or tapping of foot…
may also have increase in heart rate (sypathetic
response, become flush)
 Complex partial seizure: loss of consciousness, 1 to 3
min. Aka psychomotor seizures or temporal lobe. Often
a motor response.
 Jacksonian
 Pseudoseizure: don’t see them very often; no aura, don’t lose
bladder function, won’t fall out of chair, don’t allow
themselves to be harmed but will allow themselves to have
the movement seen in a tonic clonic seizure. May be
attention getting… could be the beginning of bad things that
are going to happen.
Clinical Manifestations
 Aura
 Tonic-hypertonic-clonic phase
 Loss of consciousness
 Bowel and bladder incontinence
 Tachycardia
 Diaphoresis
 Warm skin
 Pallor, flushing, cyanosis
 Post-ictal phase
Epilepsy
 Complications
 Status epilepticus (life threatening, need ER &
immediate meds… valium / diazapem and ativan, can
last 5 min or longer, w/ each event it increases in
intensity
 Psychosocial
 Diagnostic Studies
 Accurate description of seizures; EEG; CT; MRI
 Rule out metabolic disorders
Epilepsy : Status epilepticus
 Life threatening
 Brain in a state of persistent seizure
 Continuous seizure lasting more than 30
minutes or recurrent seizures w/o regaining
consciousness between seizures for > 30
minutes
 May be neuron damage at 5 minutes Why?
 911 for seizure lasting > 5 minutes
Epilepsy: Collaborative Care
 75% can be managed successfully with
anticonvulsant medications (great list in the book…
tegretol, dilantin, phenobarbitol, kepra [newer w/
fewer side effects],
 Medications will manage the symptoms, but will
not cure the condition
Epilepsy: Medications
 Generalized and Partial seizures
 Phenytoin (Dilantin); Side effects: gingival hyperplasia;
drug toxicity
 Carbamazepine (Tegretol)
 Phenobarbital
 Divalproex (Depakote)
 Gabapentin (Neurontin)
Epilepsy: Medications
 Absent, Akinetic
 Klonopin; Zarotin
 Status Epilepticus
 Ativan (benzodiazepine) and Valium
Epilepsy: Surgical Intervention
 Remove focus: if alcohol w/drawal is causing seizure,
then remove the problem
 Prevent spread
 Remove lobe, cortex
 Separate hemispheres at corpus callosum
 (similar to WPW ablation on heart, but done in

brain)
Immediate Seizure Management
 During Seizure
 Provide privacy
 Maintain airway (don’t put anything in mouth, maybe put them
on side if able)
 Ease to floor; protect from injury
 After Seizure
 Position on side
 Allow time to sleep
 Re-orient individual
When Observing a Seizure
 Prodromal
 Where there any warning signs?
 Ictus
 Where did it begin and how did it proceed?
 Describe movements
 How long?
 Changes in pupil size?
 Incontinence?
 LOC?
When Observing a Seizure
 Post-ictal
 Behavior after the seizure (describe)
 Any paralysis or weakness following the seizure?
 Did the individual sleep?
 After the seizure, document, do vitals, etc…

Multiple Sclerosis
 Chronic, progressive, degenerative disorder of the
CNS characterized by disseminated demyelination
and inflammation of nerve fibers of the brain and
spinal cord
 MS in a nutshell: Results from progressive
demyelination of the white matter of the brain and
spinal cord; Hard yellow plaques of scar tissue form
(gliosis); Damage to underlying axon fiber so nerve
conduction is disrupted; irreversible as disease
progresses
Multiple Sclerosis
Etiology and Pathophysiology
 Cause is unknown
 Related to infectious, immunologic, and genetic
predisposition
 Multiple genes confer susceptibility to MS
 Disease usually affects young to middle-aged
adults,= with onset between 15 and 50 years of
age
 Women are affected more than men
Multiple Sclerosis
 Possibility that the association between

pathogenetic agents and MS is random and there
is no cause-and-effect relationship
Multiple Sclerosis
 Possible precipitating factors include:
 Infection
 Physical injury
 Emotional stress
 Excessive fatigue
 Pregnancy
 Poor state of health
Multiple Sclerosis
 Primary neuropathologic condition is an autoimmune
disease orchestrated by autoreactive T-cells
 Remember “T” cells? Helper T cells and Killer T cells.
Helper T cells stimulate B cells to make antibodies, and
help killer cells develop. Killer T cells kill the body’s own
cells that have been invaded by viruses or bacteria.
 Characterized by chronic inflammation, demyelination
(damage to myelin sheath of neurons) and gliosis (scar
formation) in the CNS
Multiple Sclerosis
 Initially triggered by a virus in a genetically

susceptible individual
 Subsequent antigen-antibody reaction leads to
demyelination of axons
Multiple Sclerosis
 Disease process consists of loss of myelin,
disappearance of oligodendrocytes, and
proliferation of astrocytes
 Changes result from plaque formation with
plaques scattered throughout the CNS
Multiple Sclerosis
 Initially the myelin sheaths of the neurons in the
brain and spinal cord are attacked, but the nerve
fiber is not affected
 Patient may complain of noticeable impairment
of function
 Myelin can regenerate, and symptoms
disappear, resulting in a remission
Multiple Sclerosis
 Myelin can be replaced by glial scar tissue
 Without myelin, nerve impulses slow down
 With destruction of axons, impulses are totally
blocked
 Results in permanent loss of nerve function
Multiple Sclerosis
Clinical Presentation
 Vague symptoms occur intermittently over months
and years
 Disease may not be diagnosed until long after the
onset of the first symptom
 1st symptoms: sensory symptoms of the arms/legs;
unilateral vision loss; slowly progressive motor
deficit
Multiple Sclerosis
Clinical Presentation
 Characterized by
 Chronic, progressive deterioration in some
 Remissions and exacerbations in others
 Motor manifestations
 Weakness or paralysis of limbs, trunk, and head
 Foot drop; pressure ulcers
 Scanning speech (slurred, stretching of words); dysarthria (motor
speech disorder/poor articulation)
 Spasticity of muscles
 Tremor
Multiple Sclerosis
Clinical Presentation: Sensory
 Numbness and tingling
 Blurred vision; diplopia (double vision)
 Vertigo and tinnitus
 Decreased hearing
 Chronic neuropathic pain
Multiple Sclerosis
Clinical Presentation: Cerebellar
 Nystagmus (Involuntary movement of the eye)
 Ataxia (Inability to coordinate muscle movement)
 Dysarthria (motor speech disorder, i.e., slurred
speech)
 Dysphagia (Difficulty swallowing)
Multiple Sclerosis
Clinical Presentation: Emotional
 Anger
 Depression
 Apathy
 Inattentiveness
 Euphoria
Multiple Sclerosis
Clinical Presentation: Other
 Bowel and bladder functions may be impaired
 Constipation
 Spastic bladder; small capacity for urine results in
incontinence
 Inability of sphincter to open
 Flaccid bladder; large capacity for urine and no
sensation to urinate
Multiple Sclerosis
Clinical Presentation (Other)
 Sexual dysfunction can occur in MS
- erectile dysfunction
- decreased libido
- painful intercourse
- decreased lubrication
Multiple Sclerosis: Diagnostic Studies
 Based primarily on history, clinical presentation,

and presence of multiple plaques over time
measured by MRI
 Certain laboratory tests are used as adjuncts to
clinical exam
 CSF analysis: high lymphocytes and monocytes
(lumbar puncture, breakdown of meylin is breakdown
of protein, should not be protein in CSF)
Multiple Sclerosis: Collaborative Care
 Drug therapy
 Corticosteroids (maintiain stability of cell wall so it doesn’t break
down so fast & antiinflammatory effect… but you can’t stay on them
forever)
 Treat acute exacerbations by reducing edema and
inflammation at the site of demyelination
 Does not affect the ultimate outcome or degree of residual
neurologic impairment from exacerbation of disease
 Immunosuppressive Therapy
 Potential benefits are counterbalanced against
potentially serious side-effects (even some chemo drugs can
be used to slow down the progression of the disease, often can live a
pretty normal life for a long time… 25 years)
 Immunomodulators
 Interferon ß-1b (Betaseron)
- Interferon ß-1a (Avonex, Rebif)
 Antispasmotics (any muscle, bladder, etc…)

 CNS stimulants
 Anticholinergics and/or cholinergics
 Tricyclic antidepressants and anti-seizure
medications (unusual for anti-seizure meds)
 These are symptom relief meds

 Surgery (for patients with severe tremor)

 Dorsal-column electrical stimulation (electrodes
placed in the subdural extra arachnoid space over the center
of the thoracic spinal cord – result is increased motor/sensory
function)
 Intrathecal baclofen pump (Baclofen is a muscle
relaxant used to decrease spasticity in MS; SCI; Other
neurologic problems)
 Physical therapy helps…

 Relieve spasticity
 Increase coordination
 Trains the client to substitute unaffected muscles for
impaired ones
 Nutritional therapy includes…
 Megavitamins and diets consisting of low-fat, gluten-

free, food, and raw vegetables
 High-protein diet with supplementary vitamins is
often prescribed
Multiple Sclerosis: Nursing
Assessment
 Health history
 Viral infections or vaccinations
 Residence in cold or temperate climates
 Physical and emotional stress
 Medications
 Elimination problems
 Weight loss, dysphagia
Multiple Sclerosis: Nursing Diagnoses
 Impaired physical mobility

 Dressing/grooming self-care deficit
 Risk for impaired skin integrity
 Impaired urinary elimination pattern
 Sexual dysfunction
 Interrupted family processes
Multiple Sclerosis: Nursing Plan of
Care
 Maximize neuromuscular function
 Maintain independence in activities of daily living
for as long as possible
 Optimize psychosocial well-being
 Adjust to the illness
 Reduce factors that precipitate exacerbation of
symptoms
Implementation
 Help patient identify triggers and develop ways to
avoid them or minimize their effects
 Reassure patient during diagnostic phase
 Assist patient in dealing with anxiety caused by
diagnosis
 Prevent major complications of immobility
Implementation
 Focus teaching on building general resistance to
disease
 Avoiding fatigue; extremes of hot and cold; exposure
to infection
 Teach good balance of exercise and rest, nutrition,
avoidance of hazards of immobility
Implementation
 Teach self-catheterization if necessary
 Teach adequate intake of fiber to aid in regular
bowel habits
Parkinson’s Disease
 Disease of basal ganglia characterized by…
 Slowing down in the initiation and execution of
movement
 Increased muscle tone (no atrophy usually)
 Tremor at rest
 Impaired postural reflexes
Parkinson’s Disease: Etiology and
Pathophysiology
 Pathologic process involves degeneration of
dopamine-producing neurons in substantia nigra of
the basal ganglia
 Disrupts dopamine-acetylcholine balance in basal
ganglia (decreased acetylcholine & dopamine)
 Symptoms of the disease do not occur until 80% of
neurons in the substantia nigra (basal ganglia, lie
near the lateral ventricles, when stimulated they
release the dopamine) are lost
 Diagnosis increases with age
 Peak onset in the 6th decade of life
 Onset before age 50 is likely related to genetic
defect
 More common in men: ratio is 3:1
 Other causes include hydrocephalus; hypoxia;
infections; stroke; tumor; and trauma (i.e., injury
to the brain)
 Clinical Presentations (goes from stage 1 to stage
5… book gives good description of stages)
 Symptoms may involve only one side of the body
initially
 Beginning stages may involve only mild tremor, slight
limp or decreased arm swing
 Later stages may show shuffling, propulsive gait with
arms flexed, loss of postural reflexes
 Never progresses to complete paralysis
 Classic triad of clinical symptoms include
 Tremor
 Rigidity
 Bradykinesia (slow movement)
 (proprioception, postural instability, loosing awareness
of where their body is at all times)
 Tremors
 More prominent at rest and aggravated by emotional
stress or increased concentration
 Described as “pill rolling” because thumb and forefinger
appear to move in rotary fashion
 Tremor can involve diaphragm, tongue, lips and jaw
 Benign essential tremor, which occurs during voluntary
movement, has been misdiagnosed as Parkinson’s
disease
 Rigidity (2nd classic symptom)
 Caused by sustained muscle contraction and
consequently elicits:
 Complaints of soreness
 Feeling tired and achy
 Pain in the head, upper body, spine, or legs
 Rigidity is typified by a jerky-quality when the joint is
moved
 Rigidity is similar to intermittent catches in the movement
of a cogwheel (“cogwheel rigidity”)
 Inhibits the alternating contraction and relaxation in
opposing muscle groups, thus slowing movement
 Bradykinesia
 Slowing down in initiation and execution of
movement-lean forward to initiate ambulation
 Evident in loss of automatic movements
 Blinking
 Swinging of arms while walking
 Swallowing of saliva
 Self-expression with facial movements (“masked
facies”)
Parkinson’s Disease: Complications
 Caused by progressive deterioration and loss of

spontaneity of movement
 Dysphagia can lead to malnutrition or aspiration
 Debilitation may lead to pneumonia, UTI, and skin
breakdown
 30-40% have dementia
 Orthostatic hypotension may occur along with loss
of postural reflexes
 Falls and other injuries can result
Parkinson’s Disease: Complications
 Side effects from drugs, particularly levodopa,

include…
 Dyskinesia (involuntary movement)
 Hallucinations
 Orthostatic hypotension
 Weakness
 Akinesia (without movement or much movement)
Parkinson’s Disease: Diagnostic Tests
 No specific tests
 Diagnosis is based on history and clinical features
 Firm diagnosis can be made when at least 2 of 3
characteristics of classic triad -tremor, rigidity and
bradykinesia (slowness of movement)- are present
 Ultimate confirmation of diagnosis is a positive
response to antiparkinsonian drugs
Parkinson’s Disease: Collaborative
Care
 Drug therapy –
 Aimed at correcting imbalances of neurotransmitters
within the CNS
 Enhance or release supply of dopamine
 Antagonize or blocks the effect of over-active
cholinergic neurons in the striatum
Care
 Levodopa with carbidopa (Sinemet) is often the
first drug used
 Precursor of dopamine and crosses the blood/brain
barrier
 Converted to dopamine in the basal ganglia
 Carbidopa inhibits an enzyme that breaks down
levodopa before it reaches the brain
Care
 Effectiveness of Sinemet can wear off after a few
years of therapy
 Initiation of therapy is with a dopamine receptor
agonist (an agonist is site specific drug) instead
(Parlodel)
 Anticholinergics are also used in the management
of Parkinson’s disease (Artane, Cogentin)
 Decreases activity of acetylcholine
Care
 Antihistamines with anticholinergic or beta-
adrenergic blockers are used to manage tremors
 Antiviral agent amantadine is effective though exact
mechanism is unknown (Symmetryl)
 As disease progresses, combination therapy is often
required
 Excessive amounts of dopaminergic drugs can lead
to paradoxical intoxication (i.e., excessive drug load)
Care
 Surgical treatment
 Procedures aimed at relieving symptoms in patients who
are unusually unresponsive to drug therapy
 Ablation surgery
 Stereotactic ablation of areas in the thalamus, globus
pallidus, and subthalmic nucleus (unilateral pallidotomy
improves tremor and dyskinesia on one side of the body;
deep brain stimulation preferable)
Care
 Deep brain stimulation
 Involves placing an electrode in either the thalamus,
globus pallidus, and subthalmic nucleus
 Connected to a generator placed in the upper chest
 Device is programmed to deliver specific current to
target brain location
 Is adjustable and reversible
Care
 Transplantation of fetal neural tissue into the basal
ganglia provides dopamine producing cells in the
brains of patients
 Still experimental
 Controversial
Care
 Nutritional therapy:
 Malnutrition and constipation can be serious
consequences
 Patients with dysphagia and bradykinesia need food that is
easily chewed and swallowed
 Adequate roughage
 Several small meals to prevent fatigue
 Provide ample time to avoid frustration
 Levodopa can be impaired by protein ingestion
Parkinson’s Disease: Nursing Assessment /
Management
 History
 CNS trauma
 Cerebrovascular disorders
 Exposure to metals (23 types of heavy metals)
 Encephalitis
 Medications such as tranquilizers, amphetamines,
methyldopa
 Excessive salivation; dysphagia; weight loss
Parkinson’s Disease: Nursing Assessment /
Management
 History, continued
 Difficulty initiating movements; falls; loss of dexterity
 Constipation; incontinence
 Diffuse pain in head, shoulders, neck, back, arms, legs,
and hips
 Depression; mood swings; hallucinations
Parkinson’s Disease: Nursing
Diagnoses
 Imbalanced nutrition: less than body requirements
 Impaired verbal communication
 Deficient diversion activity
 Risk for falls
Parkinson’s Disease: Nursing Management /
Planning
 Maximize neurologic function (Pharm therapy as
prescribed; Pilates, which teaches balance and
control of body)
 Maintain independence in ADLs for as long as
possible
 Optimize psychosocial well-being
Implementation
 Teach maintenance of good health,

independence, and avoidance of complications
 Promotion of physical exercise and well-
balanced diet
 Specific exercises to strengthen muscles involved with
speaking and swallowing
 Healthy diet – fruits, vegetables, eggs, some cereal
Implementation
 Problems secondary to bradykinesia can be

alleviated by
 Consciously thinking about stepping over a line on
the floor
 Lifting toes when stepping
 One step back and…
 Two steps forward
Implementation
 Getting out of chair by using arms and placing

the back legs on small blocks
 Remove rugs and excess furniture
 Simplify clothing from buttons and hooks
 Elevated toilet seat
Myasthenia Gravis
 A chronic, progressive disease of muscular
weakness caused by a defect at the myoneural
junction (The synaptic connection of the axon of a
motor neuron with a muscle fiber)
 Etiology - possibly autoimmune
 Antibodies attack acetylcholine receptors→decreased
acetylcholine→decreased muscle contraction
 Gradual onset
 Peak onset 20 – 30 years of age
Myasthenia Gravis: Hallmarks of the
Disease
 Weakness of certain voluntary muscles
 Improvement of muscle strength at rest
 Dramatic improvement of muscle strength with

anticholinesterase drugs
Myasthenia Gravis: Symptoms
 Muscles of the eye affected first
 Facial, masticatory, speech and neck muscles are
next
 Muscles of fine hand movements
 Intercostal muscles
 Myasthenia crisis: acute exacerbation (breathing
and throat muscle weakness)
Myasthenia Gravis: Diagnosis
 Based on history of weakness in certain muscle
groups which improve with rest
 Tensilon test (Tensilon extends muscle stimulation, and
briefly improves strength. Muscle strength increased as a
result of Tensilon injection yields a probable diagnosis of MG)
 Serum antibodies to acetycholine
 Usually elevated in 80-90% of patients
Myasthenia Gravis: Medical
Management
 Anticholinesterase drugs facilitate impulse across
neuromuscular junctions
 Neostigmine; Pyridostigmine
 Corticosteroids make symptoms worsen prior to
improvement and remission
 Plasmapheresis
 Washes acetylcholine receptor antibodies from
plasma (also done for guillian barre… can be done
over & over…)
Myasthenia Gravis: Nursing
Management
 Assess
 Respiratory function
 Degree of strength of all muscles involved
 Observe for
 Signs and symptoms of pneumothorax (as result to
diaphragm & other intercostal muscles being affected)
 Unpredictable responses to drugs
 Patient teaching
 Re exacerbations of the disease
Myasthenia Gravis: Nursing
Diagnoses
 Ineffective breathing pattern
 Impaired gas exchange
 Ineffective airway clearance
 Activity intolerance
 Imbalanced nutrition
 Disturbed body image
Restless Leg Syndrome
 Etiology and pathophysiology
 Signs/Symptoms
 Diagnostic studies
 Collaborative care
 Nursing management
 Etiology and pathophysiology
 Characterized by leg paresthesias (burning or prickling
sensation, “crawing-like”) associated with a strong
urge to move
 20 million Americans affected
 Signs/Symptoms
 Worse in the evening when at rest
 Diagnosis based on history
 Possible associated conditions
 Vitamin and mineral deficiencies
 Anemias
 Polyneuropathies
 Diabetes type II
 Pregnancy
 Peripheral nerve disease
 Diagnosis based on history
 Possible associated conditions
 Pinched nerves
 Lumbar surgical procedures
 Renal failure
 Substances, i.e., caffeine, alcohol beta-
blockers
 Parkinson’s disease
 Collaborative Care
 Treatment of contributing condition
 Education on limiting caffeine, nicotine and alcohol
 Routine bedtime
 No strenuous exercise 2-3 hours before bedtime
 Nursing Management
 Education
Trigeminal Neuralgia
 Pathophysiology
 Trigeminal neuralgia a/k/a tic douloreux
 5th cranial nerve affected
 Usually affects people > 50 years of age
 Female to male ratio 2:1
 Unilateral facial pain (intense spasms)
 Provoked by minimal stimulation of a trigger zone
 Pain described as…
 Sharp; shooting; burning; jabbing; piercing; no motor or
sensory deficits; usually life-long from onset; symptoms
improve with aging
Trigeminal Nerve
(a/k/a 5th cranial nerve)
Trigeminal nerve sends sensations of

pain, touch, pressure, temperature to
the brain from the face, jaw, gums,
forehead and around the eyes (Gama
Knife Center, 2008)
 Collaborative Management
 Control pain
 Dilantin or Tegretol
 Neurontin
 Local anesthesia
 Microcirculation decompression
Trigeminal Neuralgia Nursing
Management
 Acute pain
 Imbalanced nutrition
 Anxiety
 Impaired oral mucosa
Amyotrophic Lateral Sclerosis (ALS)
(Lou Gehrig’s Disease)
 Named after 1930s baseball player, Lou Gehrig
 Rapidly progressive, degenerative, fatal disease
(generally don’t live beyond 5 yrs past diagnosis).
 Destruction of motor cells in the anterior grey
horns of the spinal cord
 Unknown etiology (no known cause, cure,
treatment)
Lou Gehrig’s Disease: Classic Pattern
 Weakness, atrophy, fasciculation (twitching) of

muscles of the hands and arms
 Converts to spastic paralysis of the limbs
(contractures)
 Sensory changes are not present (generally
mentally they are completely fine)
Lou Gehrig’s Disease: Symptoms
 Muscle weakness, wasting and atrophy
 Muscle spasticity and hyperreflexia
 Fasciculations
 Fatigue
 Dyspnea
 Brain-stem signs (atrophy of tongue)
Lou Gehrig’s Disease: Symptoms
 History and neuro exam
 Electromyelogram (EMG) (a/k/a a nerve
conduction study)
 CPK (also called creatinine kinase) elevated
 (CPK found in muscle and brain cells)
 Myelogram (contrast x-ray) to rule out other
conditions
Lou Gehrig’s Disease (Amyotrophic Lateral
Sclerosis): Management
 No known treatment or cure (symptomatic)

 PT; OT
 Gastrostomy tube
 Ongoing counseling for patient and family
(teaching)
 Drug therapy – Rilutek (specific for ALS, will help slow the
progression of the disease)
Lou Gehrig’s Disease (Amyotrophic Lateral
Sclerosis): Management
 Assist patient to remain independent

 Limit complications
 Prepare for discharge and crisis
 Provide emotional and psychological support
 Depression is common
 Referral to community resources
Bell’s Palsy
 CN VII (facial)
 Cause is unknown, but reactivation of herpes simplex
virus may be implicated
 Clinical manifestation
 Maximum paralysis evident within 48 hours for half of
those affected; within 5 days for others
Bell’s Palsy
 (Clinical manifestation, continued)
 Drawing sensation and paralysis on affected side
 Inability to close eyes, smile, grimace, wrinkle
forehead
 Face is mask-like and sags
 Impaired taste
Bell’s Palsy
 Diagnostic tests
 No specific test
 Exclusion diagnosis…
 Prednisone; Zovirax
 Management of neurological deficits
 Psychosocial support
Bell’s Palsy: Nursing Diagnoses
 Acute pain related to inflammation of CN VII
 Imbalanced nutrition related to inability to chew
 Risk for injury – corneal abrasion related to
inability to blink
 Disturbed body image related to change in
appearance related to facial muscle weakness
Bell’s Palsy: Nursing Planning
 Warm-moist heat
 Analgesics as prescribed
 Dark glasses
 Protect from cold
 Artificial tears
 Tape eyelids at night
Guillain-Barre Syndrome
 Cell mediated immunologic reaction
 Acute inflammatory polyneuropathy
 Incidence of 1.7 per 100,000
 Progressive disorder that affects the motor component of
the peripheral nerves
 Demyelination (myelin around axons is destroyed… pt has
had some type of infection to set it off, auto-immune
problem), edema and inflammation
Guillain-Barre Syndrome: Three
Stages
 Initial
 Onset until no further deterioration (usually occurs about 3
wks after viral infection) (1-3 weeks)
 Plateau
 Little change (several days to 2 weeks) (if caught
 Recovery
 Coincides with myelination and axonal regeneration
(4-6 months)
Guillain-Barre Syndrome: Types
 Ascending
 Descending
 Pure Motor
 Miller-Fisher variant
Guillain-Barre Syndrome: Ascending
 Most common type

 Weakness and numbess begin in legs
 Paresthesia (numbness; tingling), hypotonia
(abnormally low muscle tone), areflexia (absence
of neurologic reflexes)
 Respiratory function – insufficiency occurs in 50%
of patients
Guillain-Barre Syndrome: Descending
 Weakness progresses downward
 Motor deficits – initial deficitis in the brainstem,
cranial nerves, sternocleidomastoid muscle
 Sensory deficits – numbness occurs distally, more
often in the hands than in the feet
 Paresthesia, hypotonia, and areflexia
 Rapid respiratory involvement
Guillain-Barre Syndrome: Pure Motor
 Identical to ascending GBS, except sensory signs

and symptoms are absent (they have weakness &
paralysis, but no numbness or tingling)
 May be a mild form of ascending GBS
 Muscle pain is generally not present
Guillain-Barre Syndrome: Miller-
Fisher Variant
 Opthalmoplegia (paralysis or weakness in
muscle(s) that control the eye) (CN 3, 4 & 6
affected)
 Areflexia
 Severe ataxia
 Normal motor strength
 Intact sensory function
Guillain-Barre Syndrome: Clinical
Presentation
 Recent history of viral infection
 80% to 90% will have little or no residual disability
 GBS is characterized by muscle weakness and
areflexia
 Symptoms tend to be symmetrical and ascending
from legs to trunk and arms
Guillain-Barre Syndrome: Clinical
Presentation
 Respiratory failure attributed to mechanical
failure and fatigue of intercostals and diaphragm
 If cranial nerves are involved the facial (VII) is
most common
 GBS does not affect level of consciousness,
cognitive function, or pupillary signs
 Diagnosis is based upon clinical picture
Guillain-Barre Syndrome:
Collaborative Management
 Immunotherapy
 Plasmaphoresis
 Respiratory support – frequently elective
intubation
 Supportive treatment
Guillain-Barre Syndrome: Nursing
Diagnoses
 Ineffective breathing pattern: Ineffective airway
exchange; Impaired gas exchange
 Self-care deficit
 Anxiety; Anticipatory grieving
Spinal Cord Problems
 Primary injury
 Usually compression type injury; rarely dura is punctured
 Secondary injury
 Edema related to inflammatory response→cascade of
events→tissue hypoxia
Spinal Cord Trauma
 Mechanisms of injury
 Flexion
 Hyperextension
 Flexion-rotation
 Flexion/extension rotation
 Compression
Spinal Cord Injury Classification
Incomplete Spinal Cord Injury
Anterior Cord Syndrome
May result in loss or impaired ability to
sense pain, temperature or touch
below the level of injury
Central Cord Syndrome

Usually results in loss of function in the
arms, but some leg movement remains;
May have some control over bladder
and bowel. Some recovery is possible
starting in the legs and moving up
Incomplete Spinal Cord Injury
Posterior Cord Syndrome
Muscle power; pain; temperature sensations
are preserved.
May have difficulty coordinating movement of
limbs
Brown Séquard Syndrome

Pain and temperature sensations may be
preserved; has impaired or lost movement on
the injured side. Opposite side of injury will
have normal movement, but pain and
temperature sensation will be impaired or lost.
Spinal Cord Trauma
 Complete or incomplete
 Mechanisms of Injury
 Flexion
 Hyperextension
 Flexion/rotation
 Flexion/extension/rotation
 Compression
Spinal Cord Trauma
 Clinical manifestations
 Respiratory system
 Cardiovascular system
 Urinary system
 GI system
 Integumentary system
 Thermoregulation
 Metabolic needs
 Peripheral vascular problems
Spinal Cord Trauma
 Diagnostic tests
 X-ray; CT; MRI (gold standard… CT scan is waste of
time); neurologic exam; possibly angiogram
 Non-operative stabilization
 ABCs! (always critical)
 Stabilized; immobile; trach (+ halo); oxygen; maintain
heart rate (atropine); blood pressure (dopamine)
 UA catheter; NG
 DVT Prevention; stress ulcer prevention;
 Temperature control
Spinal Cord Trauma
 Drug therapy: Large doses of prednisone
 Side effects may include UGI bleeding (stress ulcer)
 Surgical therapy
 Cervical immobilization – halo
 Decompression laminectomy
SCI: Nursing Management /
Diagnoses
 Impaired gas exchange R/T diaphragmatic fatigue; paralysis;
retained secretions; as evidenced by (AEB) decreased PO2;
adventitious breath sounds; decreased respiratory rate;
respiratory fatigue or distress
 Decreased cardiac output R/T venous pooling of blood;
bradycardia; immobility; AEB hypotension, restlessness;
pulmonary edema
 Altered (spinal cord) tissue perfusion
 Impaired skin integrity
Spinal Cord Injury: Nursing Diagnoses
 Impaired urinary elimination

 Constipation
 Imbalanced nutrition: less than body requirements
 Disturbed body image
 Interrupted family processes
 Risk for ineffective coping
 Risk for autonomic dysreflexia R/T stimulated sympathetic

nervous system after spinal shock resolves as evidenced by
severe headache, hypertension, bradycardia, nasal stuffiness,
flushing, sweating above the level of injury, feeling of
apprehension related to noxious stimulation (i.e., distended
bladder, fecal impaction, tactile stimulation)
 Interventions: remove noxious stimulation
 Antihypertensive meds, reverse Trendelenburg or sitting
upright
 Patient teaching on prevention, recognition, treating
 Rehabilitation and Home Care

 Respiratory rehabilitation
 Neurogenic bladder
 Neurogenic bowel
 Neurogenic skin
 Sexuality
 Grief and depression
 Long term adaption of patient and family
Affects of Spinal Cord Injury
Segmental Spinal Cord Level and Function
Cl-C6 Neck flexors
Cl-Tl Neck extensors
C3, C4, C5 Supply diaphragm (mostly C4)
C5, C6 Shoulder movement, raise arm (deltoid); flexion of elbow
(biceps); C6 externally rotates the arm (supinates)
C6, C7 Extends elbow and wrist (triceps and wrist extensors);
pronates wrist
C7, T1 Flexes wrist
C7, T1 Supply small muscles of the hand
T1 -T6 Intercostals and trunk above the waist
T7-L1 Abdominal muscles
L1, L2, L3, L4 Thigh flexion
L2, L3, L4 Thigh adduction
L4, L5, S1 Thigh abduction
L5, S1, S2 Extension of leg at the hip (gluteus maximus)
L2, L3, L4 Extension of leg at the knee (quadriceps femoris)
L4, L5, S1, S2 Flexion of leg at the knee (hamstrings)
L4, L5, S1 Dorsiflexion of foot (tibialis anterior)
L4, L5, S1 Extension of toes
L5, S1, S2 Plantar flexion of foot
L5, S1, S2 Flexion of toes
Spinal Cord Injury: Functionality of C1, C2, C3
Quadriplegic
Mobility & Movement
Limited head and neck movement depending on muscle strength.
Complete paralysis of arms, body and legs.
Sympathetic nervous system will be compromised, possibility of Autonomic Dysreflexia.
Electric wheelchair may possibly be controlled by either a chin or "sip and puff"
controller, this will vary depending on dexterity.
The person will require total assistance when transferring from a bed to a wheelchair
and from a wheelchair into a car. A hoist will have to be used, possibly by two assistants
for safety.
Complete assistance required during mealtimes.
Respiratory System
Inability to breathe using chest muscles or diaphragm, therefore the person will be
dependant on a ventilator to breathe. A portable ventilator can be attached to the back
of a wheelchair during transport.
Oxygen and humidification may be required.
Assistance required to clear secretions from trachea, and assistance in coughing will be
required.
Personal Care
Complete personal assistance is required. The person will need assistance with washing,
dressing, and assistance with bowel and bladder management.
Domestic Care
Complete domestic care is required, such as household cleaning, washing of clothes and
kitchen duties, preparation of meals and general household duties.
Communication
A computer may be operated using iris recognition, mouth stick or voice recognition.
Telephone can be used using voice recognition and headset.
Spinal Cord Injury:
Functionality of C4 Spinal Cord Injury
Mobility & Movement
Full head and neck movement depending on muscle strength. Limited shoulder movement.
Complete paralysis of body and legs. No finger, wrist or elbow flexion or extension.
Electric wheelchair may be controlled by either a chin or "sip and puff" controller, this will
vary depending on dexterity.
The person will require total assistance when transferring from a bed to a wheelchair and
from a wheelchair into a car. A hoist will have to be used, possibly by two assistants for
safety.
Complete assistance required during mealtimes.
Respiratory System
Able to breathe without a ventilator using diaphragm.
Assistance required to clear secretions and assistance in coughing will be required.
Personal Care
Complete personal assistance is required. The person will need assistance with washing,
dressing, and assistance with bowel and bladder management.
Domestic Care
Complete domestic care is required, such as household cleaning, washing of clothes and
kitchen duties, preparation of meals and general household duties.
Communication
A computer may be operated using iris recognition, mouth stick or voice recognition.
Telephone can be used using voice recognition and headset.
Spinal Cord Injury: Functionality of C5
Spinal Cord Injury
Mobility & Movement
Full head and neck movement with good muscle strength. Good shoulder movement.
Complete paralysis of body and legs. No finger or wrist movement. No elbow
extension, good elbow flexion.
Electric wheelchair can be controlled with a hand control for uneven surfaces. A manual
wheelchair may be used for short distances on flat surfaces.
The person will require total assistance when transferring from a bed to a wheelchair
and from a wheelchair into a car. A hoist will have to be used, possibly by one to two
assistants for safety.
Ability to feed self using feeding strap and fork or spoon during mealtimes. Food will
need cutting.
Respiratory System
Able to breathe without a ventilator using diaphragm. Low stamina.
Assistance required to clear secretions and assistance in coughing will be required.
Personal Care
Complete personal assistance is required. The person will need assistance with
washing, dressing, and assistance with bowel and bladder management.
Ability to shave and brush hair may be possible with palm straps.
Domestic Care
Complete domestic care is required, such as household cleaning, washing of clothes
and kitchen duties, preparation of meals and general household duties.
Communication
A computer may be operated using a typing stick or voice recognition. Telephone can
be used using voice recognition and headset.
Spinal Cord Injury: Functionality of C6
Spinal Cord Injury
Mobility & Movement
Complete paralysis of body and legs. No finger movement, no elbow extension, no wrist flexion. Good wrist
extension, good elbow flexion.
A passive key grip may be present by flexing the wrist backwards, but will be weak.
Electric wheelchair can be controlled with a hand control for uneven outdoor surfaces. A manual wheelchair
may be used for short distances on flat surfaces.
The person will require total assistance when transferring from floor to chair. Assistance will vary for
transfer from bed to wheelchair, and wheelchair to car. A sliding board may be used in assisting with the
transfer
Ability to feed self using feeding strap and fork or spoon during mealtimes. Food will need cutting. Able to
make hot drinks with adapted kettle using a "kettle tipper".
Respiratory System
Assistance required to clear secretions and assistance in coughing may be required. Additional coughing
techniques can be applied to assist in coughing by leaning forward whilst exhaling.
Personal Care
Personal assistance is required. The person will need assistance with washing, dressing, and assistance with
bowel and bladder management. Ability to empty own legbag will depend on dexterity and strength.
Ability to partially dress upper body, however, assistance may be required to dress lower body.
Ability to shave, brush hair and brush teeth is possible with palm straps.
Domestic Care
Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties.
Ability with adapted equipment to prepare simple meals and simple general household duties.
Communication
A computer may be operated using a typing stick or voice recognition. Telephone can be used using voice
recognition and headset.
Spinal Cord Injury: Functionality of C7 - C8
Spinal Cord Injury
Mobility & Movement
Complete paralysis of body and legs. Partial finger movement,full elbow extension and flexion, full wrist
extension and flexion.
A C7 injured person will have movement in the thumb.
May use an electric wheelchair for long independent travel or uneven outdoor surfaces. A manual
wheelchair may be used for short distances on flat surfaces.
Ability to transfer independently from bed to chair, and chair to car. Car transfers may need assistance
depending on upper body strength.
Ability to drive a car adapted with hand controls. Assistance may be required to load wheelchair into car
independently.
Ability to feed self independently during mealtimes. Food may need cutting. Able to make hot drinks ,
may require an adapted kettle using a "kettle tipper".
Respiratory System
Assistance required to clear secretions and assistance in coughing may be required. Additional coughing
techniques can be applied to assist in coughing by leaning forward whilst exhaling.
Personal Care
Ability to manage bladder and bowel independently will vary depending on strength and dexterity.
Independent in upper body showering and dressing, lower body dressing and showering may need
assistance.
Independent in grooming, usually without palm straps.
Domestic Care
Partial domestic assistance is required, such as heavy household cleaning, home maintenance, and
complex preparation of meals.
Ability to prepare simple meals and simple general household duties independently.
Communication
A computer may be operated using a typing stick or voice recognition. Telephone can be used using
voice recognition and headset.
Spinal Cord Injury: Functionality of T1 - T4
Paraplegic
Mobility & Movement
Full head and neck movement with normal muscle strength. Normal shoulder movement.
Full use of arms, wrists and fingers.
Complete paralysis of lower body and legs. Upper body strength will vary depending on
level of injury, but the lower the level, the stronger the upper body strength and balance.
A T4 injured person will have good strength in the chest muscles, however this will get
progressively weaker the higher up the injury.
Sympathetic nervous system may be compromised, possibility of Autonomic Dysreflexia.
May use an electric wheelchair for long distance independent travel or uneven outdoor
surfaces. A manual wheelchair may be used for everyday living, with the ability to go
over uneven ground for short distances.
Ability to transfer independently from bed to chair, and chair to car. Car transfers may
need assistance depending on upper body strength.
Ability to drive a car adapted with hand controls. Assistance may be required to load
wheelchair into car.
Ability to feed self independently during mealtimes.
Respiratory System
Ability to breathe normal, although respiration capacity and endurance may be
compromised.
Personal Care
Should be independent in personal care as long as no other factors are involved, ie,
additional injuries, severe spasticity etc.
Domestic Care
Partial domestic assistance is required, such as heavy household cleaning and home
maintenance.
Ability to prepare complex meals and general household duties independently.
Communication
Normal communication skills apply.
Spinal Cord Injury: Functionality of T5 - T9
Spinal Cord Injury
Mobility & Movement

Full head and neck movement with normal muscle strength. Normal shoulder movement.
Full use of arms, wrists and fingers.
Complete paralysis of lower body and legs. Upper body strength will vary depending on
level of injury, but the lower the level, the stronger the upper body strength and balance.
A manual wheelchair may be used for everyday living, with the ability to go over uneven
ground.
Ability to transfer independently from bed to chair, and chair to car. Car transfers may
need assistance depending on upper body strength.
Ability to drive a car adapted with hand controls. Assistance may be required to load
wheelchair into car.
Respiratory System
Ability to breathe normal, although respiration capacity and endurance may be
compromised.
Personal Care
Domestic Care
maintenance.
Communication
Spinal Cord Injury: Functionality of T10 -
L1 Spinal Cord Injury
Mobility & Movement
Full head and neck movement with normal muscle strength. Normal shoulder
movement. Full use of arms, wrists and fingers.
Partial paralysis of lower body and legs. Upper body strength and balance will vary
depending on level of injury, but the lower the level, the stronger the upper body
strength and balance.
A manual wheelchair may be used for everyday living, with the ability to go over uneven
ground.
Ability to transfer independently from bed to chair, and chair to car. It may be possible to
transfer from floor to chair depending on upper body strength. It may also be possible
to transfer from sitting position to standing frame independently.
Ability to drive a car adapted with hand controls. Ability to load wheelchair into car
independently.
Respiratory System
Normal respiratory system.
Personal Care
Domestic Care
maintenance.
Communication
Spinal Cord Injury: Functionality of L2 - S5
Spinal Cord Injury
Mobility & Movement
Full head and neck movement with normal muscle strength. Normal shoulder
movement. Full use of arms, wrists and fingers.
Full upper body control and balance.
Some hip, knee and foot movement depending on the level of injury. The lower
the injury, the more control over movement.
A manual wheelchair may be used for everyday living, with the ability to go over
uneven ground.
Ability to transfer independently from bed to chair, and chair to car. It may be
possible to transfer from floor to chair depending on upper body strength.
Depending on the level of injury, walking may be possible with assistance or
aids. Walking will be slow and difficult though.
Ability to drive a car adapted with hand controls. Ability to load wheelchair into
car independently.
Respiratory System
Normal respiratory system.
Personal Care
Should be independent in personal care as long as no other factors are involved,
ie, additional injuries, severe spasticity etc.
Domestic Care
Partial domestic assistance is required, such as heavy household cleaning, home
maintenance.
Communication
Thank You

Chronic Neurologic Problems

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Chronic Neurologic Problems

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Chronic Neurologic

 (similar to WPW ablation on heart, but done in

 After the seizure, document, do vitals, etc…

 Possibility that the association between

 Initially triggered by a virus in a genetically

 Based primarily on history, clinical presentation,

 Antispasmotics (any muscle, bladder, etc…)

 These are symptom relief meds

 Surgery (for patients with severe tremor)

 Physical therapy helps…

 Nutritional therapy includes…

 Megavitamins and diets consisting of low-fat, gluten-

 Impaired physical mobility

 Caused by progressive deterioration and loss of

 Side effects from drugs, particularly levodopa,

 Teach maintenance of good health,

 Problems secondary to bradykinesia can be

 Getting out of chair by using arms and placing

 Improvement of muscle strength at rest

 Dramatic improvement of muscle strength with

Trigeminal nerve sends sensations of

 Weakness, atrophy, fasciculation (twitching) of

 No known treatment or cure (symptomatic)

 Assist patient to remain independent

 Most common type

 Identical to ascending GBS, except sensory signs

Central Cord Syndrome

Brown Séquard Syndrome

 Impaired urinary elimination

 Risk for autonomic dysreflexia R/T stimulated sympathetic

 Rehabilitation and Home Care

Mobility & Movement

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