Neurologic

Disorder
BY: SANDOT, ALFRIEN B.
Assessment
Neurologic Assessment

 Neurologic assessment doesn't just take place in neuro units and the ED. A patient
who doesn't have a neurologic diagnosis may also require a neuro assessment; for
example, a patient with pneumonia can develop neurologic changes due to hypoxia
or a post-op patient may have a neurologic deficit due to blood loss. 
 Begin with speaking your patient's name in a normal tone. If he doesn't respond,
say his name again in a louder tone. (If your patient is hearing-impaired, you'll
need to document this; it shouldn't change his score.) If there's still no response,
gently shake your patient. If you still can't get a reaction, you'll need to use painful
stimulation.
 A focused neurological assessment of your patient can make a difference between
life and death, permanent disability or complete recovery. It is a key standard of
care for all patients.
Neurologic Assessment

 Assessing mental status

 Glasgow Coma Scale
 LOC is crucial to test because it’s the first assessment to change when
there’s neurologic injury. You should always elicit your patient’s best
level of response for an accurate assessment of LOC. Begin with
speaking your patient’s name in a normal tone.
  If there's still no response, gently shake your patient. If you still can't
get a reaction, you'll need to use painful stimulation.
Neurologic Assessment

To do this, you can use one the following techniques:

Trapezius squeeze. Grasp and twist the muscle that runs from the back of
the neck to the shoulder.
Sternal rub. Make a fist, then push the broad side of your fist into the
sternum and press hard enough to leave a mark on your patient’s skin.
 Supraorbital pressure. Along the bone beneath the eyebrow you’ll find
an indentation near the nose. Press it with your thumbs.
Neurologic Assessment
Neurologic Assessment

 To determine orientation, ask detailed questions about your patient’s

name, where he is, and the date.
 Memory is divided into three abilities: immediate memory, short-term
memory, and remote memory. To assess immediate memory, give your
patient three unrelated words to remember, such as pencil, grape, and
car.
 To assess short-term memory, ask your patient to describe something
that happened in the last few days.
Neurologic Assessment

 Assessing the cranial nerves

 The next component of the neurologic assessment is cranial nerve testing. Test the
cranial nerves as follows:
 CN I (olfactory). Ask your patient to identify at least two common substances such
as coffee and cinnamon. Make sure his nostrils are patent before performing this
test. (Note: CN I testing is usually deferred.)
 CN II (optic). Test visual acuity with a Snellen chart and the Rosenbaum near-vision.
 CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). Assess these nerves
together using the corneal light reflex test, the six cardinal positions of gaze, and
the cover-uncover test. Also, inspect the size, shape, and symmetry of your
patient’s pupils and papillary reactions to light.
Neurologic Assessment

CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). Assess these nerves together

using the corneal light reflex test, the six cardinal positions of gaze, and the cover-uncover
test. Also, inspect the size, shape, and symmetry of your patient’s pupils and papillary
reactions to light.
 CN V (trigeminal). To assess the sensory component of the trigeminal nerve, ask your
patient to close his eyes and then touch him with a wisp of cotton on his forehead,
cheek, and jaw on each side (see photo at left). Next, test pain perception by touching
the tip of a safety pin to the same three areas. Ask him to describe and compare both
sensations. To test the motor component, ask him to clench his teeth while you palpate
the temporal and masseter muscles (see photos at bottom of page 17). Note the
strength of the muscle contraction; it should be equal bilaterally. If your patient isn’t
alert, test his corneal reflex by lightly touching the cornea with a fine wisp of cotton.
Look for the normal reaction of blinking of the eyes. (Note: Corneal reflex testing isn’t
done on an alert patient.)
Neurologic Assessment

 CN III (oculomotor), CN IV (trochlear), and CN VI (abducens). Assess these

nerves together using the corneal light reflex test, the six cardinal positions of
gaze, and the cover-uncover test. Also, inspect the size, shape, and symmetry of
your patient's pupils and papillary reactions to light.
 CN V (trigeminal). To assess the sensory component of the trigeminal nerve, ask
your patient to close his eyes and then touch him with a wisp of cotton on his
forehead, cheek, and jaw on each side (see photo at left). Next, test pain
perception by touching the tip of a safety pin to the same three areas. Ask him to
describe and compare both sensations. To test the motor component, ask him to
clench his teeth while you palpate the temporal and masseter muscles (see photos
at bottom of page 17). Note the strength of the muscle contraction; it should be
equal bilaterally. If your patient isn't alert, test his corneal reflex by lightly touching
the cornea with a fine wisp of cotton. Look for the normal reaction of blinking of the
eyes. (Note: Corneal reflex testing isn't done on an alert patient.)
Neurologic Assessment

 CN VII (facial). To assess the sensory component, test taste by placing items with various tastes
on the anterior portion of your patient's tongue, for example, sweet, sour, and bitter. To test motor
function, observe his face for symmetry at rest and while he smiles, frowns, and raises his
eyebrows. Then have him close both eyes tightly. Test muscle strength by attempting to open his
eyes (see photo at left).
 CN VIII (acoustic). To assess this nerve, use Weber's test—strike a tuning fork lightly against
your hand and place the vibrating fork on your patient's forehead at the midline or on the top of
his head—and the Rinne test—strike the tuning fork against your hand and place the vibrating fork
over his mastoid process.

 CN IX (glossopharyngeal) and CN X (vagus). Test these nerves together because their innervation
overlaps in the pharynx. Listen to your patient’s voice. Then check his gag reflex by touching the
tip of a tongue blade against his posterior pharynx and asking him to open wide and say “ah.”
Watch for symmetrical upward movement of the soft palate and uvula and for the midline position
of the uvula.
Neurologic Assessment

CN XI (spinal accessory). Assess this nerve by testing the strength of the

sternocleidomastoid muscles and the upper portion of the trapezius
muscle (see photo above)
 CN XII (hypoglossal). Observe your patient’s tongue for symmetry. His
tongue should be midline without tremors or muscle twitching. Test
tongue strength by asking him to push his tongue against his cheek as
you apply resistance (see photo at right).
Neurologic Assessment

 Assessing motor function

 When assessing motor function, you'll want to look at both sides of your
patient's body simultaneously. On inspection, note any asymmetry of
muscle; unilateral atrophy will often indicate weakness. To assess the
upper extremities, have your patient raise his arms parallel to the floor
or bed, and then have him resist when you try to push them
down. You’ll do the same for the lower extremities, having him raise his
legs and resist when you push them down. You can also have him grasp
your fingers in his fist, and then ask him to let go. If he can’t let go on
command, it’s indicative of neurologic injury.
Neurologic Assessment

Assessing pupillary response

 Now, we’ll move on to pupillary response. Along with eye motion,
pupillary response is controlled by cranial nerves III, IV, and VI. Normal
pupils are of the same size bilaterally, about 2 to 6 mm and round (see
Visualizing pupil size). About 15% of people have one pupil up to 1 mm
smaller than the other; this is a normal variant known as anisocoria.
 To check pupil reactivity, bring a small beam of light in from the outer
canthus of one eye; the normal response is for both pupils to react
equally and briskly. Keep in mind that medications, surgery, and
blindness can affect pupil size, shape, and reactivity.
 Sourve:
https://journals.lww.com/nursingmadeincrediblyeasy/fulltext/2010/0300
0/simplifying_neurologic_assessment.5.aspx
 Laboratory
tests and
Diagnostics
Laboratory and Diagnostic

 Laboratory screening tests of blood, urine, or other body fluids may help doctors diagnose
disease, understand disease severity, and monitor levels of therapeutic drugs. Certain
tests, ordered by the physician as part of a regular check-up, provide general information,
while others are used to identify specific health concerns. For example, blood tests can
provide evidence for infections, toxins, clotting disorders, or antibodies that signal the
presence of an autoimmune disease. Genetic testing of DNA extracted from cells in the
blood or saliva can be used to diagnose hereditary disorders. Analysis of the fluid that
surrounds the brain and spinal cord can detect meningitis, encephalitis, acute and chronic
inflammation, viral infections, multiple sclerosis, and certain neurodegenerative
disorders. Chemical and metabolic testing of the blood can indicate some muscle
disorders, protein or fat-related disorders that affect the brain and inborn errors of
metabolism. Blood tests can monitor levels of therapeutic drugs used to treat epilepsy
and other neurological disorders. Analyzing urine samples can reveal toxins, abnormal
metabolic substances, proteins that cause disease, or signs of certain infections.
Laboratory and Diagnostic Test

 Genetic testing of people with a family history of a neurological disease

can determine if they are carrying one of the genes known to cause the
disorder. Genetic counseling may be recommended for patients, or
parents of children being tested, to help them understand the purpose
of the tests and what the results could mean.
 Prenatal genetic testing can identify many neurological disorders and
genetic abnormalities in utero (while the child is inside the mother’s
womb).
 The mother’s blood can be screened for abnormalities that suggest a
risk for a genetic disorder. Cell-free DNA from the mother’s blood can
also be used to look for Down syndrome and some chromosomal
disorders
Laboratory and Diagnostic Test

 Doctors may also use a type of blood test called a triple screen in order
to identify some genetic disorders, including trisomies (disorders such
as Down syndrome in which the fetus has an extra chromosome) in an
unborn baby.
 Amniocentesis is usually done at 14-16 weeks of pregnancy. It tests a
sample of the amniotic fluid in the womb for genetic defects (the cells
found in the fluid and the fetus have the same DNA).
 Chorionic villus sampling is performed by removing and testing a very
small sample of the placenta during early pregnancy.
Laboratory and Diagnostic Test

 Computed tomography (CT scan) uses X-rays to produce two-

dimensional images of organs, bones, and tissues. A CT scan can aid in
proper diagnosis by showing the area of the brain that is affected.
 Magnetic resonance imaging (MRI) uses computer-generated radio
waves and a powerful magnetic field to produce detailed images of
body tissues. Using different sequences of magnetic pulses, MRI can
show anatomical images of the brain or spinal cord, measure blood
flow, or reveal deposits of minerals such as iron. MRI is used to
diagnose stroke, traumatic brain injury, brain and spinal cord tumors,
inflammation, infection, vascular irregularities, brain damage.
Laboratory and Diagnostic

 Functional MRI (fMRI) uses the blood’s magnetic properties to produce

real-time images of blood flow to particular areas of the brain. fMRI can
pinpoint areas of the brain that become active and show how long they
stay active. This imaging process may be used to localize brain regions
for language, motor function, or sensation prior to surgery for epilepsy.
 Positron emission tomography (PET) scans provide two- and three-
dimensional pictures of brain activity by measuring radioactive isotopes
that are injected into the bloodstream. PET scans of the brain are used
to detect or highlight tumors and diseased tissue, show blood flow, and
measure cellular and/or tissue metabolism.
Laboratory and Diagnostic

 Single photon emission computed tomography (SPECT) is a nuclear

imaging test that can be used to evaluate certain brain functions. As
with a PET scan, a radioactive isotope, or tracer, is injected
intravenously into the body. A SPECT scan may be ordered as a follow-
up to an MRI to diagnose tumors, infections, brain regions involved in
seizures, degenerative spine disease, and stress fractures.
 Angiography is a test that involves injecting dye into the arteries or
veins to detect blockage or narrowing. A cerebral angiogram can show
narrowing or obstruction of an artery or blood vessel in the brain, head,
or neck. It can determine the location and size of an aneurysm or
vascular malformation.
Laboratory and Diagnostic

 Biopsy involves the removal and examination of a small piece of tissue

from the body. Muscle or nerve biopsies are used to diagnose
neuromuscular disorders. A small sample of muscle or nerve is removed
under local anesthetic (pain-relieving medication) and studied under a
microscope.
 Cerebrospinal fluid analysis involves the removal of a small amount of
the fluid that surrounds the brain and spinal cord. The procedure is
commonly called a lumbar puncture or spinal tap. The fluid is tested to
detect evidence of brain hemorrhage, infection, multiple sclerosis,
metabolic diseases, or other neurological conditions
Laboratory and Diagnostic

 Electroencephalography, or EEG, monitors the brain’s electrical activity

through the skull. EEG is used to help diagnose seizure disorders and
metabolic, infectious, or inflammatory disorders that affect the brain’s
activity.
 Electromyography, or EMG, is used to diagnose nerve and muscle
disorders, spinal nerve root compression, and motor neuron disorders
such as amyotrophic lateral sclerosis.
 Electronystagmography (ENG) describes a group of tests used to
diagnose involuntary eye movement, dizziness, and balance disorders.
The test is performed at a clinic or imaging center.
Laboratory and Diagnostic

 Evoked potentials, also called evoked response, measure the electrical

signals to the brain generated by hearing, touch, or sight.
 Myelography involves the injection of contrast dye into the spinal canal
to enhance imaging of the spine, by CT or by X-ray. Myelograms have
mostly been replaced by MRI, but may be used in special situations.
 Thermography (also known as digital infrared thermal imaging) uses
infrared sensing devices to measure small temperature changes and
thermal abnormalities between the two sides of the body or within a
specific organ. Some scientists question its use in diagnosing
neurological disorders.
Laboratory and Diagnostic

 Ultrasound imaging, also called ultrasonography, uses high-frequency

sound waves to obtain images inside the body. During an ultrasound
examination, the person lies on a table or reclines in an examination
chair.
 X-rays of a person’s chest and skull may be taken as part of a
neurological work-up. X-rays can be used to view any part of the body,
such as a joint or major organ system.
 Fluoroscopy is a type of x-ray that uses a continuous or pulsed beam of
low-dose radiation to produce continuous images of a body part in
motion. The fluoroscope (x-ray tube) is focused on the area of interest
and pictures are either videotaped or sent to a monitor for viewing.
Source:https://www.ninds.nih.gov/Disorders/Patient-Caregiver-
Education/Fact-Sheets/Neurological-Diagnostic-Tests-and-Procedures-Fact
Neurologic
Disorders!
Increase
Intracranial
Pressure
Definition

Increased intracranial pressure (ICP) is a rise in pressure around your

brain. It may be due to an increase in the amount of fluid surrounding your
brain. For example, there may be an increased amount of the
cerebrospinal fluid that naturally cushions your brain or an increase in
blood in the brain due to an injury or a ruptured tumor.
 Increased ICP can also mean that your brain tissue itself is swelling,
either from injury or from an illness such as epilepsy. Increased ICP can
be the result of a brain injury, and it can also cause a brain injury.
 Risk Factor

A blow to the head is the most common cause of increased ICP. Other possible causes of increased ICP
infections
tumors
stroke
aneurysm
epilepsy
seizures
hydrocephalus, which is an accumulation of spinal fluid in the brain cavities
hypertensive brain injury, which is when uncontrolled high blood pressure leads to bleeding in the brain
hypoxemia, which is a deficiency of oxygen in the blood
 meningitis, which is inflammation of the protective membranes around the brain and spinal cord
Signs and Symptoms

Headache
nausea
vomiting
increased blood pressure
decreased mental abilities
confusion about time, and then location and people as the pressure worsens
double vision
pupils that don’t respond to changes in light
shallow breathing
seizures
 loss of consciousness
Pathophysiology
Medical Management

This is a medical emergency and may lead to brain injury if a person does not receive
rapid treatmentA doctor will measure the ICP in millimeters of mercury (mm/Hg). The
normal range is less than 20 mm/Hg. When ICP goes above this, a person may be
experiencing increased ICP.
 To diagnose increased ICP, a doctor may ask if a person has:
 experienced a blow to a head
 a previous diagnosis of a brain tumor
 Then, the doctor may carry out the following tests:
 neurological exam to test a person’s senses, balance, and mental state
 spinal tap that measures cerebrospinal fluid pressure
 CT scan that produces images of the head and brain
Treatment

Treatment methods for reducing ICP include:

draining the excess cerebrospinal fluid with a shunt, to reduce pressure on
the brain that hydrocephalus has caused
medication that reduces brain swelling, such as mannitol and hypertonic
saline
surgery, less commonly, to remove a small section of the skull and relieve
the pressure
 A doctor may give the person a sedative to help reduce anxiety and lower
their blood pressure. The person may also need breathing support. The
doctor will monitor their vital signs throughout their treatment.
Nursing Intervention

Frequent neuro checks (q1h)Neurological changes related to increasing ICP may be subtle or may occur rapidly. Frequent
detailed neuro checks allow changes to be recognized quickly so that interventions can be initiated.
Monitor Temperature and hemodynamics, including MAP and CPPWith a loss of autonomic regulation, a patient’s
temperature could become very elevated (104°+).
Monitor hemodynamics to assess for Cushing’s Triad and to evaluate Cerebral Perfusion Pressure (MAP – ICP).
Avoid sedatives or CNS depressants if possible
Administer ordered medications:
Osmotic Diuretics
Hypertonic Saline
Corticosteroids
Osmotic Diuretics (Mannitol) – decrease edema
Hypertonic Saline (3% saline) – decrease edema
 Corticosteroids – decrease inflammation
References:https://nursing.com/lesson/nursing-care-plan-for-increased-
intracranial-pressure-icp/ https://www.healthline.com/health/increased-
intracranial-pressure
Cerebrovascul
ar Accident
Definition

 Cerebrovascular accident (CVA) is the medical term for a stroke. A

stroke is when blood flow to a part of your brain is stopped either by a
blockage or the rupture of a blood vessel. There are important signs of
a stroke that you should be aware of and watch out for.
Causes of Stroke

 a haemorrhagic stroke – an artery may rupture and cause bleeding into

the brain tissue. Also called a cerebral haemorrhage
 an ischaemic stroke caused by atherosclerosis – an artery may become
blocked by progressive thickening of its walls
 an ischaemic stroke caused by embolism – a clot blocks an artery and
prevents blood getting to part of the brain.
Risk Factors

 high blood pressure

 cigarette smoking
 diabetes
 high blood cholesterol levels
 heavy drinking
 a diet high in fat (particularly saturated) and salt, but low in fibre, fruit
and vegetables
 lack of regular exercise
 obesity.
Signs and Symptoms

Difficulty walking
dizziness
loss of balance and coordination
difficulty speaking or understanding others who are speaking
numbness or paralysis in the face, leg, or arm, most likely on just one side
of the body
blurred or darkened vision
 a sudden headache, especially when accompanied by nausea,
vomiting, or dizziness
Pathophysiology

 Atherosclerosis is the most common and important underlying pathology which leads to the
formation of an atherothrombotic plaque secondary to low-density lipoprotein cholesterol (LDL) build
up in the arteries supplying the brain. These plagues may block or decrease the diameter of the neck
or intracranial arteries resulting in distal ischemia of the brain. More commonly they may also
rupture. Plague rupture leads to exposure of the underlying cholesterol crystals which attract
platelets and fibrin. Release of fibrin-platelet rich emboli causes strokes in the distal arterial
territories via an artery-to-artery embolic mechanism. The nature of the cardiac source of emboli
depends on the underlying cardiac problem. In atrial fibrillation, clots tend to be formed in the left
atrium. These are red blood cell rich clots. There may be tumor emboli in left atrial myxoma and
bacterial clumps from vegetations when emboli arise during infective eendocarditis.
 When an arterial blockage occurs, the immediately adjacent neurons lose their supply of oxygen and
nutrients. The inability to go through aerobic metabolism and produce ATP causes the Na+/K+
ATPase pumps to fail, leading to an accumulation of Na+ inside the cells and K+ outside the cells.
The Na+ ion accumulation leads to cell depolarization and subsequent glutamate release. Glutamate
opens NMDA and AMPA receptors and allows for calcium ions to flow into the cells. A continuous flow
of calcium leads to continuous neuronal firing and eventual cell death via excitotoxicity
Medical Management

 Healthcare providers have a number of tools to determine whether

you’ve had a stroke. Your healthcare provider will administer a full
physical examination, during which they’ll check your strength,
reflexes, vision, speech, and senses. They’ll also check for a particular
sound in the blood vessels of your neck. This sound, which is called a
bruit, indicates abnormal blood flow. Finally, they will check your blood
pressure, which may be high if you’ve had a stroke.
 Your doctor may also perform diagnostic tests to discover the cause of
the stroke and pinpoint its location. These tests may include one or
more of the following:
Medical Management

Blood tests: Your healthcare provider may want to test your blood for
clotting time, blood sugar levels, or infection. These can all affect the
likelihood and progression of a stroke.
Angiogram: An angiogram, which involves adding a dye to your blood and
taking an X-ray of your head, can help your doctor find the blocked or
hemorrhaged blood vessel.
 Carotid ultrasound: This test uses sound waves to create images of the
blood vessels in your neck. This test can help your provider determine if
there’s abnormal blood flow toward your brain.
Medical Management

CT scan: A CT scan is often performed soon after symptoms of a stroke

develop. The test can help your provider find the problem area or other
problems that might be associated with stroke.
MRI scan: An MRI can provide a more detailed picture of the brain compared
to CT scan. It’s more sensitive than a CT scan in being able to detect a stroke.
Echocardiogram: This imaging technique uses sound waves to create a
picture of your heart. It can help your provider find the source of blood clots.
 Electrocardiogram (EKG): This is an electrical tracing of your heart. This
will help your healthcare provider determine if an abnormal heart rhythm
is the cause of a stroke.
Surgical Intervention

Carotid endarterectomy. Carotid arteries are the blood vessels that run
along each side of your neck, supplying your brain (carotid arteries) with
blood. This surgery removes the plaque blocking a carotid artery, and may
reduce your risk of ischemic stroke. A carotid endarterectomy also involves
risks, especially for people with heart disease or other medical conditions.
 Angioplasty and stents. In an angioplasty, a surgeon threads a catheter
to your carotid arteries through an artery in your groin. A balloon is
then inflated to expand the narrowed artery. Then a stent can be
inserted to support the opened artery.
Medication

 Anticoagulants are drugs that help keep your blood from clotting easily.
They do this by interfering with the blood clotting process.
Anticoagulants are used for preventing ischemic stroke (the most
common type of stroke) and ministroke
 Antiplatelets such as clopidogrel (Plavix) can be used to help prevent
blood clots. They work by making it more difficult for the platelets in
your blood to stick together, which is the first step in the formation of
blood clots.
 Tissue plasminogen activator (tPA) is the only stroke drug that actually
breaks up a blood clot. It’s used as a common emergency treatment
during a stroke
Medication

 Statins help lower high cholesterol levels. When your cholesterol levels
are too high, cholesterol can start to build up along the walls of your
arteries. This buildup is called plaque.
 Blood pressure drugs-Your doctor may also prescribe medications to
help lower your blood pressure. High blood pressure can play a major
role in stroke. It can contribute to chunks of plaque breaking off, which
can lead to the formation of a blood clot.
Nursing Intervention

Positioning. Position to prevent contractures, relieve pressure, attain good body alignment, and prevent compressive neuropathies.
Prevent flexion. Apply splint at night to prevent flexion of the affected extremity.
Prevent adduction. Prevent adduction of the affected shoulder with a pillow placed in the axilla.
Prevent edema. Elevate affected arm to prevent edema and fibrosis.
Full range of motion. Provide full range of motion four or five times a day to maintain joint mobility.
Prevent venous stasis. Exercise is helpful in preventing venous stasis, which may predispose the patient to thrombosis and pulmonary embolus.
Regain balance. Teach patient to maintain balance in a sitting position, then to balance while standing and begin walking as soon as standing
balance is achieved.
Personal hygiene. Encourage personal hygiene activities as soon as the patient can sit up.
Manage sensory difficulties. Approach patient with a decreased field of vision on the side where visual perception is intact.
Visit a speech therapist. Consult with a speech therapist to evaluate gag reflexes and assist in teaching alternate swallowing techniques.
Voiding pattern. Analyze voiding pattern and offer urinal or bedpan on patient’s voiding schedule.
Be consistent in patient’s activities. Be consistent in the schedule, routines, and repetitions; a written schedule, checklists, and audiotapes may
help with memory and concentration, and a communication board may be used.
 Assess skin. Frequently assess skin for signs of breakdown, with emphasis on bony areas and dependent body parts.
 Sources:
 https://www.healthline.com/health/stroke/drugs#blood-pressure-drugs
 https://nurseslabs.com/cerebrovascular-accident-stroke/
Cerebral
Aneurysm
Definition

Hemorrhagic strokes are caused by bleeding into the brain tissue, the
ventricles, or the subarachnoid space, and intracranial aneurysm is one of
them.
An intracranial aneurysm is a dilation of the walls pf a cerebral artery that
develops as a result of weakness in the arterial wall.
 Subarachnoid hemorrhage results from a ruptures intracranial
aneurysm.
Causes

Atherosclerosis. Fatty plaques lining the blood vessels in the brain could
lead to aneurysm.
Congenital defect of the vessel wall. The defect has been there at the
moment of birth and could cause serious intracranial aneurysm.
 Hypertensive vascular disease. Uncontrolled hypertension could rupture
the small vessels in the brain and lead to intracranial aneurysm.
Signs and Symptoms

Severe headache. The conscious patient most commonly reports a severe headache.
Increased ICP. An increased ICP could cause vomiting.
Sudden change in the level of consciousness. As the aneurysm presses on nerves and
tissues, there is a sudden early change in the level of consciousness.
Focal seizures. Focal seizures can possibly occur due to frequent brain stem
involvement.
Nuchal rigidity. There may be pain and rigidity of the back of the neck and spine due
to irritation.
 Visual disturbances. Visual loss, diplopia, and ptosis occur if the aneurysm is
adjacent the oculomotor nerve.
Pathophysiology
Pathophysiology
Assessment and Diagnostic

Assessment and Diagnostic Findings

CT scan or MRI. These studies determine the type of stroke, the size and
location of the hematoma, and the presence or absence of ventricular
blood and hydrocephalus.
Cerebral angiography. Cerebral angiography confirms the diagnosis of an
intracranial aneurysm.
 Lumbar puncture. Lumbar puncture is performed if there is no evidence
of increased ICP, the CT scan results are negative, and subarachnoid
hemorrhage must be confirmed.
Treatment

Bed rest. Bed rest with sedation can prevent agitation and stress.
Fresh frozen plasma and vitamin K. If the bleeding is caused by anticoagulation
with warfarin, the INR may be corrected with FFP and vitamin K.
Antiseizure agents. Because seizures can occur after intracerebral hemorrhage,
antiseizure agents are often administered prophylactically for a brief period of
time.
Analgesic agents. Analgesic agents may be prescribed for head and neck pain.
 Sequential compression devices. Sequential compression devices or anti-
embolism stockings prevent deep vein thrombosis.
Surgical Management

Craniotomy. Surgical evacuation is most frequently accomplished via a

craniotomy.
Endovascular treatment. This is the surgical management for the occlusion
of the parent artery.
 Aneurysm coiling. This is the obstruction of the aneurysm site with a
coil.
Nursing Intervention

Monitor closely for neurologic deterioration, and maintain a neurologic flow record.
Check blood pressure, pulse, level of consciousness, pupillary responses, and motor function
hourly; monitor respiratory status and report changes immediately.
Implement aneurysm precautions (immediate and absolute bed rest in a quiet, nonstressful
setting; restrict visitors, except for family).
Elevate the head of bed 15 to 30 degrees or as ordered.
Avoid any activity that suddenly increases blood pressure or obstructs venous return (eg,
Valsalva maneuver, straining), instruct patient to exhale during voiding or defecation to
decrease strain, eliminate caffeine, administer all personal care, and minimize external stimuli.
 Apply antiembolism stockings or sequential compression devices. Observe legs for signs and
symptoms of deep vein thrombosis tenderness, redness, swelling, warmth, and edema.
Nursing Intervention

Assess for and immediately report signs of possible vasospasm, which may
occur several days after surgery or on the initiation of treatment
(intensified headaches, decreased level of responsiveness, or evidence of
aphasia or partial paralysis). Also administer calcium channel blockers or
fluid volume expanders as prescribed.
 Maintain seizure precautions. Also maintain airway and prevent injury if
a seizure occurs. Administer antiseizure medications as prescribed
(phenytoin [Dilantin] is medication of choice).
 Sources
 https://nurseslabs.com/intracranial-aneurysm/
 https://emedicine.medscape.com/article/1161518-overview
Arteriovenous
Malformation
Definition

 Arteriovenous malformations (AVMs) are defects in the vascular system,

consisting of tangles of abnormal blood vessels (nidus) in which the
feeding arteries are directly connected to a venous drainage network
without interposition of a capillary bed.
 Most people with AVMs have no initial symptoms or problems. Instead,
the problem is discovered when health care providers treat another
unrelated health concern. Sometimes the rupture of one of the blood
vessels in an AVM will bring the issue to medical attention. Sometimes
AVMs are only found after death, during an autopsy.
Causes and Risk Factors

 Causes:
AVMs are caused by development of abnormal direct connections between
arteries and veins, but experts don't understand why this happens. Certain
genetic changes may play a role
 Risk Factors:
 Rarely, having a family history of AVMs may increase your risk. But
most types of AVMs are not inherited.
Certain hereditary conditions may increase your risk of AVM. These include
hereditary hemorrhagic telangiectasia (HHT), also called Osler-Weber-
Rendu syndrome.
Signs and Symptoms

Bleeding
Progressive loss of neurological function
Headaches
Nausea and vomiting
Seizures
 Loss of consciousness
 Weak muscles
 Paralysis in one part of the body
 Loss of coordination (ataxia) that can cause problems with gait
 Problems performing tasks that require planning (apraxia)
 Weakness in the lower extremities
 Back pain
 Dizziness
Pathophysiology

 Arteriovenous malformations are composed of a central vascular nidus which is a conglomerate of

arteries and veins. There is no intervening capillary bed, and the feeding arteries drain directly into
the draining veins by one or multiple fistulae. These arteries lack the normal muscularis layer and
the draining veins often appear dilated due to the shunted high-velocity arterial blood flow entering
through the fistulae. 
 AVMs cause neurological dysfunction through the following three possible pathophysiological
mechanisms. Firstly, the abnormal blood vessels have a propensity to bleed resulting in hemorrhage
occurring in the subarachnoid space, the intraventricular space or, more commonly in the brain
parenchyma. Secondly, in the absence of hemorrhage, seizures may occur as a consequence of the
mass effect of AVM or venous hypertension in draining veins. The third important cause of slowly
progressive neurological deficits is attributed to the"steal phenomenon" which is thought to be
related to normal brain parenchyma deprivation from nutrients and oxygen, as blood bypasses the
normal capillary bed to the malformed arteriovenous channels.
Diagnostics

 Cerebral angiography. Also called arteriography, this test uses a special dye called a
contrast agent injected into an artery. The dye highlights the structure of blood vessels to
better show them on X-rays.
 Computerized tomography (CT). CT scans use X-rays to create images of the head, brain
or spinal cord and can help show bleeding.
 Magnetic resonance imaging (MRI). An MRI uses powerful magnets and radio waves to
show detailed images of the tissues. An MRI can pick up on small changes in these
tissues.
 Magnetic resonance angiography (MRA).An MRA captures the pattern and the speed and
distance of blood flow through the vascular abnormalities.
 Transcranial Doppler ultrasound. This type of ultrasound uses high-frequency sound
waves to create an image of the blood flow to help diagnose large and medium AVMs, as
well as bleeding.
Treatment

 Treatment for AVM depends on where the abnormality is found, the

symptoms that you have and your overall health. Sometimes, an AVM
may be monitored with regular imaging tests to watch for changes or
problems. Other AVMs require treatment. Determining whether or not
an AVM needs treatment involves factors such as:
 If the AVM has bled
 If the AVM is small enough to treat
1. If the location of the AVM is in a part of the brain that can be
reached
Surgical Mangement

 Surgical removal (resection). If the brain AVM has bled or is in an area

that can easily be reached, surgical removal of the AVM via
conventional brain surgery may be recommended. In this procedure,
your neurosurgeon removes part of your skull temporarily to gain
access to the AVM.
 Endovascular embolization. In this procedure, your doctor inserts a
long, thin tube (catheter) into a leg artery and threads it through blood
vessels to your brain using X-ray imaging
 Endovascular embolization. In this procedure, your doctor inserts a
long, thin tube (catheter) into a leg artery and threads it through blood
vessels to your brain using X-ray imaging.
Nursing Intervention

Monitor ECG continuously because hypoxemia and cerebral bleeding are

risk factors for pronounced ST segment and T-wave changes and life-
threatening dysrhythmias.
Monitor ICP, analyze the ICP waveform, and calculate CPP every hour.
Monitor BP and pulse every 15 to 30 minutes initially, then hourly.
 Obtain CVP and/ or PA pressures if available, every hour or more
frequently if indicated.
Nursing Intervention

Assess pain using the patient’s self-repot whenever possible.

Note headache onset and severity; presence of stiff neck; and insidious
onset of confusion, disoreintatio, decline in consciousness, and/or focal
deficits (weakness of extremity).
Assess neurologic status using Glascow Coma scale and assess for
changes suggesting increased ICP and herniation.
Be alert for subtle changes and new focal deficits.
 Assess for factors that can cause increased ICP, evaluate the patient for
restlessness, distended bladder, constipation, hypovolemia, headache,
fear, or anxiety.
Nursing Intervention

Maintain patent airway and administer oxygen as ordered to prevent

hypoxemia.
Institute measures to minimize external stimuli and maintain BP level.
Administer antihypertensive drugs as ordered. To control blood pressure.
Sedatives and stool softeners may be prescribed to reduce agitation and
straining.
 Anticipate interventions such as embolization, resection, clipping,
ligation of feeding vessels, proton-beam therapy, or gamma radiation.
 Sources:
 https://www.ncbi.nlm.nih.gov/books/NBK430744/
 https://www.mayoclinic.org/diseases-conditions/arteriovenous-
malformation/diagnosis-treatment/drc-20454895
 https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-
notes/arteriovenous-malformation-avm/
Head Injury
Definition

A head injury is any sort of injury to your brain, skull, or scalp. This can
range from a mild bump or bruise to a traumatic brain injury. Common
head injuries include concussions, skull fractures, and scalp wounds. The
consequences and treatments vary greatly, depending on what caused
your head injury and how severe it is.
 Head injuries may be either closed or open. A closed head injury is any
injury that doesn’t break your skull. An open (penetrating) head injury
is one in which something breaks your scalp and skull and enters your
brain.
Causes

Common causes of head injury include:

Accidents at home, work, outdoors, or while playing sports
Falls
Physical assault
 Traffic accidents
Symptoms

 some bleeding
 bruising
 a mild headache
 feeling sick or nauseated
 mild dizziness
 Significant bleeding
 passing out and not waking up
 having a seizure
 problems with vision, taste, or smell
 difficulty staying alert or awake
 clear fluid or blood coming out of the ears or nose
 bruises behind the ears
 weakness or numbness
 difficulty speaking
Types

Hematoma
A hematoma is a collection, or clotting, of blood outside the blood vessels. It can be
very serious if a hematoma occurs in the brain. The clotting can lead to pressure
building up inside your skull. This can cause you to lose consciousness or result in
permanent brain damage.
Hemorrhage
 A hemorrhage is uncontrolled bleeding. There can be bleeding in the space
around your brain, called subarachnoid hemorrhage, or bleeding within your brain
tissue, called intracerebral hemorrhage.Subarachnoid hemorrhages often cause
headaches and vomiting. The severity of intracerebral hemorrhages depends on
how much bleeding there is, but over time any amount of blood can cause
pressure buildup.
Types

Concussion
A concussion occurs when the impact on the head is severe enough to cause
brain injury. It’s thought to be the result of the brain hitting against the hard walls
of your skull or the forces of sudden acceleration and deceleration. Generally
speaking, the loss of function associated with a concussion is temporary.
However, repeated concussions can eventually lead to permanent damage.
Edema
 Any brain injury can lead to edema, or swelling. Many injuries cause swelling
of the surrounding tissues, but it’s more serious when it occurs in your brain.
Your skull can’t stretch to accommodate the swelling. This leads to pressure
buildup in your brain, causing your brain to press against your skull.
Types

Skull fracture
Unlike most bones in your body, your skull doesn’t have bone marrow. This makes
the skull very strong and difficult to break. A broken skull is unable to absorb the
impact of a blow, making it more likely that there’ll also be damage to your brain.
Learn more about skull fractures.
Diffuse axonal injury
 A diffuse axonal injury (sheer injury) is an injury to the brain that doesn’t cause
bleeding but does damage the brain cells. The damage to the brain cells results in
them not being able to function. It can also result in swelling, causing more
damage. Though it isn’t as outwardly visible as other forms of brain injury, a
diffuse axonal injury is one of the most dangerous types of head injuries. It can
lead to permanent brain damage and even death.
How to diagnosed?

One of the first ways your doctor will assess your head injury is with the Glasgow Coma Scale (GCS). The
GCS is a 15-point test that assesses your mental status. A high GCS score indicates a less severe injury.
Your doctor will need to know the circumstances of your injury. Often, if you’ve had a head injury, you
won’t remember the details of the accident. If it’s possible, you should bring someone with you who
witnessed the accident. It will be important for your doctor to determine if you lost consciousness and for
how long if you did.
Your doctor will also examine you to look for signs of trauma, including bruising and swelling. You’re also
likely to get a neurological examination. During this exam, your doctor will evaluate your nerve function
by assessing your muscle control and strength, eye movement, and sensation, among other things.
 Imaging tests are commonly used to diagnose head injuries. A CT scan will help your doctor look for
fractures, evidence of bleeding and clotting, brain swelling, and any other structural damage. CT scans
are fast and accurate, so they’re typically the first type of imaging you’ll receive. You may also receive
an MRI scan. This can offer a more detailed view of the brain. An MRI scan will usually only be ordered
once you’re in stable condition.
Medication

Medication
 If you’ve had a severe brain injury, you may be given anti-seizure
medication. You’re at risk for seizures in the week following your
injury.You may be given diuretics if your injury has caused pressure
buildup in your brain. Diuretics cause you to excrete more fluids. This
can help relieve some of the pressure.If your injury is very serious, you
may be given medication to put you in an induced coma. This may be
an appropriate treatment if your blood vessels are damaged. When
you’re in a coma, your brain doesn’t need as much oxygen and
nutrients as it normally does.
Surgery

It may be necessary to do emergency surgery to prevent further damage

to your brain. For example, your doctor may need to operate to:
remove a hematoma
repair your skull
 release some of the pressure in your skull
Nursing Intervention

Maintain ICP monitoring, as indicated, and report abnormalities.

Maintain patent airway; assist with intubation and ventilatory assistance is needed.
Turn the patient every 2 hours and encourage coughing and deep breathing.
Apply firm pressure over puncture site for subdural trap, and observe for drainage and dressing.
Suction the patient as needed.
Institute measures to prevent increased ICP or other neurovascular compromise.
Feed the patient as soon as possible after a head injury and administer histamine-2 blockers to prevent
gastric ulceration and hemorrhage from gastric acid hypersecretion.
If the patient is unable to swallow, provide enteral feedings after bowel sounds have returned.
Elevate the head of the bed after feedings, and check residuals to prevent aspiration.
 Monitor respiratory rate, depth, and pattern of respirations.
 Sources
 https://www.healthline.com/health/head-injury
 https://medlineplus.gov/ency/article/000028.htm
 https://www.healthline.com/health/head-injury#outlook
 https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-
notes/traumatic-brain-injury-nursing-management/
Spinal Cord
Injury
Definition

 A spinal cord injury — damage to any part of the spinal cord or nerves
at the end of the spinal canal (cauda equina) — often causes
permanent changes in strength, sensation and other body functions
below the site of the injury.
Causes

Causes
The anatomy of the central nervous system
Central nervous system Open pop-up dialog box
Spinal cord injuries may result from damage to the vertebrae, ligaments or disks of the spinal column or to the spinal cord itself.

A traumatic spinal cord injury may stem from a sudden, traumatic blow to your spine that fractures, dislocates, crushes or
compresses one or more of your vertebrae. It may also result from a gunshot or knife wound that penetrates and cuts your spinal
cord.

Additional damage usually occurs over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and
around your spinal cord.

 A nontraumatic spinal cord injury may be caused by arthritis, cancer, inflammation, infections or disk degeneration of the
spine.
Signs and Symptoms

Problems walking
loss of control of the bladder or bowels
inability to move the arms or legs
feelings of spreading numbness or tingling in the extremities
unconsciousness
headache
pain, pressure, and stiffness in the back or neck area
signs of shock
 unnatural positioning of the head
Pathophysiology

 The pathophysiology of spinal cord injury can be categorized as acute impact or

compression. Acute impact injury is a concussion of the spinal cord. This type of injury
initiates a cascade of events focused in the gray matter, and results in hemorrhagic
necrosis. The initiating event is a hypoperfusion of the gray matter. Increases in intracellular
calcium and reperfusion injury play key roles in cellular injury, and occur early after injury.
The extent of necrosis is contingent on the amount of initial force of trauma, but also
involves concomitant compression, perfusion pressures and blood flow, and administration
of pharmacological agents. Preventing or quelling this cascade of events must involve
mechanisms occurring in the initial stages. Spinal cord compression occurs when a mass
impinges on the spinal cord causing increased parenchymal pressure. The tissue response is
gliosis, demyelination, and axonal loss. This occurs in the white matter, whereas gray
matter structures are preserved. Rapid or a critical degree of compression will result in
collapse of the venous side of the microvasculature, resulting in vasogenic edema.
Vasogenic edema exacerbates parenchymal pressure, and may lead to rapid progression of
disfunction. Treatment of compression should focus on removal of the offending mass.
Diagnostics

X-rays. Medical personnel typically order these tests on people who are
suspected of having a spinal cord injury after trauma. X-rays can reveal
vertebral (spinal column) problems, tumors, fractures or degenerative
changes in the spine.
Computerized tomography (CT) scan. A CT scan may provide a better look
at abnormalities seen on an X-ray. This scan uses computers to form a series
of cross-sectional images that can define bone, disk and other problems.
 Magnetic resonance imaging (MRI). MRI uses a strong magnetic field and
radio waves to produce computer-generated images. This test is very
helpful for looking at the spinal cord and identifying herniated disks,
blood clots or other masses that may be compressing the spinal cord.
Treatment

Treatment
Unfortunately, there’s no way to reverse damage to the spinal cord. But
researchers are continually working on new treatments, including
prostheses and medications that may promote nerve cell regeneration or
improve the function of the nerves that remain after a spinal cord injury.
 In the meantime, spinal cord injury treatment focuses on preventing
further injury and empowering people with a spinal cord injury to return
to an active and productive life.
Immediate Treatment

Medications. Intravenous (IV) methylprednisolone (Solu-Medrol) has been used as a treatment option
for an acute spinal cord injury in the past. But recent research has shown that the potential side
effects, such as blood clots and pneumonia, from using this medication outweigh the benefits. Because
of this, methylprednisolone is no longer recommended for routine use after a spinal cord injury.
Immobilization. You may need traction to stabilize your spine, to bring the spine into proper alignment
or both. In some cases, a rigid neck collar may work. A special bed also may help immobilize your
body.
Surgery. Often surgery is necessary to remove fragments of bones, foreign objects, herniated disks or
fractured vertebrae that appear to be compressing the spine. Surgery may also be needed to stabilize
the spine to prevent future pain or deformity.
 Experimental treatments. Scientists are trying to figure out ways to stop cell death, control
inflammation and promote nerve regeneration. For example, doctors may lower the body
temperature significantly — a condition known as hypothermia — for 24 to 48 hours to help prevent
damaging inflammation. Ask your doctor about the availability of such treatments
Nursing Intervention

 Auscultate breath sounds. Note areas of absent or decreased breath sounds or development of
adventitious sounds (rhonchi).
 Suctioning may be indicated but with caution.
 Assist the patient in coughing
 Increase hydration and monitor the patient closely
 Passive range of motion exercises should be implemented ASAP
 Proper body alignment should be maintained at all times
 Assist patient is moving at all times
 Patient should be kept clean at all times and pressure-sensitive areas should be kept well
lubricated
 Turning the patient as indicated is always necessary
 General body alignment is maintained
 Sources
 https://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/diagn
osis-treatment/drc-20377895
 https://www.rnspeak.com/3-spinal-cord-injury-nursing-care-plan/
Multiple
Sclerosis
Definition

 Multiple sclerosis (MS) is a condition that can affect the brain and spinal
cord, causing a wide range of potential symptoms, including problems
with vision, arm or leg movement, sensation or balance.
Risk Factor

 Age. MS can occur at any age, but usually affects people somewhere between the ages of 16 and 55.
 Sex. Women are more than two to three times as likely as men are to have relapsing-remitting MS.
 Family history. If one of your parents or siblings has had MS, you are at higher risk of developing the disease.
 Certain infections. A variety of viruses have been linked to MS, including Epstein-Barr, the virus that causes
infectious mononucleosis.
 Race. White people, particularly those of Northern European descent, are at highest risk of developing MS.
People of Asian, African or Native American descent have the lowest risk.
 Climate. MS is far more common in countries with temperate climates, including Canada, the northern United
States, New Zealand, southeastern Australia and Europe.
 Vitamin D. Having low levels of vitamin D and low exposure to sunlight is associated with a greater risk of MS.
 Certain autoimmune diseases. You have a slightly higher risk of developing MS if you have thyroid disease,
type 1 diabetes or inflammatory bowel disease.
 Smoking. Smokers who experience an initial event of symptoms that may signal MS are more likely than
nonsmokers to develop a second event that confirms relapsing-remitting MS.
Signs and Symptoms

Numbness or weakness in one or more limbs that typically occurs on one side of your body at a time, or the legs and
trunk
Electric-shock sensations that occur with certain neck movements, especially bending the neck forward (Lhermitte sign)
Tremor, lack of coordination or unsteady gait
Partial or complete loss of vision, usually in one eye at a time, often with pain during eye movement
Prolonged double vision
Blurry Vison
Slurred speech
Fatigue
Dizziness
Tingling or pain in parts of your body
 Problems with sexual, bowel and bladder function
Diagnostics

 Blood tests, to help rule out other diseases with symptoms similar to MS. Tests to check for
specific biomarkers associated with MS are currently under development and may also aid in
diagnosing the disease.
 Spinal tap (lumbar puncture), in which a small sample of fluid is removed from your spinal
canal for laboratory analysis. This sample can show abnormalities in antibodies that are
associated with MS. A spinal tap can also help rule out infections and other conditions with
symptoms similar to MS.
 MRI, which can reveal areas of MS(lesions) on your brain and spinal cord. You may receive an
intravenous injection of a contrast material to highlight lesions that indicate your disease is in an
active phase.
 Evoked potential tests, which record the electrical signals produced by your nervous system in
response to stimuli. An evoked potential test may use visual stimuli or electrical stimuli, in which
you watch a moving visual pattern, or short electrical impulses are applied to nerves in your legs
or arms. Electrodes measure how quickly the information travels down your nerve pathways.
Treatments

 Beta interferons. These medications are among the most commonly

prescribed medications to treat MS. They are injected under the skin or into
muscle and can reduce the frequency and severity of relapses.
 Side effects of beta interferons may include flu-like symptoms and injection-
site reactions.
 You'll need blood tests to monitor your liver enzymes because liver damage
is a possible side effect of interferon use. People taking interferons may
develop neutralizing antibodies that can reduce drug effectiveness.
 Glatiramer acetate (Copaxone, Glatopa).This medication may help
block your immune system's attack on myelin and must be injected beneath
the skin. Side effects may include skin irritation at the injection site.
Treatment

Fingolimod (Gilenya). This once-daily oral medication reduces relapse rate.

You’ll need to have your heart rate monitored for six hours after the first dose because your heartbeat may be
slowed. Other side effects include rare serious infections, headaches, high blood pressure and blurred vision.
Dimethyl fumarate (Tecfidera). This twice-daily oral medication can reduce relapses. Side effects may
include flushing, diarrhea, nausea and lowered white blood cell count.
Teriflunomide (Aubagio). This once-daily oral medication can reduce relapse rate. Teriflunomide can cause
liver damage, hair loss and other side effects. It is harmful to a developing fetus and should not be used by
women who may become pregnant and they — or their male partner — are not using appropriate
contraception.
 Siponimod (Mayzent). Research shows that this once-daily oral medication can reduce relapse rate and
help slow progression of MS. It’s also approved for secondary-progressive MS. Possible side effects include
viral infections, liver problems and low white blood cell count. Other possible side effects include changes
in heart rate, headaches and vision problems. Siponimod is harmful to a developing fetus, so women who
may become pregnant should use contraception when taking this medication and for 10 days after
stopping the medication.
Treatment

Physical therapy. A physical or occupational therapist can teach you stretching and strengthening
exercises and show you how to use devices to make it easier to perform daily tasks.
Physical therapy along with the use of a mobility aid when necessary can also help manage leg weakness
and other gait problems often associated with MS.
Muscle relaxants. You may experience painful or uncontrollable muscle stiffness or spasms, particularly
in your legs. Muscle relaxants such as baclofen (Lioresal) and tizanidine (Zanaflex) may help.
Medications to reduce fatigue. Amantadine (Gocovri, Oxmolex), modafinil (Provigil) and methylphenidate
(Ritalin) may be helpful in reducing MS-related fatigue. Some drugs used to treat depression, including
selective serotonin reuptake inhibitors, may be recommended.
Medication to increase walking speed. Dalfampridine (Ampyra) may help to slightly increase walking
speed in some people. People with a history of seizures or kidney dysfunction should not take this
medication.
 Other medications. Medications also may be prescribed for depression, pain, sexual dysfunction,
insomnia, and bladder or bowel control problems that are associated with MS.
Nursing Intervention

Provide bed rest during exacerbation.

Protect the client from injury by providing safety measures.
Place an eye patch on the eye for diplopia.
Monitor for potential complications such as urinary tract infections, calculuses, decubitus
ulcers, respiratory tract infections, and contractures.
Promote regular elimination by bladder and bowel training.
Encourage independence.
Assist the client to establish a regular exercise and rest program.
Instruct the client to balance moderate activity with rest periods.
 Assess the need for and provide assistive devices.
Nursing Intervention

Initiate physical and speech therapy.

Instruct the client to avoid fatigue, stress, infection, overheating, and chilling.
Instruct the client to increase fluid intake and eat a balanced diet, including low-fat,
high-fiber foods and foods high in potassium.
Instruct the client in safety measures related to sensory loss, such as regulating the
temperature of bath water and avoiding heating pads.
Instruct the client in safety measures related to motor loss, such as avoiding the use
of scatter rugs and using assistive devices.
Instruct the client in the self-administration of prescribed medications.
 Provide information about the National Multiple Sclerosis Society.
 Sources
 https://www.nhs.uk/conditions/multiple-sclerosis/
 https://www.mayoclinic.org/diseases-conditions/multiple-
sclerosis/diagnosis-treatment/drc-20350274
 https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-
notes/multiple-sclerosis/
Myastemia
Gravis
Definition

 Myasthenia gravis (my-us-THEE-nee-uh GRAY-vis) is characterized

by weakness and rapid fatigue of any of the muscles under your
voluntary control. It's caused by a breakdown in the normal
communication between nerves and muscles.
Risk factors
Diagnostic

 Assessment and Diagnostic Findings

 Injection of edrophonium (Tensilon) is used to confirm the diagnosis
(have atropine available for side effects). Improve- ment in muscle
strength represents a positive test and usu- ally confirms the diagnosis.
 MRI may demonstrate an enlarged thymus gland.
 Tests include serum analysis for acetylcholine receptor and
electromyography (EMG) to measure electrical potential ofmuscle cells.
Signs and Symptoms

 MG is purely a motor disorder with no effect on sensation or

coordination.
 Initial manifestation involves ocular muscles (eg, diplopia and ptosis)
 Weakness of the muscles of the face (resulting in a bland facial
expression) and throat (bulbar symptoms) and gener- alized weakness

 Laryngeal involvement: dysphonia (voice impairment) and increases

the risk of choking and aspiration
Assessment and Diagnostics

 • Injection of edrophonium (Tensilon) is used to confirm the diagnosis

(have atropine available for side effects). Improve- ment in muscle
strength represents a positive test and usu- ally confirms the diagnosis.
 MRI may demonstrate an enlarged thymus gland.
 Tests include serum analysis for acetylcholine receptor and
electromyography (EM
Medical management

 Management of MG is directed at improving function and reducing and

removing circulating antibodies. Therapeutic modalities include
administration of anticholinesterase med- ications and
immunosuppressive therapy, plasmapheresis, and thymectomy. There
is no cure for MG; treatments do not stop the production of the
acetylcholine receptor antibodies.
Pharmacologic Management

 Pyridostigmine bromide (Mestinon) is the first line of therapy. It

provides symptomatic relief by inhibiting the breakdown of
acetylcholine and increasing the relative concentration of available
acetylcholine at the neuromuscular junction.
 If pyridostigmine bromide does not improve muscle strength and
control fatigue, the next agents used are the immunomodulating drugs.
Immunosuppressive therapy aims to reduce the production of
antireceptor antibody or remove it directly by plasma exchange.
Corticosteroids are given to sup- press the immune response,
decreasing the amount of blocking antibody.
Other therapy