● Antibodies directed at the acetylcholine receptor sites

NEUROLOGIC DISTURBANCES impair transmission of impulses across the myoneural

junction
(DEGENERATIVE) ● Therefore, fewer receptors are available for
stimulation, resulting in voluntary muscle weakness
● Multiple sclerosis that escalates with continued activity
● Parkinson’s disease
● Myasthenia gravis Clinical Manifestations
MYASTHENIA GRAVIS ● Dyspnea, dysphagia, decreased physical activity
● Fatigue
● Ptosis, diplopia, strabismus
● Impaired speech
● Snarl smile, mask-like facial expression
● Drooling
● Respiratory difficulty

Diagnostic Test

1. Neurologic Examination
● Testing of reflexes, muscle strength, muscle tone,
● It is neuromuscular disorder characterized by failure senses of touch and sight, gait, posture, coordination,
of transmission of nerve impulses at the myoneural balance, and mental skills
junction ● Impaired eye movement or muscle weakness may
○ Failure of transmission due to antibodies that prompt further evaluation
blocks the junction of acetylcholine receptors
● “Grave muscle weakness" or weakness of the 2. Tensilon Test (Edrophonium Test)
voluntary or striated muscles of the body ● Short-acting
● Real cause is unknown ● Tensilon is administered via IV (2 mg then 8mg)
● Incidence: ● Antidote: Atropine sulfate
○ 43 to 84 persons per million
○ Peak age of onset in women is 20 to 30 years 3. Ice Test
of age while 60 to 70 years old for men ● The test consists of the application of ice to the eyes
○ It occurs more often to women compared to for 2-5 minutes, ensuring that the ice is covered to
men prevent ice burns
● If positive, the patient no longer has the characteristic
Pathophysiology ptosis of MG

4. Nerve Conduction Studies/Repetitive Nerve Stimulation

● A small electrical impulse is applied to a nerve
resulting in muscle contraction. Muscles fatigue easily
and don't bounce back from repeated stimulation

5. Single Fiber Electromyography (EMG)

● A sterile needle electrode is inserted into a muscle
which the patient gently contracts or activates.
Computer analysis of several recorded electrical
signals in the muscle may show abnormal
neuromuscular transmission

6. Computed Tomography (CT) or Magnetic Resonance

Imaging (MRI)
● To identify an abnormal thymus gland or thymus
gland tumor (thymoma)
 ○ Instruct the client to take the medication
before meals for drug absorption
○ Observe and report possible side effects and
adverse reactions: n/v, diarrhea, abdominal
cramps, increased salivation, and tearing

2. Glucocorticoids

● Anti-inflammatory
Nursing Management
3. Antacids
● Assess swallowing and gag reflex before feeding the
client ● Because of glucocorticoids, one of the side effects is
● Administer medications 20-30 minutes before meals GI absence and increased gastric acid secretion that is
○ To improve swallowing reflex of client; soft why antacid is given
diet
● Administer medications at an exact time Surgical Management
○ 2 complications: myasthenic and cholinergic
crisis 1. Thymectomy
○ Should be administered at the exact time to ● Surgical removal of the thymus gland
prevent myasthenic crisis ● It is believed that the thymus is producing too much
○ Once myasthenic crisis happens, respiratory antibodies and thymoma occurs
distress could occur ● 25% of clients with myasthenia gravis has enlarged
● Protect the client from falls due to muscle weakness thymus — remission after 5 to 10 years
● Implement aspiration precaution
● Start meals with cold beverages Complications
○ Rationale: cold beverages will help contract
the muscles and improve ability of clients to 1. Myasthenic Crisis
swallow 2. Cholinergic Crisis
● Promote adequate ventilation
○ To prevent respiratory distress 1. Myasthenic Crisis
● Provide adequate rest with alternating activity
● Caused by under medication or delayed medication
Pharmacotherapy ● Sudden marked rise in BP
● Increased HR
1. Acetyl cholinesterase Inhibitors/Cholinesterase Inhibitors ● Severe respiratory distress and cyanosis
● Absent cough and swallowing reflex
● Examples: ● Increased secretions, increased diaphoresis, and
○ Prostigmin (Neostigmin) increased lacrimation
○ Mestinon (Pyridostigmine) ● Restlessness, dysarthria
○ Mytelase (Ambenomium) ● Bowel and bladder incontinence
● Transmit neuromuscular impulses by preventing the
destruction of acetylcholine - muscle strength Interventions
● Nursing Interventions:
○ Monitor improvement of muscle strength and ● Increased doses of cholinergic as long as the client
respirations responds positively to edrophonium treatment
○ Observe the client for s/sx of cholinergic crisis ● Possible mechanical ventilation of respiratory muscle
caused by overdosing of the drug (muscle paralysis is acute
weakness, increased salivation, sweating,
tearing) 2. Cholinergic Crisis
■ Myasthenic crisis - under dose;
cholinergic crisis - overdose ● This is caused by excessive medication.
○ Have readily available on antidote (atropine ● Weakness with difficulty swallowing, chewing,
sulfate) for cholinergic crisis speaking, and breathing
 ● Apprehension, nausea, and vomiting ● Production and storage of dopamine
● Abdominal cramps and diarrhea ○ Transmission of impulses from one neuron to
● Increased salivation and secretions another
● Sweating, lacrimation, fasciculation, and blurred ○ Muscle flexibility
vision ○ Emotional regulation
○ Attention span
● Located in the basal ganglia

Etiology

● Genetic component
● Environmental toxins (e.g. lead)
● Unknown
Interventions: ● Founder: James Parkinson

● Discontinue all cholinergic drugs until cholinergic Pathophysiology

effects decrease
● Provide adequate ventilatory support
● 1 mg IV atropine sulfate may be necessary to
counteract severe cholinergic reactions

PARKINSON’S DISEASE (PARALYSIS AGITANS)

● It is a progressive neurodegenerative disease that

affects the EPS
● Causes: Unknown, viral infections, drugs,
disequilibrium between dopamine and acetylcholine,
encephalitis
● No cure, only prevention of symptoms

● Approximately 1% of people over 65 have a diagnosis

of Parkinson's disease

Substantia Nigra

● Extrapyramidal system - involuntary movements

● 3 cardinal symptoms: tremors, rigidity, bradykinesia
Signs and Symptoms Pharmacotherapy

1. Anticholinergics

● Reduces tremors and rigidity

● Examples:
○ Artane (Trihexyphenidyl)
○ Cogentin (Benztropine)
○ Akineton (Biperiden)
○ Kimadrin (Procyclidine)
● Nursing Management:
○ Monitor VS, UO, and bowel sounds
● Difficulty in initiating movement ■ Rationale: Causes ↑ PR, urinary
● “Freezing” of gait and be unable to initiate retention, and constipation
ambulation or negotiate a turn during ambulation ○ Observe for involuntary movements
● Stooped posture ○ Advise the client to avoid alcohol, cigarette,
● Flexion of the hips, knees, and neck shifts the center and caffeine
of gravity forward ■ Stimulants, can cause gastric irritation
○ Prevent and relieve side effects of
Diagnostic Test anticholinergics:
■ Dry mouth
● There is no specific diagnostic test to confirm the ● Oral hygiene, ice chips,
diagnosis of Parkinson's disease bubble gum (sugarless)
● MRI (degeneration of substantia nigra) ■ Photophobia
● PET (loss of dopamine producing cells) ● Dim lights, wear sunglasses
when walking
Nursing Diagnosis ■ Urinary retention
● Before taking meals, have
● Impaired physical mobility related to rigidity, patient void first
bradykinesia, and akinesia ● Turn on faucet
● Impaired verbal communication related to dysarthria ● Alternate warm and cold
and tremor compress
● Imbalanced nutrition: less than body requirements ■ Increased intraocular pressure
related to dysphagia ● Advice client to visit
● Constipation related to immobility ophthalmologist
● Risk for injury related to postural instability
2. Dopaminergics
Therapeutic Interventions
● Levodopa
● There is no cure for Parkinson's disease ● Levodopa-Carbidopa (Sinemet)
● Treatment is aimed at controlling symptoms and ○ Dopamine cannot cross blood brain barrier
maintaining the patient's functional level
minimizing that is why Carbidopa is added
○ Prevent metabolism of Carbidopa in the brain
● Nursing Management:
○ Monitor VS and ECG
■ Orthostatic hypotension may happen
○ Check for weakness, dizziness, or syncope
■ Manifestations of hypotension
○ Inform the client that urine may discolor and
will darken with exposure to air
○ Symptoms of dyskinesia may take weeks or
months to be controlled
○ Avoid the following foods:
■ Vitamin B6 rich foods
 ● Blocks the effect of a scar
dopaminergic drugs ● This reduces the brain activity in that area, which may
● e.g. beef liver, tuna, salmon, help relieve movement symptoms such as tremor and
fortified cereals, chickpeas, stiffness (rigidity)
pork, dried beans
■ Tyramine rich foods Nursing Diagnosis
● Can cause hypertensive crisis
● e.g. cheese, yogurt, dairy ● Impaired verbal communication related to decreased
products, chocolate, banana speech volume, slowness of speech, inability to move
○ Prevent and relieve the following side effects: facial muscles
■ Nausea and vomiting ● Ineffective coping related to depression and
● Offer crackers dysfunction due to disease progression
■ Orthostatic hypotension
● Instruct client to move slowly, Nursing Management
raise side rails to prevent
patient from falling ● Improving Mobility
■ Renal damage ● Enhancing Self-care Activities
● Improving Bowel Elimination
3. Dopamine Agonist Antiviral Drugs ● Improving Nutrition
● Acts on the dopamine receptors and produce ● Enhancing Swallowing
improvement in symptoms of Parkinsonism ● Encouraging The Use Of Assistive Devices
● Examples: ● Thickened liquid diet (e.g. jelly yam)
○ Symmetrel (Amantadine HCL) ● Provide firm bed to prevent contractures
○ Parlodel (Bromocriptine Mesylate) ● Aspiration precaution
○ Requip (Ropinazole HCL) ● Increase fluid intake and fiber in the diet
● Nursing Interventions:
○ Advise the client to report signs of skin MULTIPLE SCLEROSIS
lesions, seizures, or depression
○ Avoid alcohol ● It is an autoimmune disorder that causes destruction
○ Advise the client not to abruptly stop the of the myelin sheath of nerve fibers in the brain and
medication without notifying the healthcare spinal cord
provider ● Role of myelin sheath: protects the nerve fibers and
allow for proper nerve transmission
Surgical Management ● If myelin sheath is damaged, scar tissues form and
nerve transmissions will be disrupted; depends on the
● Pallidotomy is an option for patients whose rigidity, demyelination of the myelin sheath
tremor, and bradykinesia are uncontrollable by
medical management
● During this stereotactic procedure, a destructive
lesion is placed in the basal ganglia

Pallidotomy

● Destroys a tiny part of the globus pallidus by creating Pathophysiology

● Predisposing factors:
○ Genetics (HLA-DRB1 gene)
■ It cannot be passed from mother to
child, but when a person is carrying
this gene, he/she may be predisposed
to have MS
■ Human leukocyte antigen (HLA)
■ Helps identify foreign bodies
■ Variations in this gene have been
linked to alterations in immune
function, which could lead to an
increased risk of MS
○ Age ( 20 and 50 y.o.) Assessment/Clinical Manifestations
■ 20 - initial maturation of the immune
system and may be susceptible to ● Eye: diplopia, nystagmus, blurred vision
dysregulation ○ Due to the involvement of the optic nerve
■ 50 - cumulative environmental ● Weakness and tingling sensation, paresthesia
exposures and age-related changes in ○ Due to the involvement of the cerebrum and
immune function may increase spinal cord
susceptibility to MS ● Bowel and bladder dysfunction (urinary retention,
○ Sex (female) spastic bladder, constipation)
■ Decreased hormones (estrogen), if it ○ Involvement of the spinal cord
is decreased, it affects the immune ● Charcoat’s Triad
system ○ Scanning speech (repetition of the first
■ Estrogen's immunomodulatory syllable of the word)
effects and genetic differences ○ Intentional tremors
between sexes may contribute to ○ Nystagmus
increased susceptibility to MS in
females
○ Autoimmune disease (Type 1 DM, Psoriasis,
Pernicious Anemia)
■ Clients with autoimmune diseases
have an overactive immune response
which causes inflammation
● Precipitating factors:
○ Vitamin D Deficiency
■ Regulate immune response,
decreased vitamin D = it decreases
the ability to protect the myelin
sheath
Diagnostic Test
○ Smoking
■ Release chemicals that trigger chronic
● There is no single diagnostic test that confirms or
inflammation
rules out the diagnosis of MS
○ Obesity (BMI more than 30)
● MRI
■ Increased adipose tissue can cause
● Lumbar puncture
inflammation
● Rule out if there are other infections of the patient
■ Associated with chronic inflammation
because of underlying problems
and increases the risk of the client for
MS
Nursing Diagnoses

● Impaired Physical mobility related to muscle muscle

weakness, paralysis, or spasticity
 ● Self-care deficit related to neuromuscular deficits
● Impaired urinary elimination related to
neuromuscular degeneration
● Constipation related to abdominal muscle weakness

Pharmacologic Therapy

1. Glucocorticoids
● Examples:
○ Prednisone
○ Decadron
○ Corticotropin
● Anti-inflammatory effect

2. Muscle relaxants
● Examples:
○ Lioresal (Baclofen)
○ Betaseron
● To relieve muscle spasms

3. Immunosuppressants
● Examples:
○ Imuran (Azathiorpine)
○ Cytoxan (Cyclophosphamide)
● Decreases activity of the immune system
● Prevent relapse of MS

Nursing Management for MS

● Patch the eye alternately for diplopia

● Provide well balanced diet (high fiber)
● Physical therapy (for muscle weakness)
● Increase fluid intake (for constipation)
● Speech therapy (due to speech problems like
scanning speech)

Evaluation

● The patient will verbalize increased strength and

endurance
● The patient will participate in ADL as much as possible
● The patient will report decreased episodes of
incontinence
● The patient will report improve in bowel movement