MS

• Professor: Dr. Potenciana A. Maroma
• Basal ganglia


  A collection of nuclei deep to the white matter of cerebral cortex
• The name includes: caudate, putamen, nucleus accumbens, globus pallidus, & substantia nigra
• Parkinson's Disease (PD)


  A progressive disorder with degeneration of the nerve cells in the basal ganglia resulting in generalized decline in muscular function; disorder of the extrapyramidal system (neural network located in the brain that is part of the motor system involved in the coordination of movement)
• Parkinson's Disease usually occurs in the older population: symptoms occur during the 5th decade of life some diagnosed at age 30
• Parkinson's Disease affects men more frequently than women
• Cause of Parkinson's Disease is UNKNOWN; but sometimes the disorder is postencephalitic, toxic, arteriosclerotic, traumatic, or drug induced (reserpine, methyldopa [Aldomet], haloperidol [Haldol], phenothiazine)
• Diagnostic tests for Parkinson's Disease are not helpful, PET is used only for evaluating levodopa uptake, diagnosed clinically from patient's history, presence of 2 of the 3 cardinal symptoms, and neurological examinations
• Assessment findings in Parkinson's Disease

  • Tremor (mainly of the upper limbs, "pill-rolling", resting tremor)
  • Rigidity: cogwheel type
  • Bradykinesia: slowness of movement
  • Fatigue
  • Stooped posture; shuffling, propulsive gait
  • Difficulty rising from sitting position
  • Masklike face with decreased blinking of eyes
  • Quiet, monotone speech
  • Emotional lability, depression
  • Increased salivation, drooling
  • Cramped, small handwriting
  • Excessive sweating, constipation, seborrhea, decreased sexual capacity, lacrimation
• Medications for Parkinson's Disease

  • Levodopa (Dopar, Larodopa)
  • Carbidopa (Sinemet)
  • Amantadine (Symmetrel)
  • Benztropine mesylate (Cogentin), procyclidine (Kemadrin)
  • Bromocriptine mesylate (Parlodel)
  • Tricyclic antidepressants
  • Antihistamines
• Levodopa


  Increases level of dopamine in the brain; relieves tremor, rigidity, and bradykinesia
• Side effects of Levodopa

  • Anorexia
  • Nausea and vomiting
  • Postural hypotension
  • Mental changes such as confusion, agitation, and hallucinations
  • Insomnia
  • Renal damage
  • Cardiac arrhythmias
  • Dyskinesias (purposeless involuntary movements that may be hyperkinetic =rapid and repetitive)
• Contraindications for Levodopa: avoid multiple vitamin preparations containing vitamin B6 (pyridoxine) and foods high in vitamin B6 (tuna, pork, dried beans, salmon), avoid Tyramine rich foods (cheese, yogurt, coffee, raisins, sausage, red wine, beer)=may cause hypertensive crisis, administer with food or snack to decrease GI irritation
• Carbidopa prevents breakdown of dopamine in the periphery and causes fewer side effects
• Amantadine


  Used in early/mild cases to reduce rigidity, tremor, and bradykinesia, acts by releasing dopamine from neuronal storage sites
• Anticholinergics (Benztropine mesylate, procyclidine)


  Inhibit action of acetylcholine, used in mild cases or in combination with Levodopa to relieve tremor and rigidity, side effects: dry mouth, blurred vision, constipation, urinary retention
• Dopamine agonist (Bromocriptine mesylate)


  Stimulates release of dopamine in the substantia nigra, often employed when Levodopa loses effectiveness
• Tricyclic antidepressants are given to treat depression in Parkinson's Disease
• Antihistamines have mild central anticholinergic & sedative effects & may reduce tremors in Parkinson's Disease
• Nursing interventions for Parkinson's Disease

  • Provide a safe environment (side rails, rails, handlebars, no scatter rugs)
  • Provide measures to increase mobility (physical therapy, assistive devices)
  • Improve communication abilities (practice reading aloud, listen to own voice, enunciate)
  • Maintain adequate nutrition (cut food, small frequent feedings, allow time for meals)
• Multiple Sclerosis (MS)


  An immune-mediated progressive demyelinating disease of the CNS which results in impaired transmission of nerve impulses
• Multiple Sclerosis typically presents in young adults 20-40, affects women more than men, and is more frequent in cool or temperate climates
• Cause of Multiple Sclerosis is UNKNOWN; may be a slow-growing virus or possibly of autoimmune origin
• Multiple Sclerosis


  Characterized by remissions and exacerbations
• Pathophysiology of Multiple Sclerosis

  1. Sensitized T cells that would typically cross the blood-brain barrier to check for antigens in the CNS and then leave; in MS would remain in the CNS

  2. Promote infiltration of other agents that damage the immune system

  3. Immune system attack leads to inflammation that destroys myelin and oligodenroglial cells
• Major types of Multiple Sclerosis

  • Relapsing-remitting MS (RRMS)
  • Progressive-relapsing MS (PRMS)
  • Primary progressive MS (PPMS)
  • Secondary progressive MS (SPMS)
• Relapsing-remitting MS (RRMS)


  Relapses develop over 1-2 weeks & resolve over 4-8 months then returns to baseline, 50% may develop secondary progressive MS within 10 yrs, 90% develop it within 25 yrs
• Progressive-relapsing MS (PRMS)


  Absence of remission & client's condition does not return to baseline, progressive, cumulative symptoms & deterioration occur over several years
• Primary progressive MS (PPMS)

  Onset tend to be between 40 and 60 years of age, steady, gradual neurologic deterioration with no remission of symptoms, progressive disability with no acute attacks
• Secondary progressive MS (SPMS)

  Begins with RRMS course that later becomes steadily progressive, attacks & partial recoveries may continue to occur
• Diagnostic tests for Multiple Sclerosis

  • CSF studies: increased protein and IgG
  • EEG: abnormal
  • CT scan: increased density of white matter
  • MRI: shows areas of demyelination
• Symptoms of Multiple Sclerosis

  • Visual disturbances: blurred vision, scotomas (patchy blindness), diplopia
  • Impaired sensation: touch, pain, temperature, or position sense; numbness, tingling
  • Impaired motor function: weakness, paralysis, spasticity
  • Impaired cerebellar function: scanning speech, ataxic gait, nystagmus, dysarthria, intention tremor
  • Euphoria or mood swings
  • Bladder: retention or incontinence
  • Constipation
  • Sexual impotence in the male
• Nursing interventions for Multiple Sclerosis

  • Promote optimum mobility (exercises, assistive devices)
  • Administer medications as ordered (corticosteroids, baclofen, dantrolene, diazepam, beta interferon)
  • Prevent injury related to sensory problems (test bath water, avoid heating pads, inspect body parts)
  • Prepare client for plasma exchange if indicated
• Plasmapheresis


  A type of "blood cleansing" in which damaging antibodies are removed from your blood, the blood cells are then put back into your body, which manufactures more plasma to make up for what was removed
• Myasthenia Gravis (MG)


  A neuromuscular disorder in which there is a disturbance in the transmission of impulses from nerve to muscle cells at the neuromuscular junction (PNS), causing extreme muscle weakness
• Myasthenia Gravis is highest between ages 15-35 for women, over 40 for men, and affects women more than men
• Cause of Myasthenia Gravis

  Thought to be autoimmune disorder whereby antibodies destroy acetylcholine receptor sites on the postsynaptic membrane of the neuromuscular junction
• The first noticeable symptoms of myasthenia gravis may be weakness of the eye muscles, difficulty in swallowing, or slurred speech
• Assessment findings in Myasthenia Gravis

  • Ptosis, diplopia, dysphagia, Extreme muscle weakness, increased with activity and reduced with rest (identifying characteristic)
  • Masklike facial expression
  • Weak voice, hoarseness
• Diagnostic tests for Myasthenia Gravis

  • Tensilon test: IV injection of Tensilon provides spontaneous relief of symptoms (lasts 5-10 minutes)
  • Electromyography (EMG): amplitude of evoked potentials decreases rapidly
  • Presence of anti-acetylcholine receptor antibodies in the serum