ADL	Activities of daily living
ALS	Amyotrophic lateral sclerosis
CVA	Cerebrovascular accident
JRA	Juvenile rheumatoid arthritis
MS	Multiple sclerosis
RA	Rheumatoid arthritis
ROM	Range-of-motion
TBI	Traumatic brain injury
TIA	Transient ischemic attack

Understanding nervous and musculo-skeletal disorders gives meaning to the required care. Refer to Chapter 10 while you study this chapter.

Nervous System Disorders

Nervous system disorders can affect mental and physical function. They can affect the ability to speak, understand, feel, see, hear, touch, think, control bowels and bladder, and move.

See Body Structure and Function Review: The Nervous System, p. 706.

Body Structure and Function Review

The Nervous System

The nervous system controls, directs, and coordinates body functions. It consists of the brain and spinal cord (Fig. 44-1) and nerves throughout the body.

Nerves connect to the spinal cord. Nerves carry messages or impulses to and from the brain. A stimulus causes a nerve impulse. A stimulus is anything that excites or causes a body part to function, become active, or respond. A reflex is the body’s response (function or movement) to a stimulus. Reflexes are involuntary, unconscious, and immediate. The person cannot control reflexes.

Some nerve fibers have a protective covering called a myelin sheath. Nerve fibers covered with myelin conduct impulses faster than those fibers without it.

The Central Nervous System

The brain and spinal cord make up the central nervous system. The brain is covered by the skull. The 3 main parts of the brain are the cerebrum, the cerebellum, and the brainstem (Fig. 44-2).

The cerebrum is the center of thought and intelligence. The cerebrum is divided into 2 halves called right and left hemispheres. The right hemisphere controls movement and activities on the body’s left side. The left hemisphere controls the right side.

The outside of the cerebrum is called the cerebral cortex. It controls reasoning, memory, consciousness, speech, voluntary muscle movement, vision, hearing, sensation, and other activities.

The cerebellum regulates and coordinates body movements. It controls balance and the smooth movements of voluntary muscles.

The brainstem contains the midbrain, pons, and medulla. The midbrain and pons relay messages between the medulla and the cerebrum. The medulla controls heart rate, breathing, blood vessel size, swallowing, coughing, and vomiting. The brain connects to the spinal cord at the lower end of the medulla.

The spinal cord lies within the spinal column. It contains pathways that conduct messages to and from the brain. The brain and spinal cord are covered and protected by 3 layers of connective tissue called meninges.

Cerebrospinal fluid circulates around the brain and spinal cord. Cerebrospinal fluid cushions shocks that could easily injure brain and spinal cord structures.

The Peripheral Nervous System

The peripheral nervous system has 12 pairs of cranial nerves and 31 pairs of spinal nerves. The cranial nerves conduct impulses between the brain and the head, neck, chest, and abdomen. They conduct impulses for smell, vision, hearing, pain, touch, temperature, and pressure. They also conduct impulses for voluntary and involuntary muscles. Spinal nerves carry impulses from the skin, extremities, and internal structures not supplied by the cranial nerves.

Some peripheral nerves form the autonomic nervous system. This system controls involuntary muscles and certain body functions—heartbeat, blood pressure, intestinal contractions, and glandular secretions.

The autonomic nervous system is divided into the sympathetic nervous system and the parasympathetic nervous system. They balance each other. The sympathetic nervous system speeds up functions. The parasympathetic nervous system slows functions.

Stroke

Stroke (brain attack or cerebrovascular accident [CVA]) occurs when 1 of these happens.

• A blood vessel in the brain bursts and bleeds into the brain (cerebral hemorrhage).

• A blood clot blocks a blood vessel in the brain. Blood flow stops.

Brain cells in the affected area do not get enough oxygen and nutrients. Brain damage occurs. Functions controlled by that part of the brain are lost (Fig. 44-3).

FIGURE 44-3 Functions lost from a stroke depend on the area of brain damage. (Modified from Thibodeau GA, Patton KT: The human body in health & disease, ed 6, St Louis, 2014, Mosby.)

Stroke is a leading cause of death in the United States. It is a leading cause of disability in adults. See Box 44-1 for warning signs. The person needs emergency care. Blood flow to the brain must be restored as soon as possible.

Box 44-1

Stroke—

Warning Signs

• Sudden numbness or weakness of the face, arm, or leg, especially on 1 side of the body

• Sudden confusion, trouble speaking or understanding speech

• Sudden trouble seeing in 1 or both eyes

• Sudden trouble walking, dizziness, loss of balance or coordination

• Sudden, severe headache with no known cause

From National Institute of Neurological Disorders and Stroke: Know stroke. Know the signs. Act in time. NIH Publication Number 08-4872, Bethesda, Md, January 2008, updated December 24, 2013, National Institutes of Health.

Warning signs may last a few minutes. This is called a transient ischemic attack ( TIA). (Transient means temporary or short term. Ischemic means to hold back [ischein] blood [hemic].) Blood supply to the brain is interrupted for a short time. A TIA may occur before a stroke. All stroke-like symptoms signal the need for emergency care.

Risk Factors.

Risk factors include:

• High blood pressure

• Lack of physical activity

• Family history of stroke

Signs and Symptoms.

Stroke can occur suddenly. The person may have warning signs (see Box 44-1). The person also may have nausea, vomiting, and memory loss. Unconsciousness, noisy breathing, high blood pressure, slow pulse, redness of the face, and seizures may occur. So can hemiplegia—paralysis (plegia) on 1 side (hemi) of the body. The person may lose bowel and bladder control and the ability to speak. (See “Aphasia” in Chapter 42.)

Effects on the Person.

If the person survives, some brain damage is likely. The entire body may be affected. Functions lost depend on the area of brain damage (see Figure 44-3). They include:

The person may forget about or ignore the weaker side. This is called neglect. It is from the loss of vision or movement and feeling on that side. Sometimes thinking is affected. The person may not recognize or know how to use common items. Activities of daily living (ADL) and other tasks are hard to do. The person may forget what to do and how to do it. If the person does know, the body may not respond.

Rehabilitation starts at once. The goal is to regain the highest possible level of function (Box 44-2, p. 708).

Box 44-2

Stroke Care Measures

• Position the person in the lateral (side-lying) position to prevent aspiration.

• Keep the bed in semi-Fowler’s position.

• Approach the person from the strong (unaffected) side. Place objects on the strong (unaffected side). The person may have loss of vision on the affected side.

• Turn and re-position the person at least every 2 hours.

• Use assist devices to move, turn, re-position, and transfer the person.

• Encourage incentive spirometry and deep breathing and coughing.

• Prevent contractures. Assist with range-of-motion (ROM) exercises.

• Meet food and fluid needs. The person may need a dysphagia diet.

• Apply elastic stockings to prevent thrombi (blood clots) in the legs.

• Meet elimination needs. Follow the care plan for:

• Catheter care or bladder training

• Bowel training

• Practice safety precautions.

• Keep the call light and other needed items within reach on the strong (unaffected) side.

• Check the person often if he or she cannot use the call light. Follow the care plan.

• Use bed rails according to the care plan.

• Prevent falls and other injuries.

• Have the person do as much self-care as possible. This includes turning, positioning, and transferring. The person uses assistive (adaptive) and walking aids as needed.

• Do not rush the person. Movements are slower after a stroke.

• Follow established communication methods.

• Give support, encouragement, and praise.

• Complete a safety check before leaving the room. (See the inside of the front cover.)

See Focus on Long-Term Care and Home Care: Effects on the Person (Stroke), p. 708.

Focus on Long-Term Care and Home Care

Effects on the Person (Stroke)

Long-Term Care

Some persons return home after rehabilitation. For others, long-term care is often permanent. Many measures listed in Box 44-2 are part of the person’s care.

Home Care

Many stroke survivors return home. The family assists with care. Home health care is often needed. The measures in Box 44-2 continue. The health team recommends home changes to help the person function.

Parkinson’s Disease

Parkinson’s disease is a progressive disorder affecting movement. Persons over the age of 50 are at risk. One or both sides of the body are affected. Signs and symptoms are mild at first (Fig. 44-4). They include:

• Tremors—often start in the hand. Pill-rolling movements—rubbing the thumb and index finger—may occur. The person may have trembling in the hands, arms, legs, jaw, and face.

• Rigid, stiff muscles—in the arms, legs, neck, and trunk.

• Stooped posture and impaired balance—it is hard to walk. Falls are a risk.

• Mask-like expression—the person cannot blink and smile. A fixed stare is common.

FIGURE 44-4 Signs of Parkinson’s disease. (From Thibodeau GA, Patton KT: The human body in health & disease, ed 6, St Louis, 2014, Mosby.)

Other signs and symptoms develop over time. They include swallowing and chewing problems, constipation, sleep problems, depression, and emotional changes (fear, insecurity). Memory loss and slow thinking can occur. The person may have slow, monotone, and soft speech.

With no cure, drugs are ordered to control the disease. Exercise and physical therapy help improve strength, posture, balance, and mobility. Therapy is needed for speech and swallowing problems. The person may need help with eating and self-care. Normal elimination is a goal. Safety measures are needed to prevent falls and injuries.

Multiple Sclerosis

Multiple sclerosis (MS) is a central nervous system disease. Multiple means many. Sclerosis means hardening or scarring. The myelin (which covers nerve fibers) in the brain and spinal cord is destroyed. Nerve impulses are not sent to and from the brain in a normal way. Functions are impaired or lost.

Symptoms usually start between the ages of 20 and 40. Women and whites are at greater risk than other groups. The risk increases if a family member has MS. Signs and symptoms may include:

• Blurred or double vision; blindness in 1 eye

• Muscle weakness in the arms and legs

• Balance and coordination problems

• Tingling, prickling, or numb sensations

• Partial or complete paralysis

• Concentration, attention, memory, and judgment problems

• Depression

• Bladder problems

• Problems with sexual function

• Hearing loss

• Fatigue

MS can present in many ways. For example:

• Symptoms appear for a while then seem to go away. The person is in remission. Later, symptoms flare up again (relapse).

• More symptoms appear. The person’s condition worsens.

• The person has remissions and relapses at first. Eventually symptoms become worse. More symptoms occur with each flare-up. The person’s condition declines.

MS has no cure. Some drugs can slow the disease. Persons with MS are kept as active and as independent as possible. The care plan reflects changing needs. Skin care, hygiene, and ROM exercises are important. So are turning, positioning, and deep breathing and coughing. Elimination needs are met. Injuries and complications from bedrest are prevented.

See Focus on Long-Term Care and Home Care: Multiple Sclerosis.

Focus on Long-Term Care and Home Care

Multiple Sclerosis

Home Care

The person may need help with housekeeping to avoid fatigue. As mobility decreases, the person depends more on others. Occupational and physical therapists are often involved in the person’s care.

Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS) attacks the nerve cells that control voluntary muscles. Commonly called Lou Gehrig’s disease, it is rapidly progressive and fatal. (Lou Gehrig was a New York Yankees baseball player who died of the disease.)

ALS usually strikes persons between 40 and 60 years of age. Most die 2 to 5 years after onset.

The disease attacks the nerve cells responsible for voluntary muscles. Such cells are in the brain, brainstem, and spinal cord. These cells stop sending messages to the muscles. The muscles weaken, waste away (atrophy), and twitch. Over time, the brain cannot start voluntary movements or control them. The person cannot move the arms, legs, and body. Muscles for speaking, chewing and swallowing, and breathing also are affected. Eventually respiratory muscles fail. The person needs a ventilator to breathe (Chapter 40).

The disease usually does not affect the mind, intelligence, or memory. However, some persons develop dementia. Sight, smell, taste, hearing, and touch are not affected. Usually bowel and bladder functions remain intact.

ALS has no cure. Some drugs can slow the disease and improve symptoms. However, damage cannot be reversed. The person is kept active and independent to the extent possible. The care plan reflects changing needs. It may include:

Head Injuries

Head injuries result from trauma to the scalp, skull, or brain. Injuries range from a minor bump to a serious, life-threatening brain injury. Traffic accidents, falls, assaults, and gunshots are common causes. So are home, work, sports, and outdoor accidents.

Head injuries are open or closed. Bleeding may occur.

• Closed—a hard blow to the head did not break the skull.

• Open (penetrating)—an object broke the skull and entered the brain.

Symptoms may develop at the time of the injury. Or they can take several hours or days to develop. Symptoms are from bleeding or swelling inside the skull.

Most head injuries need emergency care. See Chapter 54.

Traumatic Brain Injury.

Traumatic brain injury (TBI) occurs from violent injury to the brain—bumps, blows, or jolts to the head or penetrating injuries. Common causes include: