Herniated Intervertebral Disc a rupture of fibrocartilagenous material (annulus fibrosis) that surrounds the intervertebral disk.

. This rupture involves the release of the disk's center portion containing a gelatinous substance called the nucleus pulposus. The core of each disk possesses a jelly-like substance that helps the body to sustain weight and absorb shock as it bends and twists. When a person ages, the disks begin to deteriorate, losing their suppleness. As a result, a disc can prolapse, meaning some of the soft core can leak out. The incidence of cervical disk herniation is most common between the fifth and sixth cervical vertebrae. The second most common area for cervical disk herniation occurs between the sixth and seventh cervical vertebrae. Major symptom is back pain or neck pain depending on the location of the herniated disc. When the soft core of the disks are squeezed out, less cushion exists among the disks of the vertebrae. This, in turn, can cause neck pain, back pain, nerve pressure, numbness, & sharp pain in the legs. Signs & Symptoms Bulging Discs In the middle back will result in mid back pain, radiating pain around the rib cage, chest pains, & even digestive problems. Diagnostic Tests Spine x-rays: Cervical spine x-rays may reveal congenital narrowing of the cervical spinal canal when present. Thoracic and lumbar x-rays may also show evidence of degenerative disease such as bone spurs and disc space narrowing. CT scan: Bulging or herniated discs may or may not be visible on CT scan, and may or may not be related to the patients symptoms. CT scan is most useful in showing bone structures, and is not as good as MRI in showing spinal cord, nerve roots or discs. MRI: best method of imaging the spinal cord and nerve roots, the intervertebral discs, and the ligaments. Myelography: x-rays taken after the injection of radio-opaque contrast material into the spinal fluid via a lumbar puncture, and is followed by post-myelogram CT scan (myelo-CT). Reveals indentations of the spinal fluid sac caused by bulging or herniated discs that may be pressing on the spinal nerves. Electromyogram & Nerve-conduction velocities: indicates whether the weakness is due to abnormality or compression of a nerve root, or to some other cause. Treatment & Management Medications & pain injections (NSAIDS & Narcotics) Straight legs & raise when lying or sitting. Bed Rest Spinal fusion Laminectomy, discectomy, microdiscectomy, or percutanteous discectomy. Chemonucleolysis: Chymopapain, a purified enzyme derived from the papaya plant, is injected percutaneously into the disk space to reduce the size of the herniated disks. It hydrolyses proteins, thereby decreasing water-binding capacity, when injected into the nucleus pulposus inner disk material. The reduction in size of the disk relieves pressure on the nerve root. Possible complication Long-term back pain or leg pain Loss of movement or feeling in the legs or feet

Loss of bowel and bladder function Permanent spinal cord injury Prevention Safe work and play practices, proper lifting techniques, and weight control. Reduce activity for the first couple of days. Then, slowly restart your usual activities. Avoid heavy lifting or twisting your back for the first 6 weeks after the pain starts. After 2 - 3 weeks, gradually start exercising again. Physical therapy Therapists will tell you how to properly lift, walk, and perform other activities. They will work on strengthening the muscles that help support the spine. You will also learn how to increase flexibility in your spine and legs. Prognosis Most people will improve with treatment. However, you may have back pain even after treatment. It may take several months to a year or more to go back to all of your activities without having pain or straining your back. People who work in jobs that involve heavy lifting or back strain may need to change their job activities to avoid injuring their back again. MYASTHENIA GRAVIS Coming from a Greek and Latin word meaning serious muscle weakness. Is a chronic, autoimmune, progressive neuromuscular disease characterized by abnormal weakness and fatigability of skeletal muscles. EPIDEMIOLOGY The disease incidence rate in US is 5 per 100,000 people. Worldwide prevalence is 1/10,000 More common in women than men with a ratio of 6:4.women under 40 and men above 60. It can occur at any age but is Most commonly seen between 10-65 years of age. Peak age of onset is between 20-30 years of age. Familial incidence is approximately 5-7%, tumor of the thymus gland is present up to 10% of patients. CAUSES Idiopathic Acquired autoimmune overactive, overlarge, or otherwisemalfunctioning thymus Drugs Penicillamine Transient neonatal (passive transfer of maternal anti-achr antibodies) Classification The most widely accepted classification of myasthenia gravis is the Myasthenia Gravis Foundation of America Clinical Classification Class I: Any eye muscle weakness, possible ptosis, no other evidence of muscle weakness elsewhere Class II: Eye muscle weakness of any severity, mild weakness of other muscles Class IIa: Predominantly limb or axial muscles Class IIb: Predominantly bulbar and/or respiratory muscles Class III: Eye muscle weakness of any severity, moderate weakness of other muscles Class IIIa: Predominantly limb or axial muscles Class IIIb: Predominantly bulbar and/or respiratory muscles

Class IV: Eye muscle weakness of any severity, severe weakness of other muscles Class IVa: Predominantly limb or axial muscles Class IVb: Predominantly bulbar and/or respiratory muscles (Can also include feeding tube without intubation) Class V: Intubation needed to maintain airway

SIGN AND SYMPTOMS Fatigability (hallmark) Weakness of the eye muscles Difficulty speaking (dysarthria) Chewing or swallowing difficulty Eyelid drooping Double vision Hoarseness or changing voice Breathing difficulty Drooping head Facial paralysis Difficulty climbing stairs, lifting objects, or rising from a seated position some people may develop an unusual or different smile if certain facial muscles are affected. MUSCLE STRENGTH Facial muscle weakness Bulbar muscle weakness Limb muscle weakness Respiratory weakness Ocular Muscle weakness Facial muscle weakness Ptosis and bilateral muscle weakness Sclera below limbus may be exposed due to weak lower lids. Bulbar muscle weakness Palatal muscles nasal voice, nasal regurgitation Severe jaw weakness may cause Jaw to hang open. Neck muscles Neck flexors affected more than extensors. Limb muscle weakness Upper limbs more common than lower limbs. Ocular Muscle weakness Asymmetric Usually affects more than one extraocular muscle and is not limited to muscles innervated by one cranial nerve. Weakness of lateral and medial recti may produce a pseudointernuclear opthalmoplegia. Respiratory weakness Weakness of intercostal and diaphragm may result in co2 retention due to hypoventilation. Weakness of pharyngeal muscles may collapse the upper airway. - Monitor negative inspiratory force, vital capacity and tidal volume. Diagnostic test Serum assay Electromyography CT scan and MRI Tensilon test Treatment There is no cure for MG, goal of treatment of patient is to improve their muscle weakness and induce remission with minimal side effects. Patient safety and health teaching by the nurse is the primary focus. Medications Anticholinesterase agent NEOSTIGMINE and PYRIDOSTIGMINE

- improves muscle strength, it works by preventing the breakdown of certain natural substance in your body (acetylcholine). with or without food if taken with food or with milk, side effect may decrease side effect can be Nausea, vomiting, diarrhea, abdominal cramps, increased saliva/mucus, decreased pupil size, increased urination, or increased sweating MESTINON prevents the inactivation of ach and enhances the stimulus transmission at the cholinergic junction. Corticosteroids (prednisone) or immunosuppressant (azathioprine, cyclosporine) it can slow or stop the disease process. Immunoglobulin Immunoglobulin therapy involves injections of blood serum from a person without autoimmune disease. It lowers the numbers of tissue-attacking antibodies in the bloodstream of the person with myasthenia gravis. Plasmapheresis a procedure in which serum containing the abnormal antibodies is removed from the blood while cells are replaced. Thymectomy surgical removal of the thymus gland (which often is abnormal in individuals with myasthenia gravis), reduces symptoms in some individuals without thymoma and may cure some people, possibly by re-balancing the immune system. Complication Myasthenic crisis is a life-threatening condition, which occurs when the muscles that control breathing become too weak to do their jobs. Emergency treatment is needed to provide mechanical assistance with breathing. it can be triggered by infection, fever and adverse reaction to meds. Nursing intervention routinely requires assessment of muscular strength. It has to be accompanied with careful and individualized plan of care since muscle weakness is worsened when the body is put into exertion especially during its exacerbation state. Listen to the patients concerns and answer the questions honestly. Administer medications on time and at evenly spaced intervals, as ordered, to prevent relapses. Plan exercise, meals, patient care, and activities to make the most of energy peaks. When swallowing is difficult, give semi-solid foods instead of liquids to lessen the risk of choking. After severe exacerbations, try to increase social activity as soon as possible. Establish accurate neurologic and respiratory baseline. Stay alert for signs of impending myesthenic crisis such as increased muscle weakness and difficulty talking or chewing. Help the patient plan daily activities to coincide with energy peaks. Stress the need for frequent rest periods. If surgery is scheduled, provide perioperative teaching Amyotrophic Lateral Sclerosis ALS or Lou Geghrigs disease, is a progressive, degenerative neurologic disease characterized by weakness and wasting of the involved muscles, without may accompanying sensory or cognitive change. Resulting from lower motor neuron invovelvement and lateral sclerosis of the corticospinal tract in the lower lateral

column of the spinal cord resulting from uppeor motor neuron involvement. CAUSES OF ALS The cause or causes of ALS (amyotrophic lateral sclerosis) are not known, and scientists do not yet know why ALS strikes some people and not others. ALS research scientists are looking at a number of possible ALS causes, including: o Genetics o Glutamate o Autoimmune responses o Environment. RISK FACTOR OF ALS Heredity Age. Sex. Environmental factors under study that may modify a person's individual risk of ALS include: Smoking Lead exposure. Military service. MANIFESTATION OF ALS Early signs and symptoms of ALS include: Difficulty lifting the front part of your foot and toes (footdrop) Weakness in your leg, feet or ankles Hand weakness or clumsiness Slurring of speech or trouble swallowing Muscle cramps and twitching in your arms, shoulders and tongue Diagnostic test Electromyogram Nerve conduction study MRI Blood and urine tests Muscle biopsy Medication Riluzole (Rilutek),an antiglutamate, is the first medication developed to treat ALS. THERAPY Physical therapy Occupational therapy Speech therapy NURSING DIAGNOSIS Impared physical mobility related to progressive deterioration of the neurons system. ALZHEIMERS DISEASE Is a degenerative disorder of the cerebral cortex resulting to microscopic plaques. is a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception. Characterized by impaired intellectual function and progressive loss of ability to carry out ADL. Recent memory occurs first. Remote memory may remain intact for a long period of time. Cause: unknown but it may be associated with autoimmune disease and heredity. It is the most common cause of dementia in western countries 4th leading causes of death among the elderly The incidence of alzheimers is disease is slightly higher in americans with african and hispanic heritage. onset of Alzheimer's disease is usually gradual, and it is slowly progressive. Women and men are affected equally.

It has an incredible impact on the health care budget because of the chronic nature of the patients and their long-standing health care needs. 10 classic warning signs of Alzheimer's disease: memory loss, difficulty performing familiar tasks, problems with language, disorientation to time and place, poor or decreased judgment, problems with abstract thinking, misplacing things, changes in mood or behavior, changes in personality, and loss of initiative. RISK FACTORS Advancing age Family history Whiplash and HEAD INJURY Down's syndrome Gender Mild cognitive impairment Aluminum Other risk factors Atrial firbrillation Heart disease risk-factors Academic level Processed foods and fertilizers (nitrates) Some chronic inflammatory conditions A history of episodes of clinical depression Strokes/ministrokes obesity ASSESSMENT WITH CLINICAL MANIFESTATION STAGES AND PHASES OF ALZHEIMERS DISEASE

Side effects may include: Diarrhea Nausea Vomiting Loss of appetite Memantine This medication protects brain cells from damage caused by glutamate, a chemical messenger. It is used to treat moderate to severe stages of Alzheimer's. Some doctors prescribe memantine along with a cholinesterase inhibitor. Alzheimer's disease is diagnosed when: a person has sufficient cognitive decline to meet criteria for dementia the clinical course is consistent with that of Alzheimer's disease no other brain diseases or other processes are better explanations for the dementia. Diagnostic tests BRAIN AUTOPSY Use to find pathological changes in brain tissue CT (computerized tomography) scan - this device uses digital geometry processing to generate a 3dimensional (3-D) image of the inside of an object. PET (positron emission tomography) scan - uses radiation, or nuclear medicine imaging, to produce 3dimensional, color images of the functional processes within the human body. A PET scan that measures uptake of sugar in the brain significantly improves the accuracy of diagnosing a type of dementia often mistaken for Alzheimer's disease MRI-(magnetic resonance imaging) scan -A powerful magnetic field is created by passing an electric current through the wire loops. Meanwhile, other coils in the magnet send and receive radio waves MRI Scans Show Images of Amyloid Plaques in Rabbit Model Electroencephalogram (EEG) recording of the brain's spontaneous electrical activity over a short period of time, usually 2040 minutes, as recorded from multiple electrodes placed on the scalp. measures voltage fluctuations resulting from ionic current flows within the neurons of the brain NEUROPSYCHOLOGICAL TESTING MINI-MENTAL STATE EXAMINATION(MMSE) this involves an extensive assessment of cognitive (thinking) and memory skills. It can take several hours. LABORATORY TESTS: CBC Electrolytes Renal Thyroid Liver panels Urinalysis pathophysiology TREATMENT Cholinesterase inhibitors -These improve the levels of neurotransmitters in the brain. The medication contains a chemical that inhibits the cholinesterase enzyme from breaking down the neurotransmitter acetylcholine resulting in an increase in both the neurotransmitter's level and duration of action. -Cholinesterase inhibitors are prescribed to treat problems related to memory, thinking, language, judgment and other thought processes. -To improve cognition Examples of cholinesterase inhibitors include: donepezil (Aricept) galantamine (Razadyne) rivastigmine (Exelon) Memantine is prescribed to improve memory, language, reason, attention, and the ability to carry out simple tasks. EXAMPLES INCLUDE : Axura Akatinol, Namenda, Ebixa and Abixa, Memox. SIDE EFFECTS INCLUDE: Dizziness Drowsiness Headache Insomnia Constipation Agitation and delusional behavior in some patients. SEROTONIN UPTAKE INHIBITORS TO MANAGE DEPRESSION EXAMPLES:CITALOPRAM, SERTRALINE TRICYCLIC ANTIDEPRESSANTS (DESIPRAMINE) AND ANTIPSYCOTICS( HALOPERIDOL, RISPERIDONE) FOR THE MANAGEMENT OF PSYCHOSES AND BEHAVIORAL DISTURBANCES ACE Inhibitors - researchers from the Wake Forest School of Medicine found that ACE inhibitors that affect the brain by crossing the blood-brain barrier, may reduce inflammation that could contribute to the development of Alzheimer's disease. Stem cells - scientists at UC Irvine showed that neural stem cells can rescue memory in mice with advanced Alzheimer's disease, raising hopes of a potential treatment for humans. Insulin - Insulin could protect against damage to brain cells key to memory, according to researchers from Northwestern University in the US and the University of Rio de Janeiro in Brazil. They claim that treating Alzheimer's disease with insulin, or with drugs to boost its effect, may help people with the condition. PLANNING AND IMPLEMENTATION HEALTH TEACHING NUTRITION WEIGHT NEEDS TO BE MONITORED SUPPLEMENTAL FEEDING MAY REQUIRED EXERCISE AND PHYSICAL THERAPY ASSISTANCE WITH ADL, EMOTIONAL SUPPORT, AND POTENTIAL FINANCIAL CONCERNS collaborative MANAGEMENT Protect the client from injury. Provide supervision Close and secure doors. Use ID bracelets and electronic surveillance. Remove throw rugs, toxic substances and dangerous electrical appliances from the environment. Reduce hot water heater temperature. Orient client to the environment. Promote Activity Provide exercise such as walking with an escort.

Provide activities that distract and occupy time such as listening to music, coloring and watching television. Provide mental stimulation with simple games and activities. Promote activities of daily living. Promote Sleep Allow client to wander in a safe place until he/she becomes tired. Prevent shadows in the rooms. Avoid the use of hypnotics because they cause confusion and aggravate the sundown effect. Avoid Agitation and Violence Assess and remove the cause of agitation. Avoid scolding, embarrassing, arguing and reasoning with the client. Approach the client slowly and calmly. Remove the client from a stressful environment. Minimize Confusion and Disorientation Call the client by name. Orient the client frequently. Ask only one question at a time and give direction at a time. Use familiar objects in the room. Place a calendar and clock in a visible place. Provide a structured activities (routine schedule) Allow the client to reminisce. Provide simple environment that requires less decision making. Allow time for the client to complete a task. Prevent Fatigue Avoid the following: Change of routine. Excessive demands. Physical stressors. Overwhelming situation. - these factors escalate behavioral dysfunction Prevent sundown syndrome -Turn lights on before it becomes dark Refer family to support groups Exelon - G.I. upset is common adverse effect . Weight loss my be a problem. Tacrine -may improve cognitive functions for mild to moderate Alzheimers disease. - check VS periodically, for tachycardia and hypotension. COMPLICATIONS OF ALZHEIMER'S DISEASE Pneumonia Urinary tract infection Injuries Nursing diagnosis Self-care deficit to inability to perform activities of daily living without assistance Risk for injury related to impaired judgment, poor memory, and gait instability Disturbed thought process related to memory loss and cognitive deficits Risk for ineffective coping related to disease progression Impaired verbal communication related to cognitive decline.