10.2 Neurological Conditions, Stroke & Musculoskeletal Disorders

Neurological Conditions, Stroke & Musculoskeletal Disorders

The nervous and musculoskeletal systems work in intricate coordination to maintain posture, execute voluntary movement, process sensory feedback, and preserve functional autonomy. Pathologies affecting these systems—such as strokes, neurodegenerative illnesses, seizure disorders, arthritis, and orthopedic fractures—are among the most prevalent conditions in long-term care facilities across Arizona. Certified Nursing Assistants must master specialized restorative techniques to provide safe, empathetic, and evidence-based care while promoting maximum resident independence.

+-----------------------------------------------------------------------------+
|              NEUROLOGICAL & MUSCULOSKELETAL SPECTRUM OF CARE                |
|                                                                             |
|   CEREBROVASCULAR ACCIDENT       NEURODEGENERATIVE        ORTHOPEDIC        |
|   - Ischemic vs Hemorrhagic      - Parkinson's Disease    - Osteoarthritis  |
|   - FAST Recognition Protocol    - Multiple Sclerosis     - Rheumatoid Arth.|
|   - Hemiplegia & Aphasia Care    - ALS (Lou Gehrig's)     - Osteoporosis    |
|   - POW / TOS Dressing Rules     - Seizure Protocols      - Hip Replacement |
+-----------------------------------------------------------------------------+

---

1. Cerebrovascular Accident (CVA / Stroke) & Post-Stroke Care

A Cerebrovascular Accident (CVA), commonly called a stroke or "brain attack," occurs when blood supply to a specific region of the brain is disrupted, starving neurons of oxygen and glucose and resulting in cellular death.

Stroke Pathophysiology: Two Main Types

1. Ischemic Stroke (87% of all strokes): Caused by a blood clot (thrombus) forming in a cerebral vessel or an embolus traveling from elsewhere (frequently the left atrium during atrial fibrillation) that occludes cerebral arterial blood flow. Emergency intravenous thrombolytic therapy ("clot buster" tPA) must be initiated within a strict 3 to 4.5-hour window.
2. Hemorrhagic Stroke (13% of all strokes): Caused by the rupture of a weakened cerebral blood vessel or aneurysm, bleeding directly into surrounding brain parenchyma and causing rapid intracranial pressure elevation.

+-----------------------------------------------------------------------------+
|                        THE F.A.S.T. STROKE ACRONYM                          |
|                                                                             |
|   [F] - FACE DROOPING: One side of the face droops or is numb.              |
|         Ask the resident to smile. Is the smile uneven or lopsided?         |
|                                                                             |
|   [A] - ARM WEAKNESS: One arm is weak, numb, or drifts downward.            |
|         Ask the resident to raise both arms. Does one drift down?           |
|                                                                             |
|   [S] - SPEECH DIFFICULTY: Speech is slurred, garbled, or incomprehensible. |
|         Ask the resident to repeat a simple sentence.                       |
|                                                                             |
|   [T] - TIME TO ACT: Stroke is a medical emergency! Note the exact time     |
|         symptoms began and alert the charge nurse immediately.              |
+-----------------------------------------------------------------------------+

Hemispheric Brain Damage: Left vs. Right Brain Stroke

Because brain motor tracts cross over in the brainstem (decussation of pyramids), damage to one hemisphere of the brain results in neurological deficits on the opposite (contralateral) side of the body.

+-----------------------------------------------------------------------------+
|                LEFT-BRAIN STROKE vs. RIGHT-BRAIN STROKE                     |
|                                                                             |
|   LEFT-BRAIN DAMAGE (RIGHT HEMIPLEGIA)  RIGHT-BRAIN DAMAGE (LEFT HEMIPLEGIA)|
|   - Paralyzed Right Side                - Paralyzed Left Side               |
|   - Aphasia (Speech & Language Deficit) - Spatial-Perceptual Deficits       |
|     * Expressive (Broca's): Can't speak - Left-Sided Neglect (ignores left) |
|     * Receptive (Wernicke's): No comp.  - Impulsive, Denies Disabilities    |
|   - Slow, Cautious, Anxious Behavior    - High Fall Risk, Poor Judgment     |
|   - Aware of Deficits / Frustration     - Rapid Performance, Short Attention|
+-----------------------------------------------------------------------------+

CNA Restorative Care for Post-Stroke Residents:

• Dressing Technique (POW / TOS Rule):
  • POW (Put On Weak): When dressing the resident, always place clothing onto the WEAK / AFFECTED extremity FIRST.
  • TOS (Take Off Strong): When undressing the resident, always remove clothing from the STRONG / UNAFFECTED extremity FIRST.
• Feeding & Dysphagia Management:
  • Position the resident fully upright at 90 degrees (High-Fowler's) for all oral intake.
  • Place small amounts of food on the unaffected (strong) side of the mouth.
  • Check the affected cheek for pocketing of food after every meal to prevent delayed aspiration.
  • Keep the resident upright for 30 to 60 minutes after eating.
• Transfers & Ambulation:
  • Position the wheelchair on the resident's strong (unaffected) side, angled at 45 degrees to the bed.
  • Lead the transfer toward the resident's strong side so they can support their own weight.
  • Always apply a gait belt snugly around the resident's waist. Stand slightly behind and toward the resident's weak side during ambulation to provide support if they stumble.

---

2. Neurodegenerative Disorders & Seizure Safety

Chronic progressive neurological conditions result from the gradual loss of specialized neural structures and neurotransmitters.

+-----------------------------------------------------------------------------+
|                     MAJOR NEURODEGENERATIVE DISORDERS                       |
|                                                                             |
|   PARKINSON'S DISEASE                 MULTIPLE SCLEROSIS (MS)               |
|   - Loss of dopamine in basal ganglia - Autoimmune myelin sheath damage.    |
|   - Tremor, Rigidity, Bradykinesia,   - Muscle weakness, ataxia, spasticity,|
|     shuffling gait, masked facies.      visual disturbances, fatigue.       |
|                                                                             |
|   AMYOTROPHIC LATERAL SCLEROSIS (ALS) SEIZURE DISORDERS                     |
|   - Progressive motor neuron death.   - Sudden, abnormal electrical bursts  |
|   - Muscle atrophy, paralysis, speech   in cerebral neurons.                |
|     loss; COGNITION REMAINS INTACT.   - Tonic-clonic jerking, loss of cons. |
+-----------------------------------------------------------------------------+

Parkinson's Disease Management

• Cardinal Motor Manifestations (TRAP):
  • T - Tremor: Resting "pill-rolling" tremor of fingers and hands.
  • R - Rigidity: "Cogwheel" stiffness and resistance to passive limb movement.
  • A - Akinesia / Bradykinesia: Extreme slowness of voluntary physical movements.
  • P - Postural Instability: Forward-leaning stooped posture, balance impairment, and shuffling propulsive gait.
• CNA Care Measures:
  • Allow ample, unhurried time for activities of daily living (ADLs).
  • Assist with "gait freezing" (instruct resident to imagine stepping over an imaginary line on the floor).
  • High risk for aspiration due to dysphagia; enforce upright feeding posture.

Multiple Sclerosis (MS) & ALS Considerations

• Multiple Sclerosis (MS): Autoimmune destruction of the protective myelin sheath insulating nerve axons in the brain and spinal cord. Symptoms include extreme fatigue, spasticity, loss of coordination (ataxia), and sensitivity to heat. CNAs must balance physical activity with frequent rest periods and prevent overheating during bathing.
• Amyotrophic Lateral Sclerosis (ALS / Lou Gehrig's Disease): Degeneration of upper and lower motor neurons leads to progressive muscular atrophy and total paralysis, eventually affecting speech, swallowing, and breathing. Crucially, the resident's cognitive faculties, sensation, and intellect remain fully intact. CNAs must utilize adaptive communication boards, maintain dignity, and provide airway vigilance.

Seizure Disorders & Emergency Protocols

A generalized tonic-clonic (grand mal) seizure involves sudden loss of consciousness followed by muscle stiffening (tonic phase) and violent rhythmic contractions (clonic phase).

+-----------------------------------------------------------------------------+
|                     SEIZURE EMERGENCY RESPONSE ALGORITHM                    |
|                                                                             |
|   [!] STEP 1: STAY WITH RESIDENT ---> Never leave; call loudly for nurse.   |
|   [!] STEP 2: LOWER TO THE FLOOR ---> If sitting/standing, gently guide down|
|   [!] STEP 3: CLEAR THE AREA -------> Move hard furniture and sharp objects.|
|   [!] STEP 4: LATERAL RECOVERY POS -> Turn resident onto side (drains saliva|
|                                       and keeps airway clear).              |
|   [!] STEP 5: CUSHION THE HEAD -----> Place folded towel/pillow under head. |
|   [!] STEP 6: LOOSEN CLOTHING ------> Loosen tight neckties, collars, belts.|
|   [!] STEP 7: TIME THE SEIZURE -----> Note exact start time and duration.   |
|                                                                             |
|   [X] NEVER RESTRAIN LIMBS ---------> DO NOT hold down or restrain movements|
|   [X] NEVER PUT OBJECTS IN MOUTH ---> DO NOT insert tongue blades, spoons,  |
|                                       or fingers (causes airway injury).    |
+-----------------------------------------------------------------------------+

[!CAUTION] CRITICAL PROHIBITIONS DURING AN ACTIVE SEIZURE

1. DO NOT RESTRAIN THE RESIDENT: Attempting to forcefully hold down jerking limbs can cause severe bone fractures, joint dislocations, and muscle tears.
2. DO NOT INSERT ANYTHING INTO THE MOUTH: Never attempt to force a tongue blade, spoon, or fingers into the resident's mouth. This can break teeth, cause severe oral lacerations, or occlude the airway. Residents will not swallow their tongues.

---

3. Musculoskeletal Disorders & Orthopedic Care

The musculoskeletal system (bones, joints, muscles, tendons, ligaments) provides structural support, organ protection, and movement. Degenerative and inflammatory disorders severely impair mobility.

+-----------------------------------------------------------------------------+
|                     ARTHRITIS & BONE DISORDERS SPECTRUM                     |
|                                                                             |
|   OSTEOARTHRITIS (OA)                 RHEUMATOID ARTHRITIS (RA)             |
|   - "Wear and tear" joint disease.    - Systemic autoimmune inflammation.   |
|   - Non-inflammatory, asymmetrical.   - Symmetrical, joint deformities.     |
|   - Morning stiffness < 30 minutes.   - Morning stiffness > 1 hour.         |
|   - Pain worsens with joint use.      - Fatigue, fever, systemic illness.   |
|                                                                             |
|   OSTEOPOROSIS                        TOTAL HIP ARTHROPLASTY (THA)          |
|   - Severe loss of bone mass/density. - Surgical prosthetic hip replacement.|
|   - Brittle bones, silent progression.- Rigid dislocation precautions:      |
|   - High risk of pathological fractures Abduction wedge, no flexion > 90 deg|
+-----------------------------------------------------------------------------+

Osteoarthritis vs. Rheumatoid Arthritis

• Osteoarthritis (Degenerative Joint Disease - DJD): The progressive breakdown and erosion of articular cartilage in weight-bearing joints (hips, knees, lumbar spine). Joint pain increases with physical activity and is relieved by rest. Morning joint stiffness is brief (usually lasting under 30 minutes).
• Rheumatoid Arthritis (RA): A chronic, systemic autoimmune disease where the immune system attacks synovial membranes, producing severe joint inflammation, painful swelling, and permanent joint deformities (such as swan-neck and boutonnière deformities). Morning stiffness is prolonged (lasting greater than 1 hour).

Osteoporosis & Pathological Fracture Prevention

• Pathophysiology: Bone resorption exceeds bone formation, leaving bones porous, brittle, and vulnerable to pathological fractures (fractures occurring from minimal trauma or normal weight-bearing). Common sites include the femoral neck (hip), vertebrae (dowager's hump/kyphosis), and wrist.
• CNA Fall Prevention Protocols: Keep pathways clear of clutter, ensure bright lighting, ensure non-skid footwear is worn, promptly wipe up spills, answer call lights within seconds, and never yank on a resident's limbs during repositioning.

Hip Fractures & Total Hip Arthroplasty (THA) Precautions

When a resident undergoes a total hip replacement (posterior surgical approach), the femoral head prosthesis is at high risk for dislocation if specific anatomical angles are breached.

+-----------------------------------------------------------------------------+
|              TOTAL HIP ARTHROPLASTY (POSTERIOR APPROACH) PRECAUTIONS        |
|                                                                             |
|   1. ABDUCTION WEDGE ------------> Place abduction pillow between legs      |
|                                    at all times while in bed or turning.    |
|   2. NO HIP FLEXION > 90° -------> Resident MUST NOT bend forward at waist  |
|                                    past 90 degrees; knees below hips.       |
|   3. NO CROSSING LEGS -----------> Resident MUST NOT cross legs at ankles   |
|                                    or knees (adduction is prohibited).      |
|   4. NO INTERNAL ROTATION -------> Resident MUST NOT point toes inward.     |
|   5. RAISED TOILET / CHAIR ------> Use elevated toilet seats and firm       |
|                                    straight-backed chairs with armrests.    |
+-----------------------------------------------------------------------------+