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Nursing Care & Intervention for the Client with Chronic Neurological Disease Keith Rischer RN, MA, CEN 1 Today’s Objectives… Compare & contrast pathophysiology and clinical manifestations of chronic neurological disorders (MS, Myasthenia Gravis, Guillian-Barre, ALS). Identify the diagnostic tests, nursing priorities, and client education with chronic neurological disorders. Describe the mechanism of action, side effects and nursing responsibilities with pharmacologic management of chronic neurological disorders. 2 Multiple Sclerosis Patho • Autoimmune disease of myelin sheath • T cells Inflammatory response Destroys myelin sheath in patches Demyelination of nerve fibers 3 MS: Classifications Relapsing-remitting • • most common 85% of cases Attacks that become increasingly frequent 1-2 weeks relapse 4-8 months to resolve • Exacerbations (acute attacks) occurs with either full recovery or partial recovery with disability 4 MS: Assessment Fatigue Spinal cord lesions lead to: Changes in motor and sensory impairments of the trunk and limbs – Heaviness or weakness in extremities – Numbness or tingling in extremities – Bowel or bladder dysfunction – Intention tremors – Loss of fine motor movement – Spasticity 5 MS: Assessment Brain lesions lead to CNS signs: Emotional lability – euphoria or depression Irritability Changes in vision and coordination Slurred speech Ataxia Diplopia Nystagmus 6 MS: Diagnostic Tests CSF • • • MRI • Elevated protein WBC cells IgG bands due to the immune response multifocal lesions in the white matter CT scan • atrophy and white matter lesions 7 MS: Pharmacologic Management Corticosteroids • • Prednisone Solu-medrol (Methylprednisolone) Antispasmodics • Acute exacerbations Immunosuppressive Valium Adjunctive • Paresthesias Tegretol or Amitriptyline 8 MS: Pharmacologic Management • Biologic Response Modifiers • delay disability and decrease the number of and severity of relapses – Avonex (Interferon Beta 1a) – given IM q week – Betaseron (Interferon Beta 1b) – given SQ every other day – Copaxone (Glatiramer acetate) – given SQ every day Side Effects Thrombocytopenia Leukopenia Depression injection site reactions 9 MS: Nursing Diagnostic Priorities • • Fatigue Impaired physical mobility ROM-strengthening exercises Encourage ADL’s but not to excess • Urinary Retention Self cath Prevention of UTI • Constipation 10 MS: Nursing Diagnostic Priorities • Disturbed Sensory Perception: Visual Cognitive problems – Re-orient – Speech/swallowing eval • Deficient knowledge Medications Bowel/bladder programs Avoid exacerbations – Importance of rest – Stress reduction – Extremes of temperature 11 Amyotrophic Lateral Sclerosis (ALS) Patho • Amyotrophy • Lateral • hardened scar tissue when nerve cells die Characteristics • Loss of motor neurons loss of nerves on each side of the spinal cord Sclerosis process of muscle atrophy Flaccid quadriplegia Atrophy extremities Resp. impairment Causes 12 ALS: Assessment Early • • • Fatigue Dysphagia/dysarthria Weakness of extremities Late • Muscle atrophy Weakness Flaccid quadriplegia Diaphragm – Death if no ventilator Diagnosis • • CK increased Muscle biopsy 13 ALS: Interventions Rilutek • Speech therapy • • Communication Swallowing eval Dietician • Extends survival time only Enteral feedings Hospice • End of life…living will 14 ALS: A Patient’s Perspective “Having ALS is like walking into a dark room, reaching for the light switch on the wall and it’s not there. You’re in the dark…you ask will life ever be better again? At that point, it dawns on you, the light to get you through these hard times has to come from within. And that flame is fueled by the love and support of everyone around us.” 15 Guillain Barre Syndrome Patho • • • Autoimmune disorder Myelin sheath destroyed Motor, sensory, autonomic involvement Causes • Acute illness • Diseases • Hodgkin’s, Lupas, HIV Virus • GI, URI CMV, Epstein-Barr virus, HIV Vaccination Flu, Group A Strep, Rabies 16 GBS: Assessment of Ascending Paresthesia lower extremities Weakness • • progresses upward to trunk, arms and/or cranial nerves Motor deficit mild paresis to total quadriplegia Respiratory compromise • 50% prevalence 17 GBS: Assessment of Descending Weakness of facial muscles/jaw Ophthalmoplegia • Paralysis/weakness of eye muscles Diplopia Dysphagia Difficulty speaking Respiratory compromise 18 GBS: Diagnostic Lumbar puncture • Moderate leukocytosis • early in illness EMG • increase in CSF protein level without an increase in cell count decreased motor nerve conduction MRI/CT • r/o other causes 19 GBS: Nursing Diagnostic Priorities Airway • • • Cardiac • Monitor BP, dysrhythmias Acute pain Impaired physical mobility • Monitor respiratory status Manage the airway HOB 45 degrees Help prevent muscle atrophy Self-care deficit Risk for aspiration • Assess pt’s ability to swallow and chew food 20 GBS: Medical Management Plasmaphoresis – Removes circulating antibodies that cause GBS – Plasma is separated from whole blood – 3 to 4 treatments 1-2 days apart – Can reduce recovery up to 50 % IV Immunoglobulin – Chills, fever, myalgia – Acute renal failure, anaphylaxis21 GBS: Plasmaphoresis Infection Hypovolemia • VS changes Low K+, Ca++ Temporary distal extremity paresthesias • Add Ca++ gluconate to exchange fluids 22 Myasthenia Gravis Patho • Autoimmune disease of the neuromuscular junction • Antibody attack on the acetylcholine receptors in muscle end plate membranes • cranial nerves, skeletal and respiratory muscles Nerve impulses not transmitted to muscle Remissions and exacerbations Causes • • Unknown Overgrowth of thymus gland 23 Myasthenia Gravis: Assessment Early Facial/ocular involvement • • • • Incomplete eye closure PEARL Difficulty chewing Dysphagia Late Proximal limb weakness All muscles weak Respiratory • • • Difficulty breathing Diminished breath sounds Respiratory paralysis and failure 24 Cholinesterase Inhibiting Drugs Pyridostigmine (Mestinon) • Mechanism • • Enhance neuromuscular impulse transmission by preventing decrease of Ach by ChE Increases response of muscles to nerve impulsesimproves muscle strength Nursing considerations • • First line management Take w/food 1 hour before meals to prevent aspiration Side effects • Cholinergic crisis 25 Myasthenic Crisis Assessment • • • • HR/BP/RR incr. B/B incontinence Decreased u/o Cyanosis Cholinergic Crisis Assessment • • • • Hypotension N-V-D Abd cramps Facial twitching Management • • • Assess resp status closely Monitor VS closely Hold CHI drugs 26 Myasthenia Gravis: Diagnostic Tests AChR antibodies • Thyroid function tests • 5% thyrotoxicosis Tensilon testing • 80-90% present Improvement after administration EMG 27 MG: Pharmacologic Treatment Cholinesterase inhibitors • • Pyridostigmine (Mestinon) Cholinergic crisis Immunosupression • • Prednisone Chemotherapy Imuran/Cytotoxan Plasmaphoresis • 6 exchanges over 2 weeks 28 MG: Nursing Diagnostic Priorities Risk for ineffective breathing pattern • Monitor respiratory status • Monitor for respiratory failure • Monitor speech and swallowing abilities to prevent aspiration Activity intolerance r/t fatigue/muscle weakness….self care deficit • Rest • Assess abilities…adaptive equipment Deficient knowledge • avoid stress, infection, fatigue • Medications • Need for artificial tears/ointment • Nutritional support 29