Transcript 401-Chronic-Neuro2

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
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ALS: Assessment
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Early
•
•
•

Fatigue
Dysphagia/dysarthria
Weakness of extremities
Late
•
Muscle atrophy



Weakness
Flaccid quadriplegia
Diaphragm
– Death if no ventilator

Diagnosis
•
•
CK increased
Muscle biopsy
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ALS: Interventions
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Rilutek
•

Speech therapy
•
•

Communication
Swallowing eval
Dietician
•
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Extends survival time only
Enteral feedings
Hospice
•
End of life…living will
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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
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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

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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
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GBS: Nursing Diagnostic Priorities
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Airway
•
•
•

Cardiac
•
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

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
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Assessment
•
•
•
•

HR/BP/RR incr.
B/B incontinence
Decreased u/o
Cyanosis
Cholinergic Crisis
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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