Transcript Neuromuscular alterations 202

Assessment of the Nervous System
Diane McLean RN, MSN
Nursing 202
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Objectives
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Define terms associated with selected
neuromuscular system alterations.
Describe selected neurological system alterations.
Describe legal and ethical considerations related to
providing nursing care for selected neuromuscular
system alterations.
Describe the impact of selected neuromuscular
system alterations on patients throughout the
lifespan.
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Objectives…
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Relate the pathophysiology associated with selected
neuromuscular system alterations to clinical manifestations.
Describe the role of the nurse in providing care for patients
experiencing selected neuromuscular system alterations.
Explain health promotion related to selected neuromuscular
system alterations.
Interpret selected diagnostic test for neuromuscular system
alterations.
Explain complications associated with selected
neuromuscular system alterations.
Describe the pharmacological agents and/or treatments for
selected neuromuscular system alterations.
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Objectives…
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Evaluate nutritional considerations for patients experiencing
selected neuromuscular system alterations.
Identify patient response to treatment modalities for patients
experiencing selected neuromuscular system alterations.
Evaluate psychosocial needs of patients, families, and/or
support systems.
Use critical thinking to prioritize nursing care for culturally
diverse patients experiencing selected neuromuscular
system alterations.
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Objectives…
Describe the delegation process used to
provide nursing care for patients
experiencing selected neuromuscular
system alterations.
 Evaluate outcomes of nursing care for
patients experiencing selected
neuromuscular system alterations.
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Anatomy and Physiology
Chapter 43
Neurons
 Mechanism for nerve impulse conduction
 Neuroglial cells
 CNS
 Cerebral circulation
 Spinal cord
 ANS, sympathetic
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and parasympathetic
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Assessment
Family history and genetic risk
 Personal history
 Level of consciousness and orientation
 Memory: remote or long term, recall,
immediate
 Attention
 Language and copying
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Assessment …
Cognition
 Cranial nerves
 Sensory function
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Pain and temperature
 Touch
 Abnormal sensory findings
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Assessment of Motor
Function
Muscle strength
 Cerebral or brainstem integrity
 Abnormal motor findings
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Assessment of Cerebellar
Function
Coordination
 Gait and equilibrium
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Assessment of Reflex
Activity
Deep tendon reflexes
 Cutaneous reflexes: Babinski’s sign,
abdominal reflex
 Abnormal reflex findings
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Rapid Neurologic
Assessment
Glasgow Coma Scale
 Response to painful stimuli
 Level of consciousness
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Decortication
 Decerebration
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Pupil assessment
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Glasgow Coma Scale
Glasgow Coma Score
Eye Opening (E)
Verbal Response (V)
Motor Response (M)
4=Spontaneous
3=To voice
2=To pain
1=None
5=Normal
conversation
4=Disoriented
conversation
3=Words, but not
coherent
2=No words......only
sounds
1=None
6=Normal
5=Localizes to pain
4=Withdraws to pain
3=Decorticate
posture
2=Decerebrate
1=None
Total = E+V+M
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Laboratory Tests
Blood cultures necessary
 Skull and spine x-ray tests
 Cerebral angiography
 CT scan: possible use of contrast medium,
assess for allergic response, fluids
 Positron emission tomography
 Single-photon emission CT
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Lumbar Puncture
Insertion of spinal needle into the
subarachnoid space (between the third and
fourth lumbar vertebrae)
 Contraindicated in patients with increased
intracranial pressure
 Empty bladder
 Position
 Spinal headache possible from spinal tap
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Electroencephalography
(EEG)
Graphically records the electrical activity of
the cerebral hemispheres
 Sleep deprivation requirement
 Anticonvulsants possibly withheld
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Interventions
for patients with
Problems of the Central
Nervous System: The Brain
Chapter 44
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Headaches
Migraine headache
 Episodic familial disorder manifested by
unilateral, frontotemporal, throbbing pain in
the head, often worse behind one eye or ear
 Often accompanied by a sensitive scalp,
anorexia, photophobia, nausea
 Aura: sensation that signals
the onset of a headache
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or seizure
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Drug Therapy
Abortive therapy: alleviating pain during the
early aura phase includes prescribing
ergotamine derivatives, NSAIDs, triptans,
isometheptene combinations.
 Acetaminophen and NSAIDs are usually
effective for mild migraine headaches.
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Preventive Therapy
NSAID prescription
 Beta-adrenergic blocker
 Calcium channel blockers
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Complementary and
Alternative Therapies
Yoga, meditation, massage, exercise,
biofeedback, relaxation techniques
 Acupuncture
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Complementary and
Alternative Therapies…
Use of herbs and nutritional therapies with
approval
 Avoidance of trigger events that may result
in migraine episodes, such as tension and
stress
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Cluster Headache
Histamine cephalagia, uncommon type of
headache
 Cause unknown; attributed to vasoreactivity
and oxyhemoglobin desaturation
 Unilateral, radiating to forehead, temple, or
cheek
 Ipsilateral tearing of the eye, rhinorrhea,
ptosis, and miosis
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Therapy
Same types of drugs used for migraines
 patient to wear sunglasses and avoid
sunlight
 Oxygen via mask
 Avoidance of precipitating factors, such as
anger, excitement
 Surgical management
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Tension Headache
Neck and shoulder muscle tenderness and
bilateral pain at the base of the skull and in
the forehead
 Head pain without associated symptoms
 Treatment: non-opioid analgesics, muscle
relaxants, occasional opioids
 Ibuprofen plus caffeine
 Prophylactic treatment similar to that used in
treating migraine headaches
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Seizures and Epilepsy
Seizure: abnormal, sudden, excessive,
uncontrolled electrical discharge of neurons
within the brain; may result in alteration in
consciousness, motor or sensory ability,
and/or behavior
 Epilepsy: chronic disorder with recurrent,
unprovoked seizures; may be caused by
abnormality in electrical neuronal activity,
and/or imbalance of neurotransmitters (such
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as GABA
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Types of Seizures
Generalized seizures
 Partial seizures
 Unclassified seizures
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Types of Epilepsy
Primary or idiopathic epilepsy: not
associated with any identifiable brain lesion
 Secondary epilepsy: results from an
underlying brain lesion, most commonly a
tumor or trauma
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Seizures Risks
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Seizures may result from:
Metabolic disorders
 Acute alcohol withdrawal
 Electrolyte disturbances
 Heart disease
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Collaborative Management
A complete description of the type of seizure
activity that occurs and events surrounding
the seizure determines the best treatment
plan.
 Determine whether an aura was present
before the seizure in the preictal phase.
 Diagnostic testing is performed.
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Drug Therapy
Evaluate most current blood level of
medication, if appropriate.
 Be aware of drug-drug and drug-food
interactions.
 Maintain therapeutic blood levels for
maximal effectiveness.
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DRUGS to Review
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Dilantin
Topamax
Depakote
Tegretol
Klonopin
Valium
Neurotin
Keppa
Phenobarbital
Mysoline
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Drug Therapy…
Do not administer warfarin with phenytoin.
 Document and report side and adverse
effects.
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patient and Family Education
Antiepileptic drugs (AEDs) may not be
stopped, even if seizures stop.
 Refer limited-income patients to social
services.
 All states prohibit discrimination against
people who have epilepsy.
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patient and Family
Education…
Alternative employment may be needed.
 Vocational rehabilitation may be subsidized.
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Seizure Precautions
Oxygen and suctioning equipment should be
readily available.
 Saline lock may be necessary.
 Side rails should be up at all times.
 Padded side rail use is controversial.
 Place bed in lowest position.
 Never insert padded tongue blades into the
patient’s mouth during a seizure.
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Seizure Management
If simple partial seizure, observe the patient
and document the seizure.
 Turn the patient on the side during a
generalized tonic-clonic seizure; if possible,
turn the patient’s head to prevent aspiration.
 Cyanosis usually is self-limiting.
 Do not restrain.
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Status Epilepticus
Management
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Usual causes of status epilepticus:
Prolonged seizures lasting more than 5 minutes
or repeated seizures over the course of 30
minutes
 Neurologic emergency that must be treated
promptly and aggressively
 Sudden withdrawal of AEDs, infections, alcohol
withdrawal, head trauma, cerebral edema, and
metabolic disturbances
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Status EpilepticusTreatment
Establish an airway.
 Administer oxygen as indicated.
 Establish intravenous access.
 For continuous monitoring, admit patient to
intensive care unit.
 Give IV diazepam, lorazepam, phenytoin,
fosphenytoin, or general anesthesia.
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Status
EpilepticusTreatment…
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Other treatments include:
Surgical management: epileptic region in a
resectable area
 Corpuscallostomy
 Vagal nerve stimulation
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Meningitis
Meningitis: inflammation of the arachnoid
and pia mater of the brain and spinal cord
and the cerebrospinal fluid
 Bacterial and viral origins
most common:
fungal and protozoal meningitis
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Meningitis…
Viral meningitis: self-limiting and patient
recovers
 Bacterial meningitis: a medical emergency
with a mortality rate of approximately 25%.
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Physical Assessment and
Clinical Manifestations
Signs and symptoms of meningitis:
headache, nausea, vomiting, and fever
 Photophobia and indications of increased
intracranial pressure
 Nuchal rigidity and positive Kernig’s and
Brudzinski’s signs (only present in 9% of
patients)
 Seizure, decreased mental status, focal
neurologic deficits
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Laboratory Assessment of
Meningitis
Cerebrospinal fluid analysis
 Computed tomography scan
 Blood cultures
 Counterimmunoelectrophoresis
 Polymerase chain reaction
 Complete blood count
 X-ray study to determine presence of
infection
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Drug Therapy
Broad-spectrum antibiotic
 Hyperosmolar agents
 Anticonvulsants
 Steroids (controversial)
 Prophylaxis treatment for those who have
been in close contact with the meningitisinfected patient
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Encephalitis
Inflammation of the brain parenchyma and
often the meninges; affects the cerebrum,
brainstem, and cerebellum
 Viral cause, most often bacteria, fungi, or
parasites
 Degeneration of neurons of the cortex
 Hemorrhage, edema, necrosis, small
lacunae develop in cerebral hemispheres
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Encephalitis…
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Other Infections
Arboviruses
 Enteroviruses
 Herpes simplex virus type 1
 Amebae
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Interventions
Prompt recognition and treatment of signs of
cerebral edema, hemorrhage, and necrosis
of brain tissue
 Establishment of patent airway
 Assessment of vital signs
 Continuous supportive care and assessment
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Parkinson Disease
Debilitating disease affecting motor ability
characterized by tremor, rigidity, akinesia,
and postural instability
 Parkinson disease is separated into stages
by degree of disability: 1, 2, 3, 4, and 5.
 Exact cause unknown, possibly involving
environmental and genetic factors
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Parkinson’s Disease
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Parkinson’s Disease…
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Assessment
Fatigue, slight tremor, problems with manual
dexterity
 Rigidity, changes in facial expression,
uncontrolled drooling, dementia, changes in
voluntary movement, excessive perspiration,
orthostatic hypotension
 No specific diagnostic tests
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Drug Therapy in Parkinson
Disease
Anticholinergic drugs: amantadine, selegiline
(confer mild benefit)
 Dopamine agonists in the first 3 to 5 years
 Levodopa
 Bromocriptine or pergolide
 Amantadine
 Catechol O-methyltransferase inhibitors
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Drug Toxicity
Long-term drug therapy regimens often
cause delirium, cognitive impairment,
decreased effectiveness of the drug, or
hallucinations.
 Reduce medication dose.
 Change medications or frequency of
administration.
 Take “drug holiday,” especially in the use of
levodopa therapy.
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Management of Parkinson
Disease
Exercise and ambulation
 Self-care
 Injury prevention
 Nutrition
 Communication
 Psychosocial support
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Management of Parkinson
Disease…
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Surgical management includes:
Stereotactic pallidotomy
 Deep brain stimulation
 Fetal tissue transplantation
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Alzheimer’s Disease
Chronic, progressive, degenerative disease
that accounts for 60% of dementias
occurring in people older than 65 years of
age
 Loss of memory, judgment, and visuospatial
perception, and change in personality
 Increasing cognitive impairment, severe
physical deterioration, death from
complications of immobility
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Structural Changes in the
Brain
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Alzheimer’s disease creates changes that
include:
Neurofibrillary tangles
 Senile or neuritic plaques
 Granulovascular degeneration
 Increased amounts of an abnormal protein, beta
amyloid
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Structural Changes in the
Brain…
Significantly increased vascular degeneration a
contributor to mortality in this disorder
 Abnormalities of ACH, norepinephrine,
dopamine, and serotonin
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Alzheimer’s
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Chemical Changes in the
Brain
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Alzheimer’s disease creates changes that
include abnormalities in the
neurotransmitters:
Acetylcholine
 Norepinephrine
 Dopamine
 Serotonin
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Their exact role is not well understood.
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Manifestations
Changes in cognition
 Alterations in communication and language
abilities
 Changes in behavior, personality, and
judgment
 Changes in self-care skills
 Psychosocial assessment, especially
patient’s reaction to changes in routine
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Interventions in Alzheimer’s
Disease
Answer patient’s questions truthfully.
 Assess and treat other medical problems.
 Provide cognitive restructuring and memory
training.
 Structure the environment to increase
patient’s ability to function.
 Prevent overstimulation.
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Interventions
Provide consistency, orientation, and
validation therapy.
 Promote independence in activities of daily
living.
 Promote bowel and bladder continence.
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Interventions …
Assist with facial recognition as the disease
progresses to prosopagnosia, an inability to
recognize oneself and other familiar faces.
 Promote communication with clear, short
sentences.
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Drug Therapy
Cholinesterase inhibitors
 Memantine
 Donepezil
 Antidepressants
 Psychotropic drugs
 Complementary and
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alternative therapies
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Risk for Injury
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Interventions for the patient with Alzheimer’s
disease include:
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Coping with restlessness and wandering;
ensuring patient wears identification bracelet;
registering patient in Safe Return Program;
providing frequent walks and structured activities
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Risk for Injury…
Ensuring safety by removing all potentially
dangerous objects, particularly in case seizures
occur
 Minimizing agitation by talking calmly and softly;
displaying positive affect; making calm
movements; offering diversion
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Compromised Family Coping
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Interventions for the caregiver role:
Encourage family to seek legal counsel
regarding patient’s competency, need to obtain
guardianship, or durable medical power of
attorney, when necessary.
 Make caregivers and family aware of their own
health and stress resulting from new
responsibilities for care.
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Disturbed Sleep Pattern
Difficulty sleeping at night with frequent naps
in the day
 Interventions for establishing sleep pattern:
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Re-establish the usual day-night pattern by
providing activity and exercise during the day.
 Establish before-bedtime ritual.
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Disturbed Sleep Pattern…
Adjust treatment and medication schedule to
provide for uninterrupted sleep.
 Give mild antianxiety agent or hypnotic.
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Huntington Disease
Hereditary disorder transmitted as an
autosomal dominant trait at the time of
conception
 Gradual clinical onset of progressive mental
status changes, leading to dementia and
choreiform movements in the limbs, trunk,
and facial muscles
 Three stages each lasting about 5 years
over an average 15 years of the disease
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Management of Huntington
Disease
No known cure or treatment
 Genetic counseling
 Antipsychotic agents or monoaminedepleting agents used to manage movement
abnormalities that are disabling or interfere
with ADLs
 Medications to treat depression, anxiety, and
obsessive-compulsive behaviors
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Care of patients with Problems of the Central
Nervous System: The Spinal Cord
 Chapter 45
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Back Pain
Low back
 Herniated nucleus pulposus
 Physical assessment: continuous acute pain,
altered gait, vertebral alignment, paresthesia
 Diagnostic assessment using MRI, CT, and
electromyography
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Nonsurgical Management
Williams position, firm mattress or backboard
under soft mattress
 Exercise
 Drug therapy
 Heat and ice therapy
 Diet therapy
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Nonsurgical Management…
Other pain relief measures
 Complementary and alternative therapies
 Percutaneous laser disk decompression
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Surgical Management
Diskectomy
 Laminectomy
 Spinal fusion (arthrodesis)
 Minimally invasive lumbar procedures, such
as percutaneous lumbar diskectomy,
microdiskectomy, laser-assisted
laparoscopic lumbar diskectomy
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Postoperative Care
Prevention and assessment of complications
 Neurologic assessment; vital signs
 patient’s ability to void
 Pain control
 Wound care
 patient positioning and mobility
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Cervical Neck Pain
Conservative treatment is the same as
described for back pain except that the
exercises focus on shoulder and neck.
 If these treatments do not work, soft collar
may be used at night for a period of no
longer than 10 days.
 If conservative treatment is ineffective,
surgery such as an anterior cervical
diskectomy and fusion is commonly
performed.
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Spinal Cord Injury
Hyperflexion injury
 Hyperextension injury
 Axial loading injury such as those that occur
in jumping
 Rotation of the head beyond its range
 Penetration injury, such as those wounds
caused by a bullet or a knife
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Cervical Injuries
Anterior cord syndrome
 Posterior cord lesion
 Brown-Séquard syndrome
 Central cord syndrome
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Initial Assessment
Assessment of the respiratory pattern and
ensuring an adequate airway
 Assessment for indications of intraabdominal hemorrhage or hemorrhage or
bleeding around fracture sites
 Assessment of level of consciousness using
Glasgow Coma Scale
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Initial Assessment…
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Establishment of level of injury: tetraplegia,
quadraplegia, quadriparesis, paraplegia, and
paraparesis
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Spinal Shock
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This condition is characterized by the
following:
Flaccid paralysis
 Loss of reflex activity below the level of the
lesion
 Bradycardia
 Paralytic ileus
 Hypotension
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Cardiovascular Assessment
Cardiovascular dysfunction is usually the
result of disruption of the autonomic nervous
system.
 Bradycardia, hypotension, and hypothermia
result from a loss of sympathetic input and
may lead to cardiac dysrhythmias.
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Cardiovascular
Assessment…
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Systolic blood pressure lower than 90 mm
Hg requires treatment because lack of
perfusion to the spinal cord worsens the
condition.
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Autonomic Dysreflexia
Commonly seen in patients with upper spinal
cord injury
 Severe hypertension
 Bradycardia
 Severe headache
 Nasal stuffiness
 Flushing
 Treatment
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Assessments
Respiratory assessment
 Gastrointestinal and genitourinary
assessment
 Musculoskeletal assessment
 Psychosocial assessment
 Laboratory assessment
 Radiographic and other diagnostic
assessments
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Ineffective Tissue Perfusion
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Interventions include:
Reduction and immobilization of the fracture to
prevent further damage to the spinal cord from
bone fragments
 Nonsurgical techniques, such as traction or
external fixation, but surgery may be necessary
as well
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Immobilization for Cervical
Injuries
Fixed skeletal traction to realign the
vertebrae, facilitate bone healing, and
prevent further injury
 Halo fixation and cervical tongs
 Stryker frame, rotational bed, kinetic
treatment table
 Pin site care and monitoring of traction ropes
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Immobilization of Thoracic
and Lumbosacral Injuries
For patients with thoracic injuries: bedrest
and possible immobilization with a fiberglass
or plastic body cast
 For patients with lumbar and sacral injuries:
immobilization of the spine with a brace or
corset worn when the patient is out of bed;
custom-fit thoracic lumbar sacral orthoses
preferred
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Drug Therapy
Methylprednisolone (controversial)
 Dextran
 Atropine sulfate
 Dopamine hydrochloride
 Naloxone and TRH
 Sygen
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Drug Therapy…
4-AP potassium channel blocker
 Dantrolene
 Baclofen
 Etidronate disodium
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Surgical Management
Emergency surgery necessary for spinal
cord decompression
 Decompressive laminectomy
 Spinal fusion
 Harrington rods to
 stabilize thoracic
 spinal injuries
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Ineffective Airway Clearance
and Breathing Pattern…
Assisted coughing, quad cough, cough assist
 Use of incentive spirometer
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Ineffective Airway Clearance
and Breathing Pattern
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Interventions for the patient with spinal cord
injury:
Airway management is the priority.
 patients with injuries at or above the sixth
thoracic vertebra are especially at risk for
respiratory complications.
 Provide measures to maintain airway.
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Impaired Physical Mobility;
Self-Care Deficit
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Interventions include:
In patients with spinal cord injury, monitor for risk
of pressure ulcers, contractures, and deep vein
thrombosis or pulmonary emboli.
 Proper positioning, skin inspection, ROM
exercises, heparin, and graduated compression
stockings.
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Impaired Physical Mobility;
Self-Care Deficit…
Prevent orthostatic hypotension.
 Promote self-care.
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Impaired Urinary Elimination;
Constipation
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Interventions include:
A bladder retraining program
 Spastic bladder: manipulating external area
 Flaccid bladder: Valsalva maneuver
 Encouraging consumption of 2000 to 2500 mL of
fluid daily to prevent urinary tract infection
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Impaired Urinary Elimination;
Constipation…
Long-term renal complication
 Signs and symptoms of urinary tract
infection not perceived by the patient
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Establishing a Bowel
Retraining Program
Consistent time for bowel elimination
 High fluid intake for at least 200 mL/day
 High-fiber diet
 Rectal stimulation (with or without
suppositories)
 Stool softener medications, as needed
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Impaired Adjustment
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Interventions include:
Invite patients to ask questions about significant
life changes; reply openly and honestly.
 Encourage patients to discuss their perceptions
of their situation and coping strategies that can
be used.
 Begin a patient education program to clarify
misconceptions.
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Spinal Cord Tumors
Surgical management: goal of removing as
much of the tumor as possible
 Nonsurgical management: radiation therapy,
chemotherapy, pain control
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Multiple Sclerosis
Chronic autoimmune disease affecting the
myelin sheath and conduction pathway of
the CNS
 Characterized by periods of remission and
exacerbation
 Inflammatory response resulting in random
or patchy areas of plaque in the white matter
of the CNS
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Major Types of Multiple
Sclerosis
Relapsing-remitting
 Progressive-relapsing
 Primary progressive
 Secondary progressive
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Common Physical
Assessment
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Findings include:
Flexor spasms at night
 Intention tremor
 Dysmetria
 Blurred vision, diplopia, decreased visual acuity,
scotomas, nystagmus
 Hypalgesia, numbness, tingling or burning
 Bowel and bladder dysfunction
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Drug Therapy
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Therapies include:
Biological response modifiers
 Immunosuppressives
 Steroids
 Antispasmodic drugs
 Adjunctive
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Management
Promoting mobility and self-care
 Managing cognitive problems
 Adapting to changes in sexual functioning
 Managing bladder and bowel problems
 Treating visual disturbances
 Complementary and alternative therapies
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Amyotrophic Lateral
Sclerosis
Known as Lou Gehrig’s disease, a
progressive and degenerative disease that
involves the motor system
 Early symptoms: fatigue while talking,
tongue atrophy, dysphagia, weakness of the
hands and arms, fasciculations, nasal quality
of speech, dysarthria
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Interventions
No known cure, no treatment, no preventive
measures
 Riluzole, only drug approved by FDA to
extend survival time
 Exercise and mobility program
 Management of swallowing difficulties
 Respiratory support
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Chapter 46

Care of Patients with Problems of the
Peripheral Nervous System
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Guillain-Barré Syndrome
An acute autoimmune disorder characterized
by varying degrees of motor weakness and
paralysis
 The patient’s life and ultimate potential for
rehabilitation dependent upon appropriate
interventions and effectiveness of nursing
care
 Chronic inflammatory demyelinating
polyneuropathy
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Clinical Manifestations
Muscle weakness and pain have abrupt
onset; cause remains obscure.
 Cerebral function or pupillary signs are not
affected.
 The most common clinical pattern is that the
immune system starts to destroy the myelin
sheath surrounding the axons.
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Clinical Manifestations…

Weakness and paresthesia begin in the
lower extremities and progress upward
toward the trunk, arms, and cranial nerves in
ascending GBS
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Ineffective Breathing Pattern
Interventions
Priority: maintain adequate respiratory
function; implement interdisciplinary actions
 Airway management:

Elevate head of bed at least 45 degrees
 Suction
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Ineffective Breathing Pattern
Interventions…
Chest physiotherapy
 Incentive spirometer
 Oxygen
 Monitor arterial blood gas and vital capacity
 Keep equipment for endotracheal intubation at
the bedside
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Interventions for Cardiac
Dysfunction
Can affect both the sympathetic and
parasympathetic systems
 patient placed on cardiac monitor because of
the risk for arrhythmias
 Hypertension treated with beta blocker or
nitroprusside
 IV fluids for hypotension; patient placed in
supine position
 Atropine may be used for bradycardia
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
Drug Therapy
Plasmapheresis or IV immunoglobulin
 Plasma exchange
 IV immunoglobulin
 No corticosteroids
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Plasmapheresis
Plasmapheresis removes the circulating
antibodies assumed to cause the disease.
 Plasma is selectively separated from whole
blood; the blood cells are returned to the
patient without the plasma.
 Plasma usually replaces itself, or the patient
is transfused with albumin.
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Acute Pain Interventions
Assess pain, which is often worse at night
 Pain usually only relieved with opiates
 Use of analgesia pump or continuous IV drip
 Frequent repositioning, massage, ice, heat,
relaxation techniques, guided imagery, and
distraction (such as music or visitors)
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Impaired Physical Mobility
and Self-Care Deficit

Interventions include:
Assess muscle function every 2 to 4 hours.
 Provide assistive devices and instructions for
their use.
 Ensure safety in ambulation, position changes.
 Encourage independence.
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Impaired Physical Mobility
and Self-Care Deficit…
ROM exercises every 2 to 4 hours
 Diet plan to guard against malnutrition
 Prevention of pressure ulcers
 Prevention of pulmonary embolic and deep vein
thrombosis
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Impaired Verbal
Communication

Interventions include:
Develop a communication system that meets the
needs of patient.
 Devise simple techniques—eye blinking and
moving a finger to indicate yes and no
responses.
 Develop a board using letters of the alphabet.
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Powerlessness

Interventions include:
Encourage patient to verbalize feelings about
the illness and its effects.
 Examine patterns of decision-making, roles and
responsibilities, and usual coping mechanisms.
 Refer patient to other health care professionals
as needed.
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Myasthenia Gravis
Chronic disease characterized by weakness
primarily in muscles innervated by cranial
nerves, as well as in skeletal and respiratory
muscles
 Thymoma: encapsulated
 thymus gland tumor
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Myasthenia Gravis…
Progressive paresis of affected muscle
groups that is partially resolved by resting
 Most common symptoms: involvement of
eye muscles, such as ocular palsies, ptosis,
diplopia, weak or incomplete eye closure
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Tensilon Testing
Within 30 to 60 sec after injection of
Tensilon, most myasthenic patients show
marked improvement in muscle tone that
lasts 4 to 5 minutes.
 Prostigmin is also used.
 Cholinergic crisis is due to overmedication.

(Continue
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Tensilon Testing…
Myasthenic crisis is due to undermedication.
 Atropine sulfate is the antidote for Tensilon
complications.

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Diet Therapy and
Interventions
Cholinesterase-inhibitor drugs
 Immunosuppressants
 Corticosteroids for immunosuppression
 Plasmapheresis

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Diet Therapy and
Interventions…
Respiratory support
 Nonsurgical management
 Assistance with activities and
communication

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Cholinesterase Inhibitor
Drugs
Drugs include anticholinesterase and
antimyasthenics.
 Enhance neuromuscular impulse
transmission by preventing decrease of ACh
by the enzyme ChE.
 Administer with food.
 Observe drug interactions.
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Emergency Crises
Myasthenic crisis: an exacerbation of the
myasthenic symptoms caused by
undermedication with anticholinesterases
 Cholinergic crisis: an acute exacerbation of
muscle weakness caused by overmedication
with cholinergic (anticholinesterase) dr
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Myasthenic Emergency
Crisis
Tensilon test is performed.
 Priority for nursing management is to
maintain adequate respiratory function.
 Cholinesterase-inhibiting drugs are withheld
because they increase respiratory secretions
and are usually ineffective for the first few
days after the crisis begins.
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Cholinergic Emergency
Crisis
Anticholinergic drugs are withheld while the
patient is maintained on a ventilator.
 Atropine may be given and repeated, if
necessary.
 Observe for thickened secretions due to the
drugs.
 Improvement is usually rapid after
appropriate drugs have been given.
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Management
Immunosuppression
 Plasmapheresis
 Respiratory support
 Promoting self-care guidelines
 Assisting with communication
 Nutritional support
 Eye protection
 Surgical management usually involving
thymectomy
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Health Teaching
Factors in exacerbation include infection,
stress, surgery, hard physical exercise,
sedatives, enemas, and strong cathartics.
 Avoid overheating, crowds, overeating,
erratic changes in sleeping habits, or
emotional extremes.
 Teach warning signs.
 Teach importance of compliance.
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Polyneuritis and
Polyneuropathy
Syndromes whose clinical hallmarks are
muscle weakness with or without atrophy;
pain that is stabbing, cutting, or searing;
paresthesia or loss of sensation; impaired
reflexes; autonomic manifestations
 Example: diabetic neuropathy

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Peripheral Nerve Trauma
Vehicular or sports injury or wounds to the
peripheral nerves
 Degeneration and retraction of the nerve
distal to the injury within 24 hours
 Perioperative and postoperative care
 Rehabilitation through physiotherapy
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Restless Legs Syndrome
Leg paresthesias associated with an
irresistible urge to move; commonly
associated with peripheral and central nerve
damage in the legs and spinal cord
 Management: symptomatic, involving
treating the underlying cause or contributing
factor, if known
 Nonmedical treatment
 Drug therapy effective for some patients
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
Trigeminal Neuralgia
Affects trigeminal or fifth cranial nerve
 Nonsurgical management of facial pain: drug
therapy
 Surgical management: microvascular
decompression, radiofrequency thermal
coagulation, percutaneous balloon
microcompression
 Postoperative care: monitoring for
complications
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
Facial Paralysis or Bell’s
Palsy
Acute paralysis of seventh cranial nerve
 Medical management: prednisone,
analgesics
 Protection of the eye
 Nutrition
 Massage; warm, moist heat; facial exercises
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