1 nursing care & intervention for the client with chronic neurological disease keith rischer rn,...
TRANSCRIPT
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Nursing Care & Intervention for the Client with Chronic Neurological
Disease
Keith Rischer RN, MA, CEN
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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.
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Multiple Sclerosis
Patho• Autoimmune disease of
myelin sheath• T cells
Inflammatory response
Destroys myelin sheath in patches
Demyelination of nerve fibers
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MS: Classifications
Relapsing-remitting • most common 85% of cases• Attacks that become increasingly frequent
1-2 weeks relapse4-8 months to resolve
• Exacerbations (acute attacks) occurs with either full recovery or partial recovery with disability
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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
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MS: Assessment
Brain lesions lead to CNS signs:Emotional lability – euphoria or depressionIrritabilityChanges in vision and coordinationSlurred speechAtaxiaDiplopiaNystagmus
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MS: Diagnostic Tests
CSF • Elevated protein• WBC cells • IgG bands due to the immune response
MRI • multifocal lesions in the white matter
CT scan• atrophy and white matter lesions
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MS: Pharmacologic Management
Corticosteroids • Prednisone• Solu-medrol (Methylprednisolone)
Acute exacerbations Immunosuppressive
Antispasmodics• Valium
Adjunctive• Paresthesias
Tegretol or Amitriptyline
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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
ThrombocytopeniaLeukopeniaDepression injection site reactions
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MS: Nursing Diagnostic Priorities
• Fatigue• Impaired physical mobility
ROM-strengthening exercisesEncourage ADL’s but not to excess
• Urinary RetentionSelf cathPrevention of UTI
• Constipation
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MS: Nursing Diagnostic Priorities
• Disturbed Sensory Perception: VisualCognitive problems
– Re-orient– Speech/swallowing eval
• Deficient knowledgeMedicationsBowel/bladder programsAvoid exacerbations
– Importance of rest– Stress reduction– Extremes of temperature
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Amyotrophic Lateral Sclerosis (ALS)
Patho• Amyotrophy
process of muscle atrophy• Lateral
loss of nerves on each side of the spinal cord
• Sclerosis hardened scar tissue when nerve
cells die
Characteristics• Loss of motor neurons
Flaccid quadriplegia Atrophy extremities Resp. impairment
Causes
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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
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ALS: Interventions
Rilutek • Extends survival time only
Speech therapy• Communication• Swallowing eval
Dietician• 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.”
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Guillain Barre Syndrome
Patho• Autoimmune disorder• Myelin sheath destroyed• Motor, sensory, autonomic
involvement
Causes• Acute illness
GI, URI
• Diseases Hodgkin’s, Lupas, HIV
• Virus CMV, Epstein-Barr virus, HIV
• Vaccination Flu, Group A Strep, Rabies
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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
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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 • increase in CSF protein level without an
increase in cell count Moderate leukocytosis
• early in illness EMG
• decreased motor nerve conduction MRI/CT
• r/o other causes
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GBS: Nursing Diagnostic Priorities
Airway• Monitor respiratory status• Manage the airway • HOB 45 degrees
Cardiac• Monitor BP, dysrhythmias
Acute pain Impaired physical mobility
• Help prevent muscle atrophy Self-care deficit Risk for aspiration
• Assess pt’s ability to swallow and chew food
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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, anaphylaxis
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GBS: Plasmaphoresis
Infection Hypovolemia
• VS changes
Low K+, Ca++ Temporary distal
extremity paresthesias• Add Ca++ gluconate to
exchange fluids
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Myasthenia Gravis
Patho• Autoimmune disease of the
neuromuscular junction cranial nerves, skeletal and
respiratory muscles
• Antibody attack on the acetylcholine receptors in muscle end plate membranes
Nerve impulses not transmitted to muscle
• Remissions and exacerbations
Causes• Unknown • Overgrowth of thymus gland
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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
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Cholinesterase Inhibiting Drugs
Pyridostigmine (Mestinon)• First line management
Mechanism• Enhance neuromuscular impulse transmission by
preventing decrease of Ach by ChE• Increases response of muscles to nerve impulses-
improves muscle strength Nursing considerations
• Take w/food• 1 hour before meals to prevent aspiration
Side effects• Cholinergic crisis
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Myasthenic Crisis Cholinergic Crisis
Assessment• HR/BP/RR incr.• B/B incontinence• Decreased u/o• Cyanosis
Management• Assess resp status
closely• Monitor VS closely• Hold CHI drugs
Assessment• Hypotension• N-V-D• Abd cramps• Facial twitching
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Myasthenia Gravis: Diagnostic Tests
AChR antibodies• 80-90% present
Thyroid function tests• 5% thyrotoxicosis
Tensilon testing • Improvement after administration
EMG
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MG: Pharmacologic Treatment
Cholinesterase inhibitors• Pyridostigmine (Mestinon)• Cholinergic crisis
Immunosupression• Prednisone• Chemotherapy
Imuran/Cytotoxan
Plasmaphoresis • 6 exchanges over 2 weeks
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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