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Nursing Care of Patients with Peripheral Nervous System Disorders . Rita Carey-Nita . Neuromuscular Disorders . Neuromuscular Disorders involve a disruption of the transmission of impulses between neurons and the muscles they innervate They include: Multiple Sclerosis Myasthenia Gravis

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Nursing Care of Patients with Peripheral Nervous System Disorders

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Nursing care of patients with peripheral nervous system disorders

Nursing Care of Patients with Peripheral Nervous System Disorders

Rita Carey-Nita


Neuromuscular disorders

Neuromuscular Disorders

Neuromuscular Disorders involve a disruption of the transmission of impulses between neurons and the muscles they innervate

They include:

  • Multiple Sclerosis

  • Myasthenia Gravis

  • Amyotrophic Lateral Sclerosis


Multiple sclerosis

Multiple Sclerosis

Pathophysiology

  • MS is a chronic progressive degenerative disease that affects the myelin sheath of the neurons in the CNS

  • The myelin sheath begins to break down as a result of the activation of the immune system

  • The nerve becomes inflamed and edematous

  • Nerve impulse slows

  • With progression of disease scarring or sclerosis of nerve occurs

  • Nerve impulse become blocked causing permanent muscle function loss


Etiology

Etiology

  • Unknown

    May be:

  • Autoimmune process

  • May be result of viral infection

  • Hereditary

  • Environmental triggers

    Onset is usually between 20-50 years old

    Women twice as often than men

    May be mild or may be permanently debilitating


Etiology1

Etiology

Symptoms may begin slowly over long period of time or suddenly & progressive faster

Characterized by remissions and exacerbations

Triggers

  • Extreme heat or cold

  • Fatigue

  • Infection

  • Physical or emotional stress

  • Hormonal changes as in pregnancy


Signs symptoms

Signs & Symptoms

  • Muscle weakness/paralysis of limbs, trunk or dead

  • Ataxia

    • Results in falls & accidents

  • Tingling sensation

  • Numbness

  • forgetfulness/difficulty concentrating

  • Visual disturbances

    • One eye at a time

    • May have pain on eye movement

    • Diplopia

    • Blurred vision

    • Patchy blindness


Signs symptoms1

Signs & Symptoms

  • Fatigue

  • Muscle spasticity

  • Bowel or bladder dysfunction

  • Dysarthria

  • Dizziness/vertigo

  • Impaired hearing

    • Tinnitus

  • Constipation

  • Spastic bladder

  • Sexual dysfunction

  • Anger—depression—euphoria


Diagnostic tests

Diagnostic Tests

  • History and Physical

  • Signs & Symptoms

  • CSF fluid may show increase in oligoclonalimmunoglobin G

  • MRI shows sclerotic plaques


Therapeutic interventions

Therapeutic Interventions

  • No cure

  • Interferon treatment reduces exacerbations

    • Betaseron—Avonex

  • Steroids decrease inflammation and edema of neuron

    • Adrenocorticotropic—prednisone—corticotropics

  • Immunosuppresant depress immune response

    • Imuran—Cytoxan

  • Anticonvulsants decrease neuropathic pain

    • Dilantin—Tegretol

  • Parasympathetic agents help with bladder issues

    • Urecholine—Ditropan

  • Muscle spasm may be controlled with

    • Valium—Liorseal—Zanaflex

  • Fatigue is treated with antidepressants or Symmetrel (antiviral)


Therapeutic interventions1

Therapeutic Interventions

  • Rehabilitation

    • PT

    • OT

    • ST

  • Plasmaphersis

    • Removes plasma portion of whole blood and replaces it with fresh plasma

    • Removes antibodies that may be attacking the myelin sheath

    • Hope is to suppress the immune response and inflammtion


Nursing interventions

Nursing Interventions

  • Teach to avoid triggers that can cause exacerbation

  • Rest—exercise—stress reduction or avoidance—balanced diet

  • Monitor airway due to muscle weakness

    • Resp rate—depth—oxygen saturation—cough & deep breathe—suction

  • Monitor for dysphagia

    • HOB elevated—monitor cough & gag reflex—ST—swallowing precautions—soft diet—thickened liquids

  • Mobility

    • AROM & PROM—PT—OT—reposition frequently if immobile


  • Myasthenia gravis

    Myasthenia Gravis

    • Myasthenia Gravis is weakness of the voluntary muscles of the body

    • Disease of the neuromuscular junction

    • The neuron release the neurotransmitter acetycholine across the synaptic cleft which cause muscle contraction

    • With MG antibodies attack and destroy acetycholine receptors sites at the neuromuscular junction

    • Result is inability to stimulate muscle contraction and therefore loss of voluntary muscle strength


    Signs symptoms2

    Signs & Symptoms

    • Progressive extreme weakness

      • Hallmark sign—increase weakness with activity with improved strength with rest

    • Affects eye and eyelid movement

      • Ptosis

    • Chewing

    • Swallowing

    • Breathing

    • Masklike expression

    • Voice fades with long conversation


    Nursing care of patients with peripheral nervous system disorders

    • Exacerbations & Remissions

    • Triggers

      • Emotional & physical stress

      • Pregnancy

      • Illness

      • Trauma

      • Extreme temperatures

      • Surgery

      • Medications that block action at neuromuscular junction

      • Electrolyte imbalance


    Complications

    Complications

    • Aspiration

    • Respiratory infection

    • Respiratory failure

    • Mysathnic crisis

      • Not enough medication

      • Results in

        • Ptosis—dysphagia—dysarthria—dyspnea—weakness

    • Cholinergic crisis

      • Overmedication with anticholinesterase

      • Results in

        • Increased muscle weakness—dyspnea—nausea & vomiting—salivation—abd cramping—sweating—increased bronchial secretions—miosis


    Diagnostic test

    Diagnostic Test

    • Diagnosis based on history & physical

    • Patient looks up for 2-3 minutes—ptosis will occur with MG

      • With rest eyelids open without difficulty

    • IV Tensilon given—if muscle strength improves dramatically MG diagnosed

    • EMG to rule out other causes of symptoms

    • PFT’s to determine to predict myasthenic crisis leading to respiratory failure


    Therapeutic intervention

    Therapeutic Intervention

    • No Cure

    • Treatment aimed at control symptoms

    • Thymectomy to decrease the production of Ach receptor antibodies and decrease symptoms

    • Anticholinesterase drugs destroys acetycholinesterase that breaks down ACh allowing for ACh to attach to muscles causing contraction therefore strength increases

      • Prostigmin—Mestinon

    • Steroids suppress immune response

      • Prednisone—Prednisolone

    • Plasmapheresis to remove antibodies from plasma


    Nursing care

    Nursing Care

    • Monitor & teach patient signs of

      • Myasthenic crisis

      • Cholinergic crisis

    • Schedule anticholinesterase medication to peak during times of most activity

    • Teach

      • patient importance of well balance diet

      • How to conserve energy with daily activities

      • Avoidance of persons with infections

      • Teach patient to avoid medications that will exacerbate weakness

        • Beta-blockers—calcium channel blockers—quinine—quinidine—procainamide—D penicillamine—alpha-interferon—botulinum toxin—neuromuscular blocking agents


    Amyotrophic lateral sclerosis

    Amyotrophic Lateral Sclerosis

    ALS also called Lou Gehrig’s disease

    • Progressive degenerative neuromuscular condition

    • Affects motor neurons responsible for voluntary muscles

    • Upper and lower motor neurons begin to degenerate and form scar tissue or die blocking nerve impulses from brain and spinal cord

    • Muscle tissue atrophy occurs decreasing muscle strength and coordination

    • With progression more muscle groups are affected

    • Unable to breathe and swallow

    • Cognitive function remains unaffected


    Etiology2

    Etiology

    • Occurs at any age

    • No known cause

    • Genetic tendency in some cases

    • Onset between 40-70 years

    • More often in men than women


    Signs symptoms3

    Signs & Symptoms

    • Progressive muscle weakness leads to complete immobility

    • Decreased coordination of arms—legs—trunk

    • Atrophy of muscles

    • Fasciculations

    • Muscle spasms that cause pain

    • Difficulty chewing & dysphagia lead to aspiration

    • Inappropriate emotional outbursts

    • Dysarthria—progresses to complete inability to speak

    • Constipation

    • Urinary urgency—hesitancy—frequency


    Complications1

    Complications

    • Malnutrition

    • Falls

    • PE

    • CHF

    • Death related to respiratory complications

      • Atelectasis—pneumonia—respiratory failure—ventilator dependence

    • Death occurs within 3-5 years of diagnosis usually due to respiratory failure

    • Only 10% live 10 years or more


    Diagnostic tests1

    Diagnostic Tests

    • CSF analysis

    • EEG

    • EMG

    • Blood enzymes increase with muscle atrophy


    Therapeutic interventions2

    Therapeutic Interventions

    • Maintain function

    • Emotional support to patient & family

    • Baclofen—Diazepam for muscle spasms

    • Quinine for muscle cramps

    • Riluzole to reduce damage to motor neurons & prolong life

    • PT—OT

    • ST

      • AAC such as laptop computer

    • Massage

    • Position change & skin care

    • Enteral feedings

    • Prevention of infection

    • Support Groups

    • Counseling


    Guillain barre syndrome

    Guillain-Barre Syndrome

    GBS is also called acute inflammatory polyneuropathy

    • Inflammatory disorder characterized by abrupt onset of symmetrical paresis that progress to paralysis

    • Destruction of myelin sheath of spinal and cranial nerves occurs due to the diffuse inflammatory reaction

    • Peripheral nerves are infiltrated with lymphocytes leading to edema and inflammation

    • Segmental demyelination cause axonal atrophy slowing or blocking nerve conduction

    • Begins distal and ascends manner

    • Remyelination slowly occurs in a descending manner with resolution of symptoms


    Guillain barre syndrome1

    Guillain-Barre Syndrome

    • Ascending GBS

      • Progressive weakness and numbness beginning in legs and ascending up the body

      • Numbness mild but muscle weakness leads to paralysis

      • Ascends all the way to cranial nerves

      • Deep tendon reflexes depressed or absent

      • Respiratory function impaired 50% of time

    • Descending GBS

      • Less common

      • Affects cranial nerves that originate in brain stem

      • Dysarthria

      • Dysphagia

      • Respiratory function impairment rapid

      • Numbness more in hands than feet

      • Diminshed or absent reflexes


    Guillain barre syndrome2

    Guillain-Barre Syndrome

    • Miller Fisher syndrome

      • Rare

      • No respiratory compromise or sensory loss

      • Profound ataxia

      • Absence of reflexes

      • Paralysis of extraocular muscles

    • Pure motor GBS

      • Milder form

      • Mimics ascending GBS

      • Does not have numbness or paresthesias


    Etiology3

    Etiology

    • Exact cause unknown

    • Possible autoimmune response to viral infection or vaccination

    • Viral illness noted within 2 weeks prior to onset of symptoms

    • Usually occurs between 20-50 years old

      • 45 or older more often

    • Affects men and women equally

    • 50% higher incidence in Caucasians than African Americans


    Signs symptoms4

    Signs & Symptoms

    Three stages

    • Stage One

      • Start with onset of symptoms and lasts until progression stops

      • 24 hours to 3 weeks

      • Abrupt onset of muscle weakness and paralysis

      • Little or no muscle atrophy

      • Recent history of viral illness or vaccination

      • Extent of respiratory impairment is dependent on type of GBS

        • May require intubation and mechanical ventilation

      • Labile blood pressure—cardiac dysrhythmias—urinary retention—paralytic ileus—numbness—cramping—pain


    Guillain barre syndrome3

    Guillain-Barre Syndrome

    • Stage two

      • Symptoms most severe but progression has stopped

      • 2-14 days

    • Stage three

      • Recovery stage

      • Axonal regeneration and remyelination occurs

      • 6 – 24 months

      • Symptoms improve slowly

      • Takes months to a year to recover

    • Few patients suffer chronic disability


    Complications2

    Complications

    • Respiratory Failure

    • Infection

    • Depression

    • Pneumonia

    • UTI

    • Complications of immobility

      • PE—DVT—Impaired skin intergrity—muscle atrophy


    Diagnostic tests2

    Diagnostic Tests

    • Lumbar puncture to obtain CSF

      • Elevated protein

    • EMG

    • Nerve Conduction Velocity tests

    • PFT’s


    Therapeutic interventions3

    Therapeutic Interventions

    First stage

    • Complete care

    • Oxygen & mechanical ventilation

    • Plasmapheresis within 7-14 days of onset

      Second phase—plateau phase

    • Emotional support

      Third phase—recovery phase

    • Intensive rehabilitation


    Nursing care1

    Nursing Care

    Supportive

    • Monitor respiratory function

    • Monitor swallowing

    • Pain management

    • Enteral feedings

    • Communication board

    • Diversional activity during recovery phase


    Patient education

    Patient Education

    • Explain all procedures

    • Disease process—sign & symptoms—recovery

    • Discuss need for intubation as respiratory function may be impaired


    Postpolio syndrome

    Postpolio Syndrome

    Postpolio Syndrome

    • Condition that affects survivors of polio 10-40 years after recovering from infection of poliomyelitis virus

    • Severity depends on degree of residual weakness and disability from initial illness


    Signs symptoms5

    Signs & Symptoms

    • Further weakness of muscles that were affected initially with polio virus

    • Fatigue to progressive weakness to atrophy

    • Sleeping difficulties

    • Joint pain

    • Scoliosis

    • Respiratory compromise

      Symptoms vary from mild to debilitating


    Postpolio syndrome1

    Postpolio Syndrome

    Diagnostic Tests

    • History and Physical Exam

      Therapeutic Interventions

    • None other than rest and moderate exercise


    Nursing care of patients with peripheral nervous system disorders

    • Review Table 50.4 Summary of PNS Disorders

    • Review Box 50.3 Nursing Care Plan for Patients with Progressive Neuromuscular Disorder


    Cranial nerve disorders

    Cranial Nerve Disorders


    Cranial nerve disorders1

    Cranial Nerve Disorders

    • There are 12 pairs of cranial nerves that originate in the brain

    • They innervate the head—neck—special sensory organs

    • Cranial nerve disorders are classified as peripheral neuropathies

    • Disorders affect sensory—motor—or both of a single nerve

    • Cause can be unknown or may include:

      • Tumors—infection—inflammation—trauma

    • Two common cranial nerve disorders are

      • Trigeminal neuralgia

      • Bell’s palsy


    Trigeminal neuralgia

    Trigeminal Neuralgia

    Trigeminal Neuralgia is also called tic douloureux

    • Affects 5th cranial nerve—trigeminal nerve

      • Has 3 branches that have both sensory & motor function

      • Innervates the forehead—nose—cheek—gums—jaw

    • TN only affects the sensory portion of nerve

    • Irritation or chronic compression of nerve initiates symptoms

    • Seen more often in women between 50-60 years old


    Trigeminal neuralgia1

    Trigeminal Neuralgia

    Signs & Symptoms

    • Intense recurring pain in the skin of one side of the face

      • Sudden jabbing, burning, knifelike pain

    • Onset begins & ends suddenly lasting a few seconds to minutes

    • Occurs in clusters that can be many times or few

    • Slight touch—cold breeze—talking—chewing are triggers

    • Trigger zones include:

      • Lips—upper & lower gums—cheeks—forehead—side of nose

    • Sleep provides relief

    • Frequent blinking and tearing of eye on affected side


    Trigeminal neuralgia2

    Trigeminal Neuralgia

    Therapeutic Intervention

    • Anticonvulsants reduce nerve impulses

      • Dilantin—Tegretol

    • Baclofen—clonazepam—gabapentin—valproic acid

      • Help control symptoms

      • May cause bone marrow suppression so need routine CBC

    • Nerve block with local anesthetic

      • 6-8 months relief

    • Surgery if all else fails

      • Radio frequency ablation to destroy some nerve branches

      • Results are anesthesia of area

    • Gamma Knife radiosurgery

      • Creates lesion on nerve which blocks pain signal


    Trigeminal neuralgia3

    Trigeminal Neuralgia

    Patient Education

    • Eye (cornea) on affected side needs to be protected from injury due to loss of sensation

      • Goggles—sunglasses—eye patch at night

      • Artificial tears


    Bell s palsy

    Bell’s Palsy

    Pathophysiology

    • Affects cranial nerve VII—facial nerve

    • Inflammation and edema of nerve causes interruption of nerve impulse

    • Loss of motor control on one side results

    • Contracture of facial muscle can occur if slow recovery

      Etiology

    • Nerve trauma by viral or bacterial infection

    • May be autoimmune

    • Affects men and women equally

    • Affects all ages

    • Any time of year

    • More common in:

      • 3rd trimester of pregnancy—immunocompromised—diabetics


    Bell s palsy1

    Bell’s Palsy

    Signs & Symptoms

    • Onset abrupt & progresses over 2-5 days

    • Pain behind ear may precede onset of facial paralysis

    • Dry eye

    • Tingling around lips

    • Inability to close eyelid—wrinkle forehead—smile—close lip

    • Mouth pulled to unaffected side

    • Drooling on affected side

    • Constant tearing of affected eye

    • Loss of taste on anterior 2/3 of tongue

    • Dysarthria

    • Severity of paralysis peaks within several days of onset


    Bell s palsy2

    Bell’s Palsy

    Diagnostic Tests

    • 50 % of patients recover completely in short time

    • 35% within one year

    • History & Physical

      • Need to rule out CVA

        Therapeutic Interventions

    • Prevention of complications

      • Protect cornea eye on affected side

    • Prednisone for 7-10 days to decrease edema

    • Antiviral medication

    • Moist heat

    • Gentle massage

    • Facial sling


    Nursing care of patients with peripheral nervous system disorders

    • Review the Nursing Diagnosis on 1140

    • Review table 50.5 to summarize Cranial Nerve Disorders


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