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Chapter 47 Interventions for Clients with Problems of the Peripheral Nervous System Guillain-Barr é Syndrome An acute autoimmune disorder characterized by varying degrees of motor weakness and paralysis

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Chapter 47

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Chapter 47

Interventions for Clients with Problems of the Peripheral Nervous System


Guillain-Barré Syndrome

  • An acute autoimmune disorder characterized by varying degrees of motor weakness and paralysis

  • The client’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.

    (Continued)

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Clinical Manifestations (Continued)

  • 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

      (Continued)

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Ineffective Breathing Pattern Interventions(Continued)

  • 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

  • Client placed on cardiac monitor because of the risk for arrhythmias

  • Hypertension treated with beta blocker or nitroprusside

  • IV fluids for hypotension; client 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 client without the plasma.

  • Plasma usually replaces itself, or the client 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, anddistraction (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.

      (Continued)

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Impaired Physical Mobility and Self-Care Deficit(Continued)

  • 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 client.

    • 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 client to verbalize feelings about the illness and its effects.

    • Examine patterns of decision-making, roles and responsibilities, and usual coping mechanisms.

    • Refer client 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

    (Continued)

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Myasthenia Gravis (Continued)

  • 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 clients show marked improvement in muscle tone that lasts 4 to 5 minutes.

  • Prostigmin is also used.

  • Cholinergic crisis is due to overmedication.

    (Continued)

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Tensilon Testing (Continued)

  • 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

    (Continued)

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Diet Therapy and Interventions (Continued)

  • 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) drugs

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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 client 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 clients

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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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