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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