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Cholinergic Crisis cause: overmedication

Signs and symptoms: PNS, increased salivation risked for aspiration

Treatment: anticholinergic agents, atropine sulfate

2. Health teachings for energy conservation. To do this, the nurse can suggest that

frequently used items (i.e. hygiene products, cleaning products, snacks) be keep on

each floor to minimize travel between floors. Stress the need for frequent rest periods.

3. Prevention and management of complications such as aspiration. To minimize the

risk of aspiration, mealtimes should coincide with the peak effects of anticholinesterase

medication. Rest before meals is encouraged to reduce muscle fatigue. Sit upright

during meals, soft foods in gravy or sauces can be swallowed more easily.

4. Health education for strategies to help with ocular manifestations. To prevent corneal

damage when the eyelids do not close completely, the patient is instructed to tape the

eyes closed for short intervals and to regularly instill artificial tears.

5. Advise patients to wear a medical alert bracelet that identifies them as having MG

and to carry a card that has information regarding their medications and primary care

physician. Instruct them to call the doctor if weakness develops or facial or upper eyelid

drooping occurs, as it could herald an exacerbation of symptoms.

6. Suggest to patients that they wear sensible shoes to combat muscle fatigue and

potential loss of balance. Encourage them to eat regular, balanced meals to prevent

fatigue from lack of protein.

MULTIPLE SCLEROSIS

Multiple sclerosis (MS) or disseminated sclerosis is characterized by chronic

inflammation, dmyelination, and scarring (gliosis) of the myelin sheath of the central

nervous system (CNS). The manifestations of the disease vary from a benign disease toa rapidly progressive and disabling illness that has a profound effect on physical

function and quality of life.



There are four categories of Multiple Sclerosis based on clinical course:

• Relapsing-remitting MS (RRMS); 80% of all cases. It is characterized by

recurrent attacks of neurological dysfunction that evolve over days to weeks

ad may be followed by complete, partial, or no recovery; there is no

progression of symptoms between attacks; this pattern is often seen in the

early course of the disease and is the most common form seen.

• Secondary progressive MS. There is gradual neurological deterioration

with or without acute relapses, minor remissions, and plateaus in a patient

who previously had RRMS.

• Progressive-relapsing MS. From the onset, there is gradual progression

of disability; unlike RRMS, there is continuing disease progression without

stabilization of the disease.

• Primary progressive MS. A pattern of gradual neurological deterioration

from the onset of symptoms, but with superimposed relapses noted.

Etiology:

Predisposing factors:

• Age: The onset of MS is usually between 20-40 years old. Highest rate of

incidence is observed in these ages.

• Gender: Women are commonly affected twice the rate of men.

• Geographical Location: Prevalence rate increasing at higher latitudes; far from

equator such as Northern Europe, Norther USA, Canada, Canada, Atlantic & etc.

Low levels of Vitamin D is evidenced in these areas due to decrease sun

exposure. Prospective studies have confirmed that Vitamin D deficiency is

associated with increase in MS risk.

• Race: Whites are affected more frequently than any other racial group.



• Genetics: Evidence also supports an important genetic influence on MS. The

MHC on chromosome 6 is the strongest susceptibility region in the genome. One

of the definite genes identified is the (HLA)DR2 carriership, which is associated

with an increased risk for MS.

Predisposing Factors:

• Viral Infection: A virus or single infections can cause the condition.

• Immune Mechanism: The destruction in the CNS, including demyelination and

axonal loss involves the immune mechanism.

• Stress: Studies show that stress reduces the immune system of a person and

increases risk of having MS.

• Occupational Exposure: Exposure on toxins or free radicals, increases risk of

having MS due to decrease immune system.

Incidence:

An estimated 2,500,000 people in the world have multiple sclerosis. Research

suggests the proportion of women with MS is increasing and that roughly three women

have MS for every man with the condition.

The distribution of MS around the world is uneven. Generally, the prevalence

increases as you travel further north or south from the equator. Those parts of Asia,

Africa and America that lie on the equator have extremely low levels of MS, whilst

Canada and Scotland have particularly high rates.

Signs and Symptoms:

The signs and symptoms of MS vary greatly from patient to patient and can vary

over time in the same patient. The most common initial signs include fatigue,

nystagmus, vertigo, gait disturbances, sensory loss, lower extremity weakness,

spasticity, bladder disturbance, and optic neuritis. Other symptoms that may present at



any time during the course of the disease include cognitive changes such as euphoria

or depression, and physical conditions such as muscle cramping and sexual dysfunction

The symptoms of MS are listed in four categories: sensory, motor, cerebellar,

and miscellaneous.

Sensory:

- Numbness/ sensory loss

- Paresthesia

- pain

- Loss of proprioception

-Lhermitte’s sign (an electrical sensation that runs down the back when

bending the neck, are particularly characteristic of MS although not specific)

Motor:

- Paresis

- paralysis

- dragging of foot

-

spasticity (Muscle spasms are a common and often debilitating symptom of MS. Spasticity usually affects the muscles of the legs and arms, and may

interfere with a person’s ability to move those muscles freely)

- diplopia

- bladder and bowel dysfunction

Cerebellar Symptoms:

- ataxia

- loss of balance and coordination

- speech disturbances(dysarthria, dystonia, scanning of speech, slurred

speech)

- tremors (intentional tremors, described as tremors that increase when a

purposeful act is initiated)



- vertigo (sometimes accompanied by vomiting and nystagmus)

Other symptoms:

- fatigue

- optic neuritis

- impotence or decrease genital sensation and sexual dysfunction

- neurobehavioral disorders such as depression or euphoria

- 4% of patients experience paroxysmal attacks, visual loss, trigeminal

neuralgia, facial palsy

Pathophysiology:

This inflammation is caused by the T-cells which are cells that play a crucial role

in the body’s defences. In MS T-cells manage to infiltrate into the brain via the blood-

brain barrier, which is both a physical barrier and system of cellular transport. This

barrier is not normally accessible to T-cells, unless it is affected by a virus, which

reduces the strength of the junctions forming the barrier. T-cells remain then locked

inside the brain, wrongly perceiving myelin as an alien agent and attack it as if it were a

virus. This generates inflammatory processes and further damaging effects such as

swelling and activation of other immune cells and antibodies.

Complications:

In some cases, people with multiple sclerosis may also develop:

• Depression

• Difficulty swallowing

• Mental changes, such as forgetfulness or difficulties concentrating

• Paralysis, most typically in the legs

• Bladder and Urinary Dysfunction: Incontinence, or an involuntary loss of urine,

can also appear in MS patients, not necessarily due to the direct action of

multiple sclerosis but due to a combination of MS complications



• Sexual Dysfunction: Sexual problems in people with MS can result from a

multiple sclerosis attack on the part of the brain that controls sexual function or

the nerves that send impulses to the sex organs.

•

Osteoporosis or thinning of the bones (Because the condition also creates mobilityand spacticity problems, some people with MS are more prone to falling, which also

increases their chances of breaking a bone. )

• Pressure sores due to immobility

Diagnostic Exams:

• Comprehensive Medical History

• Neurological Exams

• Magnetic Resonance Imaging (MRI)

- to rule out other conditions

- Expected result for patients with MS: white matter lesions (plaques)

identified

- this is considered the best test for diagnosing MS

• Cerebrospinal fluid (CSF) Analysis

- may be used to help diagnose a wide variety of diseases and

conditions affecting the central nervous system (CNS)

- Uncovers signs of inflammation and myelin breakdown

- Expected Result: Elevated IgG index or synthesis rate and Presence of

Oligocional band (Oliogcional band are discrete electrophoretic bands

that are frequently found in the CSF of almost all [90-97%] of MS)

• Visual Evoked potentials (VEP)

- It may be used to help diagnose conditions affecting the central

nervous system (CNS)



- In this test, the doctor is looking for both size of the response and the

speed in which the brain receives the signal weaker or slow signals

may indicate the demyelination has occurred and that MS is a

possibility.

- Identifies lesions in sensory pathway; may help identify lesion not

easily visualized by MRI; for example, optic nerve

- Expected Result: Slowed Conduction

• Schumacher Criteria

- It is based on the neurologic history and examination. It includes the

following:

Neurological examination that reveals objective abnormalities attributable

to the CNS

White matter involvement

Two or more sites of CNS involvement

Relapsing-remitting or chronic (>6mos) progressive course each lasting 24

hours and at least 1 month apart, or a gradual or stepwise progression

over at least 6 months

Age at onset of 10-50 years old

No better explanation of symptoms

Medical Management:

Drug Therapy

Disease-Modifying Drugs- reduces the frequency of relapses and potentially

delay progression

Immunomodulator/ Interferons:- These medications are injected either subcutaneously or

intramuscular.

- Side Effects: flu-like symptoms, erythema to pain on injections site,

menstrual irregularities and nausea



Interferon beta-1b (Betaseron) - used to treat ambulatory patients with relapsing-

remitting MS and Secondary -progressive MS

Interferon beta 1a (Avonex) - treats relapsing forms of MS as well as initial MS

attack

Interferon beta 1a (Rebif) – treats relapsing forms of MS.

Immunomodulator:

Glatiramer acetate (Copaxone)

- treats relapsing-remitting forms

Antineoplastic/ Immunosuppressive

Mitoxantrone (Novatrone)

- Used to treat the secondary progressive, progressive-relapsing, and

worsening relapsing-remitting forms of MS

- It is administered intravenously every 3 months

- This blue color fluid may cause a bluish tinge in urine and in the whites

of the eyes

- Use of this drug for 2 and half years increases the risk of cardiac

toxicity.

Monoclonal Antibody

Natalizumab (Tysabri)

- It is given to patient in relapsing forms who have inadequate response

or who cannot tolerate other disease-modifying treatment.

Treatment of Selected symptoms of MS

CNS Stimulants

o Pemoline and Modafinil

-Treatment for fatigue

Genitourinary Antispasmodics

o Oxybutynin (Ditropan) and Tolterodine tartrate (Detrol)

- Treatment for bladder function

Skeletal Muscle Relaxant



o Oral or intrathecal baclofen

- Treatment for spasticity

Nursing Management:

1. Promote physical mobility

2. Prevent injury

3. Enhance bladder and bowel control

4. Enhance communication

5. Manage feeding difficulties

6. Provide emotional and psychological support for the patient and family.

7. Assess patient’s neurologic status for deficits.

8. Administer medications as needed.

9. Increase patient comfort with massages and relaxing baths.

10.Promote emotional stability. Help the patient establish a daily routine to maintain

optimal functioning.

11.Provide proper skin care as the patient is prone in decubitus ulcers as the

demyelination progresses.

12.Encourage adequate fluid intake and regular urination.

13.Teach the patient about bowel and bladder training if necessary.

The following may also be helpful for people with MS:

1) Physical therapy, speech therapy, occupational therapy, and support groups

2) Assistive devices, such as wheelchairs, bed lifts, shower chairs, walkers, and

wall bars

3) A planned exercise program early in the course of the disorder

4) A healthy lifestyle, with good nutrition and enough rest and relaxation

5) Avoiding fatigue, stress, temperature extremes, and illness

6) Changes in what you eat or drink if there are swallowing problems

7) Making changes around the home to prevent falls

8) Social workers or other counseling services to help you cope with the disorder

and get assistance (such as Meals-on-Wheels)



Nursing Diagnosis:

Impaired Physical Mobility r/t muscle weakness and ataxia

Determine the level of client activity and assess the weaknesses

Assist patient to ambulate and perform ADLs to provide assessment of

abilities

Facilitate transfer training by using appropriate assistance of persons or

devices when transferring patient to bed, chair or stretcher.

Encourage appropriate use of assistive devices in the home setting

Keep side rails up and bed in low position to promote a safe environment

Support affected body parts/joints using pillows/ rolls to maintain position

of function and reduce risk of pressure ulcers.

Use padding and positioning devices to prevent stress on tissues and

reduce potential for disuse complications.

Encourage and facilitate early ambulation and other ADLs when possible

Perform passive range of motion exercise to promote strength, mobility,

and proper circulation

Administer Antispasmodic medications (Baclofen) to reduce muscle

spasms or spasticity that interfere with mobility.

Risk for Injury r/t weakness, incoordination and sensory/ perceptual deficits

Ambulate patient to evaluate gait, ataxia and potential for falling

Raise the side rails to enhance safety and prevent from fall

Instruct to use mobility aids such as cane, walker or wheelchair to help

prevent injury, provide security and increase independent movement.

Turn/position patient frequently from side to side. To prevent acquiring bed

sore and promotes ventilation and circulation

Keep away sharp objects such as knife, needle from bedside to promote

safe physical environment and individual safety

Assist patient during ambulation

Constipation



Promote adequate fluid intake; 8 glasses/day or 2000 to 3000 ml/day.

Encourage increase fiber in diet (e.g., raw fruits, fresh vegetables) to

improve consistency of stool and facilitate passage through colon

Encourage activity or exercise within limits of individual’s ability to

stimulate contractions of the intestines.

Provide sitz bath after stools for soothing effect to rectal area.

Encourage patient to consume prunes, prune juice, cold cereal, and bean

products. These are “natural” cathartics because of their high-fiber

content.

Encourage a regular time for elimination.

Encourage isometric abdominal and gluteal exercises.

Restrict intake of caffeinated beverages, such as coffee, tea, colas or

energy drinks, if indicated. Diuretic effect of caffeine can reduce fluid

available in the bowel, thus increasing the risk of dry, hard-formed stool.

Self-Care Deficits

Establish rapport to the client.

Promote client participation in problem identification and decision making

Determine strengths and skills of individual

Provide for communication among those who are involved in caring for the

client to enhance coordination and continuity of care.

Assist with activities of daily living

Assist patient when removing or replacing clothing.

Maintain privacy during bathing.

Guillain-Barré Syndrome

Definition

Neuropathy is a general term indicating a disorder of the nervous

system. Peripheral neuropathy is the term for damage to nerves of the peripheral

nervous system. The most common form is (symmetrical) peripheral polyneuropathy,

which mainly affects the feet and legs.



In a polyneuropathy, many nerve cells in different parts of the body are

affected, without regard to the nerve through which they pass. Not all nerve cells are

affected in any particular case.

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