Nursing Care & Intervention for the Client with Chronic Neurological Disease

1. Nursing Care & Intervention for the Client with Chronic Neurological Disease Keith Rischer RN, MA, CEN

2. 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.

3. Multiple Sclerosis • Patho • Autoimmune disease of myelin sheath • T cells • Inflammatory response • Destroys myelin sheath in patches • Demyelination of nerve fibers

4. MS: Classifications Relapsing-remitting most common 85% of cases Attacks that become increasingly frequent 1-2 weeks relapse 4-8 months to resolve Exacerbations (acute attacks) occurs with either full recovery or partial recovery with disability

5. 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

6. MS: Assessment • Brain lesions lead to CNS signs: • Emotional lability – euphoria or depression • Irritability • Changes in vision and coordination • Slurred speech • Ataxia • Diplopia • Nystagmus

7. 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

8. MS: Pharmacologic Management • Corticosteroids • Prednisone • Solu-medrol (Methylprednisolone) • Acute exacerbations • Immunosuppressive • Antispasmodics • Valium • Adjunctive • Paresthesias • Tegretol or Amitriptyline

9. 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 Thrombocytopenia Leukopenia Depression injection site reactions

10. MS: Nursing Diagnostic Priorities Fatigue Impaired physical mobility ROM-strengthening exercises Encourage ADL’s but not to excess Urinary Retention Self cath Prevention of UTI Constipation

11. MS: Nursing Diagnostic Priorities • Disturbed Sensory Perception: Visual • Cognitive problems • Re-orient • Speech/swallowing eval • Deficient knowledge • Medications • Bowel/bladder programs • Avoid exacerbations • Importance of rest • Stress reduction • Extremes of temperature

12. 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

13. 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

14. ALS: Interventions • Rilutek • Extends survival time only • Speech therapy • Communication • Swallowing eval • Dietician • Enteral feedings • Hospice • End of life…living will

15. 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.”

16. 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

17. 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

18. GBS: Assessment of Descending Weakness of facial muscles/jaw Ophthalmoplegia Paralysis/weakness of eye muscles Diplopia Dysphagia Difficulty speaking Respiratory compromise

19. 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

20. 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

21. 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

22. GBS: Plasmaphoresis • Infection • Hypovolemia • VS changes • Low K+, Ca++ • Temporary distal extremity paresthesias • Add Ca++ gluconate to exchange fluids

23. 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

24. 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

25. 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

26. 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 Myasthenic Crisis Cholinergic Crisis

27. Myasthenia Gravis: Diagnostic Tests AChR antibodies 80-90% present Thyroid function tests 5% thyrotoxicosis Tensilon testing Improvement after administration EMG

28. MG: Pharmacologic Treatment • Cholinesterase inhibitors • Pyridostigmine (Mestinon) • Cholinergic crisis • Immunosupression • Prednisone • Chemotherapy • Imuran/Cytotoxan • Plasmaphoresis • 6 exchanges over 2 weeks

29. 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