Chapter 46

1. Chapter 46 Care of Patients with Problems of the Peripheral Nervous System Mrs. Marion Kreisel MSN, RN NU230 Adult Health 2 Fall 2011

2. Guillain-Barré Syndrome • Demyelination of the peripheral nerves, progressive motor weakness and sensory abnormalities • Ascending paralysis • Result of a variety of related immune-mediated pathologic processes

3. Clinical Manifestations • Muscle weakness and pain have abrupt onset; cause remains obscure. • Cerebral function or pupillary signs are not affected. • Cranial nerve involvement. • Autonomic dysfunction. • Weakness and paresthesia begin in the lower extremities and progress upward toward the trunk, arms, and cranial nerves in ascending GBS.

4. Interventions • Drug therapy • Plasmapheresis • Monitoring respiratory status and managing the airway • Managing cardiac dysfunction • Improving mobility and preventing complications of immobility • Managing pain • Promoting communication • Providing emotional support

5. 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 patient without the plasma. • Plasma usually replaces itself, or the patient is transfused with albumin.

6. 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 • 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

7. Tensilon Testing • Within 30 to 60 sec after injection of Tensilon, most myasthenic patients show marked improvement in muscle tone that lasts 4 to 5 minutes. • Prostigmin is also used. • Cholinergic crisis is due to overmedication. • Myasthenic crisis is due to undermedication. • Atropine sulfate is the antidote for Tensilon complications.

8. Nonsurgical Management • Respiratory support • Promoting mobility • Drug therapy: • Cholinesterase inhibitor drugs • Immunosuppression • Plasmapheresis

9. 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.

10. 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

11. 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.

12. Cholinergic Emergency Crisis • Anticholinergic drugs are withheld while the patient 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.

13. Management • Immunosuppression • Plasmapheresis • Respiratory support • Promoting self-care guidelines • Assisting with communication • Nutritional support • Eye protection • Surgical management usually involving thymectomy

14. 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, and emotional extremes. • Teach warning signs. • Teach importance of compliance.

15. 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

16. Peripheral Nerves

17. Peripheral Nerve Injury

18. 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 patients

19. 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 • Characterized by intermittent episodes of severe pain with sudden onset

20. Trigeminal Nerve

21. Facial Paralysis or Bell’s Palsy • Acute paralysis of seventh cranial nerve • Medical management—prednisone, analgesics, acyclovir • Protection of the eye • Nutrition • Massage; warm, moist heat; facial exercises • Pt education important: Usually symptoms disappear or get better within a few weeks

22. NCLEX TIME

23. Question 1 Who is the typical patient who develops myasthenia gravis? • A man whose age of onset is between 60 and 70 years • A woman whose age of onset is between 20 and 30 years • A man whose age of onset is between 40 and 50 years • A woman whose age of onset is between 40 and 50 years

24. Question 2 Which assessment variable is the best early indicator of compromised neurovascular function? • Pallor • Decreased pulses • Tingling sensation • Coolness of the extremity

25. Question 3 The effects of chemotherapy-induced peripheral neuropathy are expected to be: • Temporary and short-lived • Dose-limiting and may cause permanent disability • Controlled with steroids such as prednisone • Not dose-limiting but may cause temporary disability

26. Question 4 What conditions might the nurse expect to see in the patient with restless leg syndrome? • Diabetes and renal failure • Peripheral vascular disease and multiple sclerosis • Myasthenia gravis and decreased vision • Trigeminal neuralgia and facial paralysis

27. Question 5 A patient complains of eye dryness and acute pain of her face and behind her ear. The nurse should perform a focused assessment of which cranial nerve? • III • V • VII • VIII