Chapter 47

1. Chapter 47 Interventions for Clients with Problems of the Peripheral Nervous System

2. 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 Elsevier items and derived items © 2006 by Elsevier Inc.

3. 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) Elsevier items and derived items © 2006 by Elsevier Inc.

4. Clinical Manifestations (Continued) • Weakness and paresthesia begin in the lower extremities and progress upward toward the trunk, arms, and cranial nerves in ascending GBS. Elsevier items and derived items © 2006 by Elsevier Inc.

5. Ineffective Breathing Pattern Interventions • Priority: maintain adequate respiratory function; implement interdisciplinary actions • Airway management: • Elevate head of bed at least 45 degrees • Suction (Continued) Elsevier items and derived items © 2006 by Elsevier Inc.

6. 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 Elsevier items and derived items © 2006 by Elsevier Inc.

7. 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 Elsevier items and derived items © 2006 by Elsevier Inc.

8. Drug Therapy • Plasmapheresis or IV immunoglobulin • Plasma exchange • IV immunoglobulin • No corticosteroids Elsevier items and derived items © 2006 by Elsevier Inc.

9. 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. Elsevier items and derived items © 2006 by Elsevier Inc.

10. 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) Elsevier items and derived items © 2006 by Elsevier Inc.

11. 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) Elsevier items and derived items © 2006 by Elsevier Inc.

12. 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 Elsevier items and derived items © 2006 by Elsevier Inc.

13. 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. Elsevier items and derived items © 2006 by Elsevier Inc.

14. 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. Elsevier items and derived items © 2006 by Elsevier Inc.

15. 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) Elsevier items and derived items © 2006 by Elsevier Inc.

16. 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 Elsevier items and derived items © 2006 by Elsevier Inc.

17. 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) Elsevier items and derived items © 2006 by Elsevier Inc.

18. Tensilon Testing (Continued) • Myasthenic crisis is due to undermedication. • Atropine sulfate is the antidote for Tensilon complications. Elsevier items and derived items © 2006 by Elsevier Inc.

19. Diet Therapy and Interventions • Cholinesterase-inhibitor drugs • Immunosuppressants • Corticosteroids for immunosuppression • Plasmapheresis (Continued) Elsevier items and derived items © 2006 by Elsevier Inc.

20. Diet Therapy and Interventions (Continued) • Respiratory support • Nonsurgical management • Assistance with activities and communication Elsevier items and derived items © 2006 by Elsevier Inc.

21. 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. Elsevier items and derived items © 2006 by Elsevier Inc.

22. 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 Elsevier items and derived items © 2006 by Elsevier Inc.

23. 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. Elsevier items and derived items © 2006 by Elsevier Inc.

24. 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. Elsevier items and derived items © 2006 by Elsevier Inc.

25. Management • Immunosuppression • Plasmapheresis • Respiratory support • Promoting self-care guidelines • Assisting with communication • Nutritional support • Eye protection • Surgical management usually involving thymectomy Elsevier items and derived items © 2006 by Elsevier Inc.

26. 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. Elsevier items and derived items © 2006 by Elsevier Inc.

27. 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 Elsevier items and derived items © 2006 by Elsevier Inc.

28. 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 Elsevier items and derived items © 2006 by Elsevier Inc.

29. 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 Elsevier items and derived items © 2006 by Elsevier Inc.

30. 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 Elsevier items and derived items © 2006 by Elsevier Inc.

31. 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 Elsevier items and derived items © 2006 by Elsevier Inc.