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.A man whose age of onset is between 60 and 70 years B.A woman whose age of onset is between 20 and 30 years C.A man whose age of onset is between 40 and 50 years D.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? A.Pallor B.Decreased pulses C.Tingling sensation D.Coolness of the extremity

25. Question 3 The effects of chemotherapy-induced peripheral neuropathy are expected to be: A.Temporary and short-lived B.Dose-limiting and may cause permanent disability C.Controlled with steroids such as prednisone D.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? A.Diabetes and renal failure B.Peripheral vascular disease and multiple sclerosis C.Myasthenia gravis and decreased vision D.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? A.III B.V C.VII D.VIII