Chronic Neuro Disorders

what happens in multiple sclerosis?

an autoimmune disorder that attacks the myelin sheath (protective covering of nerve fibers) in the CNS, leading to communication problems between the brain and the body.

When does MS usually manifest?

Typically between ages 20 and 40 (women more at risk)

How is MS dx?

dx is a combination of:

clinical examination

MRI

Evoked potential studies [EPS]

Lumbar puncture to examine CSF

What are the 4 types of MS?

Relapsing-Remitting

Primary Progressive

Secondary Progressive

Progressive-Relapsing

What are primary most seen MS symptoms?

fatigue (most common) typically worse in the afternoon

uniltateral visual loss — w/ orbital pain that increases with movement “acute optic neuritis”

visual disturbances — blurry vision, dipopia, decreased visual acuity

muscle weakness

limb weakness — typically legs and arms, spasticity, numbness, and tingling

ataxia

dysarthria

nystagmus

intention tremor

muscle spascity — everywhere and very very painful

bladder dysfunction — urinary urgency, frequency, nocturia, urge incontience

Multiplie Sclerosis — Secondary Complications

UTI

Constipation

Contractures

Dependent edema

Pneumonia

Situational/Reactive Depression

Decreased bone density — bc of steroids, osteoporosis, immobility

In pts w/ MS what can a febrile, infection cause?

“MS HUG” dysesthesia → common, often paonful

Multiple Sclerosis — symptom management
faitgue

try to push through fatigue with rest breaks, engage in regular exercise, and utilize proper sleep hygiene to improve overall energy levels.

meds → (if it interferes w/ADLs) may be tx w/ amantadine, pemoline, or fluoxetine

Multiple Sclerosis — symptom management

msucle spasms

med → baclofen, administered orally or intrathecal injection (delivers medication directly into CSF)

benzo, tizanidine, and dantrolene

** pts w/ disabling spasms and contractures may require nerve blocks or surgical interventions

Multiple Sclerosis — symptom management

ataxia

working w/ PT,

use walker, other assistive devices

have pt look down at feet w/ a wide stance to help w/ balance (only in the beginning) → this is a temporary compensation strategy, not a long-term fix

chronic problem — most resistant to tx

Meds: beta-blockers, antiseizure, benzos

Multiple Sclerosis — symptom management

B&B problems

Meds:

• Anticholinergics → ↓ bladder spasms

• Alpha-adrenergic blockers → help urine flow

• Antispasmodics

Non-drug:

• Bladder training / scheduled voiding

• Self-catheterization

• Constipation: fluids + mobility

Multiple Sclerosis — symptom management

UTI Prevention

Ascorbic acid (Vitamin C) → makes urine acidic → ↓ bacteria

Antibiotics if infection occurs

Multiple Sclerosis — symptom management

Dysphagia & Dysarthria (Swallowing/Speech Issues)

Risk: aspiration

Nursing care:

• Sit upright when eating

• Pureed foods + thickened liquids

• Suction if needed

• Referral: speech therapy

Multiple Sclerosis — symptom management

Vision Problems

• See eye doctor

• Eye patch (alternate eyes) → helps with double vision

Multiple Sclerosis — symptom management

Depression/Mental health

Encourage pt to talk to someone

watch for self harm

What is MG and what does it affect?

autoimmune disorder;

the neuromuscular junction

Initial manifestations of MG

includes ocular muscles:

diplopia

ptosis (drooping eyelids) — longer the day goes in, they become more droopy EARLY MANIFESTATION

blurred vision

bland facial expression from weakened facial muscles

generalized weakness

other symptoms pts experience w/ MG

• weakness of the muscles of the face and throat

(bulbar symptoms →

slurred speech (dysarthria),

swallowing difficulties (dysphagia),

choking,

weakened cough,

and tongue atrophy/fasciculations)

• Laryngeal involvement produces dysphonia (voice impairment) & increases pt’d risk for choking & aspiration

What is the hallmark symptom of MG

fluctuating muscle weakness, which intensifies w/ activity such as exercise, and improves w/ rest

How is MG dx?

An acetylcholinestrase test.

Edrophonium chloride is given, if there is immediate improvement in muscle strength after admin of this agent = positive test &confirms dx

other tests that help doctors dx MG

ice pack test

blood test (check for antibodies)

nerve test

thymus gland check (enlarged or abnormal in pts w/ MG)

MG pharm tx

Pyridostigmine Bromide (anticholinesterase medication) FIRST LINE THERAPY

Corticosteroids

Aziathioprine

Plamapherisis (plasma exchange)

Immunoglobulin therapy (IVIG)

Thymectomy (surgical removal of thymus gland)

Nursing management MG

pt and family teaching

aspiration prevention

double vision

prevention of corneal abrasion

avoidance of triggers for exacerbation of symptoms

conservation of energy

2 complications of MG

cholinergic crisis

myasthenic crisis

What is Cholinergic crisis?

A problem w/ over medication!

results in → severe generalized muscle weakness, respiratory impairment, & excessive pulmonary secretions that may result in resp. failure

Cholinergic crisis tx

admin anticholinergics (atropine)

Cholinergic crisis s/s

1. Decreased BP

2. Abdominal cramos

3. N/V, diarrhea

4. blurred vision

5. pallor

6. facial muscle twitching

7. constriction of pupils

8. Tensilon (edrophonium test) has no effect

9. Symptoms improve w/ atropine

What is myasthenic crisis?

a problem of under-medication!

sudden, temporary exacerbation of MG symptoms

Common precipitating event for myasthenic crisis?

infection

myasthenic crisis tx

may need mechanical ventilation

temp improvement of symptoms w/ admin of Tensilon

myasthenic crisis s/s

1. Bowel and bladder incontinence

2. Decreased urine output

3. absent cough and swallow reflex

4. Increased HR/RR/BP

What is Guilain-Barre Syndrome?

autoimmune attack on the peripheral nerve myelin

(can regenerate but recovery may take up to 2 years)

What are antecedent events that cause GBS?

Viral infections such as:

1. Campylobacter jejuni

2. cytomegalovirus

3. Epstein-Barr Virus

4. mycoplasma pneymoniae

5. H. influenzae

6. HIV

GBS s/s

Muscle weakness and diminished reflexes of the lower extremities

• Acute symmetric ascending weakness of limbs

• Muscle weakness bilaterally ascending (major neurologic sign) & sensory loss, usually in the legs (spreads to arms)

• Diff. talking, chewing, and swallowing

• Paralysis of the ocular, facial, and oropharyngeal muscles

• Diminished or absent deep tendon reflexes

• tachycardia, bradycardia

• facial flushing

• urinary retention or difficulty w/ bowel and bladder function

• Poor inspiratory effort, diminished breath sounds

What are the most concerning symptoms of GBS?

Respiratory function is the main concern

** we will intubate sooner than later

GBS medical and nursing management

1. Elective intubation

2. DVT prophylaxsis

3. Skin care

4. Plasmaphersis / IVIG

5. EKG/Vital signs (worry about tachycardia, hypotension)

6. Mobility

7. Nutrition (NG tube or gastrostomy tube)

8. Fear and anxiety

GBS complications

Respiratory failure

What is Amyotrophic lateral sclerosis?

A progressive neurodegenerative disease affecting both upper and lower motor neurons

ALS clinical manifestations

1. fatigue and limb weakness CHIEF SYMPTOMS

2. gradual onset of asymmetrical, progressive weakness

3. spasticity usually is present, and the deep tendon stretch reflexes become brisk and overreactive

4. still have control of bladder and bowels

*these pts pass away from respiratory distress/failure (5 yrs to live)

How is ALS dx?

on the basis of s/s

electromyogram (EMG) will show fibrillations that are signs of motor neuron damage

MRI scan may show high spinal intensity in the corticospinal tracts and rule out other conditions

What is the focus of management of ALS?

quality of life