12.3 Autoimmune Neurologic Disorders Flashcards
Multiple Sclerosis
- Degenerative disorder of progressive demyelination of nerve fibers in the brain and spinal cord (CNS)
- The scars and plaques from demyelination is what causes symptoms of MS.
- Cause may be viral, immunologic or genetic, and may be precipitated by an infection, injury, or stress.
Types of MS
- Relapsing-Remitting (Relapses followed by recovery that increases with time)
- Primary Progressive (Acute attacks followed by remission)
- Secondary Progressive (Starts as relapsing-remitting then changes to primary progressive)
- Progressive-Relapsing (Steadily progressing disease with acute spikes (relapsing)).
Multiple Sclerosis Manifestations
- Depends on location of demyelination but leads to sensory, motor, cerebellar manifestations.
S/S
- Visual difficulties
- Weakness of extremities
- Spastic muscles/bladder
- Paresthesia in extremities
- Chronic neuropathic pain
- Ataxia (loss of coordination)
- Dysarthria (difficulty speaking)
- Dysphagia
- Fatigue
Lhermitte’s Sign - Transient sensory feeling of an electrical shock that runs down the spine into the limbs and occurs with neck flexion.
- Late MS can cause cognitive decline
MS Diagnostics
- CT/MRI/CSF/VEP
- Lesions and plaques may show up on MRI
- CSF will show high lymphocytes and monocytes.
- VEP shows slow transmission of nerve impulses.
Visual Evoked Potential (VEP)
- Measures electrical activity in the brain in response to hearing or vision. Detects the speed of impulses that pass through nerves and can also detect lesions.
- Can detect vision loss from optic nerve damage.
- Can also confirm things like brain tumors, acoustic neuroma (inner ear tumors) and spinal cord injuries.
MS Medical Management
Disease Modifying Therapy
- Interferon B
- Glatiramer acetate
- IV Methylprednisone
Symptom Management
- Manage muscle spasms, ataxia (poor muscle control), bowel/bladder control.
- Physical therapy to maintain strength and increase coordination. Also retrains unaffected muscles to compensate for affected ones.
- Speech therapy to help speech and swallow
- Nutrition (vitamins, raw food, gluten-free)
Medications
- Interferon Beta (lab made version of infection-fighting proteins made of living cells (biologics). Turns down signals in the body that trigger autoimmune responses that leads to MS)
- Glatiramer Acetate (lab made protein that protects against cells that damage myelin (protective layer of nerves. Makes relapses happen less often)
- Dimethyl Fumarate (blocks immune cells that damage nerves. It is also an antioxidant that helps protect the brain and spinal cord)
MS Nursing Care
Assessment
- Neurological deficits
- Secondary complications
- Impact of disease on social and emotional functions of life
- Patient/family coping
Example Diagnosis
- Risk for injury
- Impaired mobility, bowel/bladder function, verbal communication
- Disturbed thought process
- Ineffective coping
GOALS
- Avoid injury
- Promote mobility
- Bowel/bladder continence
- Speech/swallowing mechanisms
- Improved cognitive function
- Improved home maintenance
Interventions
- COLLABORATIVE APPROACH
- Refer to needed resources
- Avoid strenuous activities and fatigue, train muscles with stretching, coordination exercises
- Have a voiding schedule and bowel training program, adequate fluid/fiber to avoid constipation
- Strategies to reduce risk of aspiration
- Memory aides, daily routines to enhance cognitive function
- Avoid exposure to extreme heat or cold temperatures
Myasthenia Gravis (MG)
- Autoimmune disease where antibodies attack acetylcholine receptors at the neuromuscular junction preventing stimulus of muscle contraction.
Manifestations (Initial)
- Affects ocular muscles
(diplopia - double vision)
(ptosis - droopy eyelids)
Manifestations (Progression)
- HALLMARK (Fluctuating weakness and fatigue of skeletal muscles)
- Patients can become exhausted from chewing and swallowing
- Speaking fades with conversation
- Depressed rate and depth of breathing
Medical Management Myasthenia Gravis
- Improve function and remove circulating antibodies
Medications
- Cholinesterase inhibitors
- Immunosuppression
- Plasmapheresis (removing blood from body and taking out antibodies)
Other Support
- Respiratory support
- Self-care
- Communication
- Nutrition
- Eye protection
Surgery
- Thymectomy (removal of thymus)
Health Promotion
- Teaching about exacerbations such as infection, stress, surgery, physical exercise, sedatives, enemas, and strong cathartics (laxatives)
- Avoid overheating, crowds, erratic changes in sleeping habits, emotional extremes
- Teach of warning signs and importance of medication compliance
Myasthenic Crisis
- Results from disease most commonly respiratory infection
- SEVERE GENERALIZED WEAKNESS WITH RESPIRATORY AND BULBAR WEAKNESS
- Can cause respiratory failure
Management
- Educate signs and symptoms
- Ensure adequate ventilation, intubation, and mechanical ventilation
Nursing Care
- Airway/respiratory support
- ABG’s, electrolytes, I&O, daily weight
- Nasogastric feeding for patients who cannot swallow
- Avoid sedatives/tranquilizers
Cholinergic Crisis
- Caused by overmedication with cholinesterase inhibitors.
- SEVERE MUSCLE WEAKNESS WITH RESPIRATORY AND BULBAR WEAKNESS
- Patient can go into respiratory failure
Cholinesterase Inhibitors
- Prevent degeneration of acetylcholine by enhancing the action of acetylcholine released by cholinergic neurons.
- Intensifies transmission of all cholinergic junctions (muscarinic, ganglionic, neuromuscular)
Neostigmine (Prostigmin)
- Reversible cholinesterase inhibitor
- Treats myasthenia gravis
- Reverses nondepolarizing muscular blockades (pancuronium)
- Does not cross BBB
Adverse Effects
- Excessive muscarinic stimulation (RELIEVED WITH ATROPINE)
- Excessive salivation, increased gastric secretions, increase GI tone/motility, urinary urgency, bradycardia, sweating, miosis.
- CAN CAUSE RESPIRATORY DEPRESSION AND POLARIZING NEUROMUSCULAR BLOCKADE
Edrophonium (Tensilon)
- Inhibits breakdown of acetylcholine
- Used to diagnose myasthenia gravis
Adverse Effects
- Bronchospasm
- Excessive bronchial secretions
- GI problems
Pyridostigmine (Mestinon)
- Used for long term maintenance of myasthenia gravis
Amyotrophic Lateral Sclerosis (ALS)
- Lou Gehrig’s Disease
- Degenerative disorder that affects upper and lower motor neurons
- Loss of motor neurons in the anterior horn of spinal cord and loss of motor nuclei in the lower brain stem.
- SIGNALS FROM BRAIN DO NOT REACH BODY (cognitively intact trapped in their own body)
- No loss of sensory, intellectual, ocular mobility or parasympathetic neurons.
- Degenerative nerve fibers that connect neurons to skeletal muscle
ALS Manifestations
Initial
- Difficulty walking, tripping, stumbling
- Trouble preforming fine motor tasks
As the Disease Progresses
- Weakness and atrophy throughout muscles
- Difficulty eating and weight loss
- COGNITIVE FUNCTION REMAINS INTACT
Symptoms
- Painless muscle weakness/wasting
- Spasticity
- Twitching of limb and tongue
- Dysarthria (slurred speech)
- Dysphagia (difficulty swallowing)
- Dyspnea (difficulty breathing)
PRIORITY INTERVENTIONS
- Respiratory
- Swallowing
- Musculoskeletal
