Chapter 44 Flashcards
Guillain Barre syndrome
Affects axons and myelin of PNS
Causes motor weakness and abnormalities in sensory perception
Affects males 55 & older
Can cause demyelination of peripheral nerves
Begin in legs and spread to arms and upper body (ascending paralysis)
May require ventilation because of weak, paralyzed diaphragm
Healing occurs in reverse
Associated with bacterial- campylobacter
Viral- Epstein Barr, cytomegalovirus
Death caused by secondary problem
Assessment GBS
Decreased deep tendon reflexes Respiratory compromise Loss B&B Ataxia Paresthesias Pain worse at HS Facial weakness Dysphagia Diplopia Cardiac dysrthmia Tachycardia Clumsiness and falls Low BP Palpitations
Diagnostic GBS
LP- increased protein, may not occur for 1-2 weeks
EPS- demonstrate demyelinating neuropathy
CT- rule out other causes
ABG- pH decrease, paO2 decreased, paCO2 increased
Interventions
Respiratory care- maintain airway, aspiration precautions, ABGs
Pain management- worsens at night
Communication
Nutrition- caloric and protein intake goals, monitor prealbumin weekly, skin integrity
Schedule rest periods
Aspiration Precautions
Plasmapheresis
removes circulating antibodies responsible for disease, do within several days of onset, 3-4 treatments, wt before and after tx, care for shunt- assess 2-4 hrs, bulldog clamps at bed, observe for bleeding
IVIG
Infuse slowly
may cause chills, fever, myalgia, HA, anaphylaxis, aseptic meningitis, retinal necrosis, acute renal failure
Nursing safety priority for GBS
Initial phase- monitor for respiratory distress: dyspnea, air hunger, adventitious breath sounds, decreased o2 sat, cyanosis, RR, rhythm Q1-2H Vital capacity Q2-4H, auscultate lungs Monitor ability to cough and swallow Assess cognitive status
Myasthenia Gravis
Autoimmune characterized by muscle weakness
2/3 present with reports about vision
Present any age, higher in men, progressive disease
Caused by AChRs distorted
MG Assessment
Weakness may increase after vaccination, menstruation, and exposure to environmental temperatures Progressive muscle weakness Poor posture Ptosis Diplopia Dysphagia Loss B&B Fatigue Decreased smell and taste
Tensilon testing
Onset of muscle tone improvement within 30-60 seconds after injection of Tensilon
Lasts 4-5 minutes
Inhibits breakdown of ACh
Admin 2 mg followed by 8 mg if tolerated
Can cause dysrhythmias and cardiac arrest
Atropine sulfate is antidote
Critical Rescue with MG
Keep a bag valve mask setup equipment for oxygen administration, suction equipment at bedside in case is resp distress
Drugs for MG
Anticholinesterases and immunosuppressants
Give on time to maintain blood levels and improve muscle strength
Keep prescribed drugs and water at bedside
Wear a watch or alarm to remember
Post drug schedules
Keep secure supply
Managing MG
Immunosuppression Plasmapheresis Respiratory support Self care Assist communication Nutritional support Eye protection Thymectomy
Teaching MG
Exacerbations: infection, stress, surgery, hard exercise, sedatives, enemas
Avoid overheating, crowds, over eating, erratic changes in sleeping, emotional extremes
Teach warning signs
Peripheral Nerve Trauma
Associated with mechanical injury, vehicular crashes, sports, injection of drugs, military conflicts, violence
After a nerve gets damaged, the nerve distal to the injury degenerates and retracts within 24 hrs
