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NUR 265 ADVANCED MED SURG > Unit 7 Chapter 38 Guillian Barre Syndrome , and Myasthenia Gravis > Flashcards

Unit 7 Chapter 38 Guillian Barre Syndrome , and Myasthenia Gravis Flashcards

1
Q

What is Gullian Barre Syndrome?

A

Guillain-Barré syndrome (GBS) is a rare acute inflammatory disorder that affects the axons and/or myelin of the PNS resulting in ascending muscle weakness or paralysis

Autoimmune disorder with acute attack of peripheral nerves, spinal nerve roots
and cranial nerves
* Immune system starts to destroy the myelin sheath that surrounds the axons
* Characterized by varying degrees of motor weakness and pathology

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2
Q

Where does Gullian Barre start?
A. feet
B. head

A

A. feet

Weakness starts at the legs and moves upwards

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3
Q

Are clients with Gullian Barre Fall risk?
A. Yes
B. No

A

A. Yes

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4
Q

What can cause Gullian Barre Syndrome?

A

RECENT VIRAL ILLNESS

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5
Q

A client has presented to the emergency department with sudden symmetrical weakness in both legs. On assessment, the client said they had the flu 2 weeks ago. What medical diagnosis would you suspect?
A. Amyotrophic Lateral Sclerosis
B. Trigeminal Neuralgia
C. Guillian Barre Syndrome
D. Myasthenia Gravis

A

C. Guillian Barre Syndrome

Viral infections usually occur 1-3 weeks prior or have taken the flu vaccine
sudden onset muscle weakness or paralysis

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6
Q

Which patient response requires further teaching for a patient diagnosed with Gullian Barre?
A. I should expect the medical treatment to include plasmapheresis which kills the bad
antibodies
B. Since I have Gullian Barre, to prevent it again I will get the flu vaccine every season.
C. This disease is not life long.
D. Treatment of this disease may take up to 2 years

A

B. Since I have Gullian Barre, to prevent it again I will get the flu vaccine every season.

After a client has gotten GB there may NEVER take the flu vaccine again.
(ALWAYS WEAR AMASK DUE TO NOT GETTING FLU SHOT**

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7
Q

S/S OF Gullian Barre Syndrome

A

Motor–sudden onset of ascending bilateral symmetric muscle
weakness to flaccid paralysis
Decrease deep tendon reflexes,
respiratory compromise,
**loss of bowel & bladder control &
ataxia: uncordinated movements*

Sensory – paresthesia(numbness and tingling) and muscle cramping-like pain

  • Cranial nerve–facial weakness, dysphagia, diplopia & difficulty speaking *
    Autonomic manifestations **(INCONTINENCE)
  • Labile BP – loss of BP control * Cardiac dysrhythmias * Tachycardia
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8
Q

What medications would you suspect being administered for a Guillian Barre client?
A. Acetaminophen
B. Diphenhydramine
C. Prednisone
D. Ibuprohen

A

C. Prednisone : decreases the immune system and bad antibodies that affect the myelin sheath

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9
Q

Are clients with GB at risk for dysphagia?
A. No
B. Yes

A

B. Yes
monitor client while eating for aspiration

AsPIRATION PRECAUTIONS

due to the movement of muscle weakness or paralysis from the leg up

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10
Q

What is one Aspiration Precaution

A

*SMALL BITES.
*SMALL SIPS.
*Alternate liquid and solid swallows.
*Ensure oral clearance after each bite.
*Sit upright (90 degrees) when eating and drinking and for 30 minutes after eating.
*Multiple swallows per bite/sip.
*Small, frequent meals throughout the day.
*Consume one pill at a time.

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11
Q

Phases of GB

A
  1. Acute or Initial period (1-4 weeks) – from onset of symptoms and ends when
    no further deterioration occurs
    1. Plateau period (several days to 2 weeks)
    1. Recovery phase (gradually over 4-6 months, maybe up to 2 years)
  • If permanent neurologic deficits remain, their condition is referred to as Chronic GBS
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12
Q

Dx of Gb

A

LP – elevated WBC’s
Nerve Conduction
MRI
-US of peripheral nerves
-Antibody biomarkers

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13
Q

Nursing Intervention for Respiratory Paralysis for GB?
A. Assess lung sounds
B. Apply bag valve mask with 100% oxygen
C. Increase head of head
D. Anticipated Mechanical ventilation

A

D. Anticipated Mechanical ventilation

if respiratory paralysis occurs, anticipate intubation for mechanical ventilation

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14
Q

Mechanical Vent Nursing Care

A
  • drain fluid from circuit
    -monitor for cuff leak or low or high pressure alarms
    -tpn must be initiated
    -GI prophyxasis must be on board
    -turn pt q2
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15
Q

Complications of GB

A

Total paralysis
 Potentially dangerous fluctuations in Pulse and BP
 Dysrhythmias may occur
 25% unable to breathe without respiratory assistance
 *VITAL CAPACITY
 Muscles for eye movement, speaking, chewing and swallowing also may become weak or paralyzed
 Often need long-term rehabilitation to regain normal independence
 As many as 15% experience lasting physical impairment
 In 3% – 8% can be fatal d/t complications

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16
Q

Interdiscplinary Managment of GB

A
  • we need a physical therapist
    -we need an operational therapist
  • we need a speech pathologist
    -we need a dietician

Frequent Resp/Cardiac monitoring * PT/OT, Speech-language therapies, along with dietitian

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17
Q

Priority for GB clients

A

KEEP AIRWAY PATENT

Signs of aspiration?
-choking
-drooling

HOB elevated
 C&DB
Q2H/spirometry/chest physiotherapy
 Monitor neuro, respiratory and cardiac status frequently
 Pain management – beginning of motor and sensory remyelination
 Promote communication
 Psychological Support(due to loss of motor and sensory function
 Long term care – may go home on ventilator

18
Q

What should you tell a client regarding recovery of GB?

A

it may take a minimum of 1 month to 2 years to recover

19
Q

Gullian Barre Syndrome Medical treatment

A
  • Plasmapheresis – filters blood to decrease circulating bad antibodies that attack the nerves.
  • IVIG – immunoglobulin therapy: Increases the amount of good antibodies for the patient
20
Q

Myasthenia Gravis

A

A rare progressive autoimmune disease characterized by muscle weakness as a result of impaired acetylcholine receptors.

21
Q

Function of Acetylcholine

A

Acetylcholine (ACh) is an important neurotransmitter that plays a role in brain functions, such as memory, and body functions, such as muscle contractions to move your muscles.

22
Q

Where the muscle weakness for Mg originate?
A.Head
B. Legs

A

A.Head

Weakness starts at head – leads to respiratory complication
(EXTREME FATIGUE)

23
Q

Is Dyspnea, Aspiration, or Dysphagia sooner with Myasthenia gravis or Gullian Barre?
A. Myasthenia gravis
B. Gullian Barre?

A

A. Myasthenia gravis

24
Q

A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy?
a. “I have a hard time with brushing my hair”
b. “I would rather be in a wheelchair than use a walker to get around”
c. “I’ve been having problems with bladder control”
d. “I have difficulty swallowing food”

A

a. “I have a hard time with brushing my hair”

25
Q

Is MG an autoimmune disorder
a. no
b. yes

A

b. yes

In MG, the person’s own antibodies prevent the receptors for the acetylcholine therefore preventing the muscle contraction.

26
Q

Interdisciplinary Managment of MG

A
  • we need a physical therapist: MOVEMENT OF LOWER EXTREMITIES
    -we need an operational therapist: MOVEMENT OF UPEER EXTREMITIES
  • we need a speech pathologist: SWALLOW TEST
    -we need a dietician: TPN OR ASPIRATION PRECAUTION INITIATION
    -we need respiratory therapist(NEED FOR MECHANICAL VENT)
27
Q

S/s of Myasthenia Gravis

A

*S/S start at the head
CAUSES A DISRUPTION IN ADL’S)
* Diplopia
* MUSCLEWEAKNESS
* Ptosis(DROPPING EYES)
* Problems with chewing or swallowing
*SOB
*Muscle weakness with exercise that subsides rest
* Decreased senses such as smell and taste
*Thymus hyperplasia
* Limited facial expressions
* Slurred speech
* Weakness of arms

28
Q

Would a patient with MG require a mechanical ventilator?
A.yes
B. no

A

A.yes

Can lose muscle strength for breathing and need a ventilator

29
Q

Dx for MG

A

EMG tests of muscle fibers

  • ICE packs on eyes for resolution of ptosis
    (tape eyes shut when sleeping)
  • CT or MRI of thymus gland (will be enlarged – remember this is where the T-Cells are made)
  • ANA test: used to help diagnose autoimmune disorders
30
Q

Medical Tx for Myastenia Graves

A

PYRADOSTYGAMINEAnticholinesterases: Increases available acetoCHOLINESTASEE to increase muscle functioning

  • Corticosteroids:to decrease immune system
  • High dose IVIG: increases good antibodies in blood
  • Plasmapheresis: filters out bad antibodies in the blood
  • Surgical – remove the Thymus gland
31
Q

Myastenia Gravis Nursing Managment and PRIORITIES

A

MAINTAIN PATENT AIRWAY

  • The priority for nursing management of the patient in crises is maintaining
    adequate respiratory function to promote gas exchange.
    * Assess gag reflex & ability to swallow * Provide oral hygiene as needed * Collaborate with dietitian
    * Cut food into small bites or soft diet
  • Observe for choking/aspiration
  • Keep HOB elevated during meals for 30-60 min after patient eats
  • Consider thickening liquids
  • Daily weights
  • Administer anticholinesterase drugs as prescribed (45-60 before meals)
32
Q

When should you administer PYRODSTAGMINE?

A
  • Administer anticholinesterase drugs as prescribed (45-60 before meals)

ALSO IN THE MORNING

33
Q

What can cause Myasthinia Crisis?

A

Nonadherance to medication regimen or tx, skipping dose
*Abrubtly stopping the medication.
*No knowledge of having Myasthenia Gravis come into ED with the crisis
Usually immediately after a resp
infection
Can also be after other things that
cause response to stress

34
Q

S/s Mystenia Crisis

A

-HYPERTENSION
RESPIRATORY DEPRESSION
SEVERE MUSCLE WEAKNESS

Also:

  • Diplopia
  • Ptosis
  • Problems with chewing or swallowing
  • Decreased senses such as smell and taste
  • Limited facial expressions
  • Slurred speech
  • Weakness of arms
35
Q

Nursing Management of Myasthenia Gravis

A

GIVE PYRIDOSTIGAMINE IV due to lack of available acetylcholine in the body

36
Q

Whta can occur if there too much acetylcholine available in the body?
A. Cholinergic Crisis
B.Myasthenia Crisis

A

A. Cholinergic Crisis

  • Causes:
  • Too high of a dose of cholinergic
    meds
37
Q

S/s of Cholinergic Crisis

A

-Flaccid paralysis
-respiratory failure
Low BP * Look for s/s of cholinergic
-pupil constriction
-bradycardia
-stool incontinence
-urine incontinence
-teary eyes
-hypotension

38
Q

What is the medication of choice for a client going through Cholinergic Crisis?
A. Acetominophen
B. Atropine
C. Diphenhydramine
D. Dopamine

A

B. Atropine

39
Q

Do you stop Cholisterase medication when cholinergic crisis is present?
A. No
B. Yes

A

B. Yes
Stop all anticholinesterase meds
* Treat with Atropine
(speed pt up increase heart rate and bp,)

40
Q

Nursing Care for MG

A
  • The priority for nursing management of the patient in crises is maintaining
    adequate respiratory function to promote gas exchange.
    * Assess gag reflex & ability to swallow * Provide oral hygiene as needed * Collaborate with dietitian
    * Cut food into small bites or soft diet
  • Observe for choking/aspiration
  • Keep HOB elevated during meals for 30-60 min after patient eats
  • Consider thickening liquids
  • Daily weights
  • Administer anticholinesterase drugs as prescribed (45-60 before meals)
    *Assist with ambulation

NUR 265 ADVANCED MED SURG (53 decks)

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