Chapter 46

Care of Patients with Problems of the Peripheral Nervous System

Mrs. Marion Kreisel MSN, RNNU230 Adult Health 2Fall 2011

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

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.

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

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.

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

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.

Nonsurgical Management

• Respiratory support• Promoting mobility• Drug therapy:

• Cholinesterase inhibitor drugs• Immunosuppression• Plasmapheresis

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.

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

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.

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.

Management

• Immunosuppression• Plasmapheresis• Respiratory support• Promoting self-care guidelines• Assisting with communication• Nutritional support• Eye protection• Surgical management usually involving

thymectomy

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.

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

Peripheral Nerves

Peripheral Nerve Injury

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

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

Trigeminal Nerve

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

NCLEX TIME

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

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

Question 3

The effects of chemotherapy-induced peripheral neuropathy are expected to be:

A. Temporary and short-livedB. Dose-limiting and may cause permanent

disability C. Controlled with steroids such as

prednisone D. Not dose-limiting but may cause

temporary disability

Question 4

What conditions might the nurse expect to see in the patient with restless leg syndrome?

A. Diabetes and renal failureB. Peripheral vascular disease and multiple

sclerosis C. Myasthenia gravis and decreased visionD. Trigeminal neuralgia and facial paralysis

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. VIID. VIII