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LSC Ch 46 PNS
Nursing
| Question | Answer |
|---|---|
| Guillian Barre Syndrome | Acute autoimmune disease w/varying degrees of motor weakness & paralysis, destruction of myelin sheath not permanent, long term - yes |
| 3 stages of Guillian Barre | Acute phase 1-4wks, Plateau days to 2wks, and Recovery Phase* 4-6 mos up to 2yrs |
| Predisposing Factors of Guillian Barre | Acute Illness, GI Illness, Campylobacter Bacteria, HIV, mycoplasma pneumoniae, surgery, URI, Virus, Vaccinations, Drugs, Systemic Lupus Erythematosus, Hodgkin's Disease |
| Ascending Muscle Weakness | Most Common form of GB, Starts in LE and works it's way up, symptoms develop over hours to days, mild paresis to total quadriplegia |
| Cranial Nerve Involvement | VII Facial- Smile, frown, dysphagia, IX glossopharyngeal- cough gag swallow, X Vagus- same as IX, autonomic dysfunction Varying BP bradycardia, asystole, XI Accessory- Shrug shoulders, XII hypoglossal- stick out tongue |
| Variant Forms of Guillian Barre | Descending-face first then down quickly, Miller/Fisher-absent reflexes, diplopia, normal motor strenght & sensory function |
| Nursing Diagnosis GB: Respiratory Interventions | Priority: Maintain adequate resp function, monitor airway mgmt, lung sounds, cough, dyspnea, swallow, elevate HOB, frequent position changes, breathing exercises, ABG's Pulse Oximetry, Emergency intubation equipment in room |
| Nursing Diagnosis GB: Cardiac Interventions | Closely monitor VS, HTN is treated with beta blockers or Nitropresside (short duration tx), Hypotension- pt is supine w/IV fluids, Atropine for Bradycardia |
| Nursing Diagnosis GB: Impaired Physical Mobility Interventions | Prevent complications of immobility, saety w/ambulation, transfers, encourage max independence, ROM, Assistive Devices, Monitor fatigue, Skin Care, Prophylactic Anticoag-TEDS stockings, compression devices |
| Collaborative Interventions for GB | Plasma exchange/Plasmapheresis: for pt's within 2-4wks of symptoms, weigh pt before and after, if shunt is used, Check for Patency, Assess for bruits, keep double bulldog clamps at bedside, observe puncture site for bleeding, Immunoglobin: Safer, for ambu |
| Interventions GB GI/Nutrition | Decreased GI motility, Dysphagia, assistance w/feedings, cannot swallow-enteral feeding tube, weigh pt to check wt loss, monitor serum albumin weekly |
| Interventions GB: G/U | Urinary retention requires strict I&O, may eed foley cath as weakness progresses |
| Interventions GB: PAIN | Pain control develop individualized pain plan, opiates are drug of choice, Morphine sulfate, hudromorphone, Other; neurontin, other pain interventions |
| Interventions GB: Communication | Eye blinking, moving finger, communication picture board |
| Interventions GB: Emotional support | Explain illness, Verbllize feelings,, Examine roles & responsibilities, coping mechanisms, referrals to social workers, clergy support grps, possible psych eval - depression |
| Mysasethnia Gravis | chronic autoimmune disease fatigue & weakness primarily in muscle innerated by cranial nerves and in skeletal & respiratory muscles, Mild trouble w/eye movements too rapidly, progressive weakness resulting in resp failure death |
| Cause of Myasthenia Gravis | Autoantibody attack on the Ach receptors in the muscle interfering w/nerve impulse transmission at the neuromuscular junction |
| More points on MG | Grave weakness, Autoimmune disorder, antibodies directed against acetylcholine receptors, nerve impulses not transmitted, muscles can't contract, characterized by weainess & muscle fatigue w/sustained effort, 85% generalized ocular, facial, bulbar limb |
| Assessment of MG | Can be very insidious some rapidly deelop, muscle weakness & fatigue, achiness, paresthesias, ptosis, incomplete eye closure, diplopia, bulbar: facial expression, chewing, speech dysphagias, voice softens, loos b/b control, resp failure |
| Tensilon Testing for MG | Inhibits b/d of ACh Receptors, may give atropine 1st to prevent tachycardia, inj Tensilon, pts w/MG show marked improvement w/in 30-60 sec, eyes open, increased muscle tone, lasts 4-5min, ptosis returns |
| Myasthenia Crisis & Cholinergic Crisis | MC: worsening of the disease that requires anticholinesterase therapy) there is a brief improvement in muscle strengh when Tensilon testing is used CC: (OD of anticholinesterase) Tensilon will make the person even weaker |
| Common Nursing Dx for MG | Risk for ineffective breathing, airway clearance, self care deficit r/t fatigue, activity intolerance, impaired verbal communication |
| Nursing Interventions | Teach pt to monitor for increasing dysphagia & breathing difficulties, Muscle weakness increases /fatigue & excess use of muscles, pts have most muscle strenght after sleep/rest, plan activities around rest/meds |
| Drug Therapy for MG | Cholinesterase inhibitors: Mestinon (pyridostigmine bromide) Prostigmin (neostigmine bromide) |
| Myasthenia Crisis Medication MGMT | Insufficient ACh: Tx: Tensilon-no improvement, Resp Impairment, may need intubation, meds are withheld, drug therapy gradually restarted |
| Cholinergic Crisis Medication Mgmt | excess ACh: Tx Hold Anticholinergic drugs, Atropine is antidote-may thicken secretions |
| Drug Therapy for MG | Immunosupressants w/use of corticosteroids: prednisone (Deltasone), Imuran (azathioprine), Cyclosporin |
| Nursing Interventions | promote rest, promote self care plan, assist w/communication, nutritional support, high cal snacks, small frequent meals, eye protection, artifical tears, lubricant gels, patch |
| Treatment for MG | Plasmapheresis- removes circulating antibodies, 6x/2wks, surgical interventions: thmectomy, immediate preop: give Mestinon, Taper steroids before surgery, antibiotics, plasmapheresis before & after surgery |
| Home Care Mgmt for MG | Avoid heat, crowds, overeating, irregular sleep habits or emotional extremes, |
| Factors that precipitate Myasthenia Crisis | Various drugs, Alcohol, RA, Hormonal changes, stress, infection, seasonal temp changes, heat, surgery, enemas |
| How to manage meds & weakness MG | Keep drugs and a glass of water at bedside if you are weak in the am, wear a watch w/alarm function to remind you to take meds, post your med schedule so others know it, plan strenuous activities when drug peaks, keep extra supply in car/at work, no otc |
| Family Teaching for MG | Learn CPR, Manual resuscitation Bag, Note swallowing/breathing difficulties, coping |
| Peripheral Nerve Trauma | Partial or complete severance of nerve or nerve root, contusion, stretching constriction,compression of nerve root, ischemia, electrical thermal, or radiation injury, accidents, sports injuries, drug inj, war inj |
| Nerve Trauma Assessment | Hx of recent inj, surg, use of CRUTCHES, med inj, war related injuries, Warm Phase warmth, skin is flushed and rosy, Cold Phase 2-3wks later, skin turns mottled reddish blue cool, dorsal side of hand to check temp |
| Interventions for Nerve trauma | Immobilization & rest, surgical to remove scar tissue, reconnect nerve and restore function, growth limited to 1-4mm/day ie: 1mm/day for 180days =18cm (approx 5") |
| Post Surgical Care for Nerve Trauma | Casted, later splints, NV Checks hourly, chick for tightness, discomfort, tingling cool, skin care, PT |
| Restless Leg Syndrome | Leg Paresthesias associated w/an irresistable urge to move, iron def. peripheral neuropathy, tx is for symptoms and underlying cause if known |
| Interventions for Restless Leg | Education, Limit Caffeine, nicotine, routine bedtime, avoid strenuous exercise 2-3hrs prior to bed, massage, biofeedback, acupuncture |
| Drug Therapy for Restless Leg Syndrome | Same as for Parkinson's & Epilepsy: Dopamine Agonists: sinemet, Mirapex, Requip Anticonvulsants: Tegretol, Neurontin Muscle Relaxants: Lunesta, Restoril, Sonata- may cause daytime drowsiness, Analgesics- opioids |
| Cranial Nerve Disorders - Trigeminal Neuralgia | Tic duoloureux, effects the 5th cranial nerve(sensory function), unilateral face pain, degeneration or pressure on nerve, trigger zone stim: smiling, talking, chewing, brushing teeth, blowing nose, wind on face, no sensory or motor deficits, fearful to do |
| Interventions: cranial nerve disorders | First Choice: Tegretol, Neurontin, Muscle Relaxants: baclafen Analgesics: Lidocaine intranasal Spray-temp relief |
| Medical Interventions for Trigeminal Neuralgia | Rhizotomy Nerve Block, inj of ETOH, Phenol, heating current, relief of pain 6mos, Surgery only if meds can't control pain, monitor pt for perm nerve damage/hemorrhage, soft diet, eye protection dental exams r/t |
| Bells Palsy Facial Paralysis | Meds: Prednisone-controversial Neurontin-chronic pain |
| Nursing Interventions for Bells Palsy | Eye care, eat/chew on unaffectedside, facial sling as muscle tone improves, encourage facial muscle exercises, when tone improves to grimace, wrinkle brow, force eyes closed blow air out, repeat 3-4x/day, 15-20% have residual weakness, bodyimage |
Created by:
ginabeana
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