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CARE of PATIENTS with NEUROLOGICAL DISORDERS

MULTIPLE SCLEROSIS

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DISEASES/ DISORDERS:
Multiple Sclerosis Myasthenia Gravis Parkinsons Disease Guillain-Barr Syndrome

Multiple Sclerosis
Chronic, progressive degenerative disease affecting the myelin sheath of the white matter of the brain & spinal cord
Plaques form on myelin sheath causing inflammation, edema, & demyelination, eventually scarring nerve transmission becomes erratic, and slows down Age onset: 20 -40 yrs; affects women 2:1; whites are affected more often than Hispanics, blacks or Asians. More prevalent in colder climates: North America & Northern Europe. Norther Australia
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Multiple Sclerosis
Common affectation: white matter of the spinal cord optic nerve brainstem cerebrum cerebellum Exacerbation and remissions.
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Multiple Sclerosis ETIOLOGY


Exact cause: unknown Theories: some evidence suggests that an infective agent causes a predisposition to MS Precipitating factors: Infection, pregnancy, physical activity, emotional stress. Hereditary
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Multiple Sclerosis CLINICAL MANIFESTATIONS


weakness & fatigue: most common symptom paresthesias difficulty with coordination and balance spastic weakness, ataxia, tremors, sensation to temperature, foot dragging, staggering, or loss of balance Vision loss (optic neuritis) Nystagmus Bowel & bladder dysfunction: hesitancy, frequency, loss of sensation, incontinence & retention; constipation. Powerpoint Templates

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Multiple Sclerosis DIAGNOSTIC TESTS


NO single test reliable in diagnosing MS Lumbar Puncture
presence of oligoclonal banding presence of IgG antibody in CSF (provides antibody base immunity against invading pathogens)

MRI of brain & spinal cord


presence of MS plaques
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Multiple Sclerosis NURSING DIAGNOSIS


Impaired physical mobility related to fatigue & weakness Activity intolerance r/t weakness, dizziness, and unsteady gait Self-esteem disturbance r/t loss of health & lifestyle changes

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Multiple Sclerosis MEDICAL MANAGEMENT


Tx: for acute relapses
IV or oral corticosteroids
Methylprednisolone, followed by oral Prednisone taper Azathioprine (Imuran) Cyclophosphamide (Cytoxan) Chemo drug to destroy the Tcells

Tx: treating exacerbations


Interferon B (Betaseron) reduces the Powerpoint Templates production of the T cells
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Multiple Sclerosis MEDICAL MANAGEMENT


Symptomatic treatment:
Bladder dysfunction: Oxybutynin (Ditropan), Propantheline, Urecholine, Constipation: Psyllium hydromucilloid, Bisacodyl Fatigue: Amantadine, Modafinil Muscle spascity: Baclofen diazepam, Dantrolene Tremors: Propranolol, Thenobarbial, Clonazepam Trigeminal neuralgia: Carbamazepine, Phenytoin, Amitriptyline Dysesthesia: TENS (Transcutaneous Electrical Nerve Stimulation)
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Multiple Sclerosis NURSING MANAGEMENT


1. Promotes physical mobility, activity and rest no vigorous physical exercise frequent rest periods walking and gait exercises minimize spasticity and contractures (warm packs, daily muscle stretching) activities: swimming, stationary bike, progressive weight bearing
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Multiple Sclerosis NURSING MANAGEMENT


2. Minimize effects of immobility
skin integrity cough and difficulty in breathing and expectoration

3. Promote bladder & bowel control Urinal/bedpan readily available PO fluids intake schedule/voiding schedule increase fiber in diet intermittent self-catheterization

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Multiple Sclerosis NURSING MANAGEMENT


4. Improve sensory and cognitive function:

Vision
eye patch for diplopia; prism glasses for reading; talking books

Speech
slurred, low volume, problems with phonation speech therapist

Cognitive & emotional responses


forgetfulness, easily distracted, emotionally labile

5. Development of coping strengths


education about diseases process stress relief
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Multiple Sclerosis NURSING MANAGEMENT


6. Improve self care
assistive devices raised toilet seat shower bench decrease physical and emotional stress decrease exposure of extreme temperatures

7. Adapting to sexual dysfunction


counseling plan sexual activity willingness to experiment
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Multiple Sclerosis COLLABORATIVE MANAGEMENT


PT for: instruction on assistive devices conduct ROM exercise

For vision impairment scan the environment, remove sources of injury


For urological control drink 1500 cc q day of fluids and void q 3 hrs intermittent catherization & clean technique neurogenic bladder (most common in MS)
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Multiple Sclerosis COLLABORATIVE MANAGEMENT


Neurogenic bladder (most common in MS)
Refers to several bladder dysfunctions caused by lesions of CNS/ PNS 5 types:
Uninhibited Sensory paralytic (detrusor muscle hyperreflexia) Motor paralytic (detrusor muscle areflexia) Autonomous Reflex
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Multiple Sclerosis COLLABORATIVE MANAGEMENT


Tx for constipation
High-fiber diet, bulk laxatives, stool softeners, fluids > 2000 cc/ day
Laxatives & enemas should be avoided lead to dependency Bowel program should be performed every other day
45 mins after largest meal (gastrocolic reflex) give suppository

Keep environment cool


NO hot baths Plan activity at peak energy level Drugs
Amantadine (symmetrel) Modafinil (Provigil) may alleviate fatigue
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Multiple Sclerosis COLLABORATIVE MANAGEMENT


Require assistance with ADLs
ADL nursing aides assistive devices raised toilet seat reacher tongs

Fear of loss of independence & fear of disability


Depressive episodes (short anti-depressant drug therapy)

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Multiple Sclerosis COLLABORATIVE MANAGEMENT


Knowledge Deficit
unpredictable course remissions & exacerbations the role of stress National Multiple Sclerosis Society

Discharge & Home Health Care


Medications: be sure pt understands meds.
dosage, route, action, & side effects
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Multiple Sclerosis EVALUATION


The pt. with MS will:
Develop a realistic daily schedule that allows for adequate rest Achieve an activity level appropriate for the extent of disability Achieve bowel & bladder function Demonstrate self-catheterization if prescribed Verbalize and understanding of required lifestyle changes, eg: ways to manage emotional stress, maintain a nutritious diet, avoid infection, etc
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Myasthenia Gravis

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Myasthenia Gravis Autoimmune disorder affecting the myoneural junction

Antibodies directed at acetylcholine at the myoneural junction impair transmission of impulses


Myasthenia gravis is a motor disorder

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Myasthenia Gravis

Normal ACh receptor site

ACh receptor site in myasthenia gravis

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Clinical Manifestations
Initially, symptoms involve ocular muscles, causing conditions such as diplopia and ptosis Weakness of facial muscles, swallowing and voice impairment (dysphonia), Generalized weakness
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Myasthenia Gravis
Chronic autoimmune neuromuscular disease characterized by weakness of voluntary muscles Unknown etiology Autoimmune Causes:
Decreased number of ACh receptors Thymus gland

Females > Males Descending weakness


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Myasthenia Gravis
Initial Diagnosis Anticholinesterase test Edrophonium chloride (Tensilon) IV Antidote Atropine 0.4 mg should be available to control the side effects of edrophonium:
Sweating Cramping Bradycardia

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Myasthenia Gravis Nursing Diagnosis


Ineffective breathing pattern related to respiratory muscle weakness. Impaired physical mobility related to weakness of voluntary muscles. Risk for aspiration related to the weakness of bulbar muscles.
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Myasthenia Gravis NURSING PROCESS


Focus on patient and family teaching Provide medication teaching and management Implement energy conservation measures Implement strategies to help with ocular manifestations Prevent and/or manage complications and avoid crisis Implement measures to reduce risk of aspiration Avoid stress, infections, vigorous physical activity, some medications, and high environmental temperatures
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Myasthenia Gravis MEDICAL MANAGEMENT


Pharmacologic therapy
Cholinesterase inhibitor: pyrostigmine bromide (Mestinon) Immunomodulating therapy

Plasmapheresis - blood is removed and replaced to remove the antibodies Thymectomy removal of the thymus gland
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Myasthenic Crisis
Undermedication with cholinesterase inhibitors Result of disease exacerbation or a precipitating event, most commonly a respiratory infection Severe generalized muscle weakness with respiratory and bulbar weakness (weakness of the facial and pharyngeal muscles) Patient may develop respiratory compromise failure
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Cholinergic Crisis
Caused by overmedication with cholinesterase inhibitors Severe muscle weakness with respiratory and bulbar weakness Patient may develop respiratory compromise and failure

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Myastinic crisis

Cholinergic crisis

Cause: Under medication Stress Infection

Cause: Over medication

Manifestations: Unable to see ptosis and diplopia Dysphagia Unable to breathe

Manifestation: Flaccid Paralysis Respiratory failure

Management: Administer cholinesterase

Management: Administer anticholinergic

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Management of Myasthenic Crisis


Ensuring adequate ventilation; intubation and mechanical ventilation may be needed Assessment and supportive measures include:
Ensure airway and respiratory support Take ABGs, serum electrolytes, I&O, and daily weight If patient cannot swallow, nasogastric feeding may be required Avoid sedatives and tranquilizers
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Myasthenia Gravis DRUG THERAPY


Two groups of medications
Short-acting anticholinesterase compounds Mestinon (pyridostigmine) Prostigmin (neostigmine) Corticosteriods (Prednisone)
assists in reducing the levels of serum Ach receptor antibodies Inform client that ther will be no immediate relief of the symptoms
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Myasthenia Gravis DRUG THERAPY


Immunosuppressive therapy
the level of circulating Ach receptor antibodies Examples Imuran (azaathioprine) Sandimmune (cycloporine)

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Myasthenia Gravis NURSING MANAGEMENT


Improve respiratory function Increase physical mobility Improve communication Provide eye care Prevent aspiration

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Parkinsons Disease

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Parkinsons Disease
A progressively degenerative neurological disorder affecting the brain centers (substantia nigra and basal ganglia) responsible for control & regulation of movement

Occurs in 1% of pop.
Over 50, affects men > women

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Parkinsons Disease PATHOPHYSIOLOGY


depletion of dopamine levels in the basal ganglia of the mid brain
Dopamine promotes smooth, purposeful movements of motor function Dopamine depletion impairment of the extrapyramidal tracts with loss of movement coordination
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Parkinsons Disease ETIOLOGY


Cause: unknown
Some heredity causes
Secondary iatrogenic PD is drug or chemical related
Dopamine depleting drugs: Reserpine. Phenothiazine, Metoclopromide, Butyrophenones (Droperidol & Haloperidol)

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Parkinsons Disease CLINICAL MANIFESTATIONS


3 cardinal signs
Bradykinesia / akinesia
slowness of movement or complete or partial loss of movement difficulty with balance

Involuntary tremors
course, rest tremor of the fingers & thumb (pill-rolling movement) of one hand, occurs during rest, & intensifies w/ stress, fatigue, cold, disappears during sleep, the tremor can occur in tongue, lip, jaw, chin; eventually Powerpoint Templates spreads to the foot on the same side Page 44

Parkinsons Disease CLINICAL MANIFESTATIONS


Progressive muscle rigidity to antagonistic muscle groups, causing resistance to both extension & flexion
Flexion contractures develop in the neck, trunk, elbows, knees & hip Face expressionless, mask-like appearance, drooling & tearing ability Propulsive gait

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Parkinsons Disease CLINICAL MANIFESTATIONS


Speech: high-pitched monotone voice & parroting the speech of others (muscles of the voice box is affected

Hypothalmic dysfunction: perspiration, heat intolerance, seborrhea, & oil production Psychosocial : does not affect intellectual ability
20% of pts will end up having dementia (Alzheimers)
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Parkinsons Disease DIAGNOSTIC EVALUATION


No specific tests History: progresses thru stages
Mild unilateral dysfunction Mild bilateral dysfunction, expressionless face & gait changes Dysfunction w/ walking, initiating movements, and maintaining equilibrium Severe disability- difficulty in walking, & maintaining balance & steady propulsion, rigidity
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Parkinsons Disease Nursing Diagnosis


Impaired physical mobility related to the stiffness and muscle weakness. Self care deficit related to neuromuscular weakness, decline in strength, loss of muscle control / coordination. Impaired Verbal Communication related to the decline in speech and facial muscle stiffness
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Parkinsons Disease Drug therapy


Goal: enhance dopamine transmission Dopaminergics (Levodopa)
a synthetic metabolic precursor to dopamine given in combination with Sinemet (Carbidopa)
to allow more Levodopa to reach the brain prevents peripheral metabolism of levodopa beneficial first few years on & off reactions

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Parkinsons Disease Drug therapy


Dopaminergics (cont.)
Sinemet
most common drug (carbidopa-levodopa) SE: Orthostatic hypotension, nausea, hallucinations, dyskinesia Nursing Considerations: Monitor B/P Use TED hose to venous return Monitor for urinary retention

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Parkinsons Disease Drug therapy


Dopaminergics (cont.)
Symmetrel (Amantadine)
Action: causes release of dopamine in CNS Indications: rigidity, bradykinesia SE: dizziness, ataxia, insomnia, leg edema Nursing Considerations: Monitor for postural hypotension Do not administer at bed time

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Parkinsons Disease Drug therapy


Anticholinergic
to block the release of acetylcholine (balance between dopamine & acetylcholine) to block the excitatory effects of the cholinergic system Examples: Artane (trihexphenidyl) Cogentin (benztropine) Parsidol (ethopropazine)

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Parkinsons Disease Drug therapy


Anticholinergic
Indications: tremor, rigidity, drooling SE: dry mouth, constipation, blurred vision, confusion, hallucination Nursing Considerations:
Usually contraindicated in acute-angle glaucoma, & tachycardia Monitor pulse & B/P during dosage adjustments Administer w/ meals Do not withdraw meds suddenly
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Parkinsons Disease Drug therapy


Antihistamines
Benadryl Indications: tremor, rigidity, insomnia SE: dry mouth, lethargy, confusion Nursing Considerations: Use w caution in pts with seizures, hypertension, hyperthyroidism, renal disease, diabetes Administer w meals or antacids.
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Parkinsons Disease Drug therapy


Dopamine agonists Parlodel (Bromocriptine)
Action: activates dopamine receptor in the CNS, helpful for treatment of on-off reactions Indications: fluctuation of manifestations, dyskinesia, dystonia SE: hallucinations, orthostatic hypotension, confusion Nursing considerations:
monitor B/P & mental status
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Parkinsons Disease Drug therapy


COMT inhibitors [catechol-Omethyltransferase}
Tolcapone
Action: enhance effect of dopamine Indications: adjuvant treatment SE: diarrhea Nursing Considerations:
Monitor liver enzymes

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Parkinsons Disease Drug therapy


MAO (Monoamine Oxydase) inhibitors
Deprenyl (Selegiline)
Action: inhibit monoamine oxidase B, an enzyme that converts chemical byproducts in the brain into neurotoxins that prevent substantia nigra cell death Indications: adjuvant treatment SE: nausea, dizziness, confusion, hallucinations, dry mouth Nursing considerations:
Monitor for levodopa side effects
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Parkinsonian Crisis
Sudden or inadvertent withdrawal of anti-PK drugs or emotional trauma Severe exacerbation of tremor, rigidity and bradykinesia, along w/ acute anxiety, sweating, tachycardia. Interventions: respiratory & cardiac support, subdued lighting, mild barbiturates, anti PK drugs

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Parkinsons Disease NURSING MANAGEMENT


Improve mobility
Exercise & stretch regularly (first thing in morning)
Encourage daily ROM to avoid rigidity & contractures

Enhance walking walk erect, watch horizon, wide-based gait, heel-toe gait, long strides. Use cane or walker prevent falls
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Parkinsons Disease NURSING MANAGEMENT


Improve hydration & nutrition
Maintain fluid intake 2 L/24 hrs Monitor weight & ability to chew & swallow
Upright position to chew & swallow, offer small freq. meals, soft foods & thick cold foods supplemental puddings Prevent aspiration think thru the steps of swallowing, keep lips closed, keep teeth together, chew, finish one bite before another
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Parkinsons Disease NURSING MANAGEMENT


Improve bowel elimination
Stool softeners, mild laxatives, regular routine, fiber, raised toilet seat

Improve communication
Speech therapy: speak slowly, use board, mechanical voice synthesizer

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Parkinsons Disease NURSING MANAGEMENT


Enhance self-care
Extra time needed to perform ADLs, use of side rails, overhead trapeze. Reinforce occupational & physical therapy Sleep on firm mattress, prevent neck contractures
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Parkinsons Disease NURSING MANAGEMENT


Support coping abilities
Feel embarrassed, depressed, lonely, bored, more muscle rigidity & unresponsive to verbal stimuli treat w/ dignity do not ignore clients Client to be active participant Explore feelings Education Services: American Parkinsons Disease Foundation
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Parkinsons Disease Evaluation The client is able to perform physical activity according to ability. The client is able to perform self care The client is able to maximize the ability to communicate.
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Guillain-Barr Syndrome

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Guillain-Barr Syndrome
Autoimmune disorder with acute attack of peripheral nerve myelin Rapid demyelination may produce respiratory failure and autonomic nervous system dysfunction with CV instability Most often follows a viral infection (respiratory/ GI: Campilobacter jejuni) Affects both men & women equally & of all ages.
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Guillain Barre Syndrome


also known as acute demyelinating polyneuropathy or acute idiopathic polyneuritis results in a temporary, flaccid paralysis lasting 4-8 weeks ascending Medical emergency, 80% will recover
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Guillain-Barr Syndrome CLINICAL MANIFESTATIONS


variable and include:
Weakness Paralysis Paresthesias Pain diminished or absent reflexes starting with the lower extremities and progressing upward Cranial nerve symptoms tachycardia, bradycardia, hypertension, or hypotension
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Guillain-Barr Syndrome NURSING PROCESS


Conduct ongoing assessment with emphasis on early detection of life-threatening complications of respiratory failure, cardiac dysrhythmias, and deep vein thrombosis

Monitor for changes in vital capacity and negative inspiratory force


Assess VS frequently/continuously including continuous monitoring of ECG Encourage patient and family coping
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Guillain-Barr Syndrome NURSING DIAGNOSIS


Ineffective Breathing Pattern, related to respiratory muscle weakness or paralysis, decreased cough reflex, immobilization. Impaired Physical Mobility related to paralysis, ataxia. Risk for Impaired Skin Integrity related to muscle weakness, paralysis, impaired sensation, changes in nutrition, incontinence.
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Guillain-Barr Syndrome MEDICAL MANAGEMENT


Requires intensive care management with continuous monitoring and respiratory support
Plasmapheresis and IVIG (Intravenous Immunoglobulin) are used to reduce circulating antibodies Recovery rates vary but most patients recover completely
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Guillain-Barr Syndrome NURSING MANAGEMENT


Enhance physical mobility and prevent DVT
Support limbs in a functional position Perform passive ROM at least twice daily Initiate position changes at least every 2 hours Provide elastic compression hose and/or sequential compression boots Provide adequate hydration

Administer IV and parenteral nutrition as prescribed Assess swallowing and gag reflex and take measures to prevent aspiration
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Guillain-Barr Syndrome NURSING MANAGEMENT


Develop a plan for communication individualized to patient needs Decrease fear and anxiety
Provide information and support Provide referral to support group Implement relaxation measures Maintain positive attitude and atmosphere to promote a sense of well-being Implement diversional activities
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Guillain-Barr Syndrome NURSING MANAGEMENT


Develop a plan for communication individualized to patient needs Decrease fear and anxiety
Provide information and support Provide referral to support group Implement relaxation measures Maintain positive attitude and atmosphere to promote a sense of well-being Implement diversional activities
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Amyotrophic Lateral Sclerosis (ALS)

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Amyotrophic Lateral Sclerosis (ALS)


Lou Gehrigs disease Loss of motor neurons in the anterior horn of the spinal cord and loss of motor nuclei in the brain stem

Causes progressive weakness and atrophy of the muscles of the extremities and trunk; weakness of the bulbar muscles impairs swallowing and talking; and respiratory function is also impaired

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Amyotrophic Lateral Sclerosis CLINICAL MANIFESTATIONS

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Amyotrophic Lateral Sclerosis CLINICAL MANIFESTATIONS

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Amyotrophic Lateral Sclerosis (ALS)


Course of disease
Death from pneumonia in 3-5 yrs.

Diagnosis:
clinical signs & symptoms EMG changes muscle biopsies CSF analysis CT MRI Powerpoint Templates

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Amyotrophic Lateral Sclerosis MANAGEMENT


Making the client as comfortable and independent as possible

Slowing the progression of the disease: Riluzole (Rilutek)


Antibiotic Breast-cancer drug Antioxidant coenzyme
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Amyotrophic Lateral Sclerosis NURSING MANAGEMENT


Physical therapy Speech therapy Nutritional support Respiratory support

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