Chapter 50 Nursing Care of Patients with Peripheral Nervous System Disorders

Answers CHAPTER 50 NURSING CARE OF PATIENTS WITH PERIPHERAL NERVOUS SYSTEM DISORDERS AUDIO CASE STUDY Mrs. Mead Has Myasthenia Gravis 1. The eyes are controlled by very small muscles. Larger muscles have many more fibers, and if some are weak, others can take over. 2. Edrophonium (Tensilon) is an anticholinesterase medication. By inhibiting cholinesterase, more acetylcholine remains at the neuromuscular junction, which increases the muscle response to nerve impulses. 3. (1) DO NOT take any new drugs, over the counter or prescription, without consulting your neurologist. (2) The importance of around-the-clock anticholinesterase medication in preventing muscle weakness. (3) Energy conservation techniques and timing of medication with activities. VOCABULARY 1. atrophied 2. exacerbations 3. neuralgia 4. ptosis 5. demyelination 6. plasmapheresis 7. fasciculation 8. anticholinesterase PERIPHERAL NERVOUS SYSTEM DISORDERS Errors are in boldface and the corrections are detailed below. 1. Ms. Mary Garvey sees her physician because she has been seeing double off and on for several weeks and has been fatigued. Her physician suspects myasthenia gravis and schedules her for a carotid ultrasound. He confirms his suspicions with a Tensilon (edrophonium) test. He explains to Ms. Garvey that she has a disease that is characterized by a decrease in the neurotransmitter norepinephrine. He begins her on Mastodon and prednisone. Her nurse teaches her the importance of getting regular exercise and recommends joining a local health and exercise club. • Electromyography, not ultrasound, is likely to be done. • Receptor sites for the neurotransmitter acetylcholine are affected. • Mestinon (pyridostigmine), not Mastodon, is an anticholinesterase drug used to reduce symptoms. (A mastodon is a prehistoric elephant.) • It seems wise to recommend exercise, but individuals with myasthenia gravis become very fatigued, and rest, not exercise, is the only way to relieve it. Moderate exercise as tolerated is a better recommendation. 2. Mr. Tom Newby has a history of trigeminal neuralgia. He enters the emergency department with severe pain in his left wrist. The physician orders a narcotic analgesic because Mr. Newby’s third cranial nerve is inflamed. Once the acute pain has subsided, Mr. Newby is discharged with instructions to get plenty of fresh air and to take his gabapentin (Neurontin) as ordered. • Pain in the face, not the wrist, characterizes trigeminal neuralgia. • The trigeminal nerve is the fifth, not the third, cranial nerve. • Fresh air may aggravate pain because even a breeze on the face can cause excruciating pain. 3. Mrs. Mattie Schultz is admitted with exacerbated multiple sclerosis (MS). Her legs are becoming weaker, causing difficult walking, and she has been having difficulty swallowing. You know that buildup of myelin on her neurons is responsible for her weakness. You assess her for stressors that might have caused her exacerbation, such as urinary tract infection (UTI) or upper respiratory tract infection. Mrs. Schultz is started on thyroid-stimulating hormone (TSH) to stimulate her thyroid, which will help reduce her symptoms. She is also placed on trimethoprim/sulfamethoxazole (Bactrim) for the UTI you identified through your excellent assessment and on diazepam (Valium) for urinary retention. • Patchy degeneration, not buildup, of myelin accounts for symptoms of MS. • Steroids or adrenocorticotropic hormone (ACTH) to stimulate the adrenal cortex or to secrete cortisol is given to reduce inflammation and relieve symptoms. • Diazepam (Valium) might be given for muscle spasms, but bethanechol (Urecholine) or oxybutynin (Ditropan) is given for urinary problems. 1 2 Chapter 50 Answers CRITICAL THINKING REVIEW QUESTIONS—TEST PREPARATION 1. Amyotrophic lateral sclerosis (ALS) is a nerve disease in which the nerves that stimulate the muscles to make them contract degenerate and form scar tissue. This makes it difficult for muscles to contract. 2. Nerves that control the muscles in his legs are becoming more affected. A referral for physical therapy and a cane or other walking aid might help Reverend Wilson continue to function for as long as possible. 3. He should know that ALS does not affect thinking. Therefore, as long as he can function physically, there is no reason to quit his job. 4. Muscle spasms can be relieved with medications such as baclofen (Lioresal) or a benzodiazepine such as diazepam (Valium). 5. Reverend Wilson’s muscles that control swallowing may be affected now. An appropriate nursing diagnosis is Impaired Swallowing related to muscle weakness. Because his swallowing is unlikely to improve dramatically, a good goal might be that he will not aspirate. Talk to the physician about ordering a swallowing evaluation by a speech therapist, who can recommend interventions to help prevent aspiration. Additional interventions include making sure he is sitting up straight to eat, staying with him during meals in case he has difficulty, having him swallow each bite twice, and having him avoid thin liquids. Eventually he and his wife may need to decide if they want to consider tube feedings. 6. Possible nursing diagnoses include Disturbed Body Image, Risk for Imbalanced Nutrition: Less Than Body Requirements, Impaired Oral Mucous Membrane Integrity, Impaired Physical Mobility, and Risk for Impaired Skin Integrity. Note that these are only possible ideas and would need to be verified with a thorough assessment. The correct answers are in boldface. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (1) is correct. Anticholinesterase drugs reduce activity of cholinesterase, leaving more acetylcholine available to aid in muscle contraction. (2) is incorrect. Anticholinergic drugs will worsen symptoms. (3, 4) are incorrect. Adrenergic drugs or beta-blockers will not help. 2. (4) is correct. The patient with Bell palsy may have difficulty closing the affected eye, and eyedrops will keep the eye lubricated. (1, 2, 3) are not useful for Bell palsy. Heat, rather than ice, is sometimes used. 3. (3) is correct. The only way to know if nutrition is adequate without blood work is to monitor weight. (1, 2, 4) are incorrect. Monitoring meal trays, intake and output, and swallowing are all good interventions but will not show whether nutrition has been maintained. Serum albumin is also sometimes used to monitor nutrition status. 4. (4) is correct. Guillain-Barré syndrome is most likely caused by an autoimmune process. (1, 2, 3) are not causes of Guillain-Barré syndrome. 5. (2) is correct. Arterial blood gases monitor respiratory function. Deteriorating arterial blood gases signal respiratory failure from weakening respiratory muscles. (1) signals kidney disease, which is not a common problem in Guillain-Barré syndrome. (3, 4) are incorrect. Bleeding and electrolyte imbalances are not associated with Guillain-Barré syndrome. 6. (4) is correct. A Tensilon (edrophonium) test is given to determine if it is effective in reducing muscle weakness. (1, 2) are incorrect. There is no such thing as a pyridostigmine (Mestinon) test or a quinine tolerance test. (3) is incorrect. Pulmonary function studies might be done if respiratory muscles are affected but would not be diagnostic for myasthenia gravis. 7. (4) is correct. Myelin is damaged in multiple sclerosis. (1, 2, 3) are not related to multiple sclerosis. 8. (2) is correct. Amyotrophic lateral sclerosis is terminal, and advance directives are essential. (1, 3, 4) are inappropriate. Hospice is likely not necessary early in the disease; it is never too early to make important decisions. 9. (1, 2, 5) are correct. Monitoring oxygen saturation and respiratory function can help identify problems early. Elevating the head of the bed will reduce the workload of the respiratory muscles. Deep breathing and coughing can help clear lungs of retained secretions. (3) is incorrect. Bedrest can increase risk of respiratory complications. (4) is incorrect. Suction should be done only when necessary. 10. 30 mg 1 mL 50 mg = 0.6 mL 11. (1) is correct. Muscle twitching is called fasciculation. (2) is incorrect. Atrophy is wasted muscles. (3) is incorrect. Chorea is movement found in Huntington disease. (4) is incorrect. Neuropathy is nerve pain. 12. (2) is correct. Eating uses muscles innervated by the fifth cranial nerve and is most likely to cause pain. (1, 3, 4) do not use the facial muscles and are less likely to cause pain. Sleeping usually relieves pain.