Guillian-Barre Syndrome

Also known as Acute Idiopathic Polyneuropathy

Autoimmune disease affecting peripheral nerves: 80% Myelin, 20%
Axon
Neither contagious nor hereditary

Incidence & Prevalence

Affects 2 out of 100,000
Affects men more than women

Etiology:
Viral Infection, Bacterial Infection, Common Cold, Mononucleosis,
Hepatitis, GI infection, Inoculations
-Campylobacter Jejuni
-Helicobacter Pylori
-Mycoplasma Pneumoniae

PATHOPHYSIOLOGY

Exogenous trigger resembling pathogen

Activates endogenous antigen

Activates autoimmune response

Immunological reaction causes demyelination

Myelin sheath of neuron is damaged

Impulse transmission is impaired

Impairment in sensation, movement, cognition

3 Phases
1. Acute (up to 4 weeks) initial onset of symptoms
-Ascending Paralysis:
weakness beginning in the lower extremities from the trunks, the
upper limbs, bulbar muscle
-by the 3rd week 90% experience weakness
2. Plateu
 -symptoms neither worsen nor improve
3. Recovery
-gradual improvement

Clinical Manifestation
Deep aching pain
Paresthesia of the limbs
Loss of DTR
-Dyspnea
Nerve muscles slow down or -Decreased breath sounds
cease: -Decreased tidal volume
- Numbness Autonomic Dysfunction:
- Tingling in the fingers -Orthostatic hypotension
and toes -Hypertension
-Pupillary disturbances
With denervation, muscles -Sweating
atrophy: -Urinary retention
- Mild difficulty in -Dysrythmia
walking -Paralytic Ileus
- Complete paralysis of
the extremities Facial Weakness:
-Diplopia
Respiratory compromise: -Dysphagia
 Diagnostic Examination
Lumbar Puncture and CSF analysis
Electromyography
Nerve conduction studies

Medical Management
- Supportive therapy
- Administration of Steroids (Methylprednisone)
- IV Immunoglobulins - to prevent the immune system from further attack Schwann cells and the
myelin sheath by blocking receptors on macrophage
- Plasmapheresis - to remove circulating antibodies

Priority Nursing Diagnosis:

1. Ineffective Breathing Pattern r/t weakness or paralysis of respiratory muscles

Nursing Interventions:
Cluster nursing activities
1. Monitor the frequency, depth and symmetry of breathing.
Note the increased work of breathing and skin color observations and mucous membranes.
2. Assess for changes in sensation, especially a decrease in the response.
3. Note the presence of respiratory fatigue during the talk if the patient is still able to speak.
4. Auscultation of breath sounds, note the absence of sound or extra sound like crackles.
5. Elevate the head of your bed or put the patient in a sitting position leaning.
6. Encourage deep breathing exercises, chest percussion, postural drainage
7. Perform monitoring of blood gas analysis, pulse oximetry on a regular basis.
8. Administer medications as prescribed
9. Instruct on Conservation technique
Other Nursing Management
- Monitor cardiac and respiratory status
- Perform passive range of motion exercises within patients limits
- Provide skin care to prevent skin breakdowns and contractures
- Administer prescribed medication
- Provide eye and mouth care
- Monitor intake and output
- Test the gag reflex and position accordingly before feeding
- If respiratory failure occurs, establish an airway with an endotracheal tube
- Assure that respiratory support equipment is maintained at bedside. (ambu bag, O2)
- Monitor for DVT, Apply anti-embolism stockings
- Provide emotional support to the patient and family
- Safety measure

Myasthenia Gravis

An autoimmune disorder affecting the myoneural junction

 Characterized by varying degrees of muscle weakness of the voluntary
muscle
Women are more prone than men
Develops as early as 20 to 40 years of age
Men 60 to 70 years old

PATHOPHYSIOLOGY:

Clinical Manifestations

Ocular

Diplopia double vision

Ptosis drooping of the eyelids
o Bulbar symptoms
Weakness of the muscle of the face and throat
Fatigable jaw weakness is often noted halfway through a meal or when
chewing meat and other concentrated solid foods.
Hypophonic or nasal speech occurs with palatal weakness and may
worsen with prolonged speaking.
 Dysphagia
o Neck and limb muscles
A dropped head occurs, particularly later in the day because of
weakness of neck extensors.
Neck pain can occur due to the added effort of trying to keep the head
up.
Proximal arms (deltoid and triceps) are usually more involved than
proximal legs (hip flexors), distal presentations (wrist and finger
extensors or ankle dorsiflexors) can occur.
o Respiratory muscles
Increasing difficulty while supine or bending over
Respiratory muscle weakness may be sufficient to result in respiratory
failure, and the patient is said to be in crisis.
Diagnostics
Acetylcholinesterase inhibitor test stops the breakdown of
acetylcholine, thereby increasing availability at the neuromuscular
junction
Electromyography
MRI
Pulmonary function testing which measures breathing strength
helps to predict whether respiration may fail and lead to a myasthenic
crisis.

Medical management:
Pyridostigmine first line of therapy. Provides symptomatic relief by
inhibiting the breakdown of acetylcholine and increasing the relative
concentration of available acetylcholine at the neuromuscular junction
Immunosuppresives reduce production of the antibody
Plasmapheresis treat exacerbation

Surgical management
Thymectomy surgical removal of the thymus gland

Complications
Myasthenic crisis characterized by severe generalized muscle
weakness and respiratory and bulbar weakness that may result in
respiratory failure
- It may result from disease exacerbation or specific
precipitating event.
Neuromuscular respiratory failure respiratory muscle and bulbar
weakness combine to cause respiratory compromise. Weak respiratory
muscles do not support inhalation. An inadequate cough and an
 impaired gag reflex, caused by bulbar weakness, results in poor airway
clearance

Priority Nursing Diagnosis:

Impaired Physical Mobility r/t weakness of voluntary muscles

Nursing Interventions:

1. Provide a safe environment: bed rails up, necessary items close by

2. Perform passive range of motion exercises to all extremities
3. Assist with position changes
4. Allow to perform tasks at own pace. Encourage independent activity
5. Instruct on conservation techniques and encourage rest between
activities.
6. Provide positive reinforcement during activities.
7. Keep skin clean, dry, and moisturized as needed.
8. Apply anti-embolism stockings
9. Turn and position every 2 hours, maintain limbs in functional alignment
10. Encourage deep breathing exercises and coughing

Bells Palsy

Problem associated with the VII cranial nerve

May also affect cranial nerve V and VIII
Also known as Cranial Polyneuritis
Occurs in 20 out of 100,000 people
Most likely to occur with pregnant women, and diabetics

RISK FACTORS:

HIV
Bacterial infections
Neurologic disorders
Traumatic head or face injury
Viruses: influenza, infectious mononucleosis

PATHOPHYSIOLOGY:

Exposure to infection, immunosuppression, exposure to cold

Re-activation of HSV-1
 Inflammation of the facial nerve

Demyelination of the facial nerve

Compression of the facial nerve

Facial nerve impairment

Contraction of the facial muscle, impaired lacrimation, impaired

hearing, taste

Clinical Manifestation:
Unilateral manifestation
Feeling of stiffness or being pulled on one side of the face
Difficulty eating and drinking; food falls out of one side of the mouth
Drooling due to lack of control over the muscles of the face
Drooping of the face, such as the eyelid or corner of the mouth
Hard to close one eye
Problems smiling, grimacing, or making facial expressions
Twitching or weakness of the muscles in the face

Other symptoms that may occur:

Dry eye or mouth
Headache
Loss of sense of taste
Sound that is louder in one ear (hyperacusis)
Twitching in face
Dizziness
Hypersensitivity to sound

Diagnostics:
Electromyography (EMG): may confirm the nerve damage and severity of
the damage.
CT or MRI: can eliminate other possible causes of nerve damage.

Medical Management:

The objectives of management are to maintain facial muscle tone and to

prevent or minimize denervation.

Corticosteroid therapy (prednisone) may be initiated to reduce

inflammation and edema, which reduces vascular compression and
permits restoration of blood circulation to the nerve
 Early administration of corticosteroids appears to diminish severity,
relieve pain, and minimize denervation
Use of antivirals is used in managing the herpes simplex virus
associated with the disease
Facial pain is controlled with analgesic agents or heat applied to the
involved side of the face
Electrical stimulation applied to the face to prevent muscle atrophy, or
surgical exploration of the facial nerve
Surgery may be performed if a tumor is suspected, for surgical
decompression of the facial nerve, and for surgical rehabilitation of a
paralyzed face
Proper eye care and physical therapy to prevent drying of the eyes,
injuries, and facial contractures

Priority Nursing Diagnosis:

Disturbed sensory perception: visual

Nursing Interventions:
1. Orient patient to the environment
2. Remove environmental barriers to ensure safety.
3. Do not make unnecessary changes in the environment, inform
patient of changes
4. Provide adequate lighting
5. Place frequently items within range of vision
6. Recommend the use of visual aids when appropriate
7. Encourage the use of touch
8. Assist and guide during ambulation, identify obstacles
9. Instruct on proper eye care