Concepts: Immunity, MS, MG

IPE

-Anaphylaxis support Reduce response •Antihistamine •Sympathomimetic •Mast cell stabilizer •Immunosuppressive therapy •Antiinflammatory agents Symptomatic relief •Antipruritic •Decongestant •Analgesics

Nursing Implementation: teach

-Bladder control is a major problem for many patients with MS. Although anticholinergics may be beneficial for some patients to decrease spasticity, you may need to teach others self-catheterization. -Bowel problems, particularly constipation, occur frequently in patients with MS. Increasing the dietary fiber intake may help some patients achieve regularity in bowel elimination. -The patient with MS and the caregiver need to make many emotional adjustments because of the unpredictability of the disease, need for lifestyle changes, and challenge of avoiding or decreasing precipitating factors. -The National Multiple Sclerosis Society and its local chapters can offer a variety of services to meet the needs of patients with MS.

Clinical Manifestations

-Fluctuating weakness of skeletal muscles (difficult eating, swelling) -Ocular muscles are involved at onset -Facial muscles are affected -Muscles of the trunk, limbs are less often affected -Diaphragmatic breathing -No sensory loss, reflexes are normal, and muscle atrophy is rare -The course of this disease is highly variable

Nursing implementation

-Help patient identify triggers and develop ways to avoid them or minimize their effects -Reassure patient during diagnostic phase -Assist patient in dealing with anxiety and grief caused by diagnosis -During acute exacerbation, prevent major complications of immobility -Focus teaching on building general resistance to illness -Avoid fatigue, extremes of hot and cold, exposure to infection Teach patient -Good balance of exercise and rest -Minimize caffeine intake -Nutritious, well-balanced meals -Increase fiber if constipated -Treatment regimen -Management of medications

Primary Prevention

-Immunizations -Avoid high risk behaviors -Adequate nutrition -Infection control

Myasthenic Crisis

-Is an acute exacerbation of muscle weakness triggered by Resp. infection, emotional distress, surgery, etc... Complication: -Aspiration, -respiratory insufficieny, and respiratory tract infection Treatment: corticosteroids

Etiology and Patho

-MG is a disease of the Ach junction of the neuromuscular system with dysfunctions that lead to fluctuating skeletal muscle weakness -Body attack k the ach cites in the neuromuscular juntion -anti achr antibodies are in 90% of peoples bodies

Planning

-Maximize neuromuscular function -Maintain independence in activities of daily living for as long as possible -Manage disabling fatigue -Optimize psychosocial well-being -Adjust to the illness -↓ Factors that precipitate exacerbations

Origin of Cells in Immune response

-Myeloid that includes neutrophils, monocytes/macrophages, eosinophils, basophils, and mast cells. •Lymphoid includes B cells and T cells. •Compliment System includes 25 primary proteins that help boost the immune system and rid the body of antibody-antigen complex

A nurse is teaching a client with multiple sclerosis about the disease. Which statement by the client indicates to the nurse that further teaching is needed?

-Taking a hot bath The nurse needs to address the hot baths to correct this misconception. Hot baths tend to increase symptoms and may result in burns because of decreased sensation. All the rest are correct and do not require teaching. Using a straw gives the client less control of liquid intake, which may lead to aspiration. Although a bladder regimen to maintain control is preferable, the use of pads can avoid embarrassment. The disease does have periods of remission and exacerbation.

Drug therapy cont

-Teriflunomide (Aubagio) is an immunomodulatory agent with antiinflammatory properties. -The exact mechanism of action is unknown but may involve a reduction in the number of activated lymphocytes in the CNS. -Fingolimod (Gilenya) reduces MS disease activity by preventing lymphocytes from reaching the CNS and causing damage. -Both drugs are specifically indicated for treatment of relapsing forms of MS.

A client with myasthenia gravis asks the nurse why the disease has occurred. Which pathology underlies the nurse's reply?

A decreased number of functioning acetylcholine receptor (AChR) sites

Eval

Expected Outcomes -Maintain or improve muscle strength and mobility -Use assistive devices appropriately for ambulation and mobility -Maintain urinary continence -Make decisions about lifestyle modifications to manage MS

Drugs and Surgery

Anticholinergics •Pyridostigmine (Mestinon) alternate day corticosteroids, and other immunosuppressive agents •Prednisone, Azathiroprine (Imuran), Mycophenolate (Cellcept), Cyclosporine (Sandimmune). •Surgical & Other therapy •Thymectomy •Plasmapheresis or IVIG -Corticosteroids given in morning

During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states which information? plan activities for later in the day. Eat meals in a semirecumbent position. Avoid people with respiratory infections. Take muscle relaxants when under stress

Avoid people with respiratory infections.

E&P

Cause is unknown -Possible factors include infection, smoking, physical injury, emotional stress, excessive fatigue, pregnancy, poor state of health -Genetic component

Patho and Etiology

Chronic and progressive segmental delimitation of the spinal cord and brain Mylen sheath can regenerate but too much damage it can't regenerate

Drug theory continued

Corticosteroids (Solumedril: methylprednisolone, prednisone) -Helpful in treating acute exacerbations -Reduce edema and acute inflammation at the site of demyelination -Therapeutic plasma exchange and IV immunoglobulin G -However, these drugs do not affect the ultimate outcome or degree of residual neurologic impairment from the exacerbation. -Therapeutic plasma exchange (plasmapheresis) and IV immunoglobulin G may be considered when treatment with corticosteroids alone does not achieve symptom improvement.

MS drug therapy

Currently there is no cure for MS -Interprofessional care is aimed at treating the disease process and providing symptomatic relief -Therapy is tailored specifically to disease pattern and manifestations experienced by each patient -Early intervention is most effective

A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission?

Swimming Swimming helps keep the muscles supple, without requiring fine-motor activity. Hiking might prove too rigorous for the client. Sewing requires fine-motor activity and will be difficult for the client. Sedentary activities are not helpful in maintaining muscle tone.

Cont

Three pathologic processes characterize MS -Chronic inflammation -Demyelination -Gliosis (scarring) in the CNS

A healthcare provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply.

Difficulty swallowing saliva Drooping of the upper eyelids Double vision

MS Immunosuppressive therapy

Drug therapy used to slow progression of disease includes use of -Immunosuppressants -Immunomodulators -Adrenocorticotropic hormone

For active and aggressive forms of MS

For more active and aggressive forms of MS, natalizumab (Tysabri), alemtuzumab (Lemtrada), mitoxantrone (Novantrone), and dimethyl fumarate (Tecfidera) may be used. -Natalizumab is given when patients have had an inadequate response to other drugs. -An adverse effect of natalizumab is the increased risk of progressive multifocal leukoencephalopathy, a potentially fatal viral infection of the brain. -Because of its safety profile, alemtuzumab is generally reserved for patients who have an inadequate response to two or more drugs indicated for the treatment of MS. -Mitoxantrone, an antineoplastic medication, has serious effects, including cardiotoxicity, leukemia, and infertility. -Dimethyl fumarate provides a new approach to treating MS by activating the Nrf2 pathway. - This pathway provides a way for cells in the body to defend themselves against the inflammation and oxidative stress caused by MS.

Overview of Immunity

Immune organs -Bone marrow -Spleen -thymus -adenoids -Appendix

Immunomodulators

Immunomodulator drugs are used initially to modify the disease progression and prevent relapses -Interferon β-1a (SQ Rebif and Plegridy; IM Avonex) -Interferon β-1b (SQ Betaseron and Extavia) -SQ Glatiramer acetate (Copaxone) -Treatment of MS begins with use of immunomodulator drugs to modify the disease progression and prevent relapses. These drugs include (1) interferon β-1a (Rebif, Plegridy [given subcutaneously]) and interferon β-1a (Avonex) (given IM) (2) interferon β-1b (Betaseron, Extavia) (given subcutaneously) (3) glatiramer acetate (Copaxone) (given subcutaneously).

MG Issues

M. Crisis -Muscle weakness from respiratory infection -Give IV Endophronium/ or corticosteroids -Antidote: Acholinesterase Ach -Optimal functioning Cholingeric Crisis -Excessive sweating -Constricted pupils -muscle fasciulaions -Give atropine -Too much ach and are muscles are exhausted -Antidote: atropine will compete with ach receptors

Diagnostic Studies

No definitive diagnostic test for MS -MRI - plagues, atrophy, destruction -CSF - Increase Immunoglobulin G and Oligoclonal banding -Multiple demyelinating lesions at two different sites.

Clinical Manifestations of MS

Onset of the disease is often insidious and gradual 1st symptoms may include -Blurred or double vision -Red-green color distortion -Blindness in one eye -Cerebellar manifestations -Fatigue -Motor manifestations: ataxia -Sensory -Emotional -Perioids of remission

MS

Onset usually between 20 and 50 years of age -Can affect people of any age -Symptoms 1st appear ages 30-35 -Disease more progressive when diagnosed at age > 50 -Affects women 2-3 times more often

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision?

Optic nerve inflammation ptic nerve inflammation is a common early effect of multiple sclerosis caused by lesions in the optic nerves or their connections (demyelization). This effect may resolve during periods of remission. At present there is no evidence of viral infection of the eyes in multiple sclerosis. Tumors of the brain and cerebral edema, not multiple sclerosis, cause increased intracranial pressure because the skull cannot expand. Closed-angle glaucoma causes blindness as a result of increased intraocular pressure, not inflammation of the optic nerve, which is commonly associated with multiple sclerosis. Closed-angle glaucoma is unrelated to multiple sclerosis.

IPE for MS

Other interventions may be required in treatment of spasticity -Surgery -Dorsal column electrical stimulation -Intrathecal baclofen pump Water therapy: helps the body

Patho cont

Primary neuropathologic condition is an autoimmune process orchestrated by activated T cells; disrupting the BBB -Initially, attacks cause damage to myelin sheaths of neurons in brain and spinal cord -Nerve fiber is not affected -Patient may complain of noticeable impairment of function -With ongoing inflammation, myelin loses ability to regenerate -Nerve impulse transmission is disrupted without myelin -Results in permanent loss of nerve function

A client is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. The nurse explains to the client that the diagnosis of myasthenia gravis is confirmed if the administration of Tensilon produces which response? Brief exaggeration of symptoms Prolonged symptomatic improvement Rapid but brief symptomatic improvement Symptomatic improvement of only the ptosis

Rapid but brief symptomatic improvement

MS chart

Relaxing remitting: worsening of condition and then partial or complete remission Primary progressive: minor improvements with no noticeable remission

The nurse is teaching a client with multiple sclerosis methods to reduce fatigue. Which statement indicates an understanding of the education?

Rest in an air-conditioned room. Explanation: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. -A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity

A client with myasthenia gravis has increased difficulty swallowing. Which action will the nurse take to prevent the aspiration of food? Offer three large meals a day. Assess the client's respiratory status before and after meals. Seek a change in the diet prescription from soft foods to clear liquids. Schedule meals with the peak effect of an anticholinesterase muscle stimulant.

Schedule meals with the peak effect of an anticholinesterase muscle stimulant.

Clinical man Sensory Man

Sensory manifestations -Numbness and tingling: parastethias - Pain -↓ Hearing -Vertigo and tinnitus - Chronic neuropathic pain -Lhermitte's sign: electric shock when flexing the neck Cognitive manifestations Difficulty with -Short-term memory attention -Attention -Information processing -Planning -Visual perception -Word finding Bowel and bladder functions may be impaired -Constipation -Variable urinary problems -Spastic bladder -Flaccid bladder: large capacity for urine/ learn self Cath

Clinical Man cont

Sexual dysfunction can occur in MS -Erectile dysfunction -Decreased libido -Difficulty with orgasmic response -Painful intercourse -Decreased lubrication Emotional manifestations -Anger -Depression -Euphoria

Nursing Management

•Assess fatigability, coping, respiratory status, cough and gag reflex and communication. •DX: Ineffective Airway Clearance, Impaired verbal communication, Activity intolerance and disturbed body image. •Plan Manage fatigue , maintain quality of life and medication education. •Interventions: Maintain a patent airway, drug therapy and decreasing symptoms. -Do intermittent activities throughout the day; they get tired towards the end of the day -Do most important things in the morning -Not much walking or playing sports can be done

Diagnosis

•Confirm dx of MG is the Tensilon Test (Edrophoneium chloride/ anticholinergic).: should cause increases muscle contraction -Have atropine as an antidote at beside if pt gets worse (cholinergic rxn) -H&P -NCS or EMG -Serologic testing for specific Anti-AChR antibodies

Risk factors

•Nonimmunized State •Chronic Illnesses •Environmental Factors •Medical Treatments •High-Risk Behaviors & Substance Abuse •Genetics •Preganacy

Elements of History

•PAST MEDICAL HISTORY -Family History -Vaccinations -Current Meds -Allergies -Behaviors -Occupation -Social environment