Complex Health Module 1

What lab can help diagnose MG and why?

thyroid function tests (free T3/T4) because thyrotoxicosis can mimic MG, so this helps rule out thyroid issues causing the s/s

What is usually the first sign of PD?

tremors / pill-rolling tremor of the fingers

What is the cause of MG?

unknown; there may be a genetic or environmental component

The average age of onset of MG in women is __ to __ yo; in men it's __ to __ yo.

women - 20-40 years old men - 60-80 years old

PD medications/dopaminergics: _____ is converted to dopamine in the brain. _____ can be combined with it to decrease its breakdown.

*Levodopa* is converted to dopamine in the brain. *Carbidopa* can be combined with it to decrease its breakdown.

What are the three risk factors for HD?

*R*ace: Caucasian *A*ge: 30-50 *G*enetics: dominant inheritance

What are the four risk factors for PD?

*S*ex: male *A*ge (40-70) *G*enetic predisposition *E*xposure to environmental toxins/antipsychotic meds

What are three major complications in HD?

-decisional conflict r/t whether to have children -aspiration pneumonia -altered cognition (dementia, memory deficits)/mobility

What are the four diagnostic tests for HD?

-genetic test -CT scan -MRI -PET scan

What are 4 cognitive manifestations of HD?

-progressive dementia (forgetfulness) -personality changes -mood swings -depression

What are the four diagnostic methods for MG?

-radiology (EMG, CT, chest xray, MRI) -immunologic assays -tensilon test -ice pack test

What are four nursing interventions to prevent aspiration pneumonia in patients with PD?

-swallowing precautions -dysphagia diet -prevent aspiration -adaptive eating devices

PD complications & nursing care

1. Aspiration pneumonia a. Swallowing precautions b. Diet per speech therapy, maintain weight (high calorie, high protein supplements), prevent aspiration c. Occupational therapist for adaptive eating devices 2. Altered cognition (dementia, memory deficits)/mobility a. Safe environment (no throw rugs, electric razor) b. Freezing gait can be an issue - triggered when turning around or walking through a door. Have the client march in place or step over lines, imaginary lines, or objects on the floor. Or take 1 step backward and 2 steps forward to stimulate walking. c. Emphasis on maintaining independence (optimal body function) - long term treatment i. Exercise, yoga, assistive devices, ROM exercises. ii. Pace activities, schedule activities later in the day d. Emphasis on fostering the ability to communicate. Monitor for depression, self-esteem issues e. Allow extra time to answer questions, encourage client to speak slowly & pause frequently Drug therapy, exercise programs, PT

HD complications & nursing care

1. Decisional Conflict r/t whether to have children a. Encourage testing for family 2. Aspiration pneumonia 3. Altered cognition (dementia, memory deficits)/mobility a. Suicide prevention with depression b. Many have issues with low body weight - encourage 3 meals/day, dietary supplements may be necessary c. Eventually will need help with all ADLs, confined to bed and unable to speak. Able to understand language and has awareness of family/friends. d. Encourage Planning for residential and EOL care!

The neurologist is conducting a Tensilon test in a client with muscle weakness, double vision, and ptosis. Which findings would indicate a positive result for MG? Optional Answers: 1. The patient experiences improved muscle strength. 2. The patient experiences worsening of the muscle weakness. 3. The patient experiences wheezing along with facial flushing. 4. The patient report a tingling sensation in the eyelids and ringing in the ears.

1. The patient experiences improved muscle strength.

Answer PD, HD, neither or both: 1. Chronic 2. Terminal/fatal 3. Auto-immune 4. Autosomal dominant 5. Death risk from immobility issues 6. Slurred speech 7. Difficulty swallowing

1. both 2. both 3. neither 4. HD 5. both 6. HD 7. both

Which client below with MG is MOST at risk for developing a cholinergic crisis? Optional Answers: 1. A client who reports not taking their pyridostigmine for 2 weeks. 2. A client reports taking a double dose of their pyridostigmine. 3. A client who reports skipping a day or two of their pyridostigmine. 4. A client who reports a respiratory infection and recently had left hip surgery.

2. A client reports taking a double dose of their pyridostigmine.

A patient with MG has the priority patient problem of inadequate nutrition. What assessment finding indicates that the priority goal for this patient problem has been met? Optional Answers: 1. Eating 75% of meals and between-meal snacks 2. Weight gain of 3 lbs (1.4 kg) in 1 month 3. Ability to chew and swallow without aspiration 4. Intake greater than output 3 days in a row

2. Weight gain of 3 lbs (1.4 kg) in 1 month

A patient with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best? Optional Answers: 1. "MG consists of trauma-induced paralysis of specific cranial nerves." 2. "MG is an inherited destruction of peripheral nerve endings and junctions." 3. "MG is an autoimmune problem in which nerves do not cause muscles to contract." 4. "MG is a viral infection of the dorsal root of sensory nerve fibers."

3. "MG is an autoimmune problem in which nerves do not cause muscles to contract."

You're a home health who needs to help a client with MG bathe and exercise. When would be the best time to visit the patient to help these tasks? 1. Evening 2. Before bedtime 3. Morning 4. Mid-afternoon

3. Morning

A patient with MG is prescribed pyridostigmine. What teaching should the nurse plan regarding this medication? Optional Answers: 1. "Take this drug on an empty stomach for best absorption because there is a risk of crisis." 2. "Your urine may turn a reddish-orange color while on this drug." 3. "The dose never changes, and you should plan on seeing your provider at least 1 time a year." 4. "Do not eat a full meal for 1 hour after taking the drug because there is a risk of choking."

4. "Do not eat a full meal for 1 hour after taking the drug because there is a risk of choking."

The nurse is caring for a client with myasthenia gravis and is contemplating possible nursing diagnosis. Which of the following is most appropriate? Optional Answers: 1. Risk for unstable blood glucose 2. Readiness for enhanced fluid balance 3. Risk for decreased cardiac output 4. Ineffective Airway clearance

4. Ineffective Airway clearance

The med list of a patient contains ocular lubricant, Aspirin, and Pyridostigmine. The nurse is aware that this client is diagnosed with Optional Answers: 1. Amyotrophic Lateral Sclerosis 2. Multiple Sclerosis 3. Parkinson's disease 4. Myasthenia gravis

4. Myasthenia gravis

Patients with PD should have a diet high in ___ and ____.

Patients with PD should havea diet high in *calories* and *protein.*

Which of the following diseases are hereditary, resulting in muscle weakness and wasting, and is treated with Tetrabenazine (Xenazine) to suppress the chorea? a. Parkinson's disease b. Lou Gehrig's disease c. Huntington's disease d. Amyotrophic lateral sclerosis (ALS)

c. Huntington's disease

An ablative procedure for PD destroys a small portion of the ___ ___ in the brain or the _____ through electrical stimulation through a burr hole. These two procedures (depending on the location) are called a ____ and a ____.

An ablative procedure for PD destroys a small portion of the *globus pallidus* in the brain or the *thalamus* through electrical stimulation through a burr hole. These two procedures are called a *pallidotomy* and a *thalamotomy.*

What do anticholinergics do? What are two anticholinergics for PD? What are four side effects to monitor in these meds?

Anticholinergics treat tremors. Trihexyphenidyl (Artane) Benztropine (Cogentin) Four SEs: dry mouth, constipation, urinary retention, acute confusion.

What foods contain tyramine?

Avocados, bean curd, bananas, cold cuts/sausages, cured fish, *aged cheese*, yeast, beers, protein supplements, soups, shrimp, soy sauce, *wine*

You are giving instructions to Mr. Cooper and his wife about maintaining mobility safely. You determine that they understand the priority directions if they state that Mr. Cooper will: A) Use a step stool to obtain difficult-to-reach items. B) Schedule his PT appointments in the evening. C) When rising from a seat, rock back and forth to start moving. D) Sit on a large, soft sofa with supportive pillows.

C) When rising from a seat, rock back and forth to start moving.

What do COMT inhibitors do? What is one COMT inhibitor for PD? What is an important SE to mention to patients?

taken with levodopa; decrease the breakdown of levodopa Entacapone (Comtan) Entacapone causes dark urine.

Cell transplantation is an experimental procedure for PD in which ___ ___ is transplanted.

Cell transplantation is an experimental procedure for PD in which *fetal tissue* is transplanted.

What other types of medication may be given to someone with HD aside from tetrabenazine?

Other antipsychotic meds to treat psych symptoms.

The cause of primary ___ is unknown; it may have a genetic or environmental component.

PD

Freezing of gait, cogwheeling, and a flexed trunk are manifestations of what disease?

Parkinson's

What are three invasive procedures for patients with PD who have not responded to other therapy?

Deep brain stimulation, Ablative procedures, Cell transplantation

What do dopamine agonists do? What are two dopamine agonists for PD? What are four side effects of these meds?

Dopamine agonists activate the release of dopamine. Pramipexole (Mirapex) and ropinirole (Requip) are dopamine agonists. Four SEs: orthostatic hypotension, drowsiness, dyskinesias, hallucinations

What is a nursing intervention for a patient with decisional conflict r/t whether to have children?

Encourage genetic testing for family.

T/F: There is a cure for myasthenia gravis.

False, there is no cure.

HD causes _____ _____, which are uncontrolled, rapid movements/ unsteady gait when sitting still in limbs, trunk, and facial muscles. Purposeful movement can mask these at times.

HD causes *choreiform movements*, which are uncontrolled, rapid movements/ unsteady gait when sitting still in limbs, trunk, and facial muscles. Purposeful movement can mask these at times.

HD is autosomal ____. There is a ___% chance of passing the gene with __% chance of faulty/expansion gene from a carrier that will develop into the disease.

HD is autosomal *dominant.* There is an *100%* chance of passing the gene with a *50%* chance of faulty/expansion gene from a carrier that will develop into the disease.

In deep brain stimulation (DBS) for Parkinson's, an electrode is implanted in the ____ and current is delivered through a generator.

In DBS for Parkinson's, an electrode is implanted in the *thalamus* and current is delivered through a generator.

In HD, the major issue is an imbalance of ___, ____, and ___ in the basal ganglia.

In HD, the major issue is an imbalance of *dopamine, glutamate, and GABA* in the basal ganglia.

In HD, the onset of symptoms is usually between ages __ to __. It is more common in the ____ race.

In HD, the onset of symptoms is usually between ages *30 to 50*. It is more common in the *Caucasian* race.

In HD, there is a gradual decline over about __ years. Juvenile symptoms can cause death within __ years.

In HD, there is a gradual decline over about *15* years. Juvenile symptoms can cause death within *10* years.

In PD, degeneration of the ____ ____ leads to a decrease in ____ production, which causes an increase in ____ stimulating the basal ganglia.

In PD, degeneration of the *substantia nigra* leads to a decrease in *dopamine* production, which causes an increase in *acetylcholine* stimulating the basal ganglia.

In PD, overstimulation of the ___ ___ by acetylcholine causes problems with smooth, controlled movements and _____ nervous system control.

In PD, overstimulation of the *basal ganglia* by acetylcholine causes problems with smooth, controlled movements and *sympathetic* nervous system control.

In PD, the onset of symptoms is usually between ages __ to __. It is more common in (women, men).

In PD, the onset of symptoms is usually between ages *40 to 70*. It is more common in *men.*

In PD, there is a (steady, rapid) decline over ___ to ___ (months, years).

In PD, there is a *steady* decline over *10-20 years.*

What do MAO-B inhibitors do for PD? What is one MAO-B inhibitor for PD? What is an important instruction for patients taking this drug?

Increase dopamine levels and help with wearing-off effect of levodopa. Selegiline Avoid foods with tyramine when taking MAO-B inhibitors like Selegiline.

What is the effect of DBS for PD?

It decreases tremors and involuntary movements.

Most patients with PD take a medication that combines what two drugs? What is a brand name?

Levodopa and carbidopa (Brand name: Sinemet)

What are the two indicators of PD in a brain autopsy?

Lewy bodies and neuronal loss in the substantia nigra

What is the life expectancy of people with MG?

Most have a normal life expectancy.

Does the muscle weakness in MG usual start peripherally or proximally? Aggravating and alleviating factor?

Muscle weakness is progressive and starts proximally and moved outward. It worsens with repetitive use and improves with rest.

Is HD more common in men or women?

Neither; it's equally common in men and women.

What are the types of MG?

Ocular MG - affects the eyes only Generalized MG - affects many muscles

What do antivirals do for PD? What is one antiviral drug for PD?

Stimulate the release of dopamine and prevent its reuptake. Amantadine

What is the main drug to treat the symptoms of HD? What does it do and how? What are four side effects of it?

Tetrabenazine (Xenazone) Suppresses involuntary chorea movements. It's a MAOI and it protects the neuron. Four SE: New/worsening depression, drowsiness, nausea, restlessness

How many stages are there of PD? What characterizes the first and last stages?

There are 5 stages of clinical manifestations. Stage 1 is mild shaking Stage 5 is completely dependent.

What neuroprotective/neurorestorative treatments are available for HD?

There are none. Treatment is focused on support and symptom management.

Treatment of PD focuses on _____ dopamine and ____ acetylcholine. It can take several ____ before symptom improvement.

Treatment of PD focuses on *increasing* dopamine and *decreasing* acetylcholine. It can take several *weeks* before symptom improvement.

T/F: MG is relatively uncommon.

True

T/F: There are no diagnostic procedures for PD; providers diagnose by clinical manifestations and ruling out other diseases.

True

T/F: Myasthenia gravis is a chronic, progressive autoimmune disease.

True.

T/F: There are no drugs to treat the process of HD; there are only drugs for symptom management.

True.

What are two situations that trigger freezing of gait? What are two interventions to overcome FoG?

Walking through a doorway or turning around can trigger it. Have patient march in place, or step over a line, imaginary line, or object on ground. Have patient take one step back and two forward to stimulate walking.

A nurse assesses a client who has Parkinson's disease. Which manifestations would the nurse recognize as a key feature of this disease? a. flexed trunk, uncontrolled drooling b. long, extended steps; pill rolling tremors c. tachycardia, shuffling gait d. depression, expression aphasia

a. flexed trunk, uncontrolled drooling

What are the three causes of secondary PD?

antipsychotic drugs, tumor, trauma

What are two major nursing complications for PD?

aspiration pneumonia and altered cognition/mobility

Which disease manifests in slurred speech difficulty swallowing, and weight loss (among other symptoms)? a. Parkinson's b. Huntington's c. ALS d. MG

b. Huntington's

A nurse plans care for a client with Parkinson's disease. Which priority intervention would the nurse include in this client's plan of care? a. Ambulate the client in the hallway twice a day. b. Keep the head of the bed at 30 degrees or greater. c. Teach the client pursed-lip breathing techniques. d. Ensure a fluid intake of at least 3 L/day.

b. Keep the head of the bed at 30 degrees of greater

The nurse is caring for a patient with Parkinson's disease and is contemplating a possible nursing diagnosis. Which of the following is most appropriate? a. risk for latex allergy response b. risk for injury c. risk for pressure ulcer d. chronic pain syndrome

b. risk for injury

What are usually the third signs of PD (two)?

bradykinesia (slow movement) and mask-like expression

How is a true diagnosis of PD made?

by brain autopsy

What is considered the most sensitive test for MG?

single-fiber electromyography

The student nurse asks what "to maintain optimal body function" means in a care plan for a patient with Parkinson's. What is the nurse's best response? a. "These clients can't breathe because of respiratory muscles declining. The goal focuses on the use of incentive spirometer for prevention. b. "The disease is autoimmune, so we need to discuss dying with dignity since there is no cure." c. "These clients can't stand or walk immediately when they are diagnosed. They need us to do everything." d. "Clients with Parkinson's live for years. Our goal focuses on good nutrition, exercise, and a safe and supportive environment."

d. "Clients with Parkinson's live for years. Our goal focuses on good nutrition, exercise, and a safe and supportive environment."

Which of the following of clinical manifestations of PD? a. loss of normal arm swing while walking, profound weakness in all extremities b. mask-like, blank expression; hyperacusis; tinnusitis c. cog wheel, jerky movement; increased thirst d. increased resistance to passive movement, tremors that occur most often at rest

d. increased resistance to passive movement, tremors that occur most often at rest

What is usually the first choice of procedures for PD?

deep brain stimulation

Who would a nurse consult for a dysphagia diet for a patient with PD? What about for adaptive eating devices

diet - speech therapy (SLP) adaptive eating device - occupational therapy (OT)

What indicates (advanced) HD in a CT scan?

enlargement of the frontal horns of the lateral ventricles

Is MG more common in men or women?

men

What is usually the second sign of PD?

muscle rigidity (ie rhythmic interruption, restrictive, or total resistance to movement)

What are two ways to make the environment safer for a patient with PD?

no throw rugs, use an electric razor

What is usually the fourth (last) sign of PD?

postural instability (difficulty chewing/swallowing, drooling)

How can muscle weakness cause death in MG?

respiratory failure

MG clinical manifestations

· Muscle weakness (in skeletal muscles - breathing & moving arms/legs) may be mild to severe (death from respiratory failure). Leads to muscle weakness like difficulty climbing stairs, lifting heavy objects, and raising arms over the head. Watch for issues with swallowing and chewing. o Muscles for eye and eyelid movement, facial expression, chewing, talking (nasal voice, slurred speech), are often involved. o 2/3 report vision issues and weakness of the eye muscles first! Ocular palsies, Ptosis (incomplete eyelid closure/drooping), Diplopia (double vision) o Progressive (proximal - closer to the body) muscle weakness that worsens with repetitive use and usually improves with rest. o Poor posture. Some have problems holding their head up o Respiratory compromise o Loss of bowel and bladder control Fatigue, muscle achiness, paresthesias, decreased/loss sense of smell (hyposmia/anosmia) and taste (hypogeusia/ageusia)