Chapter 21 Drugs for Neuromuscular Disorders and Muscle Spasms

Multiple Sclerosis Symptoms

1) optic neuritis 2) motor and sensory problems 3) bladder defects (atonic bladder) 4) fatigue 5) hyperreflexia 6) spasticity 7) depression

A patient is prescribed carisoprodol (Soma) for relief of muscles spasms. What does the nurse instruct the patient to avoid while taking carisoprodol? A. Beer B. Coffee C. Grape juice D. Orange juice

A Alcohol can cause central nervous system depression and should be avoided while taking carisoprodol (Soma). There is no need to avoid coffee, grape juice, or orange juice while taking the drug.

A patient taking pyridostigmine (Mestinon) develops symptoms of a cholinergic crisis. What action does the nurse anticipate performing next? A. Administer atropine. B. Administer epinephrine (Adrenalin). C. Increase the dose of pyridostigmine (Mestinon). D. Monitor the patient's blood pressure.

A Atropine is the antidote for treating a cholinergic crisis. Administering epinephrine (Adrenalin) will not be effective nor will increasing the dosage of the pyridostigmine (Mestinon). Monitoring the patient's blood pressure will not alleviate the cholinergic crisis.

The nurse is providing medication instructions to a patient with acute muscle spasms who has been prescribed cyclobenzaprine (Flexeril). Which statemtn indicates to the nurse that the patient understands the instructions? A. I plan to take this medication with a glass of milk B. Cyclobenzaprine should be taken once daily at bedtime C. I will only drink one glass of wine a day D. I will not be able to drink grapefruit juice while taking this drug

A I plan to take this medication with a glass of milk

The nurse is caring for a patient who is experiencing a myasthenic crisis. What is the primary nursing intervention? A. Maintain the patient's airway. B. Administer atropine. C. Administer naloxone hydrochloride (Narcan). D. Monitor muscle strength.

A Muscle weakness can affect the airway, and maintaining the airway is the primary priority. Asphyxiation is the primary threat to the patient's life; therefore, maintaining the airway is paramount. Neither atropine nor naloxone hydrochloride (Narcan) will alleviate the crisis.

A patient newly diagnosed with myasthenia gravis (MG) is started on neostigmine (Prostigmin). What is the most important nursing intervention for this patient? A. Administer the drug on time. B. Teach the patient to take the drug with food. C. Assess the patient's temperature daily. D. Teach the patient to rise slowly.

A Neostigmine (Prostigmin) is an acetylcholinesterase inhibitor with a short half-life. It is administered every 2 to 4 hours and must be given on time to prevent muscle weakness. It is not required to administer the drug with food, and the drug should not affect the patient's temperature nor result in orthostatic hypotension.

Acetylcholine

A neurotransmitter that enables learning and memory and also triggers muscle contraction

Which instructions will the nurse include in the teaching plan for a patient who is taking pyridostigmine (Mestinon)? (Select all that apply) A. Pyridostigmine bromide must be taken on time B. Take 2 times per day C. Underdosing can result in myasthenic crisis D. Overdosing can result in cholinergic crisis E. Report the adverse effect of tachycardia to the health care provider

A, C, D Pyridostigmine bromide taken on time, underdosing can result in myasthenic crisis, and overdosing can result in cholinergic crisis

The nurse is teaching a patient recently diagnosed with multiple sclerosis about the disease. Which statement is not correct concerning multiple sclerosis? a. The disease has periods of exacerbations followed by periods of remissions. b. Goals of treatment are to decrease the inflammation in the nervous system. c. Patients experience muscle weakness, fatigue, vision and emotional problems. d. Multiple sclerosis is an autoimmune disorder that causes plaque to develop.

A. The disease has periods of exacerbation followed by periods of inflammation

The patient is admitted to the emergency department with cholinergic crisis. The nurse anticipates administration of A.atropine. B.baclofen. C.edrophonium. D.neostigmine.

A.atropine.

A patient with myasthenia gravis is prescribed neostigmine. The nurse identifies that the medication is effective when the patient experiences A.increased muscle strength. B.decrease in sweating and salivation. C.change in vital signs to within normal limits. D.a decrease in generalized pain.

A.increased muscle strength.

The nurse is caring for a patient who has been diagnosed with multiple sclerosis. The health care provider opts to include baclofen (Lioresal) as part of this patient's treatment regimen. The nurse recognizes that this is an appropriate medication for this patient because the drug will treat which symptom? A. Muscle deterioration B. Muscle spasticity C. Muscle aching D. Muscle wasting

B Baclofen (Lioresal) is a muscle relaxant that is used to treat the spasticity of the muscles that occurs with multiple sclerosis. It does not specifically address muscle aching nor deterioration of muscle tissue.

The health care provider orders pyridostigmine bromide (Mestinon) for a patient. Which assessment will help confirm the therapeutic outcome for this medication? A. Ability to walk B. Increased muscle strength C. Decrease in pain D. Clear vision

B Pyridostigmine (Mestinon) is given to increase muscle strength. It will not actually provide the ability to walk and will not decrease pain or provide clear vision.

A mechanically ventilated patient receiving a neuromuscular blocking agent has tearing in the eyes and increased heart rate and blood pressure. What is the nurse's initial action? A. Stop the medication; the patient is having an adverse reaction to the medication. B. Notify the physician; patient's level of sedation is inadequate. C. Notify the physician; patient's dose of the neuromuscular blocking agent is too high. D. Document findings and monitor; these effects are expected.

B Tearing in eyes and increased heart rate and blood pressure are symptoms of increased anxiety and/or pain. A patient receiving a neuromuscular blocking agent cannot move or communicate; thus, the nurse must rely on subtle changes to assess adequate sedation. Simply documenting findings or monitoring will not relieve the patient's symptoms.

A patient is beginning to take cyclobenzaprine (Flexeril) for treatment of acute back spasms. Which interventions will the nurse include in the care of this patient? (Select all that apply) A. Advise the patient to take this drug on an empty stomach B. Inform the patient that muscular pain is usually relieved within 1 week C. Tell the patient to report dizziness and double vision to the health care provider D. Advise the patient to avoid alcohol E. Taking narcotics at the same time can cause serious side effects

B, C, D , E Muscular pain relieved in 1 week, report dizziness and double vision, avoid alcohol, and taking narcotics at the same time and cause serous s/e

A patient with multiple sclerosis is being treated with large doses of corticosteroids. Which nursing diagnosis would be the priority at this time? A.Alteration in nutrition: less than body requirements B.Risk for infection C.Ineffective individual coping D.Fatigue

B. Risk for infection

A nurse is caring for a patient prescribed neostigmine (Prostigmin) orally. Which instruction will the nurse include in the patient's plan of care? A. Administer neostigmine every 8 hours. B. Monitor for onset of action in 4 hours. C. Monitor the patient for respiratory depression. D. Make sure that naloxone hydrochloride (Narcan) is readily available.

C Neostigmine (Prostigmin) is a fast-acting AChE inhibitor that, when administered orally, has an onset of action of 0.5 to 1 hour; it is given every 2 to 4 hours. The nurse should monitor the patient for respiratory depression, which is a life-threatening adverse effect. Atropine is the antidote for a cholinergic crisis.

The nurse is caring for a patient who is diagnosed with myasthenia gravis. The patient is experiencing muscle weakness, dyspnea, bradycardia, and diaphoresis. The nurse anticipates that the health care provider will order with medication to distinguish between myasthenia crisis and cholinergic crisis? A. adrenocorticotropic hormone (ACTH) B. diazepam (Valium) C. edrophonium chloride (Tensilon) D. mitoxantrone (Novantrone)

C edrophonium chloride (Tensilon)

The nurse is reviewing a patient's medication history for a patient who has just been prescribed cyclobenzaprine (Flexeril) for treatment of back spasms. The nurse is taking which medication? A. atorvastatin calcium (Lipitor) B. conjugated estrogen (Premarin) C. phenelzine (Nardil) D. penicillin G procaine (Crysticillin, Wycillin)

C phenelzine (Nardil)

A patient with myasthenia gravis comes to the emergency department in respiratory distress. To determine if the patient is in myasthenic crisis or cholinergic crisis, the nurse anticipates administration of which drug? A.Diazepam B.Baclofen C.Edrophonium D.Neostigmine

C. Edrophonium

A child with cerebral palsy is ordered to receive baclofen. The nurse is aware that this medication is prescribed to A.induce sleep and rest. B.increase appetite. C.reduce muscle spasticity. D.increase bowel function.

C. reduce muscle spasticity

Progressive-relapsing MS

Characterized by progressive disease from onset but without clear, acute relapses that may or may not have some recovery or remission; seen in individuals who develop the disease after the age of 40

Skeletal Muscle Relaxants

Cyclobenzaprine ➢Action •Relax skeletal muscles ➢Use •Relieves muscle spasm ➢Side effects •Anticholinergic effects (blurred vision, dry mouth, tachycardia, urine retention, constipation) •Drowsiness, dizziness •Headache, nervousness, confusion •GI distress, unpleasant taste •Dysrhythmias

The patient has been prescribed tizanidine (Zanaflex) and complains of experiencing a dry mouth. What is the nurse's highest priority action? A. Notify the health care provider; this is indicative of an anaphylactic reaction. B. Monitor the patient closely for additional unexpected side effects of the drug. C. Notify the pharmacist; the patient may be receiving too high a dosage of the drug. D. Instruct the patient to use sugar-free lozenges to moisten his mouth.

D Dry mouth is an expected side effect of treatment with tizanidine (Zanaflex) and should not be considered to be indicative of anaphylactic reaction or an overdosage of the drug.

The patient is scheduled to receive a dose of pancuronium bromide (Pavulon) prior to undergoing tracheal intubation. The nurse recognizes that this is an appropriate choice for the patient because pancuronium is which type of drug? A. Anxiolytic B. Anti-spasticity drug C. Central acting muscle relaxant D. Depolarizing muscle relaxant

D The drug is a neuromuscular blocking agent that functions as a depolarizing muscle relaxant and thus is appropriate to be used prior to tracheal intubation.

The nurse anticipates that the health care provider will prescribe which medication to treat a patient with multiple sclerosis in the chronic progressive phase? A. ambenonium (Mytelase) B. interferon B-la (Avonex, Rebif) C. glatiramer acetate (Copaxone) D. cyclophosphamide (Cytoxan)

D cyclophosphamide (Cytoxan)

A patient with myasthenia gravis comes to the emergency department in respiratory distress. He has been diagnosed with myasthenic crisis. The nurse anticipates administration of which drug? A.Diazepam B.Baclofen C.Edrophonium D.Neostigmine

D. Neostigmine

Azathioprine

Immunosuppressant

muscle spasticity

Increased muscle tone (rigidity) with sustained muscle contractions (spasms); stiffness or tightness may interfere with gait, movement, speech.

Acetylcholinesterace inhibitors-action

Increases muscle strength in patients with myasthenia gravis

Cyclobenzaprine

Muscle Relaxant

Orphenadrine Citrate

Muscle Relaxant

Clinically Isolated Syndrome (CIS)

Not clinically definite MS First neurologic episode that lasts at least 24 hours, and is caused by inflammation/demyelination in one or more sites in the central nervous system (CNS).

Nursing Process: Cyclobenzaprine

Nursing Interventions ➢Monitor serum liver enzyme levels. ➢Observe for CNS side effects. ➢Teach patient not to stop abruptly but taper off over 1 week. ➢Teach patient to avoid alcohol and CNS depressants. ➢Inform patient that most of the centrally acting muscle relaxants for acute spasms are usually taken no longer than 3 weeks.

Cholinergic Crisis

Overdose with acetylcholinesterase inhibitors causes excessive muscarinic stimulation & respiratory depression. Treat with IV atropine; supportive care - oxygen, mechanical ventilation.

Cholinergic Crisis Triggers

Overdosing

Acetylcholinesterase inhibitors

Promote the accumulation of acetylcholine, resulting in prolonged cholinergic effects

Cholinergic Crisis

The client presents with increased muscle weakness and twitching due to administration of tensilon

Cholinergic Crisis

Usually occurs within 30 to 60 minutes after taking excess anticholinergic medications

myasthenia gravis (MG)

a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles

Neostigmine

a drug that inhibits the activity of acetylcholinesterase

Fasciculations

a localized, uncoordinated twitching of a single muscle group innervated by a single motor nerve filament; it is visible or palpable (involuntary)

The nurse is providing medication instructions to a patient with acute muscle spasms who has been prescribed cyclobenzaprine. Which statement indicates to the nurse that the patient understands the instructions? a. I plan to take this medication with a glass of milk. b. Cyclobenzaprine should be taken once daily at bedtime. c. I will only drink one glass of wine a day before taking. d. I will be able to take this drug with grapefruit juice.

a. I plan to take this medication with a glass of milk.

Which instructions will the nurse include in the teaching plan for a patient who is taking pyridostigmine? (Select all that apply.) a. Pyridostigmine must always be taken on time. b. Take the prescribed dose every other week. c. Underdosing can result in myasthenic crisis. d. Overdosing can result in cholinergic crisis. e. Report the adverse effect of tachycardia to the health care provider (HCP).

a. Pyridostigmine must always be taken on time. c. Underdosing can result in myasthenic crisis. d. Overdosing can result in cholinergic crisis.

When the nurse explains the pathophysiology of myasthenia gravis to a patient, which is the best explanation? a. Degeneration of cholinergic neurons and a deficit in acetylcholine lead to neuritic plaques and neurofibrillary tangles. b. A decreased amount of acetylcholine to cholinergic receptors produces weak muscles and reduced nerve impulses. c. Myelin sheaths of nerve fibers in the brain and spinal cord develop lesions or plaques affecting the nervous system. d. An imbalance of dopamine and acetylcholine leads to degeneration of neurons in midbrain and extrapyramidal motor tracts.

b. A decreased amount of acetylcholine to cholinergic receptors produces weak muscles and reduced nerve impulses.

A patient with multiple sclerosis is having muscle spasticity. The nurse anticipates which drug will be prescribed to treat the patient's spasticity? a. Neostigmine b. Ropinirole c. Cyclobenzaprine d. Pyridostigmine

c. Cyclobenzaprine

Spasticity

continuous resistance to stretching by a muscle due to abnormally increased tension, with increased deep tendon reflexes

The nurse anticipates that the health care provider will prescribe which medication to treat a patient with relapsing remitting multiple sclerosis? a. Ambenonium b. Pyridostigmine c. Mitoxantrone d. Glatiramer acetate

d. Glatiramer acetate

Multiple Sclerosis (MS)

disease of the central nervous system characterized by the demyelination (deterioration of the myelin sheath) of nerve fibers, with episodes of neurologic dysfunction (exacerbation) followed by recovery (remission)

Secondary Progressive MS

initial relapsing-remitting MS that suddenly begins to have decline without periods of remission

muscle spasm

involuntary muscle contraction

plaques

mounds of fat, mixed with minerals, that build up along artery walls in atherosclerosis.

Myasthenia Crisis vs. Cholinergic Crisis

myasthenia crisis: low dose of meds = RESP. EMERGENCY increased RR/pulse rise in BP Anorexia Cyanosis Bowel/bladder incontinence Decrease UO Unable to cough or swallow Cholinergic crisis: too much Ach Small pupils Salvation Diarrhea N/V Abdominal cramps Increased bronchial secretions, sweating Lacrimation: tears SOB-->bronchospasms Bradycardia Facial muscle twitching

muscle relaxants

relieve muscle spasms and stiffness

Primary Progressive MS

steady increase in disability without attacks

Immunomodulators

treat moderate to severe rheumatoid arthritis by disrupting the inflammatory process and delaying disease progression

Acetylcholine is a neurotransmitter that

triggers muscle contractions

Relapsing-remitting MS

unpredictable attacks which may or may not leave permanent deficits followed by periods of remission

myasthenia crisis treatment

withdrawal anticholinesterases (pyridostigmine) and intubate looking at vitals

Pyridostigmine

•Concept ➢Sensory perception •Assessment ➢Assess for evidence of overdosing/underdosing, such as muscle weakness with difficulty breathing and swallowing. •Patient problems ➢Decreased gas exchange, reduced motor function •Planning ➢The patient's muscle weakness will improve with timely administration of pyridostigmine. •Nursing interventions ➢Monitor drug effectiveness. ➢Observe patient for signs and symptoms of cholinergic crisis ➢Encourage patient to wear medical identification. ➢Teach patient side effects and when to notify health care provider. ➢Advise patient to report recurrence of symptoms of MG to health care provider.

Multiple Sclerosis Drug Treatment

•Immunomodulators ➢First-line treatment ➢Slows disease progression and prevents relapses •Immunosuppressants •Sphingosine 1-phosphate receptor modulator •Monoclonal antibody •Corticosteroids ➢Reduces edema and acute inflammation

Myasthenic Crisis triggers

•Inadequate dosing of AChE inhibitors •Emotional stress, menses, pregnancy •Infection, surgery, trauma •Hypokalemia, alcohol intake •Temperature extremes •Medication interactions

Patients Unresponsive to Acetylcholinesterase Inhibitors

•Prednisone ➢Drug of choice •Plasma exchange •Intravenous immune globulin •Immunosuppressive drugs ➢Azathioprine •Need to monitor for leukopenia and hepatoxicity

cholinergic crisis symptoms

•Severe muscle weakness •Possible respiratory paralysis and arrest •Abnormal pupil constriction •Pallor, sweating, vertigo •Excess salivation, GI distress •Bradycardia, fasciculations

Myasthenia Gravis Pathophysiology

➢Autoimmune disorder ➢Antibodies attach to acetylcholine receptor sites, obstruct binding of acetylcholine, and destroy receptor sites ➢Lack of acetylcholine impairs transmission of messages at neuromuscular junctions •Leads to ineffective muscle contraction and muscle weakness •Leads to weakness of respiratory, facial, and extremity muscles

Multiple Sclerosis-Pathophysiology

➢Autoimmune disorder ➢Attacks myelin sheath of nerve fibers in brain and spinal cord ➢Causes lesions (plaques)

Skeletal Muscle Relaxants

➢Centrally acting muscle relaxants •Relieves muscle spasm and spasticity •Have sedative effect ➢Direct acting muscle relaxant •Decreases muscle spasm pain and increases range of motion •Ssuppresses hyperactive reflex ➢Side effects •Drowsiness, dizziness, headache, nausea, vomiting

Multiple Sclerosis-Diagnosis

➢Medical history ➢Neurologic exam ➢MRI ➢Measure electrical brain activity ➢Cerebrospinal fluid analysis

Acetylcholinesterase Inhibitors-side effects

➢Miosis ➢Blurred vision ➢Bradycardia ➢Hypotension ➢GI distress •Nausea, vomiting, diarrhea, abdominal cramps

Acetylcholinesterace inhibitors

➢Neostigmine •Short-acting ➢Pyridostigmine •Intermediate-acting

Multiple Sclerosis-Classifications

➢Relapsing remitting •Relapse with full recovery and residual deficit ➢Primary progressive •Slowly worsening neurologic function with no relapses or remissions ➢Secondary progressive •Initial course is relapsing remitting, then progression with or without occasional relapses, minor remissions, and plateaus ➢Progressive relapsing •Progressive from onset with acute relapses with or without full recovery

Multiple Sclerosis-Characteristics

➢Remissions and exacerbations ➢Weakness or paralysis of extremities, fatigue ➢Muscle spasticity, paresthesia ➢Dysarthria, dysphagia, ataxia, vertigo ➢Diplopia, blurred vision, nystagmus, tinnitus

Myasthenic Crisis

➢Severe generalized muscle weakness •Involves diaphragm and intercostal muscles

Myasthenia Gravis Characteristics

➢Skeletal muscle weakness ➢Fatigue, ptosis, diplopia ➢Dysphagia, dysarthria ➢Respiratory muscle weakness, paralysis, and arrest