Cholinergic Crisis cause: overmedication Signs and symptoms: PNS, increased salivation risked for aspiration Treatment: anticholinergic

agents, atropine sulfate 2. Health teachings for energy conservation. To do this, the nurse can suggest that frequently used items (i.e. hygiene products, cleaning products, snacks) be keep on each floor to minimize travel between floors. Stress the need for frequent rest periods. 3. Prevention and management of complications such as aspiration. To minimize the risk of aspiration, mealtimes should coincide with the peak effects of anticholinesterase medication. Rest before meals is encouraged to reduce muscle fatigue. Sit upright during meals, soft foods in gravy or sauces can be swallowed more easily. 4. Health education for strategies to help with ocular manifestations. To prevent corneal damage when the eyelids do not close completely, the patient is instructed to tape the eyes closed for short intervals and to regularly instill artificial tears. 5. Advise patients to wear a medical alert bracelet that identifies them as having MG and to carry a card that has information regarding their medications and primary care physician. Instruct them to call the doctor if weakness develops or facial or upper eyelid drooping occurs, as it could herald an exacerbation of symptoms. 6. Suggest to patients that they wear sensible shoes to combat muscle fatigue and potential loss of balance. Encourage them to eat regular, balanced meals to prevent fatigue from lack of protein.

MULTIPLE SCLEROSIS Multiple sclerosis (MS) or disseminated sclerosis is characterized by chronic inflammation, dmyelination, and scarring (gliosis) of the myelin sheath of the central nervous system (CNS). The manifestations of the disease vary from a benign disease to a rapidly progressive and disabling illness that has a profound effect on physical function and quality of life.

There are four categories of Multiple Sclerosis based on clinical course:

Relapsing-remitting MS (RRMS); 80% of all cases. It is characterized by

recurrent attacks of neurological dysfunction that evolve over days to weeks ad may be followed by complete, partial, or no recovery; there is no progression of symptoms between attacks; this pattern is often seen in the early course of the disease and is the most common form seen.
Secondary progressive MS. There is gradual neurological deterioration

with or without acute relapses, minor remissions, and plateaus in a patient who previously had RRMS.
Progressive-relapsing MS. From the onset, there is gradual progression

of disability; unlike RRMS, there is continuing disease progression without stabilization of the disease.
Primary progressive MS. A pattern of gradual neurological deterioration

from the onset of symptoms, but with superimposed relapses noted. Etiology: Predisposing factors:

Age: The onset of MS is usually between 20-40 years old. incidence is observed in these ages.

Highest rate of

Gender: Women are commonly affected twice the rate of men. Geographical Location: Prevalence rate increasing at higher latitudes; far from equator such as Northern Europe, Norther USA, Canada, Canada, Atlantic & etc. Low levels of Vitamin D is evidenced in these areas due to decrease sun exposure. Prospective studies have confirmed that Vitamin D deficiency is associated with increase in MS risk.

Race: Whites are affected more frequently than any other racial group.

Genetics: Evidence also supports an important genetic influence on MS. The MHC on chromosome 6 is the strongest susceptibility region in the genome. One of the definite genes identified is the (HLA)DR2 carriership, which is associated with an increased risk for MS.

Predisposing Factors:

Viral Infection: A virus or single infections can cause the condition. Immune Mechanism: The destruction in the CNS, including demyelination and axonal loss involves the immune mechanism.

Stress: Studies show that stress reduces the immune system of a person and increases risk of having MS.

Occupational Exposure: Exposure on toxins or free radicals, increases risk of having MS due to decrease immune system.

Incidence: An estimated 2,500,000 people in the world have multiple sclerosis. Research suggests the proportion of women with MS is increasing and that roughly three women have MS for every man with the condition. The distribution of MS around the world is uneven. Generally, the prevalence increases as you travel further north or south from the equator. Those parts of Asia, Africa and America that lie on the equator have extremely low levels of MS, whilst Canada and Scotland have particularly high rates. Signs and Symptoms: The signs and symptoms of MS vary greatly from patient to patient and can vary over time in the same patient. The most common initial signs include fatigue, nystagmus, vertigo, gait disturbances, sensory loss, lower extremity weakness, spasticity, bladder disturbance, and optic neuritis. Other symptoms that may present at

any time during the course of the disease include cognitive changes such as euphoria or depression, and physical conditions such as muscle cramping and sexual dysfunction The symptoms of MS are listed in four categories: sensory, motor, cerebellar, and miscellaneous. Sensory: Numbness/ sensory loss Paresthesia pain Loss of proprioception Lhermittes sign (an electrical sensation that runs down the back when bending the neck, are particularly characteristic of MS although not specific) Motor: -

Paresis paralysis dragging of foot spasticity (Muscle spasms are a common and often debilitating symptom of MS. Spasticity usually affects the muscles of the legs and arms, and may interfere with a persons ability to move those muscles freely)

diplopia bladder and bowel dysfunction

Cerebellar Symptoms: ataxia loss of balance and coordination speech disturbances(dysarthria, dystonia, scanning of speech, slurred speech) tremors (intentional tremors, described as tremors that increase when a purposeful act is initiated)

vertigo (sometimes accompanied by vomiting and nystagmus)

Other symptoms: fatigue optic neuritis impotence or decrease genital sensation and sexual dysfunction neurobehavioral disorders such as depression or euphoria 4% of patients experience paroxysmal attacks, visual loss, trigeminal neuralgia, facial palsy Pathophysiology: This inflammation is caused by the T-cells which are cells that play a crucial role in the bodys defences. In MS T-cells manage to infiltrate into the brain via the bloodbrain barrier, which is both a physical barrier and system of cellular transport. This barrier is not normally accessible to T-cells, unless it is affected by a virus, which reduces the strength of the junctions forming the barrier. T-cells remain then locked inside the brain, wrongly perceiving myelin as an alien agent and attack it as if it were a virus. This generates inflammatory processes and further damaging effects such as swelling and activation of other immune cells and antibodies.

Complications: In some cases, people with multiple sclerosis may also develop: Depression Difficulty swallowing Mental changes, such as forgetfulness or difficulties concentrating Paralysis, most typically in the legs Bladder and Urinary Dysfunction: Incontinence, or an involuntary loss of urine, can also appear in MS patients, not necessarily due to the direct action of multiple sclerosis but due to a combination of MS complications

Sexual Dysfunction: Sexual problems in people with MS can result from a multiple sclerosis attack on the part of the brain that controls sexual function or the nerves that send impulses to the sex organs.

Osteoporosis or thinning of the bones (Because the condition also creates mobility
and spacticity problems, some people with MS are more prone to falling, which also increases their chances of breaking a bone. )

Pressure sores due to immobility

Diagnostic Exams:

Comprehensive Medical History Neurological Exams Magnetic Resonance Imaging (MRI) to rule out other conditions Expected result for patients with MS: white matter lesions (plaques) identified this is considered the best test for diagnosing MS may be used to help diagnose a wide variety of diseases and conditions affecting the central nervous system (CNS) -

Cerebrospinal fluid (CSF) Analysis -

Uncovers signs of inflammation and myelin breakdown Expected Result: Elevated IgG index or synthesis rate and Presence of Oligocional band (Oliogcional band are discrete electrophoretic bands that are frequently found in the CSF of almost all [90-97%] of MS)

Visual Evoked potentials (VEP) It may be used to help diagnose conditions affecting the central nervous system (CNS)

In this test, the doctor is looking for both size of the response and the speed in which the brain receives the signal weaker or slow signals may indicate the demyelination has occurred and that MS is a possibility.

Identifies lesions in sensory pathway; may help identify lesion not easily visualized by MRI; for example, optic nerve Expected Result: Slowed Conduction

Schumacher Criteria
-

It is based on the neurologic history and examination. It includes the

following: Neurological examination that reveals objective abnormalities attributable to the CNS White matter involvement Two or more sites of CNS involvement
Relapsing-remitting or chronic (>6mos) progressive course each lasting 24

hours and at least 1 month apart, or a gradual or stepwise progression over at least 6 months
Age at onset of 10-50 years old

No better explanation of symptoms

Medical Management: Drug Therapy Disease-Modifying Drugs- reduces the frequency of relapses and potentially delay progression Immunomodulator/ Interferons: These medications are injected either subcutaneously or intramuscular. Side Effects: flu-like symptoms, erythema to pain on injections site, menstrual irregularities and nausea

 Interferon beta-1b (Betaseron) - used to treat ambulatory patients with relapsing-

remitting MS and Secondary -progressive MS

Interferon beta 1a (Avonex) - treats relapsing forms of MS as well as initial MS

attack Interferon beta 1a (Rebif) treats relapsing forms of MS. Immunomodulator: Glatiramer acetate (Copaxone) - treats relapsing-remitting forms Antineoplastic/ Immunosuppressive Mitoxantrone (Novatrone) Used to treat the secondary progressive, progressive-relapsing, and worsening relapsing-remitting forms of MS It is administered intravenously every 3 months This blue color fluid may cause a bluish tinge in urine and in the whites of the eyes Use of this drug for 2 and half years increases the risk of cardiac toxicity. Monoclonal Antibody Natalizumab (Tysabri) It is given to patient in relapsing forms who have inadequate response or who cannot tolerate other disease-modifying treatment. Treatment of Selected symptoms of MS CNS Stimulants o Pemoline and Modafinil Treatment for fatigue Genitourinary Antispasmodics o Oxybutynin (Ditropan) and Tolterodine tartrate (Detrol) Treatment for bladder function Skeletal Muscle Relaxant

o Oral or intrathecal baclofen Treatment for spasticity

Nursing Management: 1. Promote physical mobility 2. Prevent injury 3. Enhance bladder and bowel control 4. Enhance communication 5. Manage feeding difficulties 6. Provide emotional and psychological support for the patient and family. 7. Assess patients neurologic status for deficits. 8. Administer medications as needed. 9. Increase patient comfort with massages and relaxing baths. 10. Promote emotional stability. Help the patient establish a daily routine to maintain optimal functioning. 11. Provide proper skin care as the patient is prone in decubitus ulcers as the demyelination progresses. 12. Encourage adequate fluid intake and regular urination. 13. Teach the patient about bowel and bladder training if necessary.

The following may also be helpful for people with MS: 1) Physical therapy, speech therapy, occupational therapy, and support groups 2) Assistive devices, such as wheelchairs, bed lifts, shower chairs, walkers, and wall bars 3) A planned exercise program early in the course of the disorder 4) A healthy lifestyle, with good nutrition and enough rest and relaxation 5) Avoiding fatigue, stress, temperature extremes, and illness 6) Changes in what you eat or drink if there are swallowing problems 7) Making changes around the home to prevent falls 8) Social workers or other counseling services to help you cope with the disorder and get assistance (such as Meals-on-Wheels)

Nursing Diagnosis:
Impaired Physical Mobility r/t muscle weakness and ataxia

Determine the level of client activity and assess the weaknesses Assist patient to ambulate and perform ADLs to provide assessment of abilities
Facilitate transfer training by using appropriate assistance of persons or

devices when transferring patient to bed, chair or stretcher.

Encourage appropriate use of assistive devices in the home setting Keep side rails up and bed in low position to promote a safe environment Support affected body parts/joints using pillows/ rolls to maintain position

of function and reduce risk of pressure ulcers.

Use padding and positioning devices to prevent stress on tissues and

reduce potential for disuse complications.

Encourage and facilitate early ambulation and other ADLs when possible Perform passive range of motion exercise to promote strength, mobility,

and proper circulation Administer Antispasmodic medications (Baclofen) to reduce muscle spasms or spasticity that interfere with mobility.
Risk for Injury r/t weakness, incoordination and sensory/ perceptual deficits

Ambulate patient to evaluate gait, ataxia and potential for falling Raise the side rails to enhance safety and prevent from fall Instruct to use mobility aids such as cane, walker or wheelchair to help prevent injury, provide security and increase independent movement.
Turn/position patient frequently from side to side. To prevent acquiring bed

sore and promotes ventilation and circulation Keep away sharp objects such as knife, needle from bedside to promote safe physical environment and individual safety Assist patient during ambulation
Constipation

 Promote adequate fluid intake; 8 glasses/day or 2000 to 3000 ml/day. Encourage increase fiber in diet (e.g., raw fruits, fresh vegetables) to

improve consistency of stool and facilitate passage through colon

Encourage activity or exercise within limits of individuals ability to

stimulate contractions of the intestines. Provide sitz bath after stools for soothing effect to rectal area.
Encourage patient to consume prunes, prune juice, cold cereal, and bean

products. These are natural cathartics because of their high-fiber content.

Encourage a regular time for elimination. Encourage isometric abdominal and gluteal exercises.

Restrict intake of caffeinated beverages, such as coffee, tea, colas or energy drinks, if indicated. Diuretic effect of caffeine can reduce fluid available in the bowel, thus increasing the risk of dry, hard-formed stool.

Self-Care Deficits Establish rapport to the client. Promote client participation in problem identification and decision making Determine strengths and skills of individual Provide for communication among those who are involved in caring for the client to enhance coordination and continuity of care. Assist with activities of daily living Assist patient when removing or replacing clothing. Maintain privacy during bathing.

Guillain-Barr Syndrome
Definition Neuropathy is a general term indicating a disorder of the nervous system. Peripheral neuropathy is the term for damage to nerves of the peripheral nervous system. The most common form is (symmetrical) peripheral polyneuropathy, which mainly affects the feet and legs.

In a polyneuropathy, many nerve cells in different parts of the body are affected, without regard to the nerve through which they pass. Not all nerve cells are affected in any particular case.