Medical-Surgical Nursing: Myasthenia Gravis

Focus Topic: Medical-Surgical Nursing

Definition: This is a progressive autoimmune disorder caused by decreased levels of acetylcholine and damage to the nerve impulses.

Signs and Symptoms: Muscle weakness, diplopia (double vision), ptosis (drooping of the eyelids), difficulty swallowing, loss of bowel and urinary function, impaired breathing, fatigue, and twitching.

Diagnostics: Tensilon test (i.e., when IV Tensilon is administered, temporary relief of muscle weakness occurs); electromyography is used to evaluate muscle responses to various stimuli; CT or MRI of the brain; lab work to obtain acetylcholine levels.

Complications: Respiratory failure, paralysis, and worsening of symptoms. Two different crises may occur: a cholinergic crisis or a myasthenic crisis. A cholinergic crisis is a toxic side effect of anticholinesterase medication. Symptoms are nausea, vomiting, diarrhea, decreased BP, muscle spasms, and visual changes. If this occurs, anticholinesterase medications are held, and the antidote atropine, which should be kept at the bedside, should be administered. Myasthenic crisis occurs when there is muscle weakness and respiratory failure. Symptoms are shortness of breath, labored breathing, respiratory failure/distress, decrease in O2 levels, increased BP/HR, and difficulty swallowing. This is considered a medical emergency, and mechanical ventilation may be needed. Anticholinesterase medications are administered, as well.

Drug Therapy: Anticholinesterase medications such as neostigmine (Prostigmin) and pyridostigmine (Mestinon) are administered. Corticosteroids or plasmapheresis may also be used.

Nursing Care: Proper medication administration is crucial to avoid crises. Use diagnostic tests to determine what type of crisis is occurring. Treat respiratory distress or any changes immediately. Myasthenic crisis is a medical emergency. Maintain airway and oxygen levels. Aspiration precautions are in place. Assist patients with walking, using assistive devices when needed. Adequate rest periods are needed to decrease fatigue. Visual changes such as ptosis and diplopia can become severe, so provide a safe environment. Provide a high-calorie diet with adequate hydration.

Medical-Surgical Nursing: Guillain-Barré Syndrome

Focus Topic: Medical-Surgical Nursing


Medical-Surgical Nursing


Definition: This condition involves destruction of the myelin sheath, causing damage to the peripheral nervous system. It can occur rapidly, causing impairment of both the motor and the sensory functions. It most often occurs days or weeks after a respiratory infection.

Signs and Symptoms: Hypotension, bradycardia, weakness, difficulty speaking, difficulty chewing and swallowing, paralysis, and respiratory changes. Symptoms appear quickly over a course of 1 to 2 days. If respiratory failure occurs, mechanical ventilation may be needed.

Diagnostics: Lumbar puncture to determine if there is an increase of protein in the cerebrospinal fluid, assessment of symptoms, and electromyography to test muscle response.

Complications: Respiratory distress/failure, long-term paralysis, and death if left untreated.

Drug Therapy: Corticosteroids, immunoglobulin (IVIG), and immunosuppressive medications are often administered. IVIG is used to replace protein in patients who lack antibodies to help fight infections. Plasmapheresis may also be administered to remove damaged antibodies and replace them with healthy ones to help fight infections. Antibiotics will also be administered.

Nursing Care: Assess mental status, respiratory status, and any changes in vital signs. Maintain a patent airway. If needed, the patient may be placed on mechanical ventilation. Suction patient as needed. Keep the head of the bed (HOB) at a 45° angle. Assess the patient’s ability to swallow, and keep NPO (nothing by mouth) if patient is choking or having difficulty eating. Cardiac monitoring may be ordered for the patient. Pressure relief devices such as pneumatic boots or TED hose are applied to facilitate circulation. Ensure fall precautions are in place, and assist patient with walking and use of assistive devices. Physical therapy will be ordered in the recovery phase. Patient teaching and emotional support is provided. This diagnosis can be difficult for patients owing to the rapid onset and severity of symptoms.

Medical-Surgical Nursing: Meningitis

Focus Topic: Medical-Surgical Nursing


Medical-Surgical Nursing


Definition: This is a viral or bacterial infection that causes inflammation of the meninges of the brain and spinal cord. Bacterial meningitis is more severe than viral. Meningococcal meningitis is contagious and transmitted through droplets.

Signs and Symptoms: Stiff neck, headache, photophobia, nausea/vomiting, fever, rash, confusion, irritability, positive Kernig and Brudzinski signs. Diagnostics: Lumbar puncture to test cerebrospinal fluid, elevated WBCs, CT scan, CBC, CMP, and blood cultures.

Complications: Increased intracranial pressure, seizures, paralysis, and if left untreated, brain damage.

Drug Therapy: Corticosteroids, IV antibiotics, anticonvulsants, and oxygen therapy, if needed.

Nursing Care: These patients are placed on droplet precautions until the results of the culture distinguish what type of meningitis is present. Administer medications as ordered. Assess respiratory status, mental status, and vital signs. Assess for complications. Ensure seizure precautions are in place. If photophobia is present, decreased stimuli and dim lighting may be needed. Hydration through IVF may be administered. Provide comfort.

Medical-Surgical Nursing: Encephalopathy

Focus Topic: Medical-Surgical Nursing


Medical-Surgical Nursing


Definition: This is an infection that causes inflammation of the brain and central nervous system. Encephalopathy can be caused by medications, toxins, alcohol withdrawal, substance abuse, and infection.

Signs and Symptoms: Changes in mental status, loss of motor function, lethargy, fatigue, profound weakness, personality changes, involuntary movement, tremors, and respiratory changes.

Diagnostics: Lab work, WBC, ammonia testing CSF through a lumbar puncture, and CT of the brain. Complications: Permanent brain damage.

Drug Therapy: Antibiotics, anticonvulsants, and IV hydration. Treat the underlying cause.

Nursing Care: Assess respiratory and mental status. Provide safety, especially if patients are experiencing confusion. Assist with daily activities. Assess the swallow and gag reflex to determine the patient’s ability to swallow without aspirating or choking. Place patient on aspiration precautions. Administer medications as ordered. Treat the underlying cause.


Medical-Surgical Nursing: Increased Intracranial Pressure (ICP)

Focus Topic: Medical-Surgical Nursing

Definition: Increased intracranial pressure is caused by increased fluid in the brain tissue. ICP can be caused by hemorrhage, stroke, trauma, hydrocephalus, tumor, edema, and brain injury.

Signs and Symptoms: Headache, change in mental status (first sign), nausea/vomiting, decreased pulse and increased systolic blood pressure, vision changes, decreased motor function, seizures, changes in speech, respiratory changes, and changes in posture.

Diagnostics: Intracranial pressure monitoring, CT scan, MRI, ABGs, and lumbar puncture. Assess neuro status, pupil response, and gait. Use the Glasgow Coma Scale to assess neurological status.

Complications: Seizures and permanent brain damage.

Drug Therapy: Osmotic diuretics such as mannitol (Osmitrol), corticosteroids, IVF such as D5, anticonvulsants, antihypertensives, and antibiotics to prevent infection.

Surgical Measures: A ventriculoperitoneal shunt may be placed to drain fluid from the brain into the peritoneum. Preoperative and postoperative teaching is needed. Keep the patient NPO before surgery.

Nursing Care: Patients who are diagnosed with increased intracranial pressure are placed in the ICU for frequent neuro checks and monitoring. Assess mental status, vital signs, and respiratory status. Monitor the ICP; normal range is 5 to 15 mmHg. Mechanical ventilation may be needed to enhance oxygen intake. Keep head and neck midline, and keep the HOB at a 45° angle. Avoid any sudden changes in movement. Also avoid hip flexion. Initiate seizure precautions. A Foley catheter may be placed. Administer medications as ordered. Monitor vital signs, I/Os, and changes in mental status. Fluid restriction may be ordered. The patient is placed on strict bed rest. If the patient is unconscious, maintain skin integrity, tube feedings, mouth care, and perianal care.

Medical-Surgical Nursing: Spinal Cord Injury

Focus Topic: Medical-Surgical Nursing

Definition: This is caused by trauma or damage to the spinal cord. Spinal cord injury can be thoracic, lumbar, or cervical. Symptoms and severity can vary based on the level of injury. Injuries to C4 and above cause respiratory impairment, necessitating ventilation. An injury at the C1 to C8 level causes paralysis of all four extremities. An injury at the C6 to C8 level causes lower extremity paralysis with movement in the upper extremities. An injury that occurs at the T1 to T4 level has lower extremity paralysis, with ability to move upper extremities. Several complications can occur with spinal cord injury depending on the location of trauma to the spine.

Types of Injuries: Central cord syndrome, anterior cord syndrome, posterior cord syndrome, conus medullaris syndrome, and Brown-Séquard syndrome. The two most commonly tested are the conus medullaris syndrome and Brown-Séquard syndrome.

Signs and Symptoms:

Severity of symptoms is measured by on the level of damage and location of the injury. Injuries at C3 to C5 will cause respiratory failure, and patients need to be placed on mechanical ventilation immediately. Patients with injuries at C6 or higher will experience severe hypertension, loss of bladder function, neurogenic bladder, lack of sensation, hypertension, and loss of motor function. Patients with injuries at T6 and above can develop autonomic dysreflexia, severe hypertension, and decreased pulse. General symptoms are hypertension, urinary retention, skin ulcers, paralytic ileus, weight loss, deep vein thrombosis, pulmonary embolism, immobility, and pain.

Diagnostics: CT scan, MRI of the brain, EKG, electrolytes, ABGs, and neurological symptoms that may be present.

Complications: Many complications can arise from spinal cord injury; two of the main complications are (a) autonomic dysreflexia and (b) spinal cord shock. Autonomic dysreflexia occurs with injuries at T6 and higher. It can be life threatening and needs to be treated immediately. Symptoms are distended (full) bladder, blurred vision, headache, hypertension, sweating, and bradycardia. Treatment is elevating the HOB to 45°, loosening clothing, and checking the Foley catheter for kinks that can possibly cause the bladder to be full. Assess the bladder/bowel, monitor output, assessing BP every 15 minutes, administering hypertensive medications, and notify the physician immediately.

Spinal cord shock is caused by absence of reflexes, which usually occurs a few hours after the injury and can last for several months. Autonomic dysreflexia can result from spinal cord shock. Signs and symptoms are paralysis, hypotension, bradycardia, loss of reflexes, profuse sweating, and EKG changes. Treatment includes monitoring and controlling hypotension and bradycardia, and frequent monitoring of vital signs. Reflexes have to be assessed frequently.

Drug Therapy: Treatment of bradycardia is IV fluids, corticosteroids (IV solumedrol), pain medications, and vasopressors to increase vasodilation. Diuretics such as furosemide (Lasix) are used to increase diuresis and decrease edema. Anticoagulants such as enoxaparin (Lovenox) are used to prevent blood clots. Pain medications may be used for comfort, stool softeners such as Colace or Senna may also be prescribed, as well as anticonvulsants to prevent seizures. Provide the patient with emotional comfort.

Nursing Care: Assess respiratory status and maintain a patent airway; the patient may need to be placed on mechanical ventilation. Assess for infection, ABGs, vital signs, intake, and output. Cardiac monitoring is ordered. TED hose and pneumatic boots are applied to decrease the risk of clots. To increase BP and pulse, intravenous fluids and vasopressors are administered. Patients’ skin integrity needs to be maintained by turning and repositioning, using an air mattress, and applying barrier cream. To avoid complications, monitor bowel and bladder function. Maintain a patent Foley catheter, assess for abdominal distension, assess for bowel sounds, and administer stool softeners. A nasogastric tube (NGT) may need to be placed if a bowel obstruction occurs. Remember to keep the head and neck aligned at all times with no hip flexion. Traction such as a halo may be used to maintain alignment. Assess for other complications such as pneumonia, which can result from lack of mobility. Assess neurological status every hour, and call physician with any changes.

Medical-Surgical Nursing: Subarachnoid Hemorrhage/Aneurysm

Focus Topic: Medical-Surgical Nursing

Definition: A subarachnoid hemorrhage is a collection of blood in the subarachnoid space, typically caused by an aneurysm, which can result in death. An aneurysm is a bleed in the subarachnoid space.

Signs and Symptoms: Mental status changes, headache, nausea, vomiting, increased intracranial pressure, nuchal rigidity, seizures, photophobia, and restlessness.

Diagnostics: CT of the brain, MRI, ABGs, PT/INR, PTT, CBC, and ICP pressure.

Complications: Seizures and death if left untreated.

Drug Therapy: Osmotic diuretics, anticonvulsants, corticosteroids, CCBs, analgesics, oxygen therapy, antipyretics, stool softeners, and aminocaproic acid (Amicar).

Nursing Care: Assess respiratory status and maintain patent airway.Keep patient neck and head aligned to prevent further damage and increase ICP. Closely monitor neurological status. Tell patients to avoid factors that can increase pressure such as blowing the nose, heavy lifting, and bending. CSF can leak from the nose and ears; assess both frequently. Administer medications as ordered. Surgery such as a craniotomy may be needed. Continue to monitor for complications.