NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Degenerative Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Multiple Sclerosis

Focus topic: Medical–Surgical Nursing

Definition: A chronic, slowly progressive, noncontagious, degenerative disease of the CNS. Characterized by demyelination of the neurons, this disease affects the brain and spinal cord.

Characteristics
A. Definite cause unknown; may be autoimmune, associated with a deficit in the T lymphocytes.
B. Precipitating factors: pregnancy, fatigue, stress, infection, and trauma.
C. Incidence is greater in colder climate, equal in the sexes, and usually occurs between 20 and 40 years of age. More than 300,000 in United States alone are affected.
D. Demyelination of nerve fibers occurs within long conducting pathways of spinal cord and brain.
E. Lesions (plaques) are irregularly scattered—disseminated in pyramidal tract, posterior column, and ventricle of brain.
F. Destruction of myelin sheath creates patches of sclerotic tissue, degeneration of the nerve fiber, and disturbance in conduction of sensory and motor impulses.
G. Initially, the disease is characterized by periods of remission with exacerbation and variable manifestations, followed by irreversible dysfunction.
H. Clinical course may extend over 10–20 years.
I. Diagnostic tests: abnormal EEG, lumbar puncture (LP) indicating increased gamma globulin but normal serum levels.

Assessment
A. Clinical manifestations—variable, depending on area of involvement: sensory fibers, motor fibers, brain stem, cerebellum, internal capsule. Often insidious and gradual.
B. Initial signs and symptoms: ataxia, diplopia, blurred vision, impaired speech; ascending numbness, starting in the feet.
C. Weakness, paralysis, uncoordinated, intention tremor; spasticity, numbness, tingling, analgesia, anesthesia, loss of position sense; heat intolerance and symptoms of overheating.
D. Lhermitte’s sign is a transient sensory symptom described as an electric shock radiating down the spine or into the limbs with neck flexion.
E. Bladder/bowel retention or incontinence.
F. Impaired vision (nystagmus), dysphagia.
G. Emotional instability, impaired judgment.
H. Charcot’s neurologic triad—nystagmus, intention tremor, scanning speech.

Medical–Surgical Nursing

Implementation
A. Avoid precipitation of exacerbations.

  • Avoid fatigue, stress, infection, overheating, chilling.
  • Establish regular program of exercise and rest.
  • Provide a balanced diet, low in fat, rich in linoleic acid.

B. Administer and assess effects of medications.

  • Steroids hasten remission. Deltasone (prednisone) is used for short-term therapy.
  • Librium (chlordiazepoxide) for mood swings.
  • Lioresal (baclofen) or Dantrium (dantrolene) for spasticity.
  • Urecholine (bethanechol) to relieve urinary retention, or Ditropan (oxybutynin) to increase bladder capacity.
  • Tegretol to treat paresthesia.
  • Symmetrel (amantadine) or Cylert (pemoline) to treat fatigue.
  • Inderal or an anticonvulsant (Neurontin) to treat ataxia.
  • Interferons (Betaseron [interferon beta-1b] and Avonex [interferon beta-1a]) used in relapsing–remitting multiple sclerosis (MS).

C. Promote optimal activity.

  • Moderation in activity with rest periods.
  • Physical and speech therapy.
  • Diversionary activities, hobbies.

D. Promote safety.

  • Sensory loss—regulate bath water, caution with heating pads, inspect skin for lesions.
  • Motor loss—avoid waxed floors, throw rugs; provide rails and walker.
  • Diplopia—eye patch.

E. Promote regular elimination—bladder/bowel training programs.
F. Alternative treatments: hyperbaric oxygen, nutrition supplements (omega 3 and 6).
G. Provide education and emotional support to client and family.

  • Encourage independence and realistic goals; assess personality and behavior changes; observe for signs of depression.
  • Provide instruction and assistive devices; provide information about services of the National Multiple Sclerosis Society.

H. Assess and prevent potential complications.

  • Most common: urinary tract infection, calculi, pressure ulcers.
  • Common cause of death: respiratory tract infection, urinary tract infection.
  • Contractures, pain due to spasticity, metabolic or nutritional disorders, regurgitation, depression.

Medical–Surgical Nursing: Myasthenia Gravis

Focus topic: Medical–Surgical Nursing

Definition: A neuromuscular disease characterized by marked weakness and abnormal fatigue of voluntary muscles. Cause is unknown; question autoimmune reaction.

Characteristics
A. Clients with myasthenia have a high incidence of thymus abnormalities and frequently have systemic lupus erythematosus.
B. Basic pathology is a defect in transmission of nerve impulses at the myoneural junction, the junction of motor neuron with muscle.
C. Normally, acetylcholine is stored in synaptic vesicle of motor neurons to skeletal muscles. Defect may be due to

  • Deficiency in acetylcholine/excess acetylcholinesterase.
  • Defective motor-end plate and/or nerve terminals.
  • Decreased sensitivity to acetylcholine.

D. Muscles supplied by bulbar nuclei (cranial nerves) are commonly involved.
E. Muscle involvement usually progresses from ocular to oropharyngeal, facial, proximal muscles, respiratory muscles.
F. Generally, there is no muscle atrophy or degeneration; there may be periods of exacerbations and remissions.
G. Symptoms are related to progressive weakness and fatigue of muscles when used; muscles generally strongest in the morning.

Assessment
A. Changes in eyes (affected first): ptosis, diplopia, and eye squint.
B. Impaired speech; dysphagia; drooping facies; difficulty chewing, closing mouth, or smiling; breathing difficulty and hoarse voice.
C. Respiratory paralysis and failure.
D. Severe weakness during Tensilon (edrophonium) test.

Implementation
A. Assist with disease diagnosis.

  • Have Tensilon available for physician to inject—rapid, brief-acting anticholinesterase for testing purposes.
  • Assess results of Tensilon injections.
    a. Positive for myasthenia—improvement in muscle strength.

B. Administer medications as ordered.

  • Anticholinesterase drugs increase levels of acetylcholine at myoneural junction.
    a. Prostigmin (neostigmine), Mestinon (pyridostigmine), Mytelase (ambenonium)—main difference is duration of effect.
    b. Tensilon (edrophonium).
    c. Monitor side effects.
    (1) Related to effects of increased acetylcholine in parasympathetic nervous system: sweating, excessive salivation, nausea, diarrhea, abdominal cramps; possibly bradycardia or hypotension.
    (2) Excessive doses lead to cholinergic crisis—atropine given as cholinergic blocker.
    d. Nursing measures.
    (1) Give medication exactly on time, 30 minutes before meals.
    (2) Give medication with milk and crackers to reduce gastrointestinal upset.
    (3) Observe therapeutic or any toxic effects; monitor and record muscle strength and vital capacity.
  • Steroids.
    a. Suppress immune response. Immunosuppressive drugs such as Deltazone, Imuran (azathioprine), Restasis (cyclosporine), CellCept (mycophenolate mofetil), and Prograf (tacrolimus) may also be used. These medications improve muscle strength by suppressing the production of abnormal antibodies. Their use must be carefully monitored by a physician because they may cause major side effects.
    b. Usually the last resort after anticholinesterase
    and thymectomy.
  • The following drugs must be avoided:
    a. Streptomycin, kanamycin, neomycin, gentamicin— block neuromuscular transmission.
    b. Ether, quinidine, morphine, curare, procainamide, beta-adrenergic blockers, [Innovar (droperidol), opioid analgesic], sedatives— aggravate weakness of myasthenia.
  • Psychotropic drugs (e.g., lithium carbonate, phenothiazines, benzodiazepines, tricyclic antidepressants) have been associated with worsening of myasthenia gravis (MG).

C. Monitor client’s condition for complications.

  • Vital signs.
  • Respirations: depth, rate, vital capacity, ability to deep-breathe and cough.
  • Swallowing: ability to eat and handle secretions.
  • Muscle strength.
  • Speech: Provide method of communication if client is unable to talk.
  • Bowel and bladder function.
  • Psychological status.

D. Promote optimal activity.

  • Plan short periods of activity and long periods of rest.
  • Time activity to coincide with maximum muscle strength.
  • Encourage normal activities of daily living.
  • Encourage diversionary activities.

E. Provide education and emotional support for client and family.

  • Give reassurance and facts about the disease, medications and treatment regimen, importance of adhering to medication schedule, difference between myasthenic/cholinergic crisis, and emergency care.
  • Instruct client to avoid infection, stress, fatigue, and over-the-counter drugs.
  • Instruct client to wear identification medal and carry emergency card.
  • Provide information about services of Myasthenia Gravis Foundation.

F. Provide appropriate nursing measures in the event of thymectomy surgery.
G . Use of Tensilon.

  • Tensilon test differentiates crises, as symptoms are similar.
  • Give Tensilon; if strength improves, it is symptomatic of myasthenic crisis and the client needs more medication. If weakness is more severe, it is symptomatic of cholinergic crisis and overdose has occurred.
  • Be prepared for emergency with atropine, suction, and other emergency equipment for respiratory arrest.
  • Crisis with respiratory insufficiency—client cannot swallow secretions and may aspirate.
    a. Maintain bed rest.
    b. May require endotracheal or tracheostomy tube to assist with ventilation.
    c. Monitor vital capacity, blood gases.
    d. Give atropine and may hold anticholinesterase (cholinergic).
    e. Begin anticholinesterase (myasthenic).

Medical–Surgical Nursing

Medical–Surgical Nursing: Parkinson’s Disease

Focus topic: Medical–Surgical Nursing

Definition: A degenerative disease resulting in dysfunction of the extrapyramidal system.

Characteristics
A. Possible causes: atherosclerosis, drug induced, postencephalitic, idiopathic.
B. Degeneration of basal ganglia due to depleted concentration of dopamine.
C. Depletion of dopamine correlated with degeneration of substantia nigra (midbrain structures that are closely related functionally to basal ganglia).
D. Loss of inhibitory modulation of dopamine to counterbalance cholinergic system and interruption of balance-coordinating extrapyramidal system.
E. Slowly progressive disease with high incidence of crippling disability; mental deterioration occurs very late.

Assessment
A. Assess stage of disease—five stages: unilateral, bilateral, impaired balance, fully developed severe disease, confinement to bed or wheelchair.
B. Identify presence of initial symptoms.

  • Slowing of all movements.
  • Aching shoulders and arms.
  • Monotonous and indistinct speech.
  • Writing becomes progressively smaller.

C. Evaluate major symptoms.

  • Tremor at rest, especially in hands and fingers (pill rolling).
    a. Increases when stressed or fatigued.
    b. May decrease with purposeful activity or sleep.
  • Rigid or blank facial expression (masklike).
    a. Drooling, difficulty swallowing or speaking.
    b. Short, shuffling steps with stooped posture.
    c. Propulsive gait.
    d. Immobility of muscles in flexed position, creating jerky cogwheel motions.
    e. Loss of coordinated and associated automatic movement and balance.
  • Bradykinesia—abnormal slowness and reduction in automatic movement; sluggishness of responses.
  • Increased muscle tone rigidity.

Implementation
A. Administer and monitor drugs—drug therapy is
aimed at correcting an imbalance of neurotransmitters
within the CNS.

  • Symmetrel (amantadine): Used to treat clients with mild symptoms but no disability; side effects uncommon with usual dose.
  • Anticholinergic drugs: Most effective is Parsidol (ethopropazine); used to treat tremors and rigidity and inhibit action of acetylcholine; side effects include dry mouth, dry skin, blurring vision, urinary retention, and tachycardia.
  • Larodopa, Dopar (levodopa) (converted in body to dopamine).
    a. Reduces akinesia, tremor, and rigidity.
    b. Passes through blood–brain barrier.
    c. Effectiveness may decline after 2–3 years.
    d. Side effects.
    (1) Anorexia, nausea, and vomiting (administer drug with meals or snack; avoid coffee, which seems to increase nausea).
    (2) Postural hypotension, dizziness, tachycardia, and arrhythmias (monitor vital signs; caution client to sit up or stand up slowly; have client wear support stockings).
    e. Contraindicated in clients with closedangle glaucoma, psychotic illness, and peptic ulcer disease.
  • Sinemet—combination of carbidopa and levodopa: Has fewer side effects than levodopa.
  • Antihistamines: Reduce tremor and anxiety; side effect is drowsiness.
  • Antispasmodics (Artane [trihexyphenidyl], Kemadrin [procyclidine]): Improve rigidity but not tremor.
  • Parlodel (bromocriptine): Drug often used to replace levodopa when it loses effectiveness.

a. Acts on dopamine receptors.
b. Side effects: anorexia, nausea, vomiting, constipation, postural hypotension, cardiac arrhythmias, headache.
c. Contraindicated in clients with mental illness, myocardial infarction, peptic ulcers, peripheral vascular disease.

B. Avoid the following drugs:

  • Phenothiazines, reserpine, pyridoxine, vitamin B6: Block desired action of levodopa.
  • Monoamine oxidase inhibitors: Precipitate hypertensive crisis.
  • Methyldopa: Potentiates effects of the primary drug.

C. Maintain regular patterns of elimination.

  • Constipation is often a problem due to side effects of medications, reduced physical activity, muscle weakness, and excessive drooling.
  • Provide stool softeners, suppositories, mild cathartics.

D. Promote physical therapy and rehabilitation.

  • Provide preventive, corrective, and postural exercises.
  • Institute massage and stretching exercises, stressing extension of limbs.
  • Encourage daily ambulation: Have client lift feet up when walking and avoid prolonged sitting.
  • Facilitate adaptation for activities of daily living and self-care, encourage rhythmic patterns to attain timing, foster independence, utilize special aids and devices.
  • Remove hazards that might cause falls.

E. Provide education and emotional support to client and family.

  • Remember—intellect is usually not impaired.
  • Assess changes in self-consciousness, body image, sexuality, moods.
  • Instruct client to avoid emotional stress and fatigue, which aggravate symptoms.
  • Instruct client to avoid foods high in vitamin B6 and monoamine oxidase.

F. Complete preoperative teaching for specific surgical intervention.

  • Stereotactic surgery to reduce tremor.
    a. Pallidotomy—lesion in globus pallidus.
    b. Thalamotomy—lesion in ventrolateral portion of thalamus.
  • Deep brain stimulation (DBS): Implantation of electrodes through burr holes into either the thalamus or globus pallidus of brain. These are connected to a pulse generator in the chest (similar to a pacemaker). The device is programmed to deliver a set current to the targeted brain location. Unlike ablation treatments, DBS can be adjusted to control symptoms better and is reversible. The device can be removed.

G. Provide appropriate nursing care following surgery.

Medical–Surgical Nursing: Cranial and Peripheral Nerve Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Trigeminal Neuralgia (Tic Douloureux)

Focus topic: Medical–Surgical Nursing

Definition: A sensory disorder of the fifth cranial nerve, resulting in severe, recurrent paroxysms of sharp, facial pain along the distribution of the trigeminal nerve. Etiology and pathology are unknown; incidence is rare, more common in women in fifth or sixth decade of life.

Assessment
A. Assess for trigger points on the lips, gums, nose, or cheek.
B. Conditions that stimulate symptoms: cold breeze, washing, chewing, food/fluids of extreme temperatures.
C. Assess pain—limited to those areas innervated by the three branches of the fifth nerve.
D. Diagnostic tests.

  • History and physical exam.
  • Brain or CT scan.
  • Audiologic evaluation.
  • EMG.
  • CSF analysis to rule out MS.
  • MRI to rule out MS.

Implementation
A. Observe and record characteristics of the attack.
B. Record method client uses to protect face.
C. Avoid extremes of heat or cold.
D. Provide small feedings of semiliquid or soft food.
E. Administer medication and record effects.
F. Complete postoperative care.

  • Ophthalmic nerve—client needs protective eye care.
  • Maxillary and mandibular nerves.
    a. Avoid hot food and liquids, which might burn.
    b. Instruct client to chew on unaffected side to prevent biting denervated portion.
    c. Encourage client to visit dentist within 6 months.
    d. Provide frequent oral hygiene to keep the mouth free of debris.

Surgical Treatment
A. Peripheral: glycerol rhizotomy-injection into one or more branches of the trigeminal nerve.

B. Intracranial.

  • Percutaneous radiofrequency rhizotomy.
  • Microvascular decompression.
  • Gamma Knife radiosurgery.

Medical–Surgical Nursing

Medical–Surgical Nursing: Bell’s Palsy (Facial Paralysis)

Focus topic: Medical–Surgical Nursing

Definition: A lower motor neuron lesion of the seventh cranial nerve, resulting in paralysis of one side of the face. May occur secondary to intracranial hemorrhage, tumor, meningitis, trauma. Diagnosis made by exclusion. No definitive tests.

Assessment
A. Flaccid muscles.
B. Shallow nasolabial fold.
C. Ability to raise eyebrows, frown, smile, close eyelids, or puff out cheeks.
D. Upward movement of eye when attempting to close eyelid.
E. Loss of taste in anterior tongue.

Implementation
A. Majority of clients recover in a few weeks without residual effects.
B. Palliative measures account for majority of interventions; acupuncture; moist heat, massage.
C. Monitor use of analgesics and steroids.
D. Protect facial muscles.

  • Provide face sling to prevent stretching of weakened muscles and loss of tone.
  • Promote active facial exercises to prevent loss of muscle tone and support of facial muscles.

E. Monitor diet.

  • Instruct client to chew food on unaffected side.
  • Provide attractive, easy-to-eat foods to prevent anorexia and weight loss.

F. Provide special eye care to protect cornea and prevent keratitis, dark glasses, artificial tears.
G. Reassure and support.

Ménière’s Disease

Focus topic: Medical–Surgical Nursing

Definition: Dilatation of the endolymphatic system causing degeneration of the vestibular and cochlear hair cells.

Characteristics
A. Etiology is unknown.
B. Possible causes may include allergies, toxicity, localized ischemia, hemorrhage, viral infection, and edema.
C. Surgical procedures.

  • Surgical division of vestibular portion of nerve or destruction of labyrinth may be necessary for severe cases.
  • Endolymphatic shunt.
  • Vestibular nerve section.
  • Labyrinthotomy.
  • Labyrinthectomy.

Assessment
A. Chronic recurrent process.
B. Severe vertigo, nausea, vomiting, nystagmus, and loss of equilibrium.
C. Impaired hearing and tinnitus.
D. Nutritional needs, which will depend on amount of nausea and vomiting.

Implementation
A. Maintain bed rest during acute attack.

  • Prevent injury during attack.
  • Provide side rails if necessary.
  • Keep room dark when photophobia is present.

B. Provide drug therapy.

  • Vasodilators (nicotinic acid).
  • Diuretics, antihistamines (Benadryl), anticholinergics.
  • Sedatives.

C. Monitor diet therapy.

  • Low sodium.
  • Lipoflavonoid vitamin supplement.
  • Restricted fluid intake.

D. Assist with ambulation if necessary.

Bulbar Palsy
✦ Definition: A dysfunction of the ninth and tenth cranial
nerves. The disease is secondary to tumors, infections,
vascular
or degenerative diseases.

Assessment
A. Glossopharyngeal paralysis: absent gag reflex; difficulty swallowing, increased salivation; anesthesia of posterior palate and base of tongue.
B. Vagal paralysis: difficulty with speech, breathing, and regurgitation.
C. Possible aspiration.
D. Breathing capability.
E. Difficulty in swallowing.
F. State of depression and fear.

Implementation
A. Medical/surgical treatment is directed toward underlying cause.
B. Nursing care is directed toward prevention of complications.
C. Keep suction equipment at bedside.
D. Elevate head of bed.
E. Provide oral care.
F. Maintain open airway.
G. Keep emergency equipment available.
H. Avoid milk products and sticky carbohydrates.
I. Use small cup instead of straw for liquids.
J. Provide relationship therapy.

  • Give client time to express fears and concerns.
  • Provide consultation for depression if present.

Medical–Surgical Nursing: Guillain–Barré Syndrome

Focus topic: Medical–Surgical Nursing

Definition: An acute, rapidly progressing and potentially fatal form of polyneuritis. Immune system overreacts to an infection, destroying the myelin sheath.

Characteristics
A. Etiology is unknown.
B. Occurs at any age but increased incidence between 30 and 50 years of age.
C. Both sexes equally affected.
D. Presyndrome clients may report a mild upper respiratory infection or gastroenteritis.
E. Recovery is a slow process, taking 2 months to 2 years.
F. Diagnostic test results: cerebrospinal fluid (CSF) contains high protein, abnormal EMG, and nerve conduction.

Assessment
A. Initial symptom of weakness of lower extremities with ascending paralysis/paresthesia.
B. Gradual progressive weakness of upper extremities and facial muscles (24–72 hours); paresthesias may precede weakness.
C. Respiratory failure occurs in some clients.
D. Cardiac arrhythmias, tachycardia.
E. Sensory changes—usually minor, but in some cases severe impairment of sensory information occurs.

Implementation
A. No specific treatment available; supportive treatment includes monitoring for complications (respiratory, circulatory).
B. Carefully observe for respiratory paralysis and inability to handle secretions.
C. Provide chest physiotherapy and pulmonary toilet.
D. Maintain cardiovascular function.

  • Monitor vital signs and cardiac rhythm.
  • Vasopressors and volume replacement.

E. Prevent complications of immobility.

  • Turn frequently.
  • Provide skin care.

F. Provide appropriate diversion.
G. Reassure client, especially during paralysis period.
H. Previous treatment included corticosteroids; this is now considered controversial.

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Medical–Surgical Nursing: Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease)

Focus topic: Medical–Surgical Nursing

Definition: The most common motor neuron disease of muscular atrophy. It is a rapidly fatal, upper and lower motor neuron deficit affecting the limbs.

Characteristics
A. May result from several causes.

  • Nutritional deficiency related to disturbance in enzyme metabolism.
  • Vitamin E deficiency resulting in damage to cell membranes.
  • Metabolic interference in nucleic acid production by nerve fibers.
  • Autoimmune disorder.

B. Inherited as an autosomal dominant trait in 10% of cases.
C. Occurs after age 40; most common in men.
D. Is fatal within 2–6 years after onset. Rilutek (riluzole) slows progression of the disease.
E. Diagnostic tests: EMG and muscle biopsy; increased protein in CSF.

Assessment
A. Atrophy and weakness of upper extremities.
B. Difficulty swallowing and chewing.
C. Respiratory excursion and breathing patterns.
D. Impaired speech.

E. Secondary depression.

Implementation
A. Assist with rehabilitation program to promote independence.
B. Monitor for complications.

  • Prevent skin breakdown: reposition regularly, provide back care, and utilize pressure-relieving devices.
  • Prevent aspiration of food or fluids: Offer soft foods and keep client in upright position during meals.
  • Promote bowel and bladder function.

C. Provide emotional support.

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