The client is admitted to the hospital with a diagnosis of Guillain-Barre´ syndrome. The nurse inquires during the nursing admission interview if the client has a history of:
1. Seizures or trauma to the brain
2. Meningitis during the last 5 years
3. Back injury or trauma to the spinal cord
4. Respiratory or gastrointestinal infection during the previous month
What is Guillain-Barre`S Syndrome ( NCLEX Review)
Description
Guillain-Barre´ syndrome is an acute infectious neuronitis of the cranial and peripheral nerves.
The immune system overreacts to the infection and destroys the myelin sheath.
The syndrome usually is preceded by a mild upper respiratory infection or gastroenteritis.
The recovery is a slow process and can take years. The major concern in Guillain-Barre´ syndrome is difficulty breathing; monitor respiratory status closely.
Assessment
Paresthesias
Pain and/or hypersensitivity such as with the weight of bed sheets or other items touching the body
Weakness of lower extremities
Gradual progressive weakness of the upper extremities and facial muscles
Possible progression to respiratory failure
Cardiac dysrhythmias
CSF that reveals an elevated protein level
Abnormal electroencephalogram
Interventions
Care is directed toward the treatment of symptoms, including pain management.
Monitor respiratory status.
Provide respiratory treatments.
Prepare to initiate respiratory support.
Monitor cardiac status.
Assess for complications of immobility.
Provide the client and family with support.
The nurse has given instructions to the client with Parkinson’s disease about maintaining mobility. The nurse determines that the client understands the directions if the client states that he or she will:
1. Sit in soft, deep chairs.
2. Exercise in the evening to combat fatigue.
3. Rock back and forth to start movement with bradykinesia.
4. Buy clothes with many buttons to maintain finger dexterity.
What you Know about Parkinson`S Disease? (Nclex Review)
Description
Parkinson’s disease is a degenerative disease caused by the depletion of dopamine, which interferes with the inhibition of excitatory impulses, resulting in a dysfunction of the extrapyramidal system.
It is a slow, progressive disease that results in a crippling disability.
The debilitation can result in falls, self-care deficits, failure of body systems, and depression.
Mental deterioration occurs late in the disease.
Assessment
Bradykinesia, abnormal slowness of movement, and sluggishness of physical and mental responses
Akinesia
Monotonous speech
Handwriting that becomes progressively smaller
Tremors in hands and fingers at rest (pill rolling)
Tremors increasing when fatigued and decreasing with purposeful activity or sleep
Rigidity with jerky movements
Restlessness and pacing
Blank facial expression; mask-like facies
Drooling
Difficulty swallowing and speaking
Loss of coordination and balance
Shuffling steps, stooped position, and propulsive gait
Interventions
Assess neurological status.
Assess ability to swallow and chew.
Provide high-calorie, high-protein, high-fiber soft diet with small, frequent feedings.
Increase fluid intake to 2000 mL/day.
Monitor for constipation.
Promote independence along with safety measures.
Avoid rushing the client with activities.
Assist with ambulation and provide assistive devices.
Instruct the client to rock back and forth to initiate movement.
Instruct the client to wear low-heeled shoes.
Encourage the client to lift feet when walking and to avoid prolonged sitting.
Provide a firm mattress and position the client prone, without a pillow, to facilitate proper posture.
Instruct in proper posture by teaching the client to hold the hands behind the back to keep the spine and neck erect.
Promote physical therapy and rehabilitation.
Administer antiparkinsonian medications to increase the level of dopamine in the CNS.
Instruct the client to avoid foods high in vitamin B6 because they block the effects of antiparkinsonian medications.
Instruct the client to avoid monoamine oxidase inhibitors because they will precipitate hypertensive crisis.
The nurse is assigned to care for a client with complete right-sided hemiparesis. The nurse plans care knowing that in this condition:
1. The client has complete bilateral paralysis of the arms and legs.
2. The client has weakness on the right side of the body, including the face and tongue.
3. The client has lost the ability to move the right arm but is able to walk independently.
4. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.
What is Hemiparesis?
Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is weakness of the face and tongue, arm, and leg on one side. Complete bilateral paralysis does not occur in this condition. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.
The nurse is caring for the client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?
1. Loosening restrictive clothing
2. Restraining the client’s limbs
3. Removing the pillow and raising padded side rails
4. Positioning the client to the side, if possible, with the head flexed forward
What is Seizures ?
A seizure is the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain.
The term “seizure” is often used interchangeably with “convulsion.” Convulsions occur when a person’s body shakes rapidly and uncontrollably. During convulsions, the person’s muscles contract and relax repeatedly. There are many different types of seizures. Some have mild symptoms without shaking.
Symptoms
Seizures of all types are caused by disorganized and sudden electrical activity in the brain.
Causes of seizures can include:
Abnormal levels of sodium or glucose in the blood
Brain infection, including meningitis
Brain injury that occurs to the baby during labor or childbirth
Brain problems that occur before birth (congenital brain defects)
Brain tumor (rare)
Drug abuse
Electric shock
Epilepsy
Fever (particularly in young children)
Head injury
Heart disease
Heat illness (heat intolerance)
High fever
Phenylketonuria (PKU), which can cause seizures in infants
Poisoning
Street drugs, such as angel dust (PCP), cocaine, amphetamines
Stroke
Toxemia of pregnancy
Toxin buildup in the body due to liver or kidney failure
Very high blood pressure (malignant hypertension)
Venomous bites and stings (snake bite)
Withdrawal from alcohol or certain medicines after using for a long time