Med-Surg - Nervous System, part 11: Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Guillain-Barre Syndrome, Myasthenia Gravis

by Cathy Parkes November 09, 2021 Updated: December 29, 2021 7 min read

Full Transcript

Hi. I'm Cathy with Level Up RN. In this video, I'm going to continue my coverage of nervous system disorders. Specifically, I will be talking about Multiple Sclerosis or MS, as well as Amyotrophic Lateral Sclerosis or ALS, and Guillain-Barre Syndrome or GBS, and Myasthenia Gravis or MG. At the end of the video, I'm going to give you guys a little quiz to test your knowledge of some of the key facts I'll be covering in this video. So definitely stay tuned for that. And if you have our Level Up RN medical-surgical nursing flashcards, definitely pull those out so you can follow along with me.

Multiple sclerosis or MS is an autoimmune disorder that causes damage to the myelin sheath, which is that fatty substance that surrounds and protects the axon of the nerve. So it damages the sheath, and then it also damages the underlying nerve. And where that damage occurs, we have inflammation and the formation of scar tissue or plaques. If you look at the disease name multiple sclerosis, that means many scars. So sclerosis means scars. Because we have all this scar tissue formation from that damage.

So multiple sclerosis is characterized by periods of relapsing and remitting. So a patient may go a while without any problems and then relapse again. This disease is more common in women than men. And it is most common between the ages of 20 and 40.

In terms of signs and symptoms, patients with MS often have vision issues such as diplopia, which is double vision. Or nystagmus, which is the involuntary movement of an eye. And then patients will also have muscle spasticity and/or weakness. It can also cause balance issues as well as bowel and bladder dysfunction. It can cause fatigue as well as cognitive changes, such as difficulty concentrating. It can also cause emotional changes, such as depression or anxiety. And it causes pain as well as difficulty swallowing in many cases. So dysphagia.

In terms of diagnosis, with an MRI, we can see those plaques that I referred to. Also, if we do a lumbar puncture, the patient's CSF will show increased protein levels.

In terms of treatment, we're going to treat MS with immunosuppressants because it's an auto immune disorder. So during an exacerbation, we would typically treat that with corticosteroids. Long-term, we would treat it with a medication such as interferon beta, which will help to prevent relapses of MS. We can also use other anti-inflammatories as well as muscle relaxants if the patient is having that muscle spasticity.

In terms of patient teaching, you want to advise your patient to avoid triggers. So triggers can include temperature extremes such as very hot or very cold. Triggers can also include stress, fatigue, and illness.

Next, let's talk about ALS, which is a neurodegenerative disease that causes progressive muscle weakness.

So the exact cause of ALS is not known, but it results in the gradual deterioration of the upper and lower motor neurons such that we have the loss of voluntary movement and muscle control. So the patient will lose their ability to speak, eat, move, and eventually breathe.

So symptoms of ALS will include muscle weakness and atrophy as well as muscle cramps and twitching. Dysphagia is another symptom. So difficulty swallowing. And then eventually the patient will have respiratory paralysis, which typically occurs between three and five years after they are diagnosed.

In terms of diagnosis, there's no one definitive test that can point to ALS. So diagnosis is done based on the patient's symptoms and ruling out other causes.

In terms of treatment, there's no cure. Medications such as Riluzole can be used to help slow the deterioration of those motor neurons, but it won't cure ALS.

In terms of nursing care, your number one priority is to maintain a patent airway. So you want to monitor the patient for pneumonia as well as respiratory failure. Those respiratory muscles will get progressively weaker, such that the patient will eventually become dependent on a ventilator. So in addition, you want to initiate a consult to the palliative team for the patient with ALS.

Next, let's talk about Guillain-Barre Syndrome or GBS. This is an autoimmune disorder that affects the peripheral nervous system and causes the sudden onset of weakness and paralysis.

So the pathophysiology behind this disorder, is that patients typically have a viral infection, such as influenza or pneumonia that triggers the autoimmune destruction of the myelin sheath and of the axons in the motor and sensory nerves. And you may be thinking to yourself, this sounds a lot like multiple sclerosis. Well, with MS, we have destruction of the myelin sheath and of the nerves, but this occurs in the central nervous system. Here with GBS, this occurs in the peripheral nervous system.

So signs and symptoms of GBS include tingling in the feet and hands as well as symmetric weakness. So we're not talking about one-sided weakness like we would see with a stroke. It's going to be on both sides of the body. The patient may also have decreased deep tendon reflexes as well as paralysis. Symptoms typically occur at the feet and move up the body.

In terms of treatment, we can do a plasmapheresis, which basically is going to filter the blood and get rid of those bad antibodies that are attacking the nerves. And we can provide IVIG, which is intravenous immunoglobulin, which are good antibodies for the patient.

In terms of nursing care, because that muscle weakness can affect the respiratory muscles, we want to be sure to maintain a patent airway. And we want to monitor the patient for aspiration, pneumonia, as well as respiratory failure.

Finally, let's talk about Myasthenia Gravis or MG. This is an autoimmune disorder that causes severe muscle weakness.

And it is characterized by periods of exacerbation and periods of remission.

So the pathophysiology behind this condition, is that we have antibodies that are blocking and destroying acetylcholine receptors at the neuromuscular junction.

And this is causing symptoms such as muscle weakness, which is worse with exercise and improves with rest. Myasthenia Gravis can also cause diplopia, so double vision. As well as dysphagia, difficulty swallowing. It can cause shortness of breath as well as thymus hyperplasia. So the thymus gland is located here in the chest between the lungs and it's part of the immune system and produces T cells. If that thymus gland is enlarged, then that may be indicative of MG. In addition, the patient with MG may have drooping eyelids, which is definitely a unique feature of this disorder.

So in terms of diagnosis, we can help diagnose MG using electromyography as well as a repetitive nerve stimulation test. And then we can do something called an edrophonium or Tensilon test. And the purpose of this test is to differentiate between Myasthenia Gravis and a cholinergic crisis. So both of these things can cause extreme muscle weakness, but they're very different conditions.

So edrophonium is a cholinergic agent. So it's going to increase levels of acetylcholine, which is going to help a patient with Myasthenia Gravis. Because we have too little acetylcholine because of that destruction of the acetylcholine receptors at the neuromuscular junction. So if we give the patient edrophonium, it's going to increase acetylcholine and make the patient feel better.

However, if the patient is having a cholinergic crisis, meaning there's too much acetylcholine, by giving them more acetylcholine, it's actually going to make things worse. So if things get worse, then we know the patient had a cholinergic crisis, and we need to provide an antidote, which would be atropine, which is an anticholinergic agent.

Treatment for Myasthenia Gravis can include medications such as neostigmine and pyridostigmine, which are cholinergic agents. So they help to prevent the breakdown of acetylcholine. We can also use immunosuppressants such as prednisone to help suppress the immune response. And then the patient can get a plasmapheresis, which will filter the patient's blood to get rid of those bad antibodies. And then a thymectomy may be helpful as well. So that is removal of the thymus gland and has been shown to improve symptoms in patients with MG.

In terms of nursing care, because the patient will have muscle weakness and this includes the respiratory muscles, we want to make sure we are maintaining a patent airway. We want to assist the patient with ambulation. And encourage lots of rest periods. And then because the muscles that are involved in chewing and mastication are also potentially weak, we want to provide the patient with frequent small, high calorie meals, and then monitor them for aspiration and choking because of the risk for dysphagia. Patients with MG often have trouble closing their eyes at night, and this can cause drying and damage to the cornea. Because that is the case, we want to administer eye drops and then tape their eyes shut at night to prevent that drying and irritation.

All right, it's time for a quiz. I actually had trouble narrowing down what I wanted to ask you because there's a lot of bold red text on these cards, which means there's a lot of important points you need to know about these disorders. But here we go. Question number one, Multiple sclerosis is characterized by periods of relapsing and remitting, true or false? The answer is true. Question number two, with Guillain-Barre Syndrome, patients will have unilateral muscle weakness, true or false? The answer is false. So they will have symmetrical muscle weakness. Question number three, what medication is administered to determine if a patient is having a Myasthenia Gravis crisis or a cholinergic crisis? The answer is it edrophonium.

All right, I hope that was helpful. Hope you enjoyed the video. If so, be sure to like it and leave me a comment. Take care and I'll see you soon.


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