Autoimmune Disorders: Autoimmune Disorders By Deborah Carrasquillo, RN, MS, PMC Introduction: Introduction Read chapter 54 in Smeltzer, Assessment and Management of Patients With Rheumatic Disorders, p. 1886-1921, (Rheumatoid Arthritis, Systemic Lupus Erythematous, Fibromyalgia.) Also read chapter 64 in Smeltzer, p. 2277-2292 (Multiple Sclerosis, Myasthenia Gravis & Guillian-Barre Be sure to focus on the nursing process and care plans. Read through the power point presentation carefully and complete the case studies as directed. Answer the NCLEX questions and pay particular attention to the rationales. Look up and research the medications in this module as directed. Instructions for Learning Module: Instructions for Learning Module This learning module is set up for (you) the student to read through and work on the activities. So, read through the learning module carefully. There are case studies and NCLEX style questions imbedded within the slides to enhance the student’s (your) learning. Student Learning Outcomes: Student Learning Outcomes Upon completion of the required reading assignments, case studies, NCLEX questions, medication review, and materials presented the student will be able to: Discuss the pathophysiology of autoimmune disorders. Discuss diagnostic tests used in the diagnosis of autoimmune disorders. Distinguish between and discuss the characteristics of Rheumatoid Arthritis, Fibromyalgia, Systemic Lupus, Multiple Sclerosis, Guillian-Barre , and Myasthenia Gravis Using the nursing process, develop and discuss a plan of care for patients diagnosed with Rheumatoid Arthritis, Fibromyalgia, Systemic Lupus, Multiple Sclerosis, Guillian-Barre Discuss the role medications play in the treatment of Rheumatoid Arthritis, Fibromyalgia, Systemic Lupus, Multiple Sclerosis, Multiple Sclerosis, Guillian-Barre Pathophysiology of Autoimmune Disorders: Pathophysiology of Autoimmune Disorders An autoimmune disorder is a condition that occurs when the immune system mistakenly attacks and destroys its own healthy body tissue. Autoimmune disorders affect both male and females of all ages and ethnic backgrounds. There are over 80 known autoimmune disorders. In the autoimmune patient, the immune system can't tell the difference between healthy body tissue and antigens. The result is an immune system response that destroys normal body tissues. Immune Response: Immune Response Antigens are large molecules (usually proteins) on the surface of cells, viruses, fungi, bacteria, and some non-living substances such as toxins, chemicals, drugs, and foreign particles. The immune system recognizes antigens and produces antibodies that destroy substances containing antigens. Causes of Autoimmune Disorders : Causes of Autoimmune Disorders What causes the immune system to no longer tell the difference between healthy body tissues and antigens is unknown. One theory is that some microorganisms (such as bacteria) and drugs may trigger some of these changes, especially in people who have genes that make them more likely to get autoimmune disorders. It is also believed that sex hormones (estrogen) plays a role in the activity of the immune system. Signs and Symptoms: Signs and Symptoms The signs and symptoms of autoimmune disease may vary according to the specific type of autoimmune disease the patient has. Symptoms of an autoimmune disease vary widely, and can range from mild to severe, with periods of exacerbations and remissions. A group of symptoms that occur with autoimmune diseases may include: Dizziness Fatigue General ill-feeling Low-grade fever An autoimmune disorder may result in: : The destruction of one or more types of body tissue Abnormal growth of an organ Changes in organ function An autoimmune disorder may result in: Organs and Tissues Commonly Affected: Organs and Tissues Commonly Affected An autoimmune disorder may affect one or more organs or tissue types. The organs and tissues commonly affected by autoimmune disorders include: Red blood cells Blood vessels Connective tissues Endocrine glands such as the thyroid or pancreas Muscles Joints Skin Diagnostic Tests: Diagnostic Tests The health care provider will perform a complete history and physical exam. Specific signs vary widely and depend on the specific autoimmune disease. Tests that may be done to diagnose an autoimmune disorder may include: Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) Other tests would be specific to the signs and symptoms presented and the specific autoimmune disease. Specific Autoimmune Disorders: The following autoimmune disorders will be covered in this module: Rheumatoid Arthritis Fibromyalgia Systemic Lupus Erythematosus (SLE) Multiple Sclerosis (MS) Guillian-Barre Myasthenia Gravis Specific Autoimmune Disorders Rheumatoid Arthritis: Rheumatoid Arthritis Rheumatoid arthritis is an autoimmune disease in which the body's immune system attacks itself. The pattern of joints affected is usually symmetrical, involves the hands and other joints and is worse in the morning. Rheumatoid arthritis is also a systemic disease, involving other body organs. Over time, rheumatoid arthritis can be crippling. PowerPoint Presentation: As a systemic autoimmune disease Rheumatoid arthritis initially attacks the synovium, a connective tissue membrane that lines the cavity between joints and secretes a lubricating fluid. Symptoms: Symptoms The disease usually begins gradually with: Fatigue Loss of appetite Morning stiffness (lasting more than 1 hour) Widespread muscle aches Weakness Eventually, joint pain appears. When the joint is not used for a while, it can become warm, tender, and stiff. When the lining of the joint becomes inflamed, it gives off more fluid and the joint becomes swollen. Joint pain is often felt on both sides of the body, and may affect the fingers, wrists, elbows, shoulders, hips, knees, ankles, toes, and neck. PowerPoint Presentation: The affect of rheumatoid arthritis can progress to the degree that it is crippling. Deformities distinctive to late-stage rheumatoid arthritis such as ulnar deviation of the bones of the hands, or swan-neck deviation of the fingers occur because muscles and tendons on one side of the joint may overpower those on the other side, pulling the bones out of alignment. Additional Symptoms of Rheumatoid Arthritis: Additional Symptoms of Rheumatoid Arthritis Lung inflammation (pleurisy) Nodules under the skin (usually a sign of more severe disease) Numbness or tingling Paleness Skin redness or inflammation Swollen glands Joint destruction may occur within 1-2 years after the appearance of the disease. Anemia due to failure of the bone marrow to produce enough new red blood cells Eye burning, itching, and discharge Hand and feet deformities Limited range of motion Low-grade fever Diagnostics: Diagnostics A specific blood test is available for diagnosing RA and distinguishing it from other types of arthritis. It is called the anti-CCP antibody test. Other tests that may be done include: Complete blood count C-reactive protein Erythrocyte sedimentation rate Joint ultrasound or MRI Joint x-rays Rheumatoid factor test (positive in about 75% of people with symptoms) Synovial fluid analysis Medical Management: Medical Management RA usually requires lifelong treatment, including medications, physical therapy, exercise, education, and possibly surgery. Early, aggressive treatment for RA can delay joint destruction. Look up the following medications. You will be expected to know the appropriate dosage, route, side-effects, contraindications, and pertinent patient teaching for these medications. Medications: Immunosuppressants Cytoxan DMARDS: Rheumatrex Plaquinil NSAIDS: Motrin Voltaren Salicylates: Asprirn Corticosteroids NCLEX Question: NCLEX Question A patient with rheumatoid arthritis is receiving cyclophosphamide (Cytoxan) for treatment of his disease. When administering an immunosuppressant, the nurse must be alert to which of the following side effects of this medication? 1. Muscle rigidity 2. Nystagmus 3. Infection 4. Hyperthermia Answer: Number 3. Infection : Answer: Number 3. Infection Rationale: When administering immunosuppressant agents such as Cytoxan, the nurse should be alert to manifestations of bone marrow suppression. Clinical manifestations of infection also would be an important assessment for this patient. Nystagmus is a clinical manifestation of multiple sclerosis. Muscle rigidity occurs in Parkinson's disease. Hyperthermia does not occur as a common manifestation when receiving immunosuppressant agents. NCLEX Question: NCLEX Question A nurse caring for a patient in the early stage of rheumatoid arthritis would expect which of the following medication classifications to be used in the treatment of this patient? 1. Xanthine oxidase inhibitors 2. NSAIDs 3. Uricosuric agents 4. Antimalarial agents Answer: Number 2. NSAIDS : Answer: Number 2. NSAIDS Rationale: Medical management of RA begins with therapeutic doses of salicylates or NSAIDs. Antimalarial agents are used in the treatment of systemic lupus erythematosus. Xanthine oxidase inhibitors and uricosuric agents are used in the treatment of gout. Rheumatoid Arthritis Case Study: Rheumatoid Arthritis Case Study Open the link provided at right and log into Evolve to do the RN HESI Review Case Study on Mrs. Mitchell. The case study is located under adult health in the musculo-skeletal folder https://evolve.elsevier.com/ Review in ATI: Review in ATI Review Rheumatoid Arthritis in your ATI Medical Surgical Nursing 8.0 Edition p. 1150 – 1158. Fibromyalgia: Fibromyalgia Fibromyalgia: Fibromyalgia Fibromyalgia is a common condition characterized by long-term, body-wide pain and tender points in joints, muscles, tendons, and other soft tissues. Fibromyalgia has also been linked to fatigue, morning stiffness, sleep problems, headaches, numbness in hands and feet, depression, and anxiety. Fibromyalgia can develop on its own or along with other musculoskeletal conditions such as rheumatoid arthritis or lupus. Symptoms: Symptoms The overwhelming characteristic of fibromyalgia is long-standing, body-wide pain with defined tender points. There are eighteen tender points of fibromyalgia. Tender points are distinct from trigger points seen in other pain syndromes. Tender points are associated with pain at the site of palpation, are not associated with referred pain, and occur in the insertion zone of muscles, not in taut bands in the muscle belly. Unlike tender points, trigger points can occur in isolation and represent a source of radiating pain, even in the absence of direct pressure. Trigger Points vs. Tender Points: Trigger Points vs. Tender Points Local tenderness, taut band, local twitch response, jump sign Singular or multiple May occur in any skeletal muscle May cause a specific referred pain pattern Local tenderness Multiple Occur in specific locations that are symmetrically located Do not cause referred pain, but often cause a total body increase in pain sensitivity Trigger points Tender points Symptoms (continued): Symptoms (continued) Body aches Irritable bowel syndrome Memory difficulties and cognitive difficulties Chronic facial muscle pain or aching Fatigue Numbness and tingling Palpitations Multiple tender areas (muscle and joint pain) on the back of the neck, shoulders, sternum, lower back, hips, shins, elbows, knees Reduced exercise tolerance Sleep disturbances Tension or migraine headaches Diagnosing Fibromyalgia : Diagnosing Fibromyalgia Diagnosis of fibromyalgia requires a history of a least 3 months of widespread pain, and pain and tenderness in at least 11 of 18 tender-point sites. These tender-point sites include fibrous tissue or muscles of the: Arms (elbows) Thighs Buttocks Chest Knees Lower back Neck Rib cage Shoulders Diagnostics: Diagnostics Laboratory and x-ray tests are done to help confirm the diagnosis by ruling out other conditions that may have similar symptoms. The following conditions have been associated with fibromyalgia or mimic its symptoms: Hypothyroidism Irritable bowel syndrome Lyme disease Rheumatoid arthritis Sleep disorders Prognosis Cancer Cervical and low-back degenerative disease Chronic fatigue syndrome Depression HIV infection Medical Management of Fibromyalgia: Medical Management of Fibromyalgia Treat the specific symptoms reported by the patient NSAIDS Gabapentin Antidepressants Lyrica Cymbalta Savella Individualized exercise programs Stress reduction Support groups : Systemic Lupus Erythematosus Systemic Lupus Erythematosus (SLE): Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic inflammatory autoimmune disorder which may affect many organ systems including the skin, joints and internal organs. The disease may be mild or severe and life-threatening. Symptoms: Symptoms Symptoms vary from person to person, may come and go with periods of exacerbations and remissions. The condition may affect one organ or body system at first. Others may become involved later. Almost all people with SLE have joint pain and most develop arthritis. Frequently affected joints include: fingers hands Wrists and knees Other Symptoms Include: Other Symptoms Include General symptoms include: Arthritis Fatigue Fever General malaise Joint pain and swelling Muscle aches Nausea and vomiting Pleural effusions Pleurisy (causes chest pain) Psychosis Seizures Sensitivity to sunlight Swollen glands Butterfly Skin Rash: Butterfly Skin Rash Skin rash -- a "butterfly" rash over the cheeks and bridge of the nose affects about half of those with SLE. The rash gets worse when in sunlight. The rash may also be widespread. Diagnostics: Diagnostics Antibody tests, including: Antinuclear antibody (ANA) panel Anti-double strand (ds) DNA Anti-phospholipid antibodies Anti-smith antibodies CBC to show low white blood cells, hemoglobin, or platelets Chest x-ray showing pleuritis or pericarditis Kidney biopsy Urinalysis to show blood, casts, or protein in the urine Medical Management: Medical Management There is no cure for SLE. Treatment is aimed at controlling symptoms. Your individual symptoms determine your treatment. Preventing progressive loss of organ function Medications: (do some reading on the medications) Corticosteroids (Prednisone, Solu-Medrol ) NSAIDS ( Ibuprophen ) Immunosuppressive agents (Cytoxan, Neosar ) Antimalarial medications ( Plaquenil ) Review in ATI: Review in ATI Review Systemic Lupus Erythematosus in your ATI Medical Surgical Nursing 8.0 Edition p. 1142 – 1149. Multiple Sclerosis (MS): Multiple Sclerosis (MS) Multiple Sclerosis (MS): Multiple Sclerosis (MS) Multiple sclerosis is an autoimmune disease that affects the brain and spinal cord (central nervous system). Symptoms : Symptoms Symptoms vary, because the location and severity of each attack can be different. Episodes can last for days, weeks, or months. These episodes alternate with periods of reduced or no symptoms (remissions). Fever, hot baths, sun exposure, and stress can trigger or worsen attacks. It is common for the disease to return (relapse). However, the disease may continue to get worse without periods of remission. Because nerves in any part of the brain or spinal cord may be damaged, patients with multiple sclerosis can have symptoms in many parts of the body. Muscle Symptoms: Muscle Symptoms Loss of balance Numbness or abnormal sensation in any area Pain because of muscle spasms Pain in the arms or legs Problems moving arms or legs Problems walking Problems with coordination and making small movements Slurred or difficult-to-understand speech Tremor in one or more arms or legs Uncontrollable spasm of muscle groups (muscle spasticity) Weakness in one or more arms or legs Symptoms (continued): Symptoms (continued) Double vision Eye discomfort Uncontrollable rapid eye movements Vision loss (usually affects one eye at a time) Decreased attention span Decreased judgment Decreased memory Depression or feelings of sadness Dizziness and balance problems Facial pain Hearing loss Fatigue Eye Symptoms Brain and Nerve Symptoms Bowel and Bladder Symptoms: Bowel and Bladder Symptoms Constipation Difficulty beginning urinating Frequent need to urinate Stool leakage Strong urge to urinate Urine leakage (incontinence) Diagnostics: Diagnostics Neuropsychological testing Cerebrospinal fluid tests, including CSF oligoclonal banding Head MRI scan Lumbar puncture (spinal tap) Nerve function study (evoked potential test) Spine MRI Medical Management: Medical Management The goal of treatment focuses on supportive care and prevention of complications. Medications used to slow the progression of multiple sclerosis may include: Interferons Methotrexate Medications to control symptoms may include: Baclophen for muscle spasms Antidepressants for mood or behavior problems Cholenergic medications to reduce urinary problems Amantadine for fatigue Medical Management: Medical Management Physical therapy, speech therapy, occupational therapy, and support groups Assistive devices, such as wheelchairs, bed lifts, shower chairs, walkers, and wall bars A planned exercise program early in the course of the disorder A healthy lifestyle, with good nutrition and enough rest and relaxation Avoiding fatigue, stress, temperature extremes, and illness NCLEX Question: NCLEX Question Which intervention should the nurse suggest to help a patient with multiple sclerosis avoid episodes of urinary incontinence? Limit fluid intake to 1,000 ml/day Insert an indwelling urinary catheter Establish a regular voiding schedule Administer prophylactic antibiotics, as ordered Answer: Answer 3. Maintaining a regular voiding pattern is the most appropriate measure to help the patient avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of the last resort because of the increased risk of infection. Antibiotics do not influence urinary incontinence Myasthenia Gravis: Myasthenia Gravis Overview: Overview Characterized by weakness and rapid fatigue of any of the muscles under your voluntary control. The cause of myasthenia gravis is a breakdown in the normal communication between nerves and muscles. While myasthenia gravis can affect people of any age, it's more common in women 20 to 40 years of age and in men older than 60. Pathophysiology: Pathophysiology Your nerves communicate with your muscles by releasing chemicals, called neurotransmitters, which fit precisely into receptor sites on the muscle cells. In myasthenia gravis, your immune system produces antibodies that block or destroy many of your muscles' receptor sites for a neurotransmitter called acetylcholine. With fewer receptor sites available, your muscles receive fewer nerve signals, resulting in weakness. Causes of Myasthenia Gravis: Causes of Myasthenia Gravis It's believed that the thymus gland — a part of your immune system situated in the upper chest beneath the breastbone — may trigger or maintain the production of these antibodies. Large in infancy, the thymus is small in healthy adults. In some adults with myasthenia gravis, the thymus is abnormally large. Some people also have tumors of the thymus. Usually, thymus gland tumors are noncancerous. Chemicals messengers, called neurotransmitters, fit precisely into receptor sites on your muscle cells. In myasthenia gravis, certain receptor sites are blocked or destroyed, causing muscle weakness. : Chemicals messengers, called neurotransmitters, fit precisely into receptor sites on your muscle cells. In myasthenia gravis, certain receptor sites are blocked or destroyed, causing muscle weakness. Symptoms: Symptoms Muscle weakness caused by myasthenia gravis worsens as the affected muscle is used repeatedly. Since symptoms typically improve with rest, your muscle weakness may come and go. The symptoms of myasthenia gravis tend to progress over time, usually reaching their worst within a few years after the onset of the disease. Although myasthenia gravis can affect any of the muscles that you control voluntarily, certain muscle groups are more commonly affected than others. Eye muscles: Eye muscles In more than half the people who develop myasthenia gravis, their first signs and symptoms involve eye problems, such as: Drooping of one or both eyelids ( ptosis ) Double vision ( diplopia ) , which may be horizontal or vertical Face and Throat Muscles: Face and Throat Muscles In about 15 percent of people with myasthenia gravis, the first symptoms involve face and throat muscles, which can cause difficulties with: Altered speaking. Your speech may be very soft or may sound nasal, depending upon which muscles have been affected. Difficulty swallowing. You may choke very easily, which makes it difficult to eat, drink or take pills. Problems chewing. The muscles used for chewing may wear out halfway through a meal, particularly if you've been eating something hard to chew. Limited facial expressions. Family members may note that you've "lost your smile" if the muscles that control your facial expressions are affected. Neck and Limb Muscles: Neck and Limb Muscles Myasthenia gravis can cause weakness in your neck, arms and legs. This usually happens in conjunction with muscle weakness in other parts of your body — such as your eyes, face or throat. The disorder usually affects arms more often than legs. If it affects your legs, you may waddle when you walk. If your neck is weak, it may be hard to hold your head erect. Myasthenic Crisis : Myasthenic Crisis Myasthenic crisis is a life-threatening condition, which occurs when the muscles that control breathing become too weak to do their jobs. It is an acute exacerbation of the disease characterized by: Increased pulse, respirations, and blood pressure Anoxia and cyanosis Bowel and bladder incontinence Decreased urine output Absent cough and swallow reflex Emergency treatment is needed to provide mechanical assistance with breathing. Increase medications as prescribed Blood-filtering therapies help people recover from myasthenic crisis, so they can again breathe on their own. Cholinergic Crisis: Cholinergic Crisis Results in depolarization of the motor end plates Though rare, crisis is caused by overmedication with anticholinesterase Assessment Abdominal cramps, nausea, vomiting, and diarrhea Blurred vision Pallor Facial muscle twitching Hypotension Pupillary miosis Interventions for Cholinergic Crisis: Interventions for Cholinergic Crisis Hold anticholinesterase medication Prepare to administer antidote Atropine sulfate should be on hand to treat bradycardia or respiratory distress Other disorders: Other disorders People who have myasthenia gravis are also more likely to have the following problems: Underactive or overactive thyroid. The thyroid gland, which is in the neck, secretes hormones that regulate your metabolism. If your thyroid is underactive, your body uses energy more slowly. An overactive thyroid makes your body use energy too quickly. Pernicious anemia. This is a condition in which vitamin B-12 is not properly absorbed from the diet, leading to anemia or neurological problems. Tests and Diagnosis : Tests and Diagnosis Edrophonium (Tensilon) Test Injection of the chemical edrophonium (Tensilon) may result in a sudden, although temporary, improvement in your muscle strength — an indication that you may have myasthenia gravis. Edrophonium acts to block an enzyme that breaks down acetylcholine, the chemical that transmits signals from your nerve endings to your muscle receptor sites. Tests and Diagnosis: Tests and Diagnosis Blood analysis A blood test may reveal the presence of abnormal antibodies that disrupt the receptor sites where nerve impulses signal your muscles to move. Repetitive nerve stimulation This is a type of nerve conduction study, in which electrodes are attached to your skin over the muscles to be tested. Small pulses of electricity are sent through the electrodes to measure the nerve's ability to send a signal to your muscle. To diagnose myasthenia gravis, the nerve will be tested many times to see if its ability to send signals worsens with fatigue. Tests and Diagnosis: Tests and Diagnosis Single-fiber electromyography (EMG) Electromyography (EMG) measures the electrical activity traveling between your brain and your muscle. It involves inserting a fine wire electrode through your skin and into a muscle. In single-fiber EMGs, a single muscle fiber is tested. Most people find this test to be somewhat uncomfortable. Imaging scans CT scan or an MRI to see if there's a tumor or other abnormality in your thymus. Treatments and Medications: Treatments and Medications Medications Cholinesterase inhibitors. Drugs such as pyridostigmine (Mestinon) enhance communication between nerves and muscles. These drugs don't cure the underlying problem, but they do improve muscle contraction and muscle strength. Possible side effects may include gastrointestinal upset, excessive salivation and tearing, and frequent urination Treatments and Medications: Treatments and Medications Immunosuppressants Medications that alter your immune system Azathioprine (Imuran), Cyclosporine (Sandimmune, Neoral) Cyclophosphamide (Cytoxan) Mycophenolate (CellCept) Side effects of immunosuppressants can be serious and may include increased risk of infection, liver damage, infertility and increased risk of cancer. Treatments and Medications: Treatments and Medications Plasmapheresis This procedure uses a filtering process similar to dialysis. Your blood is routed through a machine that removes the antibodies that are blocking transmission of signals from your nerve endings to your muscles' receptor sites. The beneficial effects usually last only a few weeks. Repeated treatments can lead to difficulty gaining access to a vein, which may require implanting a catheter, a long, flexible tube, into your chest. Risks associated with plasmapheresis: a drop in blood pressure Bleeding occasionally occurs because of the medications used to keep the blood from clotting during the procedure. It's also possible to develop an allergic reaction to the solutions used to replace the plasma or to the sterilizing agents used for the tubing. Treatments and Medications: Treatments and Medications Intravenous immune globulin This therapy provides your body with normal antibodies, which alters your immune system response. It has a lower risk of side effects than do plasmapheresis and immune-suppressing therapy, but it can take a week or two to start working, and the benefits usually last no more than a month or two. Side effects, which usually are mild, may include chills, dizziness, headaches and fluid retention. Medical Management Surgery (Thymectomy) : Medical Management Surgery (Thymectomy) Surgical removal of the thymus gland can produce antigen-specific immunosuppression and result in clinical improvement The procedure results in either partial or complete remission. After surgery patient is monitored in the ICU with special attention to respiratory function Patient is removed from ventilation after thorough respiratory assessment Nursing Interventions: Nursing Interventions Monitor respiratory status and ability to cough Monitor for respiratory failure Maintain suctioning and emergency equipment at the bedside Monitor vital signs Monitor speech and swallowing abilities to prevent aspiration Encourage patient to sit up while eating Assess muscle status Plan activities to conserve strength and energy Monitor for myasthenic and cholinergic crisis Administer anticholinesterase medications as prescribed Instruct patient to take medications as prescribed, wear med alert bracelet, avoid stress, fatigue, infection, and over the counter medications Review in ATI: Review in ATI Review Myasthenia Gravis in your ATI Medical Surgical Nursing 8.0 Edition p. 123 – 131. Guillian-Barre: Guillian-Barre Guillian-Barre: Guillian-Barre Guillain-Barre syndrome is an uncommon disorder in which your body's immune system attacks your peripheral nerve mylin. Clinical Manifestations: Clinical Manifestations Guillain-Barre syndrome often begins with weakness, tingling or loss of sensation starting in your feet and legs and spreading to your upper body and arms. These symptoms may begin, often not causing much notice, in your fingers and toes. In some people, symptoms begin in the arms or even the face. As the disorder progresses, muscle weakness can evolve into paralysis. Signs and symptoms: Signs and symptoms Prickling, "pins and needles" sensations in your fingers, toes or both Weakness or tingling sensations in your legs that spread to your upper body Unsteady walking or inability to walk Difficulty with eye movement, facial movement, speaking, chewing or swallowing Severe pain in your lower back Difficulty with bladder control or intestinal functions Very slow heart rate or low blood pressure Difficulty breathing Phases of the Syndrome: Phases of the Syndrome Patients suffering from Guilain-Barre syndrome usually experience just one attack that generally lasts for a few weeks, after which the attack stops spontaneously. The rest of the time is spent recovering from the attack. Acute phase Plateau phase Recovery phase Acute Phase: Acute Phase Characterized by severe and rapid weakness, especially in the lower extremities; loss of muscle strength progressing to quadriplegia and respiratory failure; decreasing deep tendon reflexes; decreasing vital capacity; parasthesias; numbness; pain, especially nocturnal; facial muscle involvement (inability to wrinkle forehead or change expressions) Involvement of the autonomic nervous system manifested by bradycardia, sweating, fluctuating blood pressure, notably hypotension, which may last for two weeks. Stabilizing/Plateau Phase: Stabilizing/Plateau Phase Occurs 2 to 3 weeks after initial onset Marks the end of changes in condition, characterized by a leveling off of symptoms Generally, the labile autonomic functions characterized by: Fluctuating blood pressure Cardiac dysrythmias and tachycardia Paralytic ileus and urinary retention Innapropriate antidiuretic hormone (SIADH) secretion begin to stabilize Recovery Stage: Recovery Stage May take from several months to 2 years Marked by improvement in symptoms Generally, muscle strength and function return in descending order Diagnostics: Diagnostics Spinal tap (lumbar puncture) Will show elevated protein levels without increase in other cells Nerve function tests Electromyography reads electrical activity in your muscle to determine if your weakness is caused by muscle damage or nerve damage. Nerve conduction studies assess how your nerves and muscles respond to small electrical stimuli. Pulmonary Function Tests (PFT’s) and ABG’s Performed when respiratory function is compromised Nursing Assessment: Nursing Assessment Assess for: Parasthesias Weakness of lower extremeties Paralytic ileus, urinary retention Gradual progressive weakness of the upper extremeties and facial muscles Possible progression to respiratory failure Cardiac dysrythmias Cerebral spinal fluid (CSF) that reveals elevated protein levels Abnormal Electroencephalogram Nursing Interventions: Nursing Interventions Care is directed toward the treatment of symptoms Monitor respiratory status Provide respiratory treatment Prepare to initiate respiratory support, mechanical ventilation Monitor cardiac status Assess for complications of immobility Pain management Dietary management Provide patient and family support Review in ATI: Review in ATI Review Guillian-Barre in ATI RN Medical Surgical Nursing 8.0 p. 115 – 122.