Medical-surgical Nursing Demystified

(Sean Pound) #1

CHAPTER 5 Nervous System^217


INTERPRETING TEST RESULTS



  • Electromyogram (EMG) shows fibrillation and fasciculation; motor conduc-
    tion velocity normal or slightly slowed.

  • Elevated creatinine kinase due to muscle changes.

  • Muscle biopsy shows lower neuron degeneration.

  • Pulmonary function testing shows decreased vital capacity.


TREATMENT



  • Maintain adequate nutrition.

  • Consult with speech pathologist for potential swallowing difficulties.

  • Administer spasmolytic agent specific for amyotrophic lateral sclerosis, which
    reduces the transmission of glutamine across the neural synapse. Use of this
    drug appears to slow the progression of the disease:

    • riluzole



  • Administer medications to control symptoms.

  • BIPAP (bi-level positive airway pressure) to assist respiration either at night-
    time, intermittently as needed, or all day.

  • Refer to hospice for end-of-life care.


NURSING DIAGNOSES



  • Impaired physical mobility

  • Ineffective airway clearance


NURSING INTERVENTION



  • Develop a method of communication within the patient’s capabilities—ver-
    bal communication may not be possible; patient may not be able to use call
    bell system.

  • Monitor vital signs—monitor respiratory function and cardiovascular status;
    as muscular function decreases the respiratory muscles may be affected.

  • Monitor input and output.

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