ch61 Peripheral Nerve and Spinal Cord Problems
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Define trigeminal neuralgia.
Neuropathy of cranial nerve 5 with intense pain in CN-5 dermatome distribution. Abrupt onset of paroxysms of excruciating pain, burning, knife-like, or lightning-like shock in the lips, gums, cheek, forehead, or side of nose. Twitching, grimacing, blinking, and tearing may occur during an attack.
Precipitating events for trigeminal neuralgia flairup.
Chewing, toothbrushing, hot/cold blast of air to face, washing face, yawning, talking, and especially touch and tickle.
Trigeminal neuralgia medications.
- Antiseizure drugs such as carbamazepine (Tegretol), phenytoin (Dilantin), valproate (Depakene), carbazepine (Trileptal), gabapentin (Neurontin), lamotrigine (Lamictal), and topiramate (Topamax).
- Tegretol is first drug of choice, acts on Na+ channels, decreases neuronal repolarization and firing.
Trigeminal neuralgia and nursing concerns:
Nutrition status, hygiene (especially oral), and behavior (withdrawal). Degree of pain and its effects on lifestyle, drug history, emotional state, and suicidal ideation.
Define Bell's palsy.
- Disruption of one side of CN-7 facial nerve with absence of any other disease, resulting in one-sided face droop
- Etiology unknown, but virus suspected (HSV around/behind ear)
- Benign, usually full recovery after 6 months
- Residual droop may persist
Treatment for patient with Bell's palsy.
- Moise heat, gentle massage, electrical stimulation, exercises
- Corticosteroids (prednisone) started immediately; once improvement is demonstrated, taper off over 2-week period
- If HSV (70% of cases), use acyclovir (Zovirax)
- Avoid cold drafts (trigeminal sensitivity/pain)
Define Guillain-Barre syndrome.
- Cell-mediated immunologic reaction directed at peripheral nerves
- Often preceded by viral infection, trauma, surgery, viral immunizations, or HIV (stimulation of immune system)
- Affects peripheral nervous system, results in segmental demyelination, edema, and inflammation of nerves
- Loss of neurotransmission to periphery
Guillain-Barre clinical manifestations:
- Weakness in lower extremities (distally more severe)
- Paresthesias (numbness/tingling) followed by paralysis
- Hypotonia (reduced muscle tone)
- Areflexia (lack of reflexes)
- If autonomic system involvement (e.g., CN-10), orthostatic hypotension, hypertension, bradycardia, heart block, asystole, bowel/bladder dysfunction, diaphoresis, respiratory failure
Define spinal shock (spinal cord injury).
Decreased reflexes, loss of sensation, flaccid paralysis below level of injury. Lasts days to months, masks postinjury neurologic function.
Define neurogenic shock (spinal cord injury).
- Loss of vasomotor tone, hypotension, bradycardia, loss of sympathetic nervous system, peripheral vasodilation, venous pooling, deceased cardiac output. Associated with cervical or high thoracic injury
- Atropine for bradycardia
- Dopamine for hypotension
Classifying spinal cord injuries.
- Mechanism of injury - flexion, hyperextension, flexion-rotation, extension-rotation, compression; flexion-rotation most unstable (ligament tears)
- Level of injury - skeletal (vertebral) level, neurologic (cord) level
- Degree of injury - 1st affects vertebral column (fracture/dislocation); 2nd affects anterior or posterior ligaments, compression of spinal cord; 3rd affects spinal cord and roots, concussion,contusion, compression, laceration by fracture/dislocation, penetrating missiles
Spinal cord injury, functional loss:
- C1-C4: Tetraplegia, loss of all motor and sensory function neck down, loss of respiration, no bowel or bladder control
- C5: Tetraplegia, can control head, shoulders, clavicle, portions of forearms, not intercostal muscles, no bowel or bladder control
- C6: Tetraplegia, can control head, shoulders, arms, palms of hands and thumbs
- C7-C8: Tetraplegia, triceps and grasp present
- T1-T6: Paraplegia, control shoulders, upper arms, chest, hands, no bowel or bladder function
- T7-L4: Paraplegia, can use leg braces and crutches, swing gait; lower levels have increased balance
- Cause: Rise in blood pressure, sometimes fatal; occurs with cord lesions above T6; sympathetic nervous system (fight/flight) sends signals to brain, brain cannot return signal stating to turn off sympathetic response; can result in stroke, MI, or status epilepticus
- Signs & symptoms: Severe HTN, severe HA, bradycardia, sweating above injury, goosebumps, blurred vision, nausea, vomiting
- Interventions: Raise head of bed; remove possible source of stimulation; monitor BP, administer antihypertensives (per MD orders); call MD if needed
Spinal cord injury - acute nursing care:
- Maintain optimal respiratory function
- Maintain optimum CV function
- Maintain F & E balance
- Maintain immobilization & spinal cord alignment
- Prevent immobility complications
- Prevent urinary complications
- Maintain bowel elimination
- Monitor temp
- Observe for/prevent infection
- Observe for/prevent stress ulcers
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