MS CH 50 Nursing Care of Patients With Peripheral Nervous System Disorders PDF

4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1192 50 Nursing Care of Patients With Peripheral Nervous System Disorders KEY TERMS...

4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1192 50 Nursing Care of Patients With Peripheral Nervous System Disorders KEY TERMS DEBORAH L. WEAVER amyotrophic (ay-MY-oh-TROH-fik) anticholinesterase (AN-tee-KOH-lin-ESS-ter-ays) atrophy (AT-troh-fee) LEARNING OUTCOMES demyelination (dee-MY-uh-lin-AY-shun) 1. Identify disorders that are caused by disruption of the fasciculation (fah-SIK-yoo-LAY-shun) neuralgia (new-RAL-jee-ah) peripheral nervous system. neuropathies (new-ROP-uh-thees) 2. Explain the pathophysiology, major signs and symptoms, neurectomy (new-REK-tuh-mee) and complications of selected peripheral nervous system plasmapheresis (PLAZ-mah-fer-EE-siss) disorders. ptosis (TOH-sis) remyelination (ree-MY-uh-lin-AY-shun) 3. Identify therapeutic measures used for selected peripheral rhizotomy (rye-ZOT-uh-mee) nervous system disorders. sclerosis (skleh-ROH-sis) 4. List common nursing diagnoses associated with peripheral nervous system disorders. 5. Plan prioritized nursing interventions for patients with peripheral nervous system disorders. 6. Evaluate the effectiveness of nursing care. 1192 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1193 Chapter 50 Nursing Care of Patients With Peripheral Nervous System Disorders 1193 The peripheral nervous system (PNS) consists of all nervous of the body’s immune system. The nerve becomes inflamed system structures outside the central nerv ous system (CNS). and edematous, which interrupts impulses to the muscles. As A variety of disorders affect the PNS. Some of these disorders the disease progresses, sclerosis or scar tissue damages the become chronic and cause de generation of body systems. nerve. Nerve impulses become completely block ed, causing Some other disorders are more temporary. Two common types permanent loss of muscle function in that area of the body. of PNS disorders are discussed in this chapter. Neuromuscular disorders compose one group and can include motor or sen- Etiology sory disorders or both. The second group includes cranial The cause of MS is not really understood. Damage to the nerve disorders. Both types of disorders present a challenge myelin sheath is thought to be from an autoimmune process; to the nurse caring for the patient and family. however, the disease can be related to viral infections, heredity, and other unknown factors. Some research indicates that there is an inherited tendency to develop MS, and the manifestations NEUROMUSCULAR DISORDERS of the disease only appear in the presence of en vironmental triggers. The disease usually starts between ages 15 and This group of neurologic conditions is chronic and degenerative 50. Women are 2 to 3 times more lik ely to develop MS than in nature. Neuromuscular disorders in volve a disruption of men and are more likely to have relapses (National MS Society, impulse transmission between neurons and the muscles the y 2013). Smokers and those with vitamin D def iciency have a stimulate. This breakdown in transmission results in muscle higher risk of MS. Caucasians have a higher incidence of MS weakness. If the muscles of the respiratory system are affected, than those of African descent (Multiple Sclerosis Association deadly complications can develop, including pneumonia and of America [MSAA], 2013). The course of the disease is respiratory failure. Common neuromuscular disorders include unpredictable, and there are man y variations in symptoms, multiple sclerosis, myasthenia gra vis, amyotrophic lateral depending on which nerves are affected. Some individuals have sclerosis, and Guillain-Barré syndrome. mild illness, while others suffer permanent disability or rapid decline and death. Multiple Sclerosis Pathophysiology Signs and Symptoms Multiple sclerosis (MS) is a chronic progressive degenerative The patient with MS presents with muscle weakness, tingling disease that affects the myelin sheath of the neurons in the sensations, and numbness. Other common symptoms include CNS. Myelin is responsible for the smooth transmission visual disturbances, usually in one e ye at a time. These of nerve impulses. Muscles contract when nerv e impulses disturbances may be accompanied by pain with eye movement. stimulate the muscle tissue. In MS, the myelin sheath be gins Symptoms may begin slowly over weeks to months or start to break down (degenerate; Fig. 50.1) as a result of activation suddenly and dramatically. MS affects many body systems Myelin sheath A B C FIGURE 50.1 The myelin sheath breaks down in multiple sclerosis, interrupting transmission of nerve impulses. (A) Normal myelin sheath. (B) Myelin beginning to break down. (C) Total myelin disruption. Modified from Scanlon, V. C., & Sanders, T. (2014). Workbook for essentials of anatomy and physiology (7th ed.). Philadelphia: F.A. Davis, with permission. 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1194 1194 UNIT THIRTEEN Understanding the Neurologic System (Box 50-1). Many factors can trigger the onset of symptoms of the disease. Interferon therapy with beta-interferons such as or aggravate the condition, including e xtreme heat and cold, Betaseron or Avonex can reduce e xacerbations and delay fatigue, infection, and physical and emotional stress. Hormonal disability. Steroids such as adrenocorticotropic hormone changes after pre gnancy can also cause symptom onset or (ACTH) and prednisone are gi ven to decrease inflammation exacerbation. and edema of the neurons, which can relieve some symptoms. Periods of exacerbation and remission lead patients with Immunosuppressant drugs such as azathioprine (Imuran) and MS to be uncertain about when the disease will flare up and cyclophosphamide (Cytoxan) may be gi ven to suppress the what body system will be affected. Intense fatigue is common; immune system. In 2012, oral teriflunomide (Aubagio) w as therefore, immobility can become a problem. Accidents and added to the F ood and Drug Administration–approved falls are common because of muscle weakness or numbness of medications, and in 2013, dimethyl fumarate (Tecfidera) was the trunk and limbs. Some people with MS experience symp- added (MSAA, 2013). Clinical trials ha ve shown that these toms such as muscle spasticity, bowel or bladder dysfunction, medications can reduce the number and se verity of relapses, or paralysis. Difficulty with concentration or forgetfulness can reduce the number of ne w lesions shown on MRI, and for also be problematic. Pneumonia can occur from immobility some, delay disease progression and disability. Each of these and from weakness of the diaphragm and intercostal muscles. medications has serious side effects. Death, often resulting from respiratory infection, typically Anticonvulsants such as carbamazepine (T egretol) or occurs 20 to 35 years after diagnosis. duloxetine (Cymbalta) help relieve neuropathic pain. Valium (Diazepam), baclofen (Lioresal), tizanidine (Zanafle x), and Diagnostic Tests physical therapy assist in controlling muscle spasms. Bladder Diagnosis is based on the patient’ s history and signs and problems are treated with parasympathetic agents such as symptoms. Analysis of cerebrospinal fluid (CSF) may show bethanechol (Urecholine) and oxybutynin (Ditropan). Fatigue an increase in oligoclonal immunoglob ulin G (IgG). Mag- can be treated with antidepressants or an antiviral agent such netic resonance imaging (MRI) can be helpful in diagnosis as amantadine (Symmetrel). Table 50.1 reviews additional because sclerotic plaques can be detected. A new blood test, medications used to treat PNS disorders. gMS DX, is no w available to help identify people lik ely to For those who suffer sudden severe attacks or who do not have identifying antibodies associated with MS. Ev oked respond to high doses of steroids, plasma e xchange or potential tests may be done to determine slo w transmission plasmapheresis may be used to remo ve from the blood of impulses. antibodies that are attacking the myelin (Box 50-2). Ne w research is focusing on treatments to regenerate myelin. Therapeutic Measures Rehabilitation after an acute episode includes physical, MS has no cure. Many people with MS do well with no med- speech, and occupational therapies. Rehabilitation therap y ication at all, although early treatment can delay progression helps the patient and family adapt the home environment to the patient’s special needs. Assistive devices such as braces, canes, wheelchairs, and splints allo w the patient increased mobility and independence. P atients who develop speech Box 50-1 Problems Associated difficulties benefit from speech therap y. Exercise also can With Multiple Sclerosis be beneficial (see “Evidence-Based Practice”). Weakness/paralysis of limbs, trunk, or head Diplopia (double vision) Slurred speech Spasticity of muscles EVIDENCE-BASED PRACTICE Numbness and tingling Clinical Question Patchy blindness (scotomas) What is the effect of physical activity and self- Blurred vision efficacy on the quality of life of persons with MS? Vertigo Evidence Tinnitus A sample of 269 persons with relapsing– Impaired hearing remitting MS was studied for 1 year. Exercise Nystagmus strategies were implemented with individuals Ataxia who believed they could be successful in the Dysarthria treatment plan. Physical activity and self- Dysphagia efficacy were associated with improvements Constipation in reported quality of life. Spastic (uninhibited) bladder Flaccid (hypotonic) bladder Sexual dysfunction Anger, depression, euphoria WORD BUILDING plasmapheresis: plasma—liquid of blood + pheresis—removal 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1195 Chapter 50 Nursing Care of Patients With Peripheral Nervous System Disorders 1195 Implications for Nursing Practice Nursing Care As nurses we can support individuals in their See the “Nursing Care Plan for the Patient With a Progressive efforts to manage their chronic illness by Neuromuscular Disorder.” encouraging them to embrace their ability to In addition to reviewing routine care, instruct the patient be successful along with a reasonable exercise to avoid factors that can e xacerbate symptoms. This regimen. Fewer exacerbations can mean improved includes avoiding stressful situations as much as possible. quality of life as well as fewer complications. Rest, exercise, and a balanced diet are important self-care steps to control symptoms. In addition, a voiding extreme REFERENCE temperature changes, especially heat, and a voiding infec- Motl, R. W., McAuley, E., Wynn, D., Sandroff, B., & Suh, Y. tion and illness are important. Any infection, especially (2012). Physical activity, self-efficacy, and health-related respiratory, should be reported immediately to the health quality of life in persons with multiple sclerosis: Analysis care provider (HCP). Two excellent sources of information of associations between individual-level changes over one on MS are the National Multiple Sclerosis Society at year. Quality of Life Research. Retrieved June 29, 2013, www.nationalmssociety.org and the Multiple Sclerosis from http://link.springer.com/article/10.1007/s11136 Foundation at www.msfocus.org. -012-0149-z#page-1 TABLE 50.1 MEDICATIONS USED TO TREAT PERIPHERAL NERVOUS SYSTEM DISORDERS Medication Class/Action Examples Nursing Implications Cholinesterase Inhibitors Increase acetylcholine at neostigmine (Prostigmin) Atropine is antidote. synapses. pyridostigmine (Mestinon) edrophonium chloride (Tensilon, used in diagnosis of MG) Glucocorticoids Reduce inflammation. prednisone Provide calcium supplement. prednisolone Avoid crowds and others with infections. prednisolone acetate or sodium phosphate Monitor fluid balance. May need to treat blood sugar with insulin while on medication. Immunosuppressants Suppress immunity and azathioprine (Imuran) Monitor blood counts. antibody formation. cyclophosphamide (Cytoxan) Protect from bleeding and infection. Administer with meals to reduce nausea. Antispasmodics/Muscle Relaxants Relax muscles, reduce dantrolene (Dantrium) Avoid operating machinery or driving pain. baclofen (Lioresal) until effects are known. diazepam (Valium) Monitor patient for respiratory depression. tizanidine (Zanaflex) Anticonvulsants Treat nerve pain. phenytoin (Dilantin) Teach good oral hygiene with soft bris- carbamazepine (Tegretol) tle brush, floss, and gum massage gabapentin (Neurontin) (phenytoin). duloxetine (Cymbalta) Monitor for fall risk. Monitor blood counts. Continued 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1196 1196 UNIT THIRTEEN Understanding the Neurologic System TABLE 50.1 MEDICATIONS USED TO TREAT PERIPHERAL NERVOUS SYSTEM DISORDERS—cont’d Medication Class/Action Examples Nursing Implications Glutamate Antagonist Delays progression of ALS. riluzole (Rilutek) Rest, monitor for respiratory depression. Give on empty stomach. Avoid large quantities of caffeine. Avoid charcoal-broiled foods. Monitor liver function laboratory values. Biologic Response Modifiers Reduce relapses in teriflunomide (Aubagio) Monitor liver enzymes, blood pressure, relapsing-remitting MS dimethyl fumarate (Tecfidera) potassium level, and signs of infection. Monitor CBC and signs of infection. Note. ALS = amyotrophic lateral sclerosis; CBC = complete blood count; MS = muscular sclerosis. Box 50-2 Plasmapheresis Plasmapheresis, also known as plasma exchange therapy, Assess complete blood cell count (CBC), platelet is a procedure that remo ves the plasma component count, and clotting studies. from whole blood and replaces it with fresh plasma.The Check blood type and crossmatch for replacement goal is to remove antibodies through plasma exchange, blood products. suppressing the immune response and inflammation. Postprocedure Nursing Care Preprocedure Nursing Care Observe the patient for signs of hypovolemia, such as Teach patient about the procedure and what to expect, dizziness and hypotension. including what the machine looks like (similar to but Apply pressure dressings to the access sites. smaller than a dialysis machine), the need for arterial Monitor the patient for infection and bruits at the and venous access sites, and the length of the procedure access site. (2 to 5 hours). Monitor electrolytes and signs of electrolyte loss. The HCP may order medications held until after the pro- Report imbalances, and administer replacement cedure. Some patients may require premedication, espe- electrolytes as ordered. cially if they have experienced complications in the past. Compare preprocedure and postprocedure laboratory Assess baseline vital signs and weight. data, such as CBC, platelet count, and clotting times. NURSING CARE PLAN for the Patient With a Progressive Neuromuscular Disorder Nursing Diagnosis: Ineffective Airway Clearance related to respiratory muscle weakness, with impaired cough and gag reflexes Expected Outcomes: The patient will maintain a patent airway as evidenced by clear lung sounds and freedom from signs and symptoms of respiratory distress. Evaluation of Outcomes: Is patient’s airway patent and are lung sounds clear? Is patient free of signs and symp- toms of respiratory distress? 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1197 Chapter 50 Nursing Care of Patients With Peripheral Nervous System Disorders 1197 NURSING CARE PLAN for the Patient With a Progressive Neuromuscular Disorder—cont’d Intervention Monitor respiratory rate and depth, breath sounds, oxygen saturation (SpO2), and arterial blood gases (as ordered). Report deterioration. Rationale Increasing respiratory distress indicates progressing muscle weakness that may require mechanical ventilation or end-of-life decisions. Evaluation Is patient’s respiratory rate status stable or is intervention indicated? Intervention Encourage patient to cough and deep breathe every 2 hours. Rationale Effective coughing helps keep airway clear. Evaluation Does patient have the strength to cough effectively? Intervention Observe patient for breathlessness while speaking. Rationale Inability to speak without breathlessness in- dicates declining respiratory function. Evaluation Is patient able to finish sentences without needing to take a breath? Intervention Elevate head of bed. Rationale Fowler’s position improves lung expansion, decreases work of breathing, improves cough efforts, and decreases risk for aspiration. Evaluation Does elevation of head of bed help relieve dyspnea and prevent aspiration? Intervention Evaluate cough, swallow, and gag reflexes frequently. Notify HCP if absent. Rationale Frequent evaluation of reflexes is needed to prevent aspiration, respiratory infections, and respiratory failure. Evaluation Is patient able to cough effectively? Is gag reflex intact? Intervention Suction secretions as needed, noting color and amount of secretions. Rationale Muscle weakness can result in inability to clear airway. Evaluation Does patient require suctioning to clear airway? What color are secretions? Nursing Diagnosis: Impaired Physical Mobility related to muscle weakness Expected Outcomes: The patient will maintain optimum mobility and activity level, identify measures to help maintain mobility, and perform exercises that help maintain current mobility. Evaluation of Outcomes: Is optimum activity level maintained? Can patient identify measures that will help main- tain mobility? Does patient perform exercises that help maintain mobility? Intervention Determine preillness and current level of mobility. Rationale Assessment guides care planning. Evaluation Do assessment findings help determine goals and interventions? Intervention Identify factors that affect ability to be mobile and active. Rationale Some factors that interfere with mobility can be modified. Evaluation Are interfering factors modified effectively? Intervention Encourage patient to perform self-care to maximum ability. Rationale Promotes sense of control and independence for patient. Evaluation Does patient perform self-care activities? Is assistance required? Intervention Consult physical therapist or occupational therapist to provide assistive devices for walking (canes, braces, walker, wheelchair) and other activities. Rationale Assistive devices decrease fatigue and promote independence, comfort, and safety. Evaluation Does patient use assistive devices safely during activities? Do they help keep patient active? Intervention Reposition frequently when patient is immobile. Rationale Prevents skin breakdown and stasis of pulmonary secretions. Evaluation Is patient free from complications of immobility? Intervention Provide active/passive range-of-motion (ROM) exercises on a regular basis. Rationale Prevents contractures and disuse atrophy. Evaluation Does patient have any contractures or atrophy? Intervention Plan activities with a balance of frequent rest periods. Rationale Rest decreases fatigue. Evaluation Is fatigue controlled? Continued 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1198 1198 UNIT THIRTEEN Understanding the Neurologic System NURSING CARE PLAN for the Patient With a Progressive Neuromuscular Disorder—cont’d Intervention Administer medications as ordered. Rationale Medications can slow progress of disease and reduce symptoms that limit mobility. Evaluation Are symptoms controlled? Nursing Diagnosis: Risk for Imbalanced Nutrition: Less Than Body Requirements related to weakness or lack of coordination of muscles for chewing and swallowing Expected Outcome: The patient will maintain body weight within normal limits for height and frame. Evaluation of Outcome: Is patient’s weight stable and within normal limits? Intervention Evaluate cough, swallow, and gag reflexes frequently. Notify HCP if absent. Rationale If patient is unable to swallow, a feeding tube may be indicated, depending on patient’s wishes. Evaluation Does patient eat and drink without aspirating? Intervention Offer soft foods that are easy to chew and swallow. Rationale Soft foods require less effort to chew and are less fatiguing. Evaluation Is patient able to chew and swallow without excessive fatigue? Intervention Request speech therapist and dietitian consultations as indicated. Rationale Speech therapist can help evaluate swallowing and make recommendations. Dietitian can recommend appropriate foods. Evaluation Are consults indicated? Are recommendations implemented? Intervention Institute swallowing precautions as needed. Rationale Swallowing precautions help prevent aspiration and allow patient to maintain oral intake as long as possible. Evaluation Do precautions prevent aspiration? Nursing Diagnosis: Impaired Verbal Communication related to impaired respiratory and muscle function Expected Outcome: The patient will be able to communicate needs. Evaluation of Outcome: Does patient indicate that needs are met with a minimum of frustration? Intervention Assess ability to speak and communicate. Rationale Assessment is essential to planning appropriate communication interventions. Evaluation Can patient speak or communicate needs? Intervention Request referral to speech therapist for assistance if indicated. Rationale Speech therapist can recommend appropriate alternative communication techniques. Evaluation Is speech therapy referral indicated? Is referral completed? Intervention Assess for nonverbal signs of pain or distress, such as restlessness, agitation, grimacing. Rationale Patient may not be able to tell you if he or she is in pain or distress. Evaluation Are signs of pain or distress present? Are they attended to? Intervention Use picture board or paper and pencil. Ask questions that require a yes or no answer. Rationale These do not require the patient to speak to communicate. Evaluation Do alternative methods help patient communicate needs? Intervention Use nonhurried, calm, and caring approach while providing care. Rationale This will help decrease anxiety and provide emotional support to patient and family. Evaluation Do patient and family appear anxious? Does calm approach help? Intervention Explain all procedures. Rationale Patient can still hear and needs to know what is happening. Evaluation Does patient indicate understanding? 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1199 Chapter 50 Nursing Care of Patients With Peripheral Nervous System Disorders 1199 Myasthenia Gravis susceptibility may also play a role. Disorders of the thymus gland are often associated with MG. Thymomas or tumors on Pathophysiology the thymus gland can account for the malfunction of the immune Myasthenia gravis (MG) means “grave muscle weakness,” or system that initiates the autoimmune process. All ethnic groups weakness of the voluntary or skeletal muscles of the body. MG and both genders can de velop this disease. Peak age of onset is a noncommunicable (chronic) disease of the neuromuscular in women is ages 20 to 30. Men are af fected more often after junction (Fig. 50.2). Normally, at the neuromuscular junction, age 60. MG occurs slightly more often in women than men. the neuron releases the chemical neurotransmitter acetylcholine (ACh), which crosses the synaptic cleft. Receptors on the Signs and Symptoms muscle tissue take up ACh and contraction of the muscle results. MG results in progressive extreme muscle weakness. The classic In MG, the body’ s immune system is acti vated, producing sign of MG is increased muscle weakness during acti vity and antibodies that attack and destroy ACh receptors at the neuro- improvement in muscle strength after rest. Muscles are strongest muscular junction. Therefore, ACh cannot stimulate muscle in the morning, when the person is rested.Activities affected by contraction because the number of ACh receptors has been MG include eye and eyelid movements, chewing, swallowing, reduced, resulting in loss of voluntary muscle strength. speaking, and breathing, as well as sk eletal muscle function. Patients often present with drooping of the e yelids (ptosis). Etiology Facial expressions become masklike. After long conversations, MG is a chronic autoimmune process. No specif ic cause has the patient’s voice can fade. Falls occur because of weakness of been found for MG. Ho wever, current thought is that a virus the arm and leg muscles. Patients with MG experience periods or bacteria may initiate the autoimmune process. Genetic of exacerbation and remission of symptoms, similar to patients with MS. Exacerbations can be caused by emotional or physical stress such as menses, illness, trauma, extremes in temperature, pregnancy, electrolyte imbalance, surgery, and drugs that block Motor neuron action at the neuromuscular junction. Neuro-musculus Complications junction Major complications associated with MG result from weakness of muscles that assist with swallowing and breath- Vesicles of ing. Aspiration, respiratory infections, and respiratory acetylcholine failure are the leading causes of death. Sudden onset of Acetylcholine muscle weakness in patients with MG resulting from not enough medication is called a myasthenic crisis. Overmedication with anticholinesterase (anti-ACh) drugs Acetylcholine causes a cholinergic crisis (Table 50.2). Both crises require receptors immediate medical attention. A Sarcomere LEARNING TIP Symptoms of cholinergic crisis can be remembered with the acronym SLUDGE: salivation, lacrimation, urination, diarrhea, gastrointestinal (GI) cramping, and emesis. A severe crisis has been described as “liquid pouring out of every body orifice.” Diagnostic Tests Diagnosis of MG is based on history of symptoms and physical examination of the patient. A simple test involves the patient looking upward for 2 to 3 minutes. Increased droop of the Damaged eyelids (ptosis) occurs if MG is present. After a brief rest, the receptors eyelids can be opened without difficulty. Another test is done B by injecting edrophonium (T ensilon, an anticholinesterase FIGURE 50.2 Myasthenia gravis. (A) Normal neuromuscular junction. (B) Note damaged acetylcholine receptor sites in myasthenia gravis. Modified from Scanlon, V. C., & Sanders, T. WORD BUILDING (2014). Workbook for essentials of anatomy and physiology anticholinesterase: anti—against + cholinesterase—chemical (7th ed.). Philadelphia: F.A. Davis, with permission. that breaks down acetylcholine 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1200 1200 UNIT THIRTEEN Understanding the Neurologic System TABLE 50.2 COMPARISON OF MYASTHENIC CRISIS AND Box 50-3 Medications That Can CHOLINERGIC CRISIS Exacerbate Symptoms Myasthenic Cholinergic of Myasthenia Gravis Crisis Crisis Antibiotics (some) Alpha interferon Cause Too little Too much Anticholinergic agents medication medication Beta blockers Botulinum toxin Signs and Ptosis Increasing muscle Calcium channel blockers Symptoms weakness Chloroquine Difficulty Dyspnea Lithium swallowing Magnesium Difficulty Salivation Neuromuscular blocking agents (such as those used speaking during surgery) Dyspnea Lacrimation Penicillamine Weakness Incontinent Prednisone urination Procainamide Abdominal Quinidine cramping, diarrhea Nausea, emesis Increased Nursing Process for the Patient With Myasthenia bronchial Gravis secretions DATA COLLECTION. Determine the patient’s baseline muscle Sweating Miosis (constric- strength. Ask how much activity is tolerated before f atigue tion of pupils) and muscle weakness occur. Identify the patient’s support systems and determine whether the patient’s needs are being met. Assess the knowledge base of the patient and f amily. Check respiratory function and swallowing ability. drug) intravenously (IV). If muscle strength improves dramat- NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION. ically (e.g., the patient can suddenly open the eyes wide), MG Activity Intolerance related to muscle weakness is diagnosed. However, improvement is only temporary. An EXPECTED OUTCOME: The patient will improve activity increased number of anti-ACh receptor antibodies in the blood tolerance as evidenced by ability to carry out necessary are present in 90% of patients with MG. Electromyography activities. (EMG) may be done to rule out other conditions. Pulmonary function tests may be done to predict potential myasthenic Schedule anticholinesterase drugs so that peak action crisis leading to respiratory failure. occurs at times when increased muscle strength is needed so the patient has strength for activities such as meals Therapeutic Measures and physical therapy. No cure is currently available for MG. Treatment is aimed Teach the patient to schedule activities such as grocery at controlling symptoms. Remo val of the thymus gland shopping or errands at times when medication is at peak (thymectomy) can decrease production of ACh receptor action, so that muscle strength is adequate for the activity. antibodies and decrease symptoms in most patients. Med- Be aware of symptoms and treatment of myasthenic and ications used to treat MG include the anticholinesterase cholinergic crises, so quick intervention can be carried drugs neostigmine (Prostigmin) and pyridostigmine (Mesti- out to prevent worsening symptoms. non). These drugs improve MG symptoms by destroying the Teach the patient and significant others signs and symptoms acetylcholinesterase that breaks do wn ACh. Remember of crisis conditions because both crises constitute medical that ACh causes muscles to contract. If ACh is allo wed emergencies and require immediate medical attention more time to attach to muscle tissue receptors, the muscle (see Table 50.2). contracts and strength is increased. Steroids such as Teach methods to conserve energy, such as sitting down to prednisone and immunosuppressants are used to suppress do grooming and housekeeping activities whenever possible. the body’s immune response. Plasmapheresis can be used This helps the patient conserve energy to manage ADLs. to remove antibodies from the patient’s blood (Box 50-3). Teach the patient to rest between activities to allow time Use of immune globulin is being researched. for muscle strength to be restored. 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1201 Chapter 50 Nursing Care of Patients With Peripheral Nervous System Disorders 1201 Teach the importance of avoiding people with infections involuntarily, and so are not affected by ALS. The ability to and exposure to cold to minimize risk for respiratory think and reason also is not affected. infections, which can exacerbate symptoms and increase ALS can occur at any age but usually does not appear until risk for ineffective airway clearance. adulthood. The cause of ALS is not known, but it is believed Instruct the patient to eat nutritious, well-balanced meals to have a genetic component. to maintain strength and resistance to infections, which can exacerbate symptoms. Signs and Symptoms Teach the patient to only use medications that are prescribed Symptoms are v ague early in the course of ALS. Primary by the HCP. If multiple providers are used, all medications symptoms include progressive muscle weakness and decreased should be checked with the provider who is treating the coordination. This can begin in the arms, le gs, or muscles of MG. Many medications can exacerbate muscle weakness speech and swallowing. Atrophy of muscles and fasciculations (Box 50-3). (twitching) also occur. Muscle spasms can cause pain. Difficulty Provide information about support groups that can provide with chewing and swallowing place the patient at a risk for encouragement and assistance to patients and their families. choking and aspiration as the disease progresses. Inappropriate emotional outbursts of laughing and crying can occur. Speech EVALUATION. If the plan of care has been ef fective, the becomes increasingly difficult. Bladder and bowel functions patient’s activity and self-care needs will be met, either by remain intact, yet problems such as constipation, urinary the patient or by other support individuals. urgency, hesitancy, or frequency can occur. Also see the “Nursing Care Plan for the P atient With a Late in the disease, communication becomes limited to Progressive Neuromuscular Disorder.” More information can moving and blinking the e yes in response to questions. be found at the Myasthenia Gra vis Foundation of America Pulmonary function becomes se verely compromised to the website at www.myasthenia.org. point of requiring mechanical ventilator assistance if the patient chooses. Other complications can include extreme malnutrition, falls, pulmonary emboli, and congesti ve heart f ailure. ALS CRITICAL THINKING eventually leads to death from respiratory complications such as atelectasis, respiratory failure, and pneumonia. Jamie Diagnostic Tests Jamie is referred to a neurologist because of muscle weakness. Diagnosis is made based on clinical symptoms. Additional tests such as CSF analysis, electroencephalogram (EEG), 1. What history can help differentiate between MS and nerve biopsy, nerve conduction velocity (NCV), or EMG may MG? be done to rule out other conditions. Blood enzymes can be 2. What physical examination can be done to increased as a result of muscle atrophy. differentiate between MS and MG? 3. The neurologist prepares to do a Tensilon test Therapeutic Measures and asks you to prepare 2 mg of Tensilon for IV There is no cure forALS, and treatments are palliative in nature. injection. It is supplied as 10 mg per milliliter. Goals of treatment are aimed at improving function as long as How much should you draw up? possible and emotionally supporting the patient and f amily 4. In preparing for a case management meeting for a through the illness. Baclofen (Lioresal) and diazepam (Valium) patient with a neuromuscular disease, which other may be given to relieve muscle spasticity. Quinine may be used HCPs should be invited? for muscle cramps. Riluzole (Rilutek) slo ws the progression Suggested answers are at the end of the chapter. of the disease and can prolong life by 3 to 4 months. Ne w treatments are constantly being researched. Nonpharmacological measures such as physical therap y, massage, position changes, and diversional activities can help Amyotrophic Lateral Sclerosis control pain. Tube feedings via a surgically placed gastrostomy Pathophysiology and Etiology tube help provide adequate nutrition. Prevention of infections, Amyotrophic lateral sclerosis (ALS, also called Lou such as pneumonia and urinary tract infection (UTI), is vital. Gehrig’s disease) is a progressive, degenerative condition that Meticulous skin care minimizes the incidence of pressure affects motor neurons responsible for the control of voluntary ulcers. Physical, occupational, and speech therapies allo w the muscles. In the brain and spinal cord, upper and lower motor patient to maximize function and control for as long as possible. neurons begin to de generate and form scar tissue or die, Therapy can also decrease the occurrence of complications such blocking transmission of nerv e impulses. Without stimula- as aspiration, falls, and contractures. tion, muscles atrophy, and muscle strength and coordination decrease. As the disease progresses, more muscle groups, WORD BUILDING including muscles controlling breathing and sw allowing, amyotrophic: a—without + myo—muscle + trophic—nourishment become involved. The heart and GI tract are controlled atrophy: a—without + trophy—nourishment 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1202 1202 UNIT THIRTEEN Understanding the Neurologic System Patients with speech problems may benef it from the use of the spinal and cranial nerv es is destro yed by a dif fuse of augmentative alternative communication. A variety of such inflammatory reaction. The peripheral nerves are infiltrated systems are a vailable; most in volve laptop computers that by lymphocytes, which leads to edema and inflammation. patients can use to type in words or symbols to generate speech. Segmental demyelination causes axonal atrophy, resulting Medicare pays at least a portion of the cost for the equipment. in slowed or blocked nerve conduction. Typically, the demyeli- Support groups and counseling provide emotional support for nation begins in the most distal nerv es and ascends in a the patient and family. symmetrical fashion. Remyelination, which is a much slower process, occurs in a descending pattern and is accompanied Nursing Care by a resolution of symptoms. See the “Nursing Care Plan for the Patient With a Progressive There are four recognized variants of GBS; however, only Neuromuscular Disorder.” the most common type, ascending GBS, is addressed in this chapter. It is characterized by progressi ve weakness and PATIENT EDUCATION. Reinforce information given by the HCP numbness that begins in the legs and ascends up the body. The to the patient and family about ALS and its prognosis. Support numbness tends to be mild, but the muscle weakness usually groups can provide emotional support as the patient and family progresses to paralysis. The paralysis can ascend all the way deal with the likely reality of untimely death. Assistive devices to the cranial nerves or stop anywhere between the legs and and exercises help pre vent complications. Teaching family head. Deep tendon refle xes are either depressed or absent. members how to perform physical therapy and other health care Respiratory function becomes compromised in approximately activities allows the patient to spend as much time as possible 50% of patients with ascending GBS. at home. Teach the patient to a void exposure to persons with infections because an infection can be deadly to a patient with Etiology a debilitating disease. Request a consultation with a palliati ve GBS is believed to be caused by an autoimmune response to care specialist or other resource person at your institution to some type of viral infection or to certain v accines, although help the patient and family develop an advance directive. the exact cause is not known. Usually the viral illness affects the respiratory or GI system, and occurs within 2 weeks before onset of neurologic symptoms. The most common organism NURSING CARE TIP found to be associated with GBS is Campylobacter jejuni, When planning care, remember that a person with a common cause of gastroenteritis. ALS has an intact mind—it is the body that is deteriorating. Signs and Symptoms GBS is divided into three stages. STAGE 1, ONSET OF SYMPTOMS. The first stage starts with the onset of symptoms and lasts until the progression of symptoms CRITICAL THINKING stops. This stage can last from 24 hours to 3 weeks and is characterized by abrupt and rapid onset of muscle weakness Mr. Miller and paralysis, with little or no muscle atrophy. Many patients Mr. Miller has been having difficulty swallowing. He give a history of a recent viral illness or vaccination, supporting is diagnosed with ALS. the theory that the cause is autoimmune in nature. The degree of respiratory in volvement correlates to the type of GBS 1. What are the priority nursing diagnoses for and the level of paralysis. Patients with ascending GBS may Mr. Miller? gradually notice a reduced ability to take deep breaths or carry 2. How can the patient and his family be supported on conversations and may feel short of breath. These patients in coping with this disease? are terrified that the y will not be able to breathe and may 3. What other team members should be consulted require intubation and artificial ventilation. for his care? The autonomic nerv ous system is often af fected by Suggested answers are at the end of the chapter. GBS. Patients can experience labile blood pressure, cardiac dysrhythmias, urine retention, or paralytic ileus. Patient reports of discomfort range from anno ying numbness and cramping Guillain-Barré Syndrome to severe pain. The discomfort is exacerbated by the patient’s inability to move voluntarily. Pathophysiology Guillain-Barré syndrome (GBS) is a rare neuromuscular disease affecting only 1 in every 100,00 persons. Both men and WORD BUILDING women in the United States are affected equally. Onset is usu- demyelination: de—down or from + myelin—sheath surrounding ally between 30 and 50 years of age. GBS is an inflammatory neurons + ation—process disorder characterized by abrupt onset of symmetrical paresis remyelination: re—repeat + myelin—sheath surrounding neurons (weakness) that progresses to paralysis. The myelin sheath + ation—process 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1203 Chapter 50 Nursing Care of Patients With Peripheral Nervous System Disorders 1203 STAGE 2, PLATEAU. The second stage is the plateau stage, Nursing Process for the Patient With Guillain-Barré when symptoms are most severe but progression has stopped. Syndrome It can last from 2 to 14 days. Patients may become discouraged See the “Nursing Care Plan for the Patient With a Progressive if no improvement is evident. Neuromuscular Disorder.” In addition, be prepared to teach STAGE 3, RECOVERY. Axonal regeneration and remyelination the patient and family about the disease and treatment. occur during the third state, recovery. This stage lasts from 6 DATA COLLECTION. Assess the patient’s vital signs, ABGs, to 24 months and symptoms slo wly improve. Most patients and SpO2 to monitor respiratory status. Assess gag, corneal, with GBS recover completely within a few months to a year. and swallowing reflexes to determine whether safety measures A few patients experience chronic disability. are needed to prevent aspiration or injury to the eyes. Assess the patient’s and family’s knowledge about the disease and Complications treatment. Complications that can occur include respiratory failure, infec- tion, and depression. Fatigue and paralysis of the respiratory NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION. muscles lead to insufficient respiratory effort. Some patients Deficient Knowledge related to new diagnosis and treatment with impending respiratory failure attempt to convince the staff EXPECTED OUTCOME: The patient and family will verbalize that they are not in distress and do not need to be intubated. understanding of what to expect as disease progresses, It is important to discuss the possible need for intubation early how treatments will help, and how to participate in care. in the patient’s illness. The decision to intubate in GBS is Explain all procedures to the patient and family. Patients different from that with other PNS disorders because GBS and family members who understand the rationale for patients are expected to recover. It is important to be vigilant assessments or interventions are more likely to cooperate in monitoring pulse oximetry, respiratory rate and depth, and and assist. dyspnea to predict the need for interv ention and maintain the Educate the patient and family about the need for frequent patient’s safety. respiratory assessments and possible need for temporary Patients with GBS are prone to pneumonia and UTIs. respiratory support. Patients may deny respiratory difficulty Maintaining infection control practices and maximizing the because of a fear of intubation and mechanical ventilation. patient’s nutritional status help decrease the lik elihood of Teach and encourage use of diversional activities such as infection. Immobility leads to such problems as skin breakdown, visits from family and friends, listening to music or pulmonary embolus, deep v enous thrombosis, and muscle relaxation tapes, and watching television or videos. atrophy. Patients with GBS ha ve little time to adjust to their Recovery can be prolonged, and diversional activities illness and deterioration, and often fear the y will not recover can help alleviate boredom, loneliness, and depression. function. Calm, supportive reassurance is important. As the patient begins to regain function, assist in teaching Diagnostic Tests patient and family how to participate in patient care and therapies. Encourage family members to attend therapy A lumbar puncture is performed to obtain CSF. The CSF appointments. Participation in patient care activities and analysis shows a normal cell count with an ele vated protein therapies can provide a sense of control over the situation level. Electromyographic and nerv e conduction v elocity and helps prepare the patient and family for discharge. tests are done to evaluate nerve function. Pulmonary function Provide information about the disease, treatments, and testing helps confirm impending respiratory problems. recovery. Recovery can take months or years; most of Therapeutic Measures that time will be spent at home. During the initial stages, patients are partially or completely EVALUATION. If interventions have been effective, the patient dependent for all needs. They are often frightened and anxious. and family will demonstrate understanding of the disease Oxygen and mechanical ventilation may be required. Plasma- process and participate in care appropriately. Table 50.3 pheresis may be used to remove the patient’s plasma and replace summarizes and compares MS, MG, ALS, and GBS. it with fresh plasma. This procedure is thought to lessen the body’s immune response. To be most effective, plasmapheresis Postpolio Syndrome should begin 7 to 14 days from the onset of symptoms. Pathophysiology and Etiology Immunoglobulin therapy may help reduce the se verity of the Postpolio syndrome is a condition that af fects survivors of disease. Steroid hormones, although used in the past, are not polio 20 to 40 years after they have recovered from infection effective and may be harmful. Supportive interventions include caused by the poliomyelitis virus. Up to 40% of patients who anticoagulants to prevent deep vein thrombosis, and analgesics previously had polio develop this syndrome. The severity of for pain. the syndrome depends on the de gree of residual weakness During the plateau phase, patients can become discouraged and disability left from the initial illness. because they are not getting an y better. Emotional support is important during this phase. Axonal regeneration and Signs and Symptoms remyelination occur during the reco very phase. Intensi ve Postpolio syndrome in volves a further weak ening of the rehabilitation helps the patient regain function during this phase. muscles that were af fected with the f irst involvement with 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1204 1204 UNIT THIRTEEN Understanding the Neurologic System TABLE 50.3 SUMMARY OF PERIPHERAL NERVOUS SYSTEM DISORDERS Multiple Myasthenia Amyotrophic Lateral Guillain-Barré Sclerosis Gravis Sclerosis Syndrome Signs and Muscle weakness Progressive severe Progressive muscle Three stages: Symptoms Muscle paralysis muscle weakness of weakness 1. Ascending Visual disturbances voluntary muscles Decreased paralysis Fatigue Muscles regain coordination 2. Plateau strength with rest Muscle twitching 3. Descending Masklike face Muscle spasms resolution Pain Pain, cramping or Emotional outbursts numbness Difficulty with speech Intact thought processes Diagnosis CSF analysis Ptosis test CSF analysis CSF MRI Tensilon test EEG EMG gMS DX (blood test) EMG Nerve biopsy NCV NCV Therapeutic Interferon therapy Plasmapheresis Antispasmodics/ Plasmapheresis Measures Steroids Thymectomy quinine Ventilation support Immunosuppressants Anticholinesterase Riluzole (Rilutek) Physical therapy Plasmapheresis agents Physical therapy Anticonvulsants Steroids Massage Antiviral agents Muscle relaxants Muscle relaxants Diversional Physical therapy activities Assistive devices Tube feeding for ADLs Alternative Speech therapy communications devices Complications Falls Aspiration Communication Respiratory Muscle spasms Respiratory infections problems infection Bowel and bladder Respiratory failure Risk for aspiration Respiratory failure problems, risk for Myasthenic crisis or Pain Depression UTI cholinergic crisis Respiratory failure Fatigue Forgetfulness UTI Extreme fatigue Complications of immobility Priority Ineffective Airway Clearance Nursing Impaired Physical Mobility Diagnoses Risk for Imbalanced Nutrition: Less Than Body Requirements Impaired Communication CSF = cerebrospinal fluid; EEG = electroencephalography; EMG = electromyography; MRI = magnetic resonance imaging; NCV = nerve conduction velocity; UTI = urinary tract infection. 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1205 Chapter 50 Nursing Care of Patients With Peripheral Nervous System Disorders 1205 the poliovirus. Symptoms range from fatigue to progressive muscle weakness and atrophy. Sleeping problems, joint pain, scoliosis, and respiratory compromise can occur. Some Trigeminal nerve people suffer great debilitation; others have fewer problems. Ophthalmic Diagnostic Tests Observation and history and e xcluding other problems are most important in diagnosis of this syndrome. Maxillary Therapeutic Measures Mandibular No interventions have been found to be effective at this time. Symptoms seem to be best controlled by rest and moderate exercise without pushing the limits of tolerance. FIGURE 50.3 Areas innervated by the three main branches of CRANIAL NERVE DISORDERS the trigeminal nerve (cranial nerve V) are affected in trigeminal neuralgia. Cranial nerves are the peripheral nerves of the brain. There are 12 pairs of cranial nerves. Areas that the cranial nerves innervate Diagnostic Tests include the head, neck, and special sensory structures (see Chapter 48). Cranial nerve problems are classified as peripheral History of symptoms and direct observ ation of an attack neuropathies. Disorders can affect the sensory, motor, or both confirm diagnosis. Radiological studies, including computed branches of a single nerv e. Causes of cranial nerv e disorders tomography (CT) and MRI, may be used to rule out other include tumors, infections, inflammation, trauma, and unknown causes of the pain. causes. Two common cranial nerv e problems are trigeminal Therapeutic Measures neuralgia (tic douloureux) and Bell’s palsy. Initial management includes the use of anticonvulsants such as Trigeminal Neuralgia phenytoin (Dilantin), gabapentin (Neurontin), or carbamazepine (Tegretol) to reduce transmission of painful nerv e impulses. Pathophysiology and Etiology Baclofen or clonazepam may also be ef fective in controlling Trigeminal neuralgia (TN), sometimes called tic douloureux, symptoms. If medications are not effective, a nerve block using involves the f ifth cranial (trigeminal) nerv e. This cranial a local anesthetic may be performed. This option offers 8 to nerve has three branches that include both sensory and motor 16 months of relief. If medications and nerve blocks do not pro- functions. The branches innervate areas of the face, including vide relief, a rhizotomy can be done to destroy selected nerve the forehead, nose, cheek, gums, and ja w. TN affects only fibers. A neurectomy may be done if no vessel is found to be the sensory portion of the nerv e. Irritation or chronic com- compressing the nerve. Surgical options leave the patient with pression of the nerve is suspected to initiate symptoms. This varying degrees of numbness. Complementary and alternative condition is seen more often in w omen and usually be gins therapies such as acupuncture, electrical stimulation, vitamin around age 50 to 60. and nutritional therapy may be used with varying success. Signs and Symptoms PATIENT EDUCATION POSTPROCEDURE. The patient will need to learn to protect anesthetized areas of the f ace after nerve Intense recurring episodes of pain, described as sudden, block or ablation. If corneal sensation is lost, goggles and sun- jabbing, burning, or knifelike, characterize this condition. glasses should be used as needed to protect the affected eye. An Episodes of pain be gin and end suddenly , lasting a fe w eye patch may be needed at night to prevent injury during sleep. seconds to minutes. Attacks can occur in clusters up to Artificial tears may also be needed to prevent corneal damage. hundreds of times daily. However, some patients have only a few attacks per year. Pain is felt in the skin on one side of Bell’s Palsy the face. A slight touch, cold breeze, talking, or che wing Pathophysiology and Etiology can trigger attacks of pain. The areas of the face where pain In Bell’s palsy, the facial nerve (cranial nerve VII) becomes in- is triggered are referred to as trigger zones. Areas affected flamed and edematous, causing interruption of nerve impulses. include the lips, upper or lo wer gums, cheeks, forehead, The cause is thought to be nerve trauma from a viral infection or side of the nose (Fig. 50.3). Sleep pro vides a period of relief from the pain. Therefore, persons with trigeminal neuralgia may sleep most of the time to a void painful WORD BUILDING attacks. They also may refrain from acti vities such as neuropathies: neuro—nerve + pathies—disease talking, face washing, teeth brushing, sha ving, and eating neuralgia: neur—nerve + algia—pain to prevent pain. Frequent blinking and tearing of the eye on rhizotomy: rhiz-nerve root + otomy—incision, excision the affected side also occur. neurectomy: neur-nerve + ectomy—excision 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1206 1206 UNIT THIRTEEN Understanding the Neurologic System such as Epstein-Barr, herpes simplex, or herpes zoster. Loss of motor control typically occurs on one side of the face; bilateral facial palsy occurs in less than 1% of cases. Contracture of Patient Perspective facial muscles can occur if recovery is slow. Men and women are affected equally. Bell’s palsy is more common in w omen Angela, Bell’s Palsy in the third trimester of pre gnancy, in people with immune I woke up that Thursday morning with the same intense disorders such as human immunodef iciency virus (HIV) pain in my forehead that I had been experiencing for infection, and in people with diabetes. It occurs in all ages the past week. When I rolled out of bed, I realized that (including children) and at all times of the year. I didn’t have morning breath (or so I thought). Knowing that I had not brushed my teeth yet, I proceeded to do Signs and Symptoms so and noticed that I could not taste the toothpaste. The Onset of symptoms may be sudden or may progress o ver a fruit cup I ate for lunch tasted like Clorox. I chomped 2- to 5-day period. The severity of the paralysis usually peaks up and down on each bite, then carefully attempted to within several days of onset of symptoms. Pain behind the ear swallow. It was like I had been injected with several may precede the onset of f acial paralysis. Other vague initial shots of Novocain. My throat felt like it had closed up, symptoms are dry eye or tingling around the lips with progres- and each swallow took a concentrated effort. Over the sion to the more recognizable symptoms of Bell’ s palsy. course of eating my fruit, I managed to bite my tongue The patient may be unable to close the e yelid, wrinkle the three times. forehead, smile, raise the eyebrow, or close the lips effectively. I was 35 weeks pregnant and on strict bedrest due The mouth is pulled to ward the unaffected side (Fig. 50.4). to pregnancy-induced hypertension and severe edema Drooling of saliva occurs, and the af fected eye has constant (which later spiraled into toxemia). We attributed the tearing. Sense of taste is lost over the anterior two-thirds of the numbness in my mouth to the edema. I had already tongue. Speech difficulties occur. Fifty percent of patients will swollen up like a balloon and had experienced intense have complete reco very in a short period of time. Thirty- numbness in my extremities since the 12th week of five percent will experience full recovery in less than 1 year pregnancy. As the afternoon progressed, I grew more (“Patient Perspective—Angela, Bell’s Palsy”). and more concerned. I knew something was not quite right. By 5:30 that evening, I had lost control of the Forehead not wrinkled entire left side of my face. I called my obstetrician, and Eyeball rolls up, she said to get to the ER because I was either having a eyelid does not close stroke or had developed Bell’s palsy. The doctor at the ER confirmed that I had Bell’s palsy and prescribed Valtrex and prednisone to treat it. The symptoms of Bell’s that I experienced were severe pain in my forehead, not being able to breathe out of the left side of my nose, and difficulty chewing, swallowing, and saying most consonants. I completely lost the ability to smile, blink, close my eye, raise my eyebrow, or use a straw or blow. My eyesight in the left eye blurred, and I could not go out at night due to the intense pain behind my eye triggered Flat nasal labial fold, paralysis of by headlights and having to use eyedrops every 5 to A lower face 20 minutes. I delivered my baby (after induction, 2 days of labor, 2 hours of pushing, and emergency C section) 2 weeks after being diagnosed with Bell’s palsy. During labor, I continuously asked for my eyedrops and the pain in my head was so fierce that it overshadowed the contractions. After delivery, I was desperate for my face to be “fixed.” I tried everything that anyone suggested: herbal supplements, chiropractic, facial massage, laser treat- ments, facial exercise, shock treatments, a neurologist consultation, and physical therapy. The only thing that B Facial nerve has worked for me is time (and lots of it)! For the first 15 weeks after being diagnosed, I FIGURE 50.4 Bell’s palsy. (A) Note weakness of affected side wanted to hide from the world. However, here it is of face. (B) Distribution of facial nerve. 4068_Ch50_1192-1210 15/11/14 2:08 PM Page 1207 Chapter 50 Nursing Care of Patients With Peripheral Nervous System Disorders 1207 Teach the patient to chew on the opposite side of the face 7 months later, and I have come to terms with it. I am to avoid triggering pain and injury. constantly aware of it, though I have regained a tremen- Encourage use of an electric razor rather than blades to dous amount of the muscle control. I still have not shared prevent injury to numb areas. a “real smile” with my daughter and do not blink my left Provide measures for trigeminal neuralgia to reduce pain eye. Covering my mouth when I smile or laugh so others triggers. do not see has become almost like a reflex now. Provide soft cloths for facial hygiene using lukewarm water. Avoid touching the patient’s face. Provide a soft bristle toothbrush for oral care. Diagnostic Tests Teach patient to protect face from cold or wind. History of the onset of symptoms is used to diagnose Bell’ s Provide measures for Bell’s palsy to reduce pain and palsy. Observation of the patient confirms the diagnosis. EMG prevent muscle atrophy. may be done. The possibility of a stroke must be ruled out. Provide warm, moist compresses prn. Massage face. Therapeutic Measures Assist with facial exercises as prescribed by physical Prevention of complications is the goal of treatment. Prednisone therapy. may be given over 7 to 10 days to decrease inflammation. Provide a facial sling. Antiviral agents such as acyclovir may be used to fight the virus Imbalanced Nutrition: Less Than Body Requirements, related and can shorten the course of the disease. Analgesics are given to fear of triggering pain as evidenced by poor intake, for pain control. Moist heat and gentle massage to the face and weight loss ear also ease pain. A facial sling can be used to aid in eating and support of facial muscles. EXPECTED OUTCOME: The patient will maintain sufficient nutrition as evidenced by stable weight. Nursing Process for the Patient with a Cranial Nerve Weigh patient twice weekly and record to monitor weight Disorder (Trigeminal Neuralgia and Bell’s Palsy) loss or gain. Provide small, frequent meals to promote nutrition without DATA COLLECTION. Assess attacks using the WHAT’S UP? increasing pain. format, being sure to include f actors that trigger pain. Are Provide soft, easy-to-chew foods at lukewarm temperature sensory or motor problems associated with the pain? Assess to prevent triggering pain. the effect of the disorder on the patient’ s life, including Provide a high-protein and high-calorie diet. Protein and nutritional status, general and oral hygiene, beha vior, and calories are needed for cellular repair. emotional state. Carefully document all findings. Avoid hot or cold foods and drinks. Temperature extremes NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION. can trigger pain. If foods are associated with pain, the Acute Pain related to inflammation or compression of the nerve patient may avoid them. EXPECTED OUTCOME: The patient will state pain is controlled Encourage oral hygiene after each meal and at bedtime to at an acceptable level. prevent gum and tooth disease as triggers for pain. Insert a feeding tube as ordered on unaffected side if Assess pain level and response to interventions as needed. nutrition is severely impaired to provide means for Assessment guides intervention. nutrient intake while avoiding painful nerve areas. Administer medications as needed for pain. Anticonvul- sant and antidepressant agents used to treat neuropathic Risk for Injury to Eyes related to inability to blink (Bell’s palsy) pain must be given routinely to prevent pain. Medications EXPECTED OUTCOME: The patient’s cornea will remain intact prevent or decrease pain and increase comfort. and without injury. Discuss and implement alternative and complementary Administer eyedrops or eye ointment as ordered by the pain relief measures to complement medications and in- HCP to protect the eye. crease patient’s control over pain. Teach patient to use a patch over the affected eye to protect Biofeedback the eye. Diversional activities Advise patient to wear glasses or goggles, especially Plan hygiene activities when pain relief is at its peak to when outside or in areas with particles in the air, to decrease discomfort with activities. protect the eyes. Provide alternative communication methods. The patient may not be able to speak clearly or want to speak due to pain. EVALUATION. Nursing care has been successful if the patient Paper and pencil/pen