Common Disorders

1. Common Disorders

2. HeadachesNeurological Pain Cranial and Peripheral Nerve Disorders: Bell’s Palsy Trigeminal Neuralgia

3. HEADACHE • Significance is variable • Source of recurring headaches should be determined through careful physical examination with appropriate neurological assessment • Exact mechanism of head pain is not known • The skull and brain tissue are not able to feel sensory pain Pain arises from the scalp, its blood vessels and muscles, the dura mater and its venous sinuses

4. HEADACHE • Can be classified as: • Vascular, Tension, and Traction-Inflammatory 1.Vascular: migraine, cluster, and hypertensive headaches 2.Tension: arise from tension or stress 3.Traction-Inflammatory: caused by infection, intracranial or extracranial causes, occlusive vascular structures, and temporal arteritis

5. Headaches • Clinical Manifestations: • Headache pain may be made worse by tension and stress • Migraine: prodromal signs and symptoms include: visual field defects, experiencing unusual smells or sounds, disorientation, parasthesis, and in some cases, paralysis • During an attack: n/v, light sensitivity, chilliness, fatigue, irritability, diaphoresis, edema • Abnormal metabolism of serotonin, a vasoactive neurotransmitter [found in platelets and cells of the brain], plays a major role

6. Headaches • Assessment: • Subjective data: pt. report and understanding of the headache; possible causes; and any precipitating factors. What measures relieve or make it worse; characteristics • Objective data: behaviors indicating stress, anxiety, or pain; changes ability to carry out ADLs, increased body temp., sinus drainage

7. Headaches • Diagnostic Tests: • Important to evaluate headaches that are not transient • Neuro exam • CT (MRI, or PET scans) • Medical Management • Dietary counseling: some foods or additives may cause or worsen headaches • Psychotherapy: pain may be physiological, and counseling can help pt. develop awareness of stress factors

8. Headaches • Medical Management cont. • Medication • Migraine: • ASA – pain relief • Ergotamine Tartrate– act by constricting blood vessel walls and reducing cerebral blood flow; reduce inflammation reduce pain • Combination drugs: ergotamines plus caffeine, phenobarbital, and belladonna

9. Headaches • Medication cont. • Elitriptan (Relpax) • Triptans are thought to act on receptors in the extracerebral and intracranial vessels that become dilated during a migraine • Also relieve nausea, vomiting, photophobia • E.g. Sumatriptan = Imitrex • Non-opiod analgesics

10. Headaches • Nursing Interventions: • Facilitate relaxation and rest – plan day accordingly • Patient Education re: nature of their headaches, medication and treatment specifics • Help pt. identify triggers • Regular exercise may help prevent

11. Headaches • Nursing Interventions (cont.) • Reduction of stress and emotional upsets • May need counseling with a professional • Comfort measures • Medication administration, other treatments/modalities • Diversional activities

12. Cluster Headaches Vascular Occur in a series of episodes followed by a long period with no symptoms Intensely painful and seem to be related to stress or anxiety Usually have no warning symptoms Treatment may include cold application, indomethacin (Indocin), and tricyclic antidepressants (Elavil); narcotic analgesics are sometimes given IM

13. Tension Headache Result from prolonged muscle contraction from anxiety, stress, or stimuli from other sources Pain location may vary; may have nausea and vomiting, dizziness, tinnitus, or tearing Treatment: correction of known causes,, massage, heat application, and relaxation techniques, psychotherapy Analgesics, usually non-narcotic: acetaminophen, ibuprofen, ASA, propoxyphene

14. Neurological Pain • Caused by a disorder within the nervous system or • Caused peripherally at a distant part of the body • Pain receptors can be activated by cellular damage, certain chemicals such as histamine, heat, ischemia, muscle spasm, cold, and pruritus • Each produces characteristic pain

15. Neurological Pain • Intractable pain =Pain that is described as “unbearable” and does not respond to treatment • Assessment: • Subjective: interview with pt. re: pain characteristics • Objective: observations, behavioral signs, ability to perform ADLs

16. Neurological Pain • Diagnostic Tests: • Electrical stimulation, myelogram, psychological testing • Medical Management • Nonsurgical methods: TENS stimulation, nerve block, medication • Surgical: neurectomy, rhizotomy, cordotomy, percutaneouscordotomy

17. Neurological Pain • Nursing Interventions: • Comfort measures: positioning, assist with turning or movement • Bowel Regime • Promotion of rest and relaxation: reduce headaches, stress and precipitating factors • Counseling to help pt. cope with discomfort

18. Neurological Pain • Nursing Diagnosis: • Risk for disuse syndrome, related to lack of use of a body part as a result of pain • Self-care deficit related to pain • Alteration in comfort related to pain • Patient Teaching: • Identifying triggers • Reducing stress and emotional upsets • Comfort measures • Structuring the home and work settings

19. Cranial and Peripheral Nerve Disorders Trigeminal Neuralgia Bell’s Palsy (Peripheral Facial Paralysis)

20. Cranial and Peripheral Nerve Disorders • Trigeminal neuralgia • Etiology/pathophysiology • Also called: tic douloureux • Degeneration of or pressure on the trigeminal nerve (5th cranial nerve) • Maxillary and mandibular branches of the 5th cranial nerve are involved

21. Cranial and Peripheral Nerve Disorders • Clinical manifestations/assessment • Characterized by excruciating, knifelike, or lightning-like shock in the lips, upper or lower gums, cheek, forehead, or side of the nose • Attacks last only seconds  2-3 minutes • Along the nerve are “trigger points” – slightest stimulation of these areas can initiate pain

22. Cranial and Peripheral Nerve Disorders • Medical management • Tegretol, Dilantin, Valproate (Depakote), and Gabapentin (Neurontin) = drugs of choice • Nerve block • Surgical resection of the trigeminal nerve • Avoid stimulation of face on affected side • Nursing interventions • Rehydration measures; improved nutrition • Oral hygiene; assistance with ADLs • Comfort measures (p. 701 Box 14-3)

23. Bell’s Palsy (Peripheral Facial Paralysis) • Etiology/Pathophysiology • Inflammatory process involving facial nerve VII • Evidence that reactivated Herpes Simplex virus may be involved causing inflammation, edema, ischemia, and eventual demyelination of the facial nerve

24. Bell’s Palsy • Clinical manifestations/assessment • Facial numbness or stiffness, or drooping feeling • Unilateral slow or inability to close eye • Unilateral weakness of facial muscles  asymmetric appearance • Loss of taste • Reduction of saliva • Pain behind the ear • Ringing in ear or other hearing loss

25. Bell’s Palsy • Medical management • Electrical stimulation • Warm moist heat (ear pain) • Steroids and possibly antivirals (Zovirax, Famvir) • Nursing Intervention • Medication administration • Massage of the affected area • Facial exercises • Eye drops (for moisture), eye patch at night

26. Infection and Inflammation Guillain-Barre’ Syndrome Meningitis Encephalitis

27. Guillain-Barre’ Syndrome(Polyneuritis) • Etiology/Pathophysiology • Also called: “Acute Inflammatory Polyradiculopathy” • Or “Postinfectious polyneuritis” • Results in widespread inflammation and demyelination of the PNS

28. Guillain-Barre’ Syndrome(Polyneuritis) • Etiology/Pathophysiology • Antibodies attack the Schwann cells causing the sheath to break down (demyelination) • Nerve conduction is interrupted  muscle weakness, tingling and numbness. Begins in the legs and works upward

29. Guillain-Barre’ Syndrome(Polyneuritis) • Etiology/Pathophysiology • Widespread inflammation and demyelination of the PNS is self-limiting. Once it stops, the Schwann cells can rebuild the lining • Recovery occurs in reverse

30. Guillain-Barre’ Syndrome(Polyneuritis • Clinical Manifestations: • Variation in the pattern of the onset of weakness as well as the rate of progression; symmetrical • Start usually in the legs  thorax face • Progression may stop at any point Pt. may have difficulty swallowing, breathing , or speaking if cranial nerves VII, IX, and X are involved

31. Guillain-Barre’ Syndrome(Polyneuritis) • Diagnostic Tests • CT scan • LP – CSF usually has elevated protein • Electromyography : to record muscle activity • Hx. – of recent infection • Medical Management • Hospitalization is essential! Pt. condition can rapidly deteriorate into paralysis that affects the respiratory muscles  mechanical ventilation • G-tube prn • Medication: Adrenocorticosteroids • Therapeutic plasmaphoresis

32. Guillain-Barre’ Syndrome(Polyneuritis) • Nursing Interventions: • Close monitoring of respiratory function • If on a mechanical ventilator: reassurance • Nutritional maintenance via IV or G-tube • Prevention of complications: turning, skin care, pressure relief, ROM measures • Administration of medication • VS and motor function assessment frequently

33. Guillain-Barre’ Syndrome(Polyneuritis) • Prognosis: • 85% will regain complete function • 20% will have some weakness at 1 year • 5 percent – severe permanent disability • Recovery period may be from weeks to years

34. Meningitis • Etiology/Pathophysiology: • An acute infection of the meninges • Usually caused by one of the following: • Pneumococci • Meningococci • H. influenza • Staphylococci or streptococci • Inflammatory reaction in the subarachnoid space involving the pia mater and arachnoid • Pus accumulates and the bacteria may injure nerve tissue

35. Meningitis • Classified as: • Bacterial: incidence is higher in the fall and winter when URIs common • Can lead to edema of the brain, ICP, exudate occluding ventricles  hydrocephalus in infants • Aseptic • Clinical Manifestations • 2 abnormal signs: • Kernig’s sign • Brudzinski’s sign

36. Meningitis • Clinical Manifestions • Severe headache, stiff neck, irritability, malaise, and restlessness • Nausea/vomiting, and delirium may develop • Increased TPR • Diagnostic Tests • Examining CSF with culture to determine the pathological organism • CT • EEG

37. Meningitis • Medical Management • Massive doses of multiple antibiotics (ampicillin, penicillin, cephalosporins, Rocephin, etc.) • These drugs can penetrate the blood-brain barrier • Given IV or intrathecally • Steroids • Anticonvulsants

38. Meningitis • Nursing Interventions • Maintain Respiratory isolation until the pathogen can no longer be cultured from the nasopharynx • Maintain IV line if ordered • Nutrition status – ongoing eval • Darkened room: increased sensory stimulation may cause a seizure • Safety precautions appropriate to age and cognitive status. SRDs as needed.

39. Meningitis • Prognosis: • Good for a complete recovery if antibiotics are started quickly • With severe cases, may be residual neurological damage or death

40. Encephalitis • Etiology/Pathophysiology • Acute inflammation of the brain • Usually caused by a virus • Some are associated with certain seasons of the year and endemic to certain geographic locations • Epidemic encephalitis is transmitted by tics and mosquitos • Nonepidemic encephalitis may occur as a complication of measles, chickenpox, or mumps

41. Encephalitis • Etiology/Pathophysiology cont. • Overall mortality rate = 5-20% • Most common form: HSV encephalitis • Cytomegalovirus encephalitis is one of the common complications of AIDS

42. Encephalitis • Clinical Manifestations: • Resemble those of meningitis with gradual onset • Headache • High fever • Seizures • Change in LOC • Cerebral edema

43. Encephalitis • Early diagnosis and tx. is essential to a favorable outcome: • MRI, PET scans • Viral studies of CSF (LP)

44. Encephalitis • Medical management/Nursing Interventions • Symptomatic and supportive • Use of and monitoring of response to diuretics and corticosteroids • Antiviral medications (start before onset of coma)

45. Encephalitis • Nursing Implications: • Are related to long-term symptoms: • Memory impairment • Epilepsy • Personality changes • Anosmia (absence of the sense of smell) • Behavioral abnormalities • dysphagia