Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 61: Nursing Management: Peripheral Nerve and Spinal Cord Problems

Key Points – Printable

CRANIAL NERVE DISORDERS
TRIGEMINAL NEURALGIA
•	Trigeminal neuralgia (tic douloureux) is a relatively uncommon cranial nerve disorder. However, it is the most commonly diagnosed neuralgic condition.
•	The trigeminal nerve (CN V) has both motor and sensory branches. In trigeminal neuralgia, the sensory or afferent branches, primarily the maxillary and mandibular branches, are involved.
•	The classic feature of trigeminal neuralgia is an abrupt onset of paroxysms of excruciating pain described as a burning, knifelike, or lightning-like shock in the lips, upper or lower gums, cheek, forehead, or side of the nose. Intense pain, twitching, grimacing, and frequent blinking and tearing of the eye occur during the acute attack.
•	The painful episodes are usually initiated by a triggering mechanism of light cutaneous stimulation at a specific point (trigger zone) along the distribution of the nerve branches.
•	Although this condition is considered benign, the severity of the pain and the disruption of lifestyle can result in almost total physical and psychologic dysfunction or even suicide.
•	The majority of patients obtain adequate relief through antiseizure drugs such as carbamazepine (Tegretol). Another treatment option is nerve blocking with local anesthetics; if a conservative approach is not effective, surgical therapy is available.
•	The overall nursing goals are that the patient with trigeminal neuralgia will be free of pain, maintain adequate nutritional and oral hygiene status, have minimal to no anxiety, and return to normal or previous socialization and occupational activities.
•	The nurse must teach the patient about the importance of nutrition, hygiene, and oral care and convey understanding if previous oral neglect is apparent. The patient should be encouraged to keep environmental stimuli to a moderate level and to use stress reduction methods.

BELL’S PALSY
•	Bell’s palsy (peripheral facial paralysis, acute benign cranial polyneuritis) is a disorder characterized by a disruption of the motor branches of the facial nerve (CN VII) on one side of the face resulting in acute peripheral facial paresis. 
•	The resulting paralysis is typically seen as drooping of the mouth accompanied by drooling, often accompanied by tinnitus, fever, and an inability to close the eye.
•	Methods of treatment for Bell’s palsy include moist heat, gentle massage, and electrical stimulation of the nerve and prescribed exercises. Bell’s palsy is considered benign with full recovery after 6 months in most patients, especially if treatment is instituted immediately.
•	The overall nursing goals are that the patient with Bell’s palsy will be pain free or have pain controlled, maintain adequate nutritional status, maintain appropriate oral hygiene, not experience injury to the eye, return to normal or previous perception of body image, and be optimistic about disease outcome.

POLYNEUROPATHIES
GUILLAIN-BARRÉ SYNDROME
•	Guillain-Barré syndrome is an acute, rapidly progressing, and potentially fatal form of polyneuritis. It affects the peripheral nervous system and results in loss of myelin and edema and inflammation of the affected nerves, causing a loss of neurotransmission to the periphery.
•	The etiology of this disorder is unknown, but it is believed to be an immunologic reaction directed at the peripheral nerves. It is often preceded by a viral infection, trauma, surgery, viral immunizations, or human immunodeficiency virus (HIV).
•	The most serious complication of this syndrome is respiratory failure, which occurs as the paralysis progresses to the nerves that innervate the thoracic area. Constant monitoring of the respiratory system provides information about the need for immediate intervention.
•	Management is aimed at supportive care, particularly ventilatory support, during the acute phase. The objective of nursing care is to support the body systems until the patient recovers.

BOTULISM
•	Botulism is the most serious type of food poisoning. It is caused by GI absorption of the neurotoxin produced by Clostridium botulinum, an organism found in the soil. Improper home canning of foods is often the cause.
•	It is thought that the neurotoxin destroys or inhibits the neurotransmission of acetylcholine at the myoneural junction, resulting in disturbed muscle innervations.
•	Neurologic manifestations include development of a descending flaccid paralysis with intact sensation, photophobia, ptosis, paralysis of extraocular muscles, blurred vision, diplopia, dry mouth, sore throat, and difficulty in swallowing.
•	The initial treatment of botulism is IV administration of botulinum antitoxin.
•	Primary prevention is the goal of nursing management by educating consumers to be alert to situations that may result in botulism. Particular attention should be given to foods with a low acid content, which support germination and the production of botulin, a deadly poison.

TETANUS
•	Tetanus (lockjaw) is an extremely severe polyradiculitis and polyneuritis affecting spinal and cranial nerves. It results from the effects of a potent neurotoxin released by the anaerobic bacillus Clostridium tetani.
•	The spores of the bacillus are present in soil, garden mold, and manure. Thus Clostridium tetani enters the body through a traumatic or suppurative wound that provides an appropriate low-oxygen environment for the organisms to mature and produce toxin.
•	Initial manifestations of generalized tetanus include stiffness in the jaw (trismus) and neck, fever, and other symptoms of general infection. As the disease progresses, the neck muscles, back, abdomen, and extremities become progressively rigid.
•	The management of tetanus includes administration of a tetanus and diphtheria toxoid booster (Td) and tetanus immune globulin (TIG) in different sites before the onset of symptoms to neutralize circulating toxins. A much larger dose of TIG is administered to patients with manifestations of clinical tetanus.

NEUROSYPHILIS
•	Neurosyphilis (tertiary syphilis) is an infection of any part of the nervous system by the organism Treponema pallidum. It is the result of untreated or inadequately treated syphilis.
•	Neurologic symptoms associated with neurosyphilis are numerous and many times nonspecific.
•	Management includes treatment with penicillin, symptomatic care, and protection from physical injury.

SPINAL CORD PROBLEMS
SPINAL CORD INJURY
•	The segment of the population with the greatest risk for spinal cord injury is young adult men between the ages of 16 and 30 years. Causes of spinal cord injury include many types of trauma, with motor vehicle crashes being the most common.
•	About 50% of people with acute spinal cord injury experience spinal shock, a temporary neurologic syndrome characterized by decreased reflexes, loss of sensation, and flaccid paralysis below the level of the injury. Neurogenic shock, in contrast, is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia.
•	Spinal cord injuries are classified by the mechanism of injury, skeletal and neurologic level of injury, and completeness or degree of injury.
o	The major mechanisms of injury are flexion, hyperextension, flexion-rotation, extension-rotation, and compression.
o	The degree of spinal cord involvement may be either complete or incomplete. Complete cord involvement results in total loss of sensory and motor function below the level of the lesion (injury). Incomplete cord involvement results in a mixed loss of voluntary motor activity and sensation and leaves some tracts intact.
o	Six syndromes are associated with incomplete lesions: central cord syndrome, anterior cord syndrome, Brown-Séquard syndrome, posterior cord syndrome, cauda equina syndrome, and conus medullaris syndrome.
•	Manifestations of spinal cord injury are related to the level and degree of injury.
o	Respiratory complications closely correspond to the level of the injury. Cervical injury above the level of C4 presents special problems because of the total loss of respiratory muscle function.
o	Any cord injury above the level of T6 greatly decreases the influence of the sympathetic nervous system. Bradycardia occurs, peripheral vasodilation results in hypotension, and a relative hypovolemia exists.
o	Urinary retention is a common development in acute spinal cord injuries and spinal shock.
o	If the cord injury has occurred above the level of T5, the primary GI problems are related to hypomotility. In the early period after injury when spinal shock is present and for patients with an injury level of T12 or below, the bowel is areflexic and sphincter tone is decreased.
o	Poikilothermism, the adjustment of the body temperature to the room temperature, occurs because the interruption of the sympathetic nervous system prevents peripheral temperature sensations from reaching the hypothalamus.
•	Immediate postinjury problems include maintaining a patent airway, adequate ventilation, and adequate circulating blood volume and preventing extension of cord damage (secondary damage).
•	After stabilization at the injury scene, the person is transferred to a medical facility. A thorough assessment is done to specifically evaluate the degree of deficit and to establish the level and degree of injury.
•	The decision to perform surgery on a patient with a spinal cord injury often depends on the preference of a particular physician. When cord compression is certain or the neurologic disorder progresses, benefit may be seen following immediate surgery.
•	Significant improvement in motor function and sensation in patients with complete or incomplete spinal cord injuries who were treated with high doses of methylprednisolone within 8 hours of injury has been found.

NURSING MANAGEMENT: SPINAL CORD INJURY
•	The overall goals are that the patient with a spinal cord injury will maintain an optimal level of neurologic functioning; have minimal or no complications of immobility; learn new skills, gain new knowledge, and acquire new behaviors to be able to care for self or successfully direct others to do so; and return to home and the community at an optimal level of functioning.
•	Nursing diagnoses for the patient with a spinal cord injury depend on the severity of the injury and the level of dysfunction.
•	Proper immobilization at all times, including during transfers and repositioning, is critical to prevent extension of cord damage. 
•	Spinal cord edema may increase the level of dysfunction, and respiratory distress may occur. The nurse needs to regularly perform a thorough assessment of the respiratory system and use interventions to promote airway maintenance.
•	Because of unopposed vagal response, the heart rate is slowed, often to below 60 beats/ min. Any increase in vagal stimulation such as turning or suctioning can result in cardiac arrest. Vital signs should be assessed frequently.
•	During the first 48 to 72 hours after the injury, the GI tract may stop functioning and a nasogastric tube must be inserted. Fluid and electrolyte needs must be carefully monitored. Once bowel sounds are present or flatus is passed, oral food and fluids can gradually be introduced.
•	Because of severe catabolism, a high-protein, high-calorie diet is necessary for energy and tissue repair.
•	Because of the loss of voluntary neurologic control over the bowel, a bowel program should be started during the acute phase.
•	Immediately after injury, urine is retained because of the loss of autonomic and reflex control of the bladder and sphincter. Overdistention of the bladder can result in reflux into the kidney with eventual renal failure. Measures to prevent urinary tract infections (UTIs), which are a common problem, are necessary. 
•	Because there is no vasoconstriction, piloerection, or heat loss through perspiration below the level of injury, temperature control is largely external to the patient. Therefore the nurse must monitor the environment closely to maintain an appropriate temperature.
•	The nurse must compensate for the patient’s absent sensations to prevent sensory deprivation. This is done by stimulating the patient above the level of injury. Conversation, music, strong aromas, and interesting flavors should be a part of the nursing care plan.
•	The return of reflexes after the resolution of spinal shock means that patients with an injury level at T6 or higher may develop a life-threatening condition known as autonomic dysreflexia. 
o	The most common precipitating cause is a distended bladder or rectum, although any sensory stimulation may cause autonomic dysreflexia.
o	Immediate care is required, including elevating the head of the bed 45 degrees or sitting the patient upright, performing an assessment to determine the cause, and notifying the physician. 
•	The physiologic and psychologic rehabilitation of the person with spinal cord injury is complex and involved. Rehabilitation is a multidisciplinary endeavor carried out through a team approach.
•	Patients with spinal cord injuries may feel an overwhelming sense of loss. The nurse’s role in grief work is to allow mourning as a component of the rehabilitation process.

GERONTOLOGIC CONSIDERATIONS: SPINAL CORD INJURY
•	An increasing number of older adults are living with a chronic spinal cord injury.
•	More older adults are experiencing spinal injuries; they are at greater risk for complications.

SPINAL CORD TUMORS
•	Spinal cord tumors are classified as extradural (outside the spinal cord), intradural extramedullary (within the dura but outside the actual spinal cord), and intradural intramedullary (within the spinal cord itself).
•	Both sensory and motor problems may result with the location and extent of the tumor determining the severity and distribution of the problem. The most common early symptom of a spinal cord tumor outside the cord is pain in the back with radicular pain simulating intercostal neuralgia, angina, or herpes zoster.
•	Treatment for nearly all spinal cord tumors is surgical removal.