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

CRANIAL NERVE DISORDERS • Cranial nerve disorders are commonly classified as peripheral neuropathies. The 12 pairs of cranial nerves are considered the peripheral nerves of the brain. • Two cranial nerve disorders are trigeminal neuralgia and acute peripheral facial paralysis (Bell’s palsy).

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 is the fifth cranial nerve (CN V) and 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), phenytoin (Dilantin), and valproate (Depakene). Nerve blocking with local anesthetics is another treatment option. If a conservative approach including drug therapy is not effective, surgical therapy is available. The overall nursing goals are that the patient with trigeminal neuralgia will (1) be free of pain, (2) maintain adequate nutritional and oral hygiene status, (3) have minimal to no anxiety, and (4) 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 nurse should provide lukewarm water and soft cloths or cotton saturated with solutions not requiring rinsing for cleansing the face. The nurse is responsible for instruction related to diagnostic studies to rule out other problems, such as multiple sclerosis, dental or sinus problems, and neoplasms, and for preoperative teaching if surgery is planned. Regular follow-up care should be planned. The patient needs instruction regarding the dosage and side effects of medications. Although relief of pain may be complete, the patient should be encouraged to keep environmental stimuli to a moderate level and to use stress

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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 in the absence of any other disease such as a stroke. Bell’s palsy is an acute, peripheral facial paresis of unknown cause. The paralysis of the motor branches of the facial nerve typically results in a flaccidity of the affected side of the face, with drooping of the mouth accompanied by drooling. 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 (1) be pain free or have pain controlled, (2) maintain adequate nutritional status, (3) maintain appropriate oral hygiene, (4) not experience injury to the eye, (5) return to normal or previous perception of body image, and (6) be optimistic about disease outcome.

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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 a cell-mediated immunologic reaction directed at the peripheral nerves. The syndrome is often preceded by immune system stimulation from 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. Assessment of the patient is the most important aspect of nursing care during the acute phase.

• 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 innervation. 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 (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 (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 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 a temporary neurologic syndrome known as spinal shock that is 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, which are important clinical clues.

The degree of spinal cord involvement may be either complete or incomplete. o Complete cord involvement results in total loss of sensory and motor function below the level of the lesion (injury). o Incomplete cord involvement results in a mixed loss of voluntary motor activity and sensation and leaves some tracts intact. 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 is the adjustment of the body temperature to the room temperature. This occurs in spinal cord injuries because the interruption of the sympathetic nervous system prevents peripheral temperature sensations from reaching the hypothalamus. o Deep vein thrombosis (DVT) is a common problem accompanying spinal cord injury during the first 3 months. 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.

Nursing Management
• • • The patient must be moved in alignment as a unit or “logrolled” during transfers and when repositioning to prevent further injury. Proper immobilization 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 assess breath sounds, ABGs, tidal volume, vital capacity, skin color, breathing patterns, subjective comments about the ability to breathe, and the amount and color of sputum. Because of unopposed vagal response, the heart rate is slowed, often to below 60 beats per

minute. 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. Because the patient cannot have oral intake, fluid and electrolyte needs must be carefully monitored. o Once bowel sounds are present or flatus is passed, oral food and fluids can gradually be introduced. o Because of severe catabolism, a high-protein, high-calorie diet is necessary for energy and tissue repair. o Less voluntary neurologic control over the bowel results in a neurogenic bowel. Immediately after injury, urine is retained because of the loss of autonomic and reflex control of the bladder and sphincter. Because there is no sensation of fullness, overdistention of the bladder can result in reflux into the kidney with eventual renal failure. o Consequently, an indwelling catheter is usually inserted as soon as possible after injury. o UTIs are a common problem. The best method for preventing UTIs is regular and complete bladder drainage. o A neurogenic bladder is any type of bladder dysfunction related to abnormal or absent bladder innervation. 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 autonomic dysreflexia. Autonomic dysreflexia is a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system. o The condition is a life-threatening situation that requires immediate resolution. o The most common precipitating cause is a distended bladder or rectum, although any sensory stimulation may cause autonomic dysreflexia. o Nursing interventions in this serious emergency are elevation of the head of the bed 45 degrees or sitting the patient upright, notification of the physician, and assessment to determine the cause. 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.

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.

POSTPOLIO SYNDROME • Polio, also known as poliomyelitis, is an infectious viral disease transmitted through the oral route by ingestion of contaminated water or food, or contact with infected sources such as unwashed hands. • Polio survivors who recovered from the disease decades ago, notably those who had paralytic poliomyelitis, are now experiencing a recurrence of neuromuscular symptoms as they age. These late effects of polio are collectively referred to as postpolio syndrome. Postpolio syndrome is manifested by a new onset of joint and muscle weakness, easy fatigability, generalized fatigue, and pain. Uncommonly, individuals may also exhibit speech, swallowing, and respiratory difficulties. There is no specific treatment for postpolio syndrome. Management approaches are targeted at controlling symptoms, particularly fatigue, weakness, and pain. An interdisciplinary team approach is essential to manage the patient.