Alexa-Rae P.

Zagado
BSN-III
NCM 104 – Clinicals
Sir Cresencio Cajigal, RN, MAN
April 29, 2020

Perception & Coordination

1. Trigeminal Neuralgia:

A) Trigeminal neuralgia is sudden, severe facial pain. It's often described as a sharp

shooting pain or like having an electric shock in the jaw, teeth or gums.
It usually happens in short, unpredictable attacks that can last from a few seconds to
about 2 minutes. The attacks stop as suddenly as they start. In most cases,
trigeminal neuralgia affects just one side of the face, with the pain usually felt in the
lower part of the face. Very occasionally the pain can affect both sides of the face,
although not usually at the same time.

People with the condition may experience attacks of pain regularly for days, weeks
or months at a time. In severe cases attacks may happen hundreds of times a day.
It's possible for the pain to improve or even disappear altogether for several months
or years at a time (remission), although these periods tend to get shorter with time.
Some people may then develop a more continuous aching, throbbing or burning
sensation, sometimes accompanied by the sharp attacks.

Trigeminal neuralgia is usually caused by compression of the trigeminal nerve. This

is the nerve inside the skull that transmits sensations of pain and touch from your
face, teeth and mouth to your brain. The compression of the trigeminal nerve is
usually caused by a nearby blood vessel pressing on part of the nerve inside the
skull. Trigeminal neuralgia can also happen when the trigeminal nerve is damaged
by another medical condition, such as multiple sclerosis (MS) or a tumor.
The attacks of pain are usually brought on by activities that involve lightly touching
the face, such as washing, eating and brushing the teeth, but they can also be
triggered by wind – even a slight breeze or air conditioning – or movement of the
face or head. Sometimes the pain can happen without a trigger.

B) The main symptom of trigeminal neuralgia is sudden attacks of severe, sharp, shooting
facial pain that last from a few seconds to about 2 minutes. The pain is often described as
excruciating, like an electric shock. The attacks can be so severe that you're unable to do
anything while they're happening.

Trigeminal neuralgia usually affects one side of the face. In some cases it can affect both
sides, although not usually at the same time. The pain can be in the teeth, lower jaw,
upper jaw or cheek. Less commonly the pain can also be in the forehead or eye.
You may sense when an attack is about to happen, although they usually start
unexpectedly. After the most severe pain has subsided you may experience a slight ache
or burning feeling. You may also have a constant throbbing, aching or burning sensation
between attacks.

You may experience regular episodes of pain for days, weeks or months at a time.
Sometimes the pain may disappear completely and not return for several months or years.
This is known as remission. In severe cases of trigeminal neuralgia the attacks may
happen hundreds of times a day and there may be no periods of remission.

Symptom Triggers:
Attacks of trigeminal neuralgia can be triggered by certain actions or movements, such
as:
• talking
• smiling
• chewing
• brushing your teeth
• washing your face
• a light touch
• shaving or putting on make-up
• swallowing
• kissing
• a cool breeze or air conditioning
• head movements
• vibrations, such as walking or travelling in a car

However, pain can happen spontaneously with no trigger whatsoever.

C) Medicine:
As painkillers like paracetamol are not effective in treating trigeminal neuralgia,
you'll usually be prescribed an anticonvulsant – a type of medicine used to
treat epilepsy – to help control your pain. Anticonvulsants were not originally
designed to treat pain, but they can help to relieve nerve pain by slowing down
electrical impulses in the nerves and reducing their ability to send pain messages.
They need to be taken regularly, not just when the pain attacks happen, but you can
stop taking them if the episodes of pain cease and you're in remission. 

Unless a GP or specialist tells you to take your medicine in a different way, it's
important to increase your dosage slowly. If the pain goes into remission, you can
gradually reduce the dosage over the course of a few weeks. Taking too much too
soon, or stopping the medicine too quickly can cause serious problems.

At the start, the GP will probably prescribe a type of anticonvulsant

called carbamazepine, although a number of alternative anticonvulsants are
available if this is ineffective or unsuitable.

Other Medicines:
Carbamazepine may stop working over time. In this case, or if you experience
significant side effects while taking it, you should be referred to a specialist to
consider alternative medicines or procedures.

There are a number of specialists you may be referred to for further treatment,
including neurologists specialising in headaches, neurosurgeons, and pain medicine
specialists.
In addition to carbamazepine, a number of other medicines have been used to treat
trigeminal neuralgia, including:
• oxcarbazepine
• lamotrigine
• gabapentin
• pregabalin
• baclofen

None of these medicines are specifically licensed for the treatment of trigeminal
neuralgia, which means they have not undergone rigorous clinical trials to
determine whether they're effective and safe to treat the condition.
However, many specialists will prescribe an unlicensed medicine if they think it's
likely to be effective and the benefits of treatment outweigh any associated risks.

Percutaneous Procedures:
There are a number of procedures that can offer some relief from the pain of trigeminal
neuralgia, at least temporarily, by inserting a needle or thin tube through the cheek and
into the trigeminal nerve inside the skull.
These are known as percutaneous procedures. X-rays of your head and neck are taken to
help guide the needle or tube into the correct place while you're heavily sedated with
medicine or under a general anaesthetic, where you're unconscious.
Percutaneous procedures to treat trigeminal neuralgia include:

• glycerol injections – where a medicine called glycerol is injected around the

Gasserian ganglion, where the 3 main branches of the trigeminal nerve join together
• radiofrequency lesioning – where a needle is used to apply heat directly to the
Gasserian ganglion
• balloon compression – where a tiny balloon is passed along a thin tube that has
been inserted through the cheek. The balloon is then inflated around the Gasserian
ganglion to squeeze it; the balloon is then removed
These procedures work by deliberately injuring or damaging the trigeminal nerve, which
is thought to disrupt the pain signals travelling along it. You're usually able to go home
the same day.

Overall, these procedures are similarly effective in relieving trigeminal neuralgia pain,
although there can be complications with each. These vary depending on the procedure
and the individual.

Stereotactic Radiosurgery:
Stereotactic radiosurgery is a fairly new treatment that uses a concentrated beam
of radiation to deliberately damage the trigeminal nerve where it enters the
brainstem. Stereotactic radiosurgery does not require a general anaesthetic and no
cuts (incisions) are made in your cheek. A metal frame is attached to your head with
4 pins inserted around your scalp – a local anaesthetic is used to numb the areas
where these are inserted. Your head, including the frame, is held in a large machine
for 1 to 2 hours while the radiation is given. The frame and pins are then removed,
and you're able to go home after a short rest. It can take a few weeks – or sometimes
many months – to notice any change after stereotactic radiosurgery, but it can offer
pain relief for some people for several months or years. Facial numbness and pins
and needles in the face are the most common complications associated with
stereotactic radiosurgery. These side effects can be permanent and, in some cases,
very troublesome.

Microvascular Decompression:
Microvascular decompression (MVD) is an operation that can help relieve
trigeminal neuralgia pain without intentionally damaging the trigeminal nerve.
The procedure relieves the pressure placed on the trigeminal nerve by blood vessels
that are touching the nerve or are wrapped around it.
MVD is a major procedure that involves opening the skull, and is carried out under
general anaesthetic by a neurosurgeon.

A surgeon makes an incision in your scalp, behind your ear, and removes a small
piece of skull bone. They then separate the blood vessel(s) from the trigeminal
nerve using an artificial pad or a sling constructed from adjoining tissue.
Many people find this surgery is effective at easing or completely stopping the pain
of trigeminal neuralgia.

It provides the longest lasting relief, with some studies suggesting that pain returns
in about 3 out of 10 cases within 10 to 20 years of surgery.
Currently, MVD is the closest possible cure for trigeminal neuralgia. However, it's an
invasive procedure and carries a risk of potentially serious complications, such as
facial numbness, hearing loss, stroke and even death in around 1 in every 200 cases.

D) The management of TN requires a multidisciplinary approach. Although there is

little or no evidence to support their use, some patients report that other treatment
options offer some relief. These include acupuncture, distraction techniques,
relaxation training, biofeedback, meditation, and physical therapy.

The nurse’s role in assessing and managing patients’ pain is vital and will vary
enormously depending on where the patient is being managed. In the case of
patients with TN, their pain is likely to be managed primarily through a specialist
unit or pain service, which is multidisciplinary. The nurse is therefore usually a
specialist or consultant nurse and will have additional skills to be able to assess and
manage pain of a complex nature. The specialist nurse role will vary from service to
service but may include specialist assessment techniques, advising on
pharmacological interventions and reviews, offering a variety of psychological and
physical therapies, and being an educator. It will involve liaison with other health
professionals and services.

Patients who are cared for in the community may have their TN monitored by
district nurses or practice nurses and again the nurses’ skills will vary depending
upon the services provided by their primary care trust. The nurse’s main role will be
that of assessment and ensuring that any changes in the pain are managed
appropriately, and when necessary seeking specialist advice.
Nurses in acute care settings need to ensure that appropriate assessment of
patients’ pain is undertaken and, when necessary, ensure that specialist advice is
sought.

2. Bell’s Palsy:

A) Bell’s palsy is a condition that causes a temporary weakness or paralysis of the

muscles in the face. It can occur when the nerve that controls your facial muscles
becomes inflamed, swollen, or compressed.

The condition causes one side of your face to droop or become stiff. You may have
difficulty smiling or closing your eye on the affected side. In most cases, Bell’s palsy
is temporary and symptoms usually go away after a few weeks.

Although Bell’s palsy can occur at any age, the condition is more common among
people between ages 16 and 60. Bell’s palsy is named after the Scottish anatomist
Charles Bell, who was the first to describe the condition.

The exact reason Bell's palsy occurs isn't clear, it's often related to having a viral
infection. Viruses that have been linked to Bell's palsy include viruses that cause:
• Cold sores and genital herpes (herpes simplex)
• Chickenpox and shingles (herpes zoster)
• Infectious mononucleosis (Epstein-Barr)
• Cytomegalovirus infections
• Respiratory illnesses (adenovirus)
• German measles (rubella)
• Mumps (mumps virus)
• Flu (influenza B)
• Hand-foot-and-mouth disease (coxsackievirus)

The nerve that controls your facial muscles passes through a narrow corridor of bone on
its way to your face. In Bell's palsy, that nerve becomes inflamed and swollen — usually
related to a viral infection. Besides facial muscles, the nerve affects tears, saliva, taste and
a small bone in the middle of your ear.

Risk Factors:
Bell's palsy occurs more often in people who:
• Are pregnant, especially during the third trimester, or who are in the first
week after giving birth
• Have an upper respiratory infection, such as the flu or a cold
• Have diabetes
Recurrent attacks of Bell's palsy are rare. But in some of these cases, there's a family
history of recurrent attacks — suggesting a possible genetic predisposition to Bell's
palsy.

B) Signs and symptoms of Bell's palsy come on suddenly and may include:

• Rapid onset of mild weakness to total paralysis on one side of your face —
occurring within hours to days
• Facial droop and difficulty making facial expressions, such as closing your eye or
smiling
• Drooling
• Pain around the jaw or in or behind your ear on the affected side
• Increased sensitivity to sound on the affected side
• Headache
• A loss of taste
• Changes in the amount of tears and saliva you produce

In rare cases, Bell's palsy can affect the nerves on both sides of your face.

C) Medications:
Commonly used medications to treat Bell's palsy include:
• Corticosteroids, such as prednisone, are powerful anti-inflammatory agents.
If they can reduce the swelling of the facial nerve, it will fit more comfortably within
the bony corridor that surrounds it. Corticosteroids may work best if they're started
within several days of when your symptoms started.
• Antiviral drugs. The role of antivirals remains unsettled. Antivirals alone
have shown no benefit compared with placebo. Antivirals added to steroids are
possibly beneficial for some people with Bell's palsy, but this is still unproved.
However, despite this, valacyclovir (Valtrex) or acyclovir (Zovirax) is sometimes
given in combination with prednisone in people with severe facial palsy.

Physical Therapy:
Paralyzed muscles can shrink and shorten, causing permanent contractures. A
physical therapist can teach you how to massage and exercise your facial muscles to
help prevent this from occurring.

Surgery:
In the past, decompression surgery was used to relieve the pressure on the facial
nerve by opening the bony passage that the nerve passes through. Today,
decompression surgery isn't recommended. Facial nerve injury and permanent
hearing loss are possible risks associated with this surgery.
Rarely, plastic surgery may be needed to correct lasting facial nerve problems.
Facial reanimation helps to make the face look more even and may restore facial
movement. Examples of this type of surgery include eyebrow lift, eyelid lift, facial
implants and nerve grafts. Some procedures, such as an eyebrow lift, may need to be
repeated after several years.

D) Patients need reassurance that a stroke has not occurred and that spontaneous

recovery occurs within 3 to 5 weeks in most patients. Teaching patients with Bell’s
palsy to care for themselves at home is an important nursing priority.

Teaching Eye Care:

Because the eye usually does not close completely, the blink reflex is diminished, so
the eye is vulnerable to injury from dust and foreign particles. Corneal irritation and
ulceration may occur. Distortion of the lower lid alters the proper drainage of tears.
Key teaching points include the following:
• Cover the eye with a protective shield at night.
• Apply eye ointment to keep eyelids closed during sleep.
• Close the paralyzed eyelid manually before going to sleep.
• Wear wraparound sunglasses or goggles to decrease normal evaporation
from the eye.

Teaching About Maintaining Muscle Tone:

• Show patient how to perform facial massage with gentle
• upward motion several times daily when the patient can tolerate the
massage.
• Demonstrate facial exercises, such as wrinkling the forehead,
• blowing out the cheeks, and whistling, in an effort to prevent muscle atrophy.
• Instruct patient to avoid exposing the face to cold and drafts.

Diet & Nutrition:

• Instruct patient to chew on the unaffected side of his mouth.
• Provide soft and nutritionally balanced diet. Eliminate hot fluids and foods.
• Give frequent mouth care, being particularly careful to remove residues of
food that collects between the cheeks and gums.

3) Guillan-Barré Syndrome:

A) Guillain-Barré syndrome is a rare disorder in which your body's immune system

attacks your nerves. Weakness and tingling in your extremities are usually the first
symptoms.
These sensations can quickly spread, eventually paralyzing your whole body. In its most
severe form Guillain-Barré syndrome is a medical emergency. Most people with the
condition must be hospitalized to receive treatment.

The exact cause of Guillain-Barré syndrome is unknown. But it is often preceded by an

infectious illness such as a respiratory infection or the stomach flu.

There's no known cure for Guillain-Barré syndrome, but several treatments can ease
symptoms and reduce the duration of the illness. Most people recover from Guillain-
Barré syndrome, though some may experience lingering effects from it, such as
weakness, numbness or fatigue.

Types:
Once thought to be a single disorder, Guillain-Barré syndrome is now known to occur in
several forms.

The main types are:

• Acute inflammatory demyelinating polyradiculoneuropathy (AIDP), the most
common form in the U.S. The most common sign of AIDP is muscle weakness that starts
in the lower part of your body and spreads upward.
• Miller Fisher syndrome (MFS), in which paralysis starts in the eyes. MFS is also
associated with unsteady gait. MFS occurs in about 5 percent of people with Guillain-
Barré syndrome in the U.S. but is more common in Asia.
• Acute motor axonal neuropathy (AMAN) and acute motor-sensory axonal
neuropathy (AMSAN) are less common in the U.S. But AMAN and AMSAN are more
frequent in China, Japan and Mexico.

B) Symptoms:
Guillain-Barré syndrome often begins with tingling and weakness starting in your feet
and legs and spreading to your upper body and arms. In about half of people with the
disorder, symptoms begin in the arms or face. As Guillain-Barré syndrome progresses,
muscle weakness can evolve into paralysis.

Signs and symptoms of Guillain-Barré syndrome may include:

• Prickling, pins and needles sensations in your fingers, toes, ankles or wrists
• Weakness in your legs that spreads to your upper body
• Unsteady walking or inability to walk or climb stairs
• Difficulty with eye or facial movements, including speaking, chewing or
swallowing
• Severe pain that may feel achy or cramplike and may be worse at night
• Difficulty with bladder control or bowel function
• Rapid heart rate
• Low or high blood pressure
• Difficulty breathing

Complications:
Guillain-Barré syndrome affects your nerves. Because nerves control your
movements and body functions, people with Guillain-Barré may experience:
• Breathing difficulties. The weakness or paralysis can spread to the muscles
that control your breathing, a potentially fatal complication. Up to 30 percent of
people with Guillain-Barré syndrome need temporary help from a machine to
breathe when they're hospitalized for treatment.
• Residual numbness or other sensations. Most people with Guillain-Barré
syndrome recover completely or have only minor, residual weakness, numbness or
tingling.
• Heart and blood pressure problems. Blood pressure fluctuations and
irregular heart rhythms (cardiac arrhythmias) are common side effects of Guillain-
Barré syndrome.
• Pain. Up to half of people with Guillain-Barré syndrome experience severe
nerve pain, which may be eased with medication.
• Bowel and bladder function problems. Sluggish bowel function and urine
retention may result from Guillain-Barré syndrome.
• Blood clots. People who are immobile due to Guillain-Barré syndrome are at
risk of developing blood clots. Until you're able to walk independently, taking blood
thinners and wearing support stockings may be recommended.
• Pressure sores. Being immobile also puts you at risk of developing bedsores
(pressure sores). Frequent repositioning may help avoid this problem.
• Relapse. Around 3 percent of people with Guillain-Barré syndrome
experience a relapse.

Severe, early symptoms of Guillain-Barré syndrome significantly increase the risk of

serious long-term complications. Rarely, death may occur from complications such
as respiratory distress syndrome and heart attack.

C) Treatment:
There's no cure for Guillain-Barré syndrome. But two types of treatments can speed
recovery and reduce the severity of the illness:

• Plasma exchange (plasmapheresis). The liquid portion of part of your blood

(plasma) is removed and separated from your blood cells. The blood cells are then put
back into your body, which manufactures more plasma to make up for what was
removed. Plasmapheresis may work by ridding plasma of certain antibodies that
contribute to the immune system's attack on the peripheral nerves.
• Immunoglobulin therapy. Immunoglobulin containing healthy antibodies from
blood donors is given through a vein (intravenously). High doses of immunoglobulin can
block the damaging antibodies that may contribute to Guillain-Barré syndrome.

These treatments are equally effective. Mixing them or administering one after the other
is no more effective than using either method alone.
You also are likely to be given medication to:

• Relieve pain, which can be severe

• Prevent blood clots, which can develop while you're immobile
People with Guillain-Barré syndrome need physical help and therapy before and during
recovery. Your care may include:
• Movement of your arms and legs by caregivers before recovery, to help keep your
muscles flexible and strong
• Physical therapy during recovery to help you cope with fatigue and regain
strength and proper movement
• Training with adaptive devices, such as a wheelchair or braces, to give you
mobility and self-care skills

D) Nursing Management:
Maintaining Respiration:
• Vital capacity, breath sounds and depth and rates of respiration monitoring are
done to observe the respiratory status.
• Assess the muscle weakness level and monitor as it goes up to the muscles of the
respiratory system.
• Watch out for respiratory fatigue as manifested by breathlessness while talking.
• Provide a non-stimulating environment.
• Assist to a position with elevated head of bed for full chest excursion.
• Avoid giving sedative and narcotic medications so as not to depress the
respiration.
• Watch out for imminent signs of respiratory failure. Signs include heart rate that
is more than 120 bpm or 70 bpm and lower and respiratory rate of more than 30 bpm.
Prepare intubation set.

Prevent Immobility Complications:

•  Instruct to do range-of-motion (ROM) exercises.
•  Encourage to perform exercises according to physical and occupational therapy
guidelines during recovery period.
• Watch out for problems such as pressure sores, contractures, leg edema and
constipation.
• Arrange for assistive devices as necessary.

Encourage Ample Nutrition:

• Auscultate to check for bowel sounds. If bowel sounds are not present, stop
enteral feeding to avoid gastric distention.
• Assess the fifth and ninth cranial nerve to check ability for swallowing and
chewing. In case of poor function, do alternate feeding methods.
• Encourage small but frequent meals, that are both well-balanced and nourishing,
during the recovery period.

Relieving Pain:
• Administer pain reliever medications as necessary.
• Perform pain management techniques such as therapeutic massage, imagery and
diversion.
• Turn the patient every two hours to prevent the pressure areas from feeling
painful.

Maintain Communication:
• Conceptualize a system for communication to compensate for speaking difficulty.
• Maintain frequent contact.
• Encourage speech therapy lessons during recovery period.

Relieving Anxiety:
• Provide a trusting relationship with the patient.
• Encourage frequent verbalization of feelings.
• Provide a clear explanation of the Guillain-Barré Syndrome.

Complications:
• Respiratory failure
• Cardiac dysrhythmias
• Immobility complications

Discharge Plan:
Activity Do's and Don'ts:
• Stay active, but don’t overdo it. Get advice from healthcare professionals, such as
your therapists, on what your activity should be. 
• Be patient. Recovery from nerve damage is a slow process, and each person’s
recovery is unique. You may recover in as little as 3 weeks, or it could take as long as 3
years.
• Be careful. If you still have numbness and weakness, limit activities in which you
could fall or hurt yourself.
• Set priorities. Decide which tasks you need to do on a given day. Save the others
for another time.
• Talk to your healthcare provider about physical therapy and occupational therapy.
Physical therapy and occupational therapy can help you get your strength back.
• Don’t drive until your healthcare provider says it’s OK.

4. Amyotrophic Lateral Sclerosis (Lou Gehreg’s Disease)

A) Amyotrophic lateral sclerosis (ALS), also known as motor neurone disease (MND)

or Lou Gehrig's disease, is a disease that causes the
death of neurons controlling voluntary muscles. Some also use the term motor neuron
disease for a group of conditions of which ALS is the most common.

ALS is characterized by stiff muscles, muscle twitching, and gradually worsening

weakness due to muscles decreasing in size. It may begin with weakness in the arms or
legs, or with difficulty speaking or swallowing. About half of the people affected develop
at least mild difficulties with thinking and behavior and most people experience pain.
Most eventually lose the ability to walk, use their hands, speak, swallow, and breathe.

The cause is not known in 90% to 95% of cases, but is believed to involve
both genetic and environmental factors. The remaining 5–10% of cases are inherited from
a person's parents. About half of these genetic cases are due to one of two specific genes.
The underlying mechanism involves damage to both upper and lower motor neurons.
The diagnosis is based on a person's signs and symptoms, with testing done to rule out
other potential causes.

B) Symptoms:
Signs and symptoms of ALS vary greatly from person to person, depending on which
neurons are affected. Signs and symptoms might include:
• Difficulty walking or doing normal daily activities
• Tripping and falling
• Weakness in your leg, feet or ankles
• Hand weakness or clumsiness
• Slurred speech or trouble swallowing
• Muscle cramps and twitching in your arms, shoulders and tongue
• Inappropriate crying, laughing or yawning
• Cognitive and behavioral changes

ALS often starts in the hands, feet or limbs, and then spreads to other parts of your body.
As the disease advances and nerve cells are destroyed, your muscles get weaker. This
eventually affects chewing, swallowing, speaking and breathing.
There's generally no pain in the early stages of ALS, and pain is uncommon in the later
stages. ALS doesn't usually affect your bladder control or your senses.

C) Medications:
The Food and Drug Administration has approved two drugs for treating ALS:

• Riluzole (Rilutek). Taken orally, this drug has been shown to increase life
expectancy by three to six months. It can cause side effects such as dizziness,
gastrointestinal conditions and liver function changes. Your doctor will monitor your
blood counts and liver functions while you're on the drug.
• Edaravone (Radicava). This drug, given by intravenous infusion, has been shown
to reduce the decline in daily functioning. Its effect on life span isn't yet known. Side
effects can include bruising, headache and shortness of breath. This medication is given
daily for two weeks a month.

D) Nursing Management:
• Provide intellectual stimulating activities, because the client typically experiences
no cognitive deficits and retains mental abilities.
• Provide client and family teaching.
• Promote measures to enhance body image.
• Promote client and family coping as the client and his family deal with the poor
prognosis and the grieving process
• Provide referrals.
• Maximize functional abilities
Prevent complications of immobility
 Promote self-care
Maximize effective communication
• Ensure adequate nutrition
• Prevent respiratory complications
• Promote measures to maintain adequate airway
• Promote measures to enhance gas exchange, such as oxygen therapy and
ventilator assistance.
• Promote measures to prevent respiratory infection

Client Teaching & Discharge Plan:

Medicines:
• Medicines may be given to reduce the damage to the motor neurons by decreasing
the release of glutamate. You may also be given medicines to ease muscle cramps,
fatigue, and excessive saliva or mucus.
• If pills are difficult to swallow, grind them into powder. You may mix the powder
with applesauce or other foods that are easy to swallow. Some medicines are available in
liquid form. Ask your healthcare provider the best way to take your medicines.
• Take your medicine as directed. Contact your healthcare provider if you think
your medicine is not helping or if you have side effects. Tell him or her if you are allergic
to any medicine. Keep a list of the medicines, vitamins, and herbs you take. Include the
amounts, and when and why you take them. Bring the list or the pill bottles to follow-up
visits. Carry your medicine list with you in case of an emergency.

Rehabilitation Programs for ALS:

Rehabilitation programs can teach you skills to ease symptoms and improve your quality
of life:
• A physical therapist can teach you exercises to stay active and independent as
long as possible. In the early stages of ALS, low-impact exercises will help strengthen
your muscles that are not affected. Leg and ankle splints may support your weak muscles.
Range of motion exercises will help the jerkiness in your muscles and prevent shortening
of muscles.
• A speech therapist may work with you to improve how you communicate and eat.
ALS may cause your voice to change or cause you to have problems talking or
swallowing. The speech therapist will also teach you which foods and liquids are safe to
eat and drink. He or she can also help you with devices to help you communicate with
others.
• An occupational therapist can help you care for yourself as long as possible. He or
she can teach you skills to help you bathe, dress, and eat. An occupational therapist
suggests equipment to help you at home or work. Examples of equipment include a
walker, wheelchair, or ramp. The therapist will suggest ways to keep your home or work
place safe.

Nutrition:
You may need to change what you eat and drink if you have problems chewing and
swallowing. A dietitian or nutritionist will help you plan meals and answer your
questions. Eat softer and smaller pieces of food, such as custards, puddings, yogurt,
gelatins, and soft fruits. You will not need to chew these foods. Avoid foods that may
cause eating and swallowing problems:
• Food or liquid that is thin or runny can run into your lungs and cause irritation or
blockage.
• Food that is dry, fibrous, or bony, such as dry toast, pineapple, or bony fish, may
irritate your throat.
• Food that is sticky, such as a thick sauce or peanut butter, may be hard to
swallow. Thinning the sauce may help.
• Avoid food with skin or seeds, such as corn, berries, and nuts. These foods may
be difficult to chew and digest.

5. Meniere’s Disease

A) Meniere’s disease is a disorder that affects the inner ear. The inner ear is responsible
for hearing and balance. The condition causes vertigo, the sensation of spinning. It also
leads to hearing problems and a ringing sound in the ear. Meniere’s disease usually
affects only one ear.

The National Institute on Deafness and Other Communication Disorders (NIDCD)

estimates that 615,000 people in the United States have Meniere’s disease. Around
45,500 people are diagnosed each year. It’s most likely to occur in people in their 40s and
50s.

Meniere’s disease is chronic, but treatments and lifestyle changes can help ease
symptoms. Many people diagnosed with Meniere’s disease will go into remission within
a few years after their diagnosis.

The cause of Meniere’s disease isn’t known, but scientists believe it’s caused by changes
in the fluid in tubes of the inner ear. Other suggested causes include autoimmune
disease, allergies, and genetics.

B) Meniere’s disease symptoms tend to come on as “episodes” or “attacks.” These

symptoms include:

• vertigo, with attacks lasting anywhere from a few minutes to 24 hours

• loss of hearing in the affected ear
• tinnitus, or the sensation of ringing, in the affected ear
• aural fullness, or the feeling that the ear is full or plugged
• loss of balance
• headaches
• nausea, vomiting, and sweating caused by severe vertigo
•
Someone with Meniere’s disease will experience at least two to three of the following
symptoms at one time:
• vertigo
• hearing loss
• tinnitus
• aural fullness
•
Most people with Meniere’s disease don’t experience symptoms between episodes. So,
many of these symptoms can be caused by other problems in the ear if they occur during
a period with no attacks. Meniere’s disease may also be confused for other inner ear
disorders, such as labyrinthitis.

C) Medications for Vertigo

Your doctor may prescribe medications to take during a vertigo episode to lessen the
severity of an attack:
• Motion sickness medications, such as meclizine or diazepam (Valium), may
reduce the spinning sensation and help control nausea and vomiting.
• Anti-nausea medications, such as promethazine, might control nausea and
vomiting during an episode of vertigo.

Long-Term Medication Use:

Your doctor may prescribe a medication to reduce fluid retention (diuretic) and suggest
that you limit your salt intake. For some people, this combination helps control the
severity and frequency of Meniere's disease symptoms.
Noninvasive therapies and procedures
Some people with Meniere's disease may benefit from other noninvasive therapies and
procedures, such as:
• Rehabilitation. If you have balance problems between episodes of vertigo,
vestibular rehabilitation therapy might improve your balance.
• Hearing aid. A hearing aid in the ear affected by Meniere's disease might improve
your hearing. Your doctor can refer you to an audiologist to discuss what hearing aid
options would be best for you.
• Positive pressure therapy. For vertigo that's hard to treat, this therapy involves
applying pressure to the middle ear to lessen fluid buildup. A device called a Meniett
pulse generator applies pulses of pressure to the ear canal through a ventilation tube. You
do the treatment at home, usually three times a day for five minutes at a time.Positive
pressure therapy has shown improvement in symptoms of vertigo, tinnitus and aural
pressure in some studies, but not in others. Its long-term effectiveness hasn't been
determined yet.
If the conservative treatments listed above aren't successful, your doctor might
recommend some of these more-aggressive treatments.

Middle Ear Injections:

Medications injected into the middle ear, and then absorbed into the inner ear, may
improve vertigo symptoms. This treatment is done in the doctor's office. Injections
available include:
• Gentamicin, an antibiotic that's toxic to your inner ear, reduces the balancing
function of your ear, and your other ear assumes responsibility for balance. There is a
risk, however, of further hearing loss.
• Steroids, such as dexamethasone, also may help control vertigo attacks in some
people. Although dexamethasone may be slightly less effective than gentamicin, it's less
likely than gentamicin to cause further hearing loss.

Surgery:
If vertigo attacks associated with Meniere's disease are severe and debilitating and other
treatments don't help, surgery might be an option. Procedures include:
• Endolymphatic sac procedure. The endolymphatic sac plays a role in regulating
inner ear fluid levels. During the procedure, the endolymphatic sac is decompressed,
which can alleviate excess fluid levels. In some cases, this procedure is coupled with the
placement of a shunt, a tube that drains excess fluid from your inner ear.
• Labyrinthectomy. With this procedure, the surgeon removes the balance portion
of the inner ear, thereby removing both balance and hearing function from the affected
ear. This procedure is performed only if you already have near-total or total hearing loss
in your affected ear.
• Vestibular nerve section. This procedure involves cutting the nerve that connects
balance and movement sensors in your inner ear to the brain (vestibular nerve). This
procedure usually corrects problems with vertigo while attempting to preserve hearing in
the affected ear. It requires general anesthesia and an overnight hospital stay.

D) Nursing Management:
• Provide nursing care during acute attack.
Provide a safe, quiet, dimly lit environment and enforce bed rest
Provide emotional support and reassurance to alleviate anxiety
Administer prescribed medications, which may include antihistamines,
antiemetics, and possibly, mild diuretics
• Instruct the client on self-care instructions to control the number of acute attacks.
Discuss the nature of the disorder
Discuss the need for a low-salt diet
Explain the importance of avoiding stimulants and vasoconstrictions (e.g.
caffeine, decongestants, alcohol)
Discuss medications that may be prescribed to prevent attacks or self-
administration of appropriate medications during an attack, which may include
anticholinergics, vasodilation, antihsitamines, and possibly, diuretics or nicotinic acid.
• Discuss, prepare and assist the client with surgical options.
A labyrinthectomy is the most radical procedure and involves resection of the vestibular
nerve or total removal of the labyrinth performed by the transcanal route, which results in
deafness in that eat.
An endolynmphatic decompression consists of draining the endolymphatic sac and
inserting a shunt to enhance the fluid drainage

Client Teaching & Discharge Plan:

• During an attack of vertigo, lie down and hold your head very still until the
feeling passes. This may help you cope with vertigo.
• Take your medicines exactly as prescribed. Call your doctor or nurse call line if
you think you are having a problem with your medicine. You will get more details on the
specific medicines your doctor prescribes.
• Avoid caffeine, alcohol, tobacco, and stress, along with any other substances or
conditions that trigger an attack.
• Eat a diet low in sodium to reduce fluid buildup in the inner ear.
• Do exercises to improve your balance. These can help ease vertigo.Stand with
your feet together, arms at your sides, and hold this position for 30 seconds.
• For slightly harder exercise, stand with your feet together and arms at your sides
while slowly moving your head up and down and side to side.
• Keep a chart to track your progress. It can make you aware of any improvements.
Include the date, the time you spent exercising, how often your eyes were open or closed,
and how you felt during each exercise.
• Walk 5 steps and then stop abruptly. Wait for any dizzy feeling to go away, and
do it again. Repeat until you have walked about 15 metres. Walking exercises for vertigo
may improve your balance and your symptoms of vertigo. You may want to have
someone next to you while you do these exercises in case you lose your balance.
• For another walking exercise, walk 5 steps, turn, and walk back. Wait for any
dizziness to go away. Repeat 5 more times.
• For harder exercise, walk and turn your head to the right or left with every other
step. Try to walk about 15 metres. Repeat the exercise while moving your head up and
down. Then repeat while moving your head up to one side and down to the other side,
and then switching.
• Prepare a list that shows the distance you walked, how often you walked, and how
you felt while you were walking.
• Make sure your home is safe for those times when you have an attack of vertigo.
• Get rid of throw rugs, and use non-skid mats.
• Use grab bars near the bathtub and toilet.
• Use night-lights.
• Keep floors dry to prevent slipping.
• Store items you use often on low shelves so you do not have to climb or reach
high. If you have to climb, use a step stool with handrails.
• Keep driveways, sidewalks, and other walkways clear of things that might cause
you to trip.
• There are other steps you can take to stay safe.
• Avoid driving or working at heights.
• Wear shoes with low heels and non-slip soles.
• Keep your shoes tied.
• Alert family and friends to your condition.
• Know whether medicines you take can affect your sense of balance.