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BIOC33H3 (127)

Peripheral Nerve and Spinal Cord Problems

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Biological Sciences
Stephen Reid

Chapter 61: 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 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. 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  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  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
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