Tumors

Trauma

Infections

Inflammatory processes

Idiopathic (unknown) causes

Intense pain, twitching of facial muscles (tic), grimacing, and frequent blinking and tearing of the eye.

Note: some patients may also experience facial sensory loss

They are usually brief, lasting only 2-3 minutes

Precipitating stimuli include chewing, tooth brushing, a hot or cold blast of air on the face, washing the face, yawning, or even talking.

Note:

The patient may eat improperly, neglect hygienic practices, wear a cloth over the face, and withdraw from interaction with other individuals. The patient may also sleep excessively as a means of coping with the pain.

Note: 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.

CT scan - performed to rule out any lesions, tumors, or vascular abnormalities

MRI - done to rule out multiple sclerosis

Complete Neurologic Assessment - includes audiologic evaluation, although results are usually normal

1. A blood vessel pressing on the trigeminal nerve at the brainstem causes the myelin sheath to wear away

2. May be part of the normal aging process - lengthening blood vessels may end up pressing against the nerve

3. Symptoms can occur in people with MS - condition that causes deterioration of the myelin sheath throughout the body

4. Tumor, HTN, infection of the teeth, or herpes may cause damage to the myelin sheath as well

If nerve function is interrupted in a patient with trigeminal neuralgia, what three nursing actions would you do?

• Have patient chew on good side
• Monitor food temps (watch for burns)
• Manual removal of pouched foods

This is the removal of blood vessels that are irritating the trigeminal nerve.

Note: high success rate, but risk of double vision, hearing loss, and facial weakness.

Pain around and behind the ear

Fever

Tinnitus

Hearing deficit

Flaccidity on affected side

Drooping of mouth and drooling

Inability to close eyelid

Inability to smile, frown, or whistle

increased tear production

Corticosteroids - decreases edema and pain

Acyclovir (Zovirax) - alone or in conjunction with prednisone because HSV is implicated in 70% of cases.

Note: MUST TAKE WITHIN 24 HOURS OF SYMPTOMS STARTING TO BE MOST EFFECTIVE

Often Gullain-Barre Syndrome occurs 1-3 weeks after an infection of the lungs or stomach and intestines. What are some examples of infections that could trigger it?

Infections that may trigger GBS include:  Campylobacter jejuni, which can cause a type of food poisoning.  Mycoplasma , which can cause pneumonia.

Cytomegalovirus (CMV), which can cause fever, chills, sore throat, swollen glands, body aches, and fatigue.  Epstein-Barr virus (EBV), which can cause mononucleosis (mono).  Varicella-zoster virus, which can cause chickenpox and shingles. HIV

Muscle weakness or the loss of muscle function (paralysis) affects both sides of the body and usually starts in the legs and spreads to the arms. 

Note: weakness usually peaks around 14th day

Pain (worse at night), loss of reflexes (areflexia), numbness and tingling (paresthesia), reduced muscle tone (hypotonia).

Note: If condition persists and brainstem becomes involved, may see facial weakness, extraocular eye movement difficulties, dysphagia, and paresthesia of the face

CSF - initially normal, but shows elevated protein after 7-10 days

EMG - markedly abnormal (shows reduced nerve conduction in affected extremities)

If mild dysphagia, can place patient in upright position and flex the head during feedings. If severe dysphagia, tube feedings may be required.

Note: Patient with paralytic ileus or intestinal obstruction may need parenteral nutrition.

Ascending paralysis

Respiratory function

ABGs

Reflexes - gag, corneal, & swallowing (decreased or absent)

Blood pressure (orthostatic hypotension - Vasopressers)

Cardiac rate & rhythm (bradycardia & dysrhythmias)

Primary injury - initial mechanical disruption of axons as a result of stretch or laceration

Secondary injury - the ongoing, progressive damage that occurs after the initial injury [apoptosis (cell death) may continue for weeks to months after initial injury]

Decreased reflexes

Loss of sensation

Flaccid paralysis below the level of the injury

Note: lasts days to months, may mask postinjury neurologic function, and active rehab may begin in the presence of spinal shock.

Skeletal level of injury is the vertebral level where there is the most damage to vertebral bones and ligaments.

Neurologic level is the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body.

Paralysis of all four extremities, resulting in tetraplegia (quadraplegia).

Note: when damage is low in the cervical cord, the arms are rarely completely paralyzed.

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.

Central cord syndrome

Anterior cord syndrome

Brown-Séquard syndrome

Posterior cord syndrome

Cauda equina syndrome

Conus medullaris syndrome

Damage to the central spinal cord (involves motor weakness and sensory loss in upper and lower extremities).

Note: upper extremities affected more than lower ones

Damage to one half of the spinal cord. Characterized by loss of motor function/position and vibratory sense, as well as vasomotor paralysis on the same side as lesion. Opposite side has loss of pain and temperature sensation below level of lesion.

Note: Usually from penetrating injury

True

Note: Spinal cord edema and hemorrhage can affect function of phrenic nerve and cause respiratory insufficiency

• Continued hypotension in spite of vigorous treatment
• Decreased hemoglobin and hematocrit
• Expanding girth of the abdomen

• Poikilothermism is the adjustment of the body temperature to the room temperature.
• With spinal cord disruption there is also decreased ability to sweat or shiver below the level of the lesion, which also affects the ability to regulate body temperature.

Suctioning could cause metabolic alkalosis. Must monitor until suctioning is discontinued and a normal diet is resumed.

Note: Decreased tissue perfusion can lead to acidosis

• Doppler examination
• Impedance plethysmography
• Measurement of leg and thigh girth

When there is a penetrating trauma to the spinal cord.

Note: should be used with caution in elderly population.

• Immunosupression
• Increased frequency of upper GI bleeding
• Increased risk of infection

True or False? Bladder overdistention can result in reflux into kidneys with eventual renal failure.

True. Indwelling catheter used in acute phase followed by intermittent catheterization program (q3-4h) once stabilized.

Note: need high fluid intake during indwelling catheter phase

• Injury is at or above C3
• Patient is exhausted from labored breathing
• ABGs deteriorate (indicating inadequate oxygenation or ventilation)

Unopposed vagal response (give Atropine).

Note: Any increase in vagal stimulation, such as turning or suctioning, can result in cardiac arrest.

Lack of muscle tone to aid venous return can result in sluggish blood flow and predispose the patient to DVT. Obviously, immobility is another concern.

Note: will use Heparin or Lovenox to prevent DVT unless patient has internal bleeding or recent surgery

• Autonomic Dysreflexia is when there is stimulation of sensory receptors below the level of cord lesion and the intact sympathetic nervous system below the level of the lesion responds to the stimulation with a reflex arteriolar vasoconstriction that increases blood pressure but the parasympathetic nervous system is unable to directly counteract these responses via the injured spinal cord.
• Life-threatening - requires immediate resolution.
• If resolution doesn't occur, can lead to status epilepticus, stroke, myocardial infarction, & death.

• Hypertension (up to 300 mm Hg systolic)
• Throbbing headache (measure BP immediately)
• Marked diaphoresis above the level of the lesion
• Bradycardia (30 to 40 beats/minute)
• Piloerection (erection of body hair)
• Flushing of the skin above the level of the lesion
• Blurred vision or spots in the visual fields
• Nasal congestion
• Anxiety
• Nausea

• Elevation of the head of the bed 45 degrees or sitting the patient upright
• Notification of the physician
• Assessment to determine the cause
• May be necessary to relieve bladder distention with catheterization if this is the cause (use lidocaine)
• May be necessary to do digital rectal exam to assess for impaction (use anesthetic ointment first)
• Remove all skin stimuli (restrictive clothing/tight shoes)