Common Disorders. Headaches Neurological Pain Cranial and Peripheral Nerve Disorders: Bell’s Palsy...

Common Disorders

HeadachesNeurological Pain

Cranial and Peripheral Nerve Disorders:Bell’s Palsy

Trigeminal Neuralgia

HEADACHE

• Significance is variable– Source of recurring headaches should be determined

through careful physical examination with appropriate neurological assessment

• Exact mechanism of head pain is not known– The skull and brain tissue are not able to feel

sensory painPain arises from the scalp, its blood vessels and

muscles, the dura mater and its venous sinuses

HEADACHE

• Can be classified as:– Vascular, Tension, and Traction-Inflammatory

1.Vascular: migraine, cluster, and hypertensive headaches

2.Tension: arise from tension or stress

3.Traction-Inflammatory: caused by infection, intracranial or extracranial causes, occlusive vascular structures, and temporal arteritis

Headaches• Clinical Manifestations:

– Headache pain may be made worse by tension and stress

– Migraine: prodromal signs and symptoms include: visual field defects, experiencing unusual smells or sounds, disorientation, parasthesis, and in some cases, paralysis

• During an attack: n/v, light sensitivity, chilliness, fatigue, irritability, diaphoresis, edema

• Abnormal metabolism of serotonin, a vasoactive neurotransmitter [found in platelets and cells of the brain], plays a major role

Headaches

• Assessment: – Subjective data: pt. report and understanding

of the headache; possible causes; and any precipitating factors. What measures relieve or make it worse; characteristics

– Objective data: behaviors indicating stress, anxiety, or pain; changes ability to carry out ADLs, increased body temp., sinus drainage

Headaches

• Diagnostic Tests:– Important to evaluate headaches that are not

transient– Neuro exam– CT (MRI, or PET scans)

• Medical Management– Dietary counseling: some foods or additives may

cause or worsen headaches– Psychotherapy: pain may be physiological, and

counseling can help pt. develop awareness of stress factors

Headaches

• Medical Management cont.– Medication

• Migraine:– ASA – pain relief– Ergotamine Tartrate – act by constricting

blood vessel walls and reducing cerebral blood flow; reduce inflammation reduce pain

– Combination drugs: ergotamines plus caffeine, phenobarbital, and belladonna

Headaches

– Medication cont.–Elitriptan (Relpax)

»Triptans are thought to act on receptors in the extracerebral and intracranial vessels that become dilated during a migraine

»Also relieve nausea, vomiting, photophobia

»E.g. Sumatriptan = Imitrex–Non-opiod analgesics

Headaches

• Nursing Interventions:– Facilitate relaxation and rest – plan day

accordingly– Patient Education re: nature of their

headaches, medication and treatment specifics

– Help pt. identify triggers– Regular exercise may help prevent

Headaches

• Nursing Interventions (cont.)

– Reduction of stress and emotional upsets• May need counseling with a professional

– Comfort measures• Medication administration, other

treatments/modalities• Diversional activities

Cluster Headaches

• Vascular• Occur in a series of episodes followed by a

long period with no symptoms • Intensely painful and seem to be related to

stress or anxiety • Usually have no warning symptoms• Treatment may include cold application,

indomethacin (Indocin), and tricyclic antidepressants (Elavil); narcotic analgesics are sometimes given IM

Tension Headache

• Result from prolonged muscle contraction from anxiety, stress, or stimuli from other sources

• Pain location may vary; may have nausea and vomiting, dizziness, tinnitus, or tearing

• Treatment: correction of known causes,, massage, heat application, and relaxation techniques, psychotherapy

• Analgesics, usually non-narcotic: acetaminophen, ibuprofen, ASA, propoxyphene

Neurological Pain

• Caused by a disorder within the nervous system or

• Caused peripherally at a distant part of the body

• Pain receptors can be activated by cellular damage, certain chemicals such as histamine, heat, ischemia, muscle spasm, cold, and pruritus– Each produces characteristic pain

Neurological Pain

• Intractable pain = Pain that is described as “unbearable” and does not respond to treatment

• Assessment: – Subjective: interview with pt. re: pain

characteristics– Objective: observations, behavioral signs,

ability to perform ADLs

Neurological Pain

• Diagnostic Tests: – Electrical stimulation, myelogram,

psychological testing

• Medical Management– Nonsurgical methods: TENS stimulation,

nerve block, medication– Surgical: neurectomy, rhizotomy, cordotomy,

percutaneous cordotomy

Neurological Pain

• Nursing Interventions:– Comfort measures: positioning, assist with

turning or movement– Bowel Regime– Promotion of rest and relaxation: reduce

headaches, stress and precipitating factors– Counseling to help pt. cope with discomfort

Neurological Pain

• Nursing Diagnosis: – Risk for disuse syndrome, related to lack of use of

a body part as a result of pain– Self-care deficit related to pain– Alteration in comfort related to pain

• Patient Teaching: – Identifying triggers– Reducing stress and emotional upsets– Comfort measures– Structuring the home and work settings

Cranial and Peripheral Nerve Disorders

Trigeminal NeuralgiaBell’s Palsy (Peripheral Facial

Paralysis)


• Trigeminal neuralgia– Etiology/pathophysiology

• Also called: tic douloureux• Degeneration of or pressure on the

trigeminal nerve (5th cranial nerve)• Maxillary and mandibular branches of the

5th cranial nerve are involved


• Clinical manifestations/assessment• Characterized by excruciating, knifelike, or

lightning-like shock in the lips, upper or lower gums, cheek, forehead, or side of the nose

• Attacks last only seconds 2-3 minutes• Along the nerve are “trigger points” –

slightest stimulation of these areas can initiate pain


• Medical management• Tegretol, Dilantin, Valproate (Depakote), and

Gabapentin (Neurontin) = drugs of choice• Nerve block• Surgical resection of the trigeminal nerve• Avoid stimulation of face on affected side

• Nursing interventions– Rehydration measures; improved nutrition – Oral hygiene; assistance with ADLs– Comfort measures (p. 701 Box 14-3)

Bell’s Palsy (Peripheral Facial Paralysis)

• Etiology/Pathophysiology• Inflammatory process involving facial nerve

VII

• Evidence that reactivated Herpes Simplex virus may be involved causing inflammation, edema, ischemia, and eventual demyelination of the facial nerve

Bell’s Palsy

• Clinical manifestations/assessment• Facial numbness or stiffness, or drooping feeling• Unilateral slow or inability to close eye• Unilateral weakness of facial muscles

asymmetric appearance• Loss of taste• Reduction of saliva• Pain behind the ear• Ringing in ear or other hearing loss

Bell’s Palsy

• Medical management• Electrical stimulation• Warm moist heat (ear pain)• Steroids and possibly antivirals (Zovirax, Famvir)

• Nursing Intervention• Medication administration• Massage of the affected area• Facial exercises• Eye drops (for moisture), eye patch at night

Infection and InflammationGuillain-Barre’ Syndrome

MeningitisEncephalitis

Guillain-Barre’ Syndrome(Polyneuritis)

• Etiology/Pathophysiology– Also called: “Acute Inflammatory

Polyradiculopathy”– Or “Postinfectious polyneuritis”

– Results in widespread inflammation and demyelination of the PNS


• Etiology/Pathophysiology

– Antibodies attack the Schwann cells causing the sheath to break down (demyelination)

– Nerve conduction is interrupted muscle weakness, tingling and numbness. Begins in the legs and works upward


• Etiology/Pathophysiology– Widespread inflammation and demyelination

of the PNS is self-limiting. Once it stops, the Schwann cells can rebuild the lining

– Recovery occurs in reverse

Guillain-Barre’ Syndrome(Polyneuritis

• Clinical Manifestations:– Variation in the pattern of the onset of weakness

as well as the rate of progression; symmetrical– Start usually in the legs thorax face– Progression may stop at any pointPt. may have difficulty swallowing, breathing , or

speaking if cranial nerves VII, IX, and X are involved


• Diagnostic Tests– CT scan– LP – CSF usually has elevated protein– Electromyography : to record muscle activity– Hx. – of recent infection

• Medical Management– Hospitalization is essential! Pt. condition can rapidly deteriorate

into paralysis that affects the respiratory muscles mechanical ventilation

– G-tube prn– Medication: Adrenocorticosteroids– Therapeutic plasmaphoresis


• Nursing Interventions:– Close monitoring of respiratory function– If on a mechanical ventilator: reassurance– Nutritional maintenance via IV or G-tube– Prevention of complications: turning, skin care,

pressure relief, ROM measures– Administration of medication– VS and motor function assessment frequently


• Prognosis: – 85% will regain complete function– 20% will have some weakness at 1 year– 5 percent – severe permanent disability– Recovery period may be from weeks to years

Meningitis

• Etiology/Pathophysiology:– An acute infection of the meninges – Usually caused by one of the following:

• Pneumococci • Meningococci• H. influenza• Staphylococci or streptococci

– Inflammatory reaction in the subarachnoid space involving the pia mater and arachnoid

• Pus accumulates and the bacteria may injure nerve tissue

Meningitis

• Classified as: – Bacterial: incidence is higher in the fall and winter

when URIs common• Can lead to edema of the brain, ICP, exudate occluding

ventricles hydrocephalus in infants

– Aseptic• Clinical Manifestations

– 2 abnormal signs:• Kernig’s sign• Brudzinski’s sign

Meningitis

• Clinical Manifestions– Severe headache, stiff neck, irritability, malaise, and

restlessness– Nausea/vomiting, and delirium may develop– Increased TPR

• Diagnostic Tests– Examining CSF with culture to determine the

pathological organism– CT– EEG

Meningitis

• Medical Management– Massive doses of multiple antibiotics (ampicillin,

penicillin, cephalosporins, Rocephin, etc.)– These drugs can penetrate the blood-brain barrier– Given IV or intrathecally– Steroids– Anticonvulsants

Meningitis

• Nursing Interventions– Maintain Respiratory isolation until the pathogen

can no longer be cultured from the nasopharynx– Maintain IV line if ordered– Nutrition status – ongoing eval– Darkened room: increased sensory stimulation

may cause a seizure– Safety precautions appropriate to age and

cognitive status. SRDs as needed.

Meningitis

• Prognosis:– Good for a complete recovery if antibiotics are

started quickly

– With severe cases, may be residual neurological damage or death

Encephalitis

• Etiology/Pathophysiology– Acute inflammation of the brain– Usually caused by a virus

• Some are associated with certain seasons of the year and endemic to certain geographic locations

• Epidemic encephalitis is transmitted by tics and mosquitos

• Nonepidemic encephalitis may occur as a complication of measles, chickenpox, or mumps

Encephalitis

• Etiology/Pathophysiology cont.– Overall mortality rate = 5-20%

– Most common form: HSV encephalitis

– Cytomegalovirus encephalitis is one of the common complications of AIDS

Encephalitis

• Clinical Manifestations:– Resemble those of meningitis with gradual

onset• Headache• High fever• Seizures• Change in LOC• Cerebral edema

Encephalitis

• Early diagnosis and tx. is essential to a favorable outcome:– MRI, PET scans– Viral studies of CSF (LP)

Encephalitis

• Medical management/Nursing Interventions– Symptomatic and supportive– Use of and monitoring of response to diuretics

and corticosteroids– Antiviral medications (start before onset of

coma)

Encephalitis

• Nursing Implications:– Are related to long-term symptoms:

• Memory impairment• Epilepsy• Personality changes• Anosmia (absence of the sense of smell)• Behavioral abnormalities• dysphagia

Common Disorders. Headaches Neurological Pain Cranial and Peripheral Nerve Disorders: Bell’s Palsy...

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