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Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 41: Assessment of the Nervous System
Key Points: Priority concepts applied in this chapter are COGNITION, MOBILITY, and SENSORY PERCEPTION.
ANATOMY AND PHYSIOLOGY REVIEW
 The major divisions of the nervous system are the central nervous system (CNS) and peripheral nervous
system (PNS). The PNS is further divided into the somatic and autonomic systems. These systems work
together to control COGNITION, MOBILITY, and SENSORY PERCEPTION.
 The CNS is composed of the brain, which directs the regulation and function of the nervous system and
other body systems, and the spinal cord, which initiates reflex activity and transmits impulses to and
from the brain.
 The PNS is composed of 12 pairs of cranial nerves, 31 pairs of spinal nerves, and the autonomic nervous
system (ANS).
 The posterior branch of each spinal nerve carries sensory information (SENSORY PERCEPTION) to the cord.
The anterior branch of the spinal nerves transmits motor impulses (MOBILITY) to the muscles of the body.
 The ANS is further subdivided into sympathetic and parasympathetic fibers.
 The nervous system contains neurons, which transmit or conduct nerve impulses, and neuroglia cells,
which have an interdependent role with the neuron.
 Some neurons are motor, enabling MOBILITY, and some are sensory, enabling SENSORY PERCEPTION.
 Some process information, and some retain information.
 When a neuron receives an impulse from another neuron, the effect may be excitation or inhibition as
well as conduction of the impulse.
 Neuroglia cells provide protection, structure, and nutrition for the neurons.
 They are classified into four types: astroglial cells, ependymal cells, oligodendrocytes, and microglial
cells.
 These cells are also part of the blood-brain barrier and help regulate cerebrospinal fluid (CSF), which
surrounds and protects the spinal cord against damage from banging against the inside of the
vertebrae.
ASSESSMENT METHODS
 Depending on the type of information needed, a complete neurologic assessment can be done or just a
focused assessment.
 Observation of the patient is key throughout the assessment process.
 During the introduction, note the patient’s appearance and assess speech, affect, and motor function.
 Ask the patient about medical history to determine its association with the current health problem and
to evaluate their ability to perform activities of daily living.
 Ask about family medical history, such as stroke or myocardial infarction, since some diseases occur
more often in certain cultural groups or with genetic influence.
 Assess the patient’s memory because loss of memory, especially recent memory, tends to be an early
sign of neurologic problems.
 Assess the mental status of patients, including orientation, as part of the neurologic assessment.
 Establishing baseline data for subsequent comparison is important.
 Compare each assessment with baseline and compare differences between right and left sides and
upper and lower extremities.
 An organized head-to-toe physical assessment begins with the mental status and includes assessment
of consciousness and cognition.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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 Determine level of consciousness by observing responsiveness and awareness.
 A change in level of consciousness is the first indication that central neurologic function has declined.
 Assessment of cognition is usually done in a focused manner using tests of memory and attention that
require verbal or written ability.
 Loss of memory, especially recent memory, tends to be an early sign of neurologic problems.
 Evaluate the patient’s SENSORY PERCEPTION and MOBILITY, as well as gait, balance, and coordination.
 Cranial nerves are tested to establish a baseline from which to compare progress or deterioration when
the patient has a suspected problem affecting cranial nerves.
 Pupils should be equal in size, round and regular in shape, and reactive to light and accommodation
(PERRLA). Pinpoint, dilated, and nonreactive pupils are late signs of neurologic deterioration.
 The assessment of sensory function is reserved for patients with problems affecting the spinal cord or
spinal nerves, such as trauma, intervertebral disk disease, Guillain-Barré syndrome, tumor, infection,
stenosis, or transverse myelitis.
 Components of SENSORY PERCEPTION assessment include pain, superficial and deep sensation, light touch,
and proprioception.
 Throughout the physical assessment, observe the patient for involuntary tremors or movements.
 A special spinal cord assessment flow sheet may be used to document SENSORY PERCEPTION and MOBILITY
findings for the patient with a spinal cord injury.
 Measure the patient’s muscle strength, equality, and strength against resistance.
 Cerebral motor or brainstem integrity may also be assessed by testing muscles.
 Cerebellar function can be evaluated through assessment of fine coordination of muscle activity,
coordination, gait, and equilibrium.
 The deep tendon reflexes of the biceps, triceps, brachioradialis, and quadriceps muscles and of the
Achilles tendon are routinely tested.
 The cutaneous or superficial reflexes normally tested are the plantar reflexes and sometimes the
abdominal reflexes.
 A complete neurologic assessment, or “neuro check,” is performed when the patient is admitted to a
health care facility on an emergent basis, as part of ongoing patient assessment, and in the event of a
sudden change in neurologic status.
 Often a decrease in mental status is a key early sign of an infectious process in the older patient.
 Nurses collect and document data related to level of consciousness, orientation, movement of arms
and legs, and pupil size and reaction to light.
 Use the Glasgow Coma Scale as one measure of neurologic functioning—the lower the score, the
poorer the function. The Glasgow Coma Scale is used reliably to help describe the patient’s level of
consciousness.
 Observe the patient for other signs of altered COGNITION, such as reports of headache; restlessness,
irritability, or unusual quietness; slurred speech; and a change in the level of orientation.
 Be aware that decerebrate or decorticate posturing and pinpoint or dilated nonreactive pupils are late
signs of neurologic deterioration.
 Patients vary in their responses to a suspected or actual health problem, often depending on whether it
is acute or chronic. Response is also influenced by MOBILITY, SENSORY PERCEPTION, and/or COGNITION; these
abilities can be temporarily or permanently altered as a result of neurologic disease or injury.
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 Explain what patients should expect before diagnostic testing for neurologic structure and function.
 Provide pretest and post-test nursing care for patients having neurologic diagnostic testing.
 X-rays of the skull and spine are used to determine bony fractures, curvatures, bone erosion, bone
dislocation, and possible calcification of soft tissue.
 In head trauma and multiple injuries, one of the first priorities is to rule out cervical spine fracture.
 Cerebral angiography (arteriography) is done using contrast to visualize the cerebral circulation to
detect blockages in the arteries or veins in the brain, head, or neck.
 Risk factors for adverse events, including allergic reactions to the contrast medium, must be
determined before scheduling the test.
 Computed tomography (CT) scanning distinguishes bone, soft tissue, the vascular system and
ventricular system, and fluids such as CSF or blood.
 Tumors, infarctions, hemorrhage, hydrocephalus, and bone malformations can also be identified.
 CT angiography involves administering contrast dye intravenously to identify blood vessel abnormalities
such as blockages or narrowing and aneurysms.
 Magnetic resonance imaging (MRI) produces better images used to determine normal and abnormal
anatomy.
 Positron emission tomography provides information about the function of the brain, specifically glucose
and oxygen metabolism and cerebral blood flow.
 Single-photon emission computed tomography (SPECT) uses a radiopharmaceutical agent that enables
radioisotopes to cross the blood-brain barrier.
 Magnetoencephalography (MEG) is a noninvasive imaging technique used to measure the magnetic
fields produced by electrical activity to localize brain function in action.
 Electromyography (EMG) is used to identify nerve and muscle disorders as well as spinal cord disease.
 Electroencephalography (EEG) records the electrical activity of the cerebral hemispheres and is
performed to determine the origin of seizure activity, determine cerebral function in pathologic
conditions, differentiate between organic and hysterical or feigned blindness or deafness, monitor
cerebral activity during surgical anesthesia, diagnose sleep disorders, and determine brain death.
 Evoked potentials or evoked responses measure the electrical signals generated by hearing, touch, or
sight to assess sensory nerve problems and confirm conditions such as multiple sclerosis, brain tumor,
acoustic neuromas, and spinal cord injury.
 Evoked potentials are also used to test sight and hearing, especially in young children; monitor brain
activity in coma patients; and confirm brain death.
 Cerebral blood flow (CBF), especially for cerebral vasospasm, can be measured in many areas of the
brain with the use of radioactive substances.
 Lumbar puncture or spinal tap is used to obtain pressure readings, obtain CSF, check for spinal
blockage attributable to a spinal cord lesion, inject contrast medium or air for diagnostic study, inject
spinal anesthetics or other medications, and reduce mild increased intracranial pressure in certain
conditions.
 Assist with patient positioning during a lumbar puncture (fetal position preferred). Be sure that the
patient does not move during a lumbar puncture.
 Because of the danger of sudden release of CSF pressure, a lumbar puncture is contraindicated in
patients with symptoms suggestive of increased intracranial pressure.
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 Recall that normal CSF is clear, colorless with few cells, and contains glucose.
 Intracranial hemodynamics can be evaluated by using a transcranial Doppler, which uses sound waves
to measure blood flow through the arteries.
 It is particularly valuable in evaluating cerebral vasospasm or narrowing of arteries.
 Muscle or nerve biopsies are used to diagnose neuromuscular disorders and may also reveal if a person
is a carrier of a defective gene.
 Check for bleeding after patients have an angiography. If bleeding is observed, call the radiologist
immediately.
 Before MRI, check for ferromagnetic devices, such as pacemakers, vascular stents, and implanted
pumps.
 Reinforce teaching and use teaching aids for older adults who typically have recent memory loss.
 Explain what patients should expect before diagnostic testing for neurologic structure and function.
 Remember to encourage patients who receive contrast media or isotopes to drink fluids to increase
elimination of the material.
 When caring for older adults, remind them to move slowly and use caution when ambulating. Older
adults have an altered balance and decreased coordination.
 Reinforce teaching by repetition using written teaching, and employing memory aids such as electronic
alarms or applications for electronic devices that provide recurrent alerts.
Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 42: Care of Patients with Problems of the
Central Nervous System: The Brain
Key Points: Priority concepts applied in this chapter are COGNITION, PAIN, MOBILITY, and INFECTION.
 Acute central nervous system infections and common chronic neurodegenerative diseases of the brain
may impair a person’s MOBILITY and COGNITION and be a source of chronic PAIN.
 The brain is part of the central nervous system that functions as the body’s center for controlling
movement, sensation, and cognition.
 Health problems involving disease or damage of the brain can be acute or chronic and often affect the
patient’s level of independence and quality of life.
HEADACHES
Migraine Headaches
 A migraine headache is a chronic, episodic disorder with multiple subtypes classified as a long-duration
headache because it usually lasts more than 4 hours.
 It is characterized by an intense pain in one side of the head (unilateral), worsening with movement,
and occurs with either photophobia (sensitivity to light) or phonophobia (sensitivity to noise).
 Migraines tend to be familial and may have a genetic basis, although vascular, neurologic, chemical, and
environmental factors may also be involved.
 Abortive therapy alleviates PAIN during the aura phase or soon after the start.
 The priority of care for the patient having migraines is pain management. Drug therapy is prescribed,
but complementary and alternative therapies, such as yoga, meditation, massage, exercise,
biofeedback, ice, darkened room, and relaxation techniques may be helpful.
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 Drugs used may include triptans, ergotamine preparations, and antiepileptic drugs. Caution is
warranted with opioids and barbiturates for PAIN control because of their addictive nature, and because
some opioids can cause migraines.
 Both calcium channel blockers and beta blockers are used in the treatment of migraines by interfering
with vasodilation, a contributing cause of migraine PAIN. Both beta-adrenergic blockers and calcium
channel blocking drugs can lower blood pressure and decrease pulse rate.
 Teach patients with migraine headaches about triggers that could cause an episode, such as caffeine,
wine, and pickled or aged foods.
Cluster Headaches
 Cluster headaches are manifested by brief (30 minutes to 2 hours), intense unilateral PAIN that generally
occurs in the spring and fall without warning.
o They are classified as the most common chronic short-duration headaches.
 The PAIN of cluster headaches is described as excruciating, boring, and nonthrobbing and is usually
accompanied by ipsilateral eye tearing, rhinorrhea or congestion, ptosis, facial sweating, eyelid edema,
and miosis.
 Teach patients with cluster headaches about precipitating factors, such as anger episodes, excitement,
and excessive physical activity.
PARKINSON DISEASE – NEED TO KNOW
 Parkinson disease (PD), also referred to as paralysis agitans, is a progressive neurodegenerative disease
that most often is idiopathic in origin.
 A neurotransmitter system of checks and balances allows for refined, coordinated movement through
the balance of acetylcholine (ACh) and dopamine.
 Acetylcholine-producing neurons transmit excitatory messages and dopamine inhibits the function of
neurons.
 When dopamine levels are decreased, a person loses the ability to refine voluntary movement. The
large number of excitatory ACh-secreting neurons remains active, creating an imbalance between
excitatory and inhibitory neuronal activity.
 PD is a debilitating disease affecting motor ability and is characterized by four cardinal symptoms:
tremor, rigidity, bradykinesia or akinesia (slow movement/no movement), and postural instability.
 Patients can also develop emotional changes such as depression, irritability, pessimism, fear, and
insecurity.
 A few patients have secondary parkinsonian symptoms from conditions such as brain tumors and
certain anti-psychotic drugs.
 Primary PD often has a familial tendency.
o The disease is associated with deletion of mitochondrial DNA (mtDNA).
o These deletions cause a loss of neurons that produce dopamine in the substantia nigra.
 Although the cause is often not known, it may be due to environmental and genetic factors.
 Exposure to pesticides, herbicides, industrial chemical, and metals as well as well water, age over 40,
and reduced estrogen levels are known risk factors.
 The diagnosis is made based on clinical findings after other disorders have been ruled out.
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 Drug therapy decreases signs and symptoms and allows the patient to provide self-care and have a
reasonable quality of life.
 Monitor for drug toxicity when patients are taking medications for PD, especially levodopa
combinations such as Sinemet.
o Drug toxicity may be evidenced by changes in COGNITION such as delirium (acute confusion) or
hallucinations and decreased effectiveness of the drug.
 Surgery, when drugs are not effective, may include stereotactic pallidotomy and thalamotomy.
 Newer surgical procedures such as deep brain stimulation and experimental stem cell therapies are
becoming increasingly more common options to control symptoms of PD.
 Help patients and families identify community resources for chronic brain disorders, including the
National Parkinson Foundation.
DEMENTIA – NEED TO KNOW
 Dementia is a chronic and progressive loss of brain function that affects the ability to learn new
information.
 While symptoms of dementia can vary greatly, at least two of the following cognitive functions must be
significantly impaired to be considered dementia:
o Memory
o Communication and language
o Attention span or ability to focus and pay attention
o Reasoning and judgment
o Visual perception
 Alzheimer’s disease is the most common type of dementia, accounting for most of the chronic
confusional states that occur in older adults, eventually causing complete disorientation, physical
deterioration, and death usually associated with complications of immobility.
 Vascular dementia is the second most common dementia and is associated with stroke.
 When dementia occurs in people in their 40s and 50s, it is referred to as early dementia, Alzheimertype disease, or presenile dementia.
 Difficulty with short-term memory is also a problem.
 Many dementias are progressive and result in a chronic confusional state.
 The most important risk factors are age, female gender, and family history.
 Recall that familial Alzheimer’s disease has a genetic predisposition.
 The primary focus of the neurologic assessment is to identify abnormalities in COGNITION, including
language, personality, and behavior.
 Physical manifestations of neurologic impairment, such as seizures, tremors, or ataxia, tend to occur
late in the disease process.
 As the disease progresses, the patient may experience prosopagnosia, an inability to recognize oneself
and other familiar faces.
 The priority for interdisciplinary care is safety since chronic confusion and physical deficits place the
patient at a high risk for injury.
 Alterations in communication abilities include apraxia (inability to use words or objects correctly),
aphasia (inability to speak or understand), anomia (inability to find words), and agnosia (loss of sensory
comprehension).
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 Observe patients with Alzheimer’s disease closely because they tend to wander and make inappropriate
decisions.
 For patients with Alzheimer’s disease, the newer drugs seem to improve function and cognition
(cholinesterase inhibitors, such as donepezil [Aricept]) or slow the disease process (memantine), but
they do not cure the disease.
 Administer psychotropic drugs to patients with Alzheimer’s disease who also have mental/behavioral
health problems, such as depression and severe agitation.
 When the patient and family receive the diagnosis, one or more family members may desire genetic
testing. Support the patient’s/family’s decisions regarding testing and assist them in finding credible
resources for testing and the appropriate level of genetics professional.
 Collaborate with the health care team in discharge planning and health teaching for patients who have
chronic neurodegenerative diseases such as Alzheimer’s disease.
 Remind caregivers of patients with chronic neurologic diseases, such as Alzheimer’s disease, to find
ways to cope with their stress in order to remain physically and psychologically healthy.
 Teach caregivers of patients with dementia to use validation therapy, rather than reality orientation.
Acknowledge the patient’s feelings and concerns.
 The patient is to have an established exercise program to maintain MOBILITY for as long as possible, as
well as to prevent complications of immobility.
 Involve patients and families in developing a continuing plan of care to meet expected outcomes and
maintain quality of life.
 Adapt communication techniques for the patient with dementia.
 Help patients and families identify community resources for chronic brain disorders, including the
Alzheimer’s Association.
Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 43: Care of Patients with Problems of the
Central Nervous System: The Spinal Cord
Key Points: Priority concepts applied in this chapter are MOBILITY, SENSORY PERCEPTION, PAIN, INFLAMMATION,
TISSUE INTEGRITY, PALLIATION, and SEXUALITY.
 Spinal cord problems share a common characteristic of impaired MOBILITY and often include problems
with SENSORY PERCEPTION and PAIN.
 Besides injuries, the spinal cord can develop tumors, infections, inflammatory and autoimmune
diseases, and degenerative diseases.
 The spinal cord itself may be damaged or the spinal nerves may be affected, often by chronic
INFLAMMATION.
 The patient’s ability to perform activities of daily living, as well as his or her skin TISSUE INTEGRITY,
elimination patterns, and SEXUALITY, are often affected.
 SENSORY PERCEPTION may be impaired, either temporarily or permanently.
 Health care team members with expertise in symptom management can provide significant
contributions to this population’s quality of life by providing PALLIATION of symptoms that are chronic
and often progressive.
BACK PAIN – Review for final and HESI
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 The lumbosacral (lower back) vertebrae and cervical (neck) vertebrae are most commonly affected.
Low Back Pain (Lumbosacral Back Pain)
 Disabling low back pain (LBP) is the single greatest injury in employees.
 Acute PAIN is usually self-limiting, but if it continues for 3 months or if repeated episodes occur, it is
considered chronic back pain.
 Acute LBP is caused by muscle strain or spasm, ligament sprain, disk degeneration, or herniation of the
nucleus pulposus from the center of the disk.
 Conduct a complete PAIN assessment in patients with back injury, including the severity and nature of
the PAIN, location, and precipitating and relieving factors.
 In addition to PAIN, there may be both muscle spasm and numbness and tingling (paresthesia) in the
affected leg.
 Both legs may be checked for SENSORY PERCEPTION by using a cotton ball and a paper clip for comparison
of light and deep touch.
 Bowel and bladder incontinence or retention may occur with motor nerve involvement and can impact
SEXUALITY.
 Good posture, proper lifting techniques, and exercise can significantly decrease the incidence of LBP. To
help prevent back injury, use proper body mechanics.
 Ergonomics is an applied science in which the workplace is designed to increase worker comfort, while
increasing efficiency and productivity.
 Patients with severe deficits require diagnostic assessment, spinal x-rays, magnetic resonance imaging,
or a computed tomography scan to determine cause.
o X-rays of the spine are important to exclude fracture, spondylosis, or neoplasm as the causative
agent. Flexion-extension views can be very useful to show instability of the spine.
 Implement conservative interventions for neck or back PAIN, such as analgesics, nonsteroidal antiinflammatory drugs, muscle relaxants, heat, positioning, physical therapy, and weight control.
 Short-term oral steroids or an epidural steroid/anesthetic injection may be used to rapidly reduce
INFLAMMATION.
 Suggest heat as an adjunct to medication. Hot showers or baths may also be beneficial, although there
are insufficient data to support the use of superficial heat/cold applications for LBP.
 Phonophoresis is the application of a topical drug (e.g., lidocaine, hydrocortisone) followed by
continuous ultrasound for 10 minutes.
 Iontophoresis is a similar procedure in which a small electrical current and dexamethasone are typically
used.
 Minimally invasive or open surgical procedures may be performed when conservative measures fail to
relieve back pain or if neurologic deficits continue to progress.
 Postoperatively, monitor vital signs at least every 4 hours for the first 24 hours to assess for fever and
hypotension, as well as performing a neurologic assessment, particularly noting movement, strength,
and SENSORY PERCEPTION in the legs.
 Observe the incision site for bleeding and cerebrospinal fluid leakage, which is clear fluid.
 To prevent complications of limited MOBILITY, log roll patients having spinal surgery, especially those
who have fusions.
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 Teach patients who have had spinal surgery to avoid lifting and driving, to use proper body mechanics,
and to perform strengthening exercises as instructed.
 Teach overweight and obese patients the importance of losing weight to reduce back pain and strain.
Cervical Neck Pain
 Cervical neck PAIN often results from a herniation of the nucleus pulposus in a disk.
 Acute or chronic cervical PAIN may also occur from muscle strain, ligament sprain resulting from aging or
poor posture, lifting incorrectly, tumor, rheumatoid arthritis, osteoarthritis, or infection.
 Implement interventions to prevent complications associated with decreased MOBILITY, including
turning, early ambulation or transfers out of bed, and incentive spirometry.
 Monitor patients with cervical spinal injuries for manifestations of autonomic dysreflexia.
 Provide emergency care for patients who experience autonomic dysreflexia.
 During a cervical fusion, the surgeon reduces the fracture by placing the bone ends in proper alignment.
Metal wiring is then used to secure bone chips (bone graft) taken from the patient’s hip. The patient
wears a halo fixator to immobilize the spine during the healing process.
SPINAL CORD INJURY – OVERVIEW FOR NOW AND FOR FUTURE BLOCKS
 Trauma, especially motor vehicle accidents, is the leading cause of spinal cord injury (SCI).
 Spinal cord damage can also result from diseases such as polio and tumors.
 Loss of motor function (MOBILITY), SENSORY PERCEPTION, reflex activity, and bowel and bladder control often
result from an SCI. In addition, the patient may experience significant behavior and emotional
problems, body image, role performance, and self-concept.
 A complete spinal cord injury is one in which the spinal cord has been severed or damaged in a way
that eliminates all innervation below the level of the injury.
 With a complete SCI, changes below the level of the injury include:
o Absence of tactile sensation
o Flaccid paralysis (inability to move) of all voluntary muscles
 Incomplete spinal cord injuries allow some function or movement below the level of the injury.
 Incomplete lesions demonstrate a mix of partial motor, sensory, and reflex function.
 Although no cure exists, a combination approach of cell transplantation, growth of new neurons, drug
therapy, and surgery may be the key to restore some function.
 Five primary mechanisms that may result in an SCI include hyperflexion, hyperextension, axial loading
or vertical compression, excessive rotation, and penetrating trauma.
 Secondary injuries, which may worsen the primary injury, include hemorrhage, ischemia, lack of
oxygen, hypovolemia, impaired tissue perfusion from neurogenic shock, and edema.
 Cervical injuries may produce anterior cord syndrome, posterior cord syndrome, Brown-Séquard
syndrome, or central cord syndrome.
 For patients with an SCI, assess airway first! The first priority is to assess the patient’s airway, breathing
pattern, and circulation status.
 The level of injury is the lowest neurologic segment with intact or normal function.
 Tetraplegia or quadriplegia and quadriparesis, or weakness, involve all four extremities, as seen with
cervical cord and upper thoracic injury.
 Paraplegia and paraparesis involve only the lower extremities, as seen in lower thoracic and
lumbosacral injuries or lesions.
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 Spinal shock or spinal shock syndrome occurs immediately as a concussion response to the injury,
resulting in flaccid paralysis and loss of reflex activity.
 Spinal shock usually resolves within 24 hours and muscle spasticity begins in patients with cervical or
high thoracic injuries.
 Perform a detailed assessment of the patient’s motor and sensory status to assist in determining the
level of injury and serve as baseline data for future comparison.
 Cardiovascular dysfunction from disruption of the autonomic nervous system results in bradycardia,
hypotension, and hypothermia, which can lead to cardiac dysrhythmias.
 A patient with a cervical SCI is at risk for breathing problems resulting from reduced MOBILITY or from an
interruption of spinal innervation to the respiratory muscles.
 Assess the abdomen for indications of hemorrhage, distention, or paralytic ileus.
 Assess for skin TISSUE INTEGRITY with each turn or re-positioning.
 Muscle wasting results from the long-term flaccid paralysis seen in patients with lower motor neuron
lesions.
 Incomplete lesions or upper motor neuron lesions may cause muscle spasticity, which can lead to
contractures after neurogenic shock has resolved.
 The patient with an SCI must cope with changes in body image, self-esteem, independence, role
relationships, and SEXUALITY.
 In addition, assess family members or significant others to determine how well they are coping with the
patient’s injury and their role changes.
 Patients must be prepared for extensive rehabilitation and lifestyle changes.
 Computed tomography or magnetic resonance imaging is performed to determine the degree and
extent of damage to the spinal cord and to detect the presence of blood and bone within the spinal
column.
 The health care provider orders a complete x-ray series of the spine to identify vertebral fractures,
subluxation, or dislocation.
 The primary concern of the health care team is to reduce and immobilize the fracture to prevent
further damage to the spinal cord from bone fragments.
 Nonsurgical techniques include traction, external fixation, or braces, but surgery may be required to
stabilize the spine, relieve compression, and prevent further damage.
 Surgery is also necessary to remove bone fragments from a vertebral fracture, evacuate a hematoma,
or remove penetrating objects such as a bullet.
 Psychosocial adaptation is a critical factor in determining rehabilitation success.
 Nursing management strategies should promote a high level of patient participation in self-care,
prevent complications of immobility and INFECTION, and promote patient, family, and health team
communication, collaboration, and individualized intervention.
 The teaching plan includes MOBILITY skills; pressure ulcer prevention; activities of daily living (ADL) skills;
bowel and bladder program; education about SEXUALITY; prevention of autonomic dysreflexia with
appropriate bladder, bowel, and skin care practices; and recognition of early signs or symptoms of
autonomic dysreflexia.
 Observe patients with spinal injuries and diseases for complications of immobility.
 Assess patients with SCI and disease for the need for adaptive/assistive devices to become independent
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in ADLs.
 Implement bowel and bladder retraining programs for patients with SCI and spinal diseases.
 Refer patients to appropriate resources, such as a sexuality counselor or urologist for sexual
dysfunction resulting from illness or disease. Counsel them as needed about SEXUALITY issues.
 Recognize that SCI requires the patient to adjust to major life changes.
 Encourage patients to share their feelings about life-altering SCI or neurodegenerative disease.
Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 44: Care of Patients with Problems of the
Peripheral Nervous System
Key Points: Priority concepts applied in this chapter are MOBILITY, SENSORY PERCEPTION, PAIN, INFLAMMATION,
and GAS EXCHANGE.
 The peripheral nervous system is composed of the spinal nerves, cranial nerves, and the autonomic
nervous system.
 Its function is to provide communication from the brain and spinal cord to other parts of the body.
 Neuropathy (or peripheral neuropathy) is a global term that refers to any acute or chronic disease,
disorder, or damage to the peripheral nervous system that interferes with MOBILITY, alters SENSORY
PERCEPTION, and causes PAIN.
 Typical clinical manifestations of neuropathy include pain, muscle cramps, and muscle weakness.
 Acquired neuropathies are grouped into three broad categories: inflammatory, traumatic, and systemic.
PERIPHERAL NERVE TRAUMA
 The peripheral nerves are subject to injuries associated with mechanical or vehicular accidents, sports,
the injection of particular drugs, military conflicts or wars, and acts of violence.
 Specific mechanisms of injury include partial or complete severance of a nerve or nerves; contusion,
stretching, constriction, or compression of a nerve or nerves; ischemia; or electrical, thermal, or
radiation injury.
 Injuries to the peripheral nerves may result in loss of motor function (reduced MOBILITY), sensory
function (impaired SENSORY PERCEPTION), or both.
 Interventions for the patient with peripheral nerve trauma depend on the location as well as the type
and degree of injury.
 If the nerve trauma results from a primary lesion, such as a tumor, the underlying problem is addressed
first.
 The health care provider may prescribe immobilization of the involved area by splint, cast, or traction to
provide the rest needed to limit and resolve any INFLAMMATION.
 The purpose of surgical management is to restore the function of the damaged nerve.
 Perform frequent neurovascular assessments for patients having a peripheral nerve repair, including
checking the skin around the splints and casts for tightness, warmth, and color.
RESTLESS LEGS SYNDROME Know for HESI and the Final
 Restless legs syndrome (RLS) is characterized by leg paresthesias associated with an irresistible urge to
move.
 The most common type is associated with peripheral and central nerve damage in the legs and spinal
cord.
 Primary disease often has a positive family history, possibly a genetic basis.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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 Management is symptomatic and involves treating the underlying cause or contributing factor, if
known.
 Both drug therapy and nonpharmacologic measures are used, including avoiding risk factors such as
caffeine, alcohol, and smoking; losing weight; and exercising.
 Dopamine agonists such as pramipexole (Mirapex) and ropinirole (Requip) are oral drugs used
extensively.
 For insomnia from RLS, the herbs melatonin and valerian have been proven to be effective for many
people, especially older adults.
 Strategies to relieve symptoms of RLS include walking, stretching, moderate exercise, or a warm bath,
and sometimes other alternative strategies.
 Teach patients with RLS to minimize risk factors for the disorder, including quitting smoking, exercising,
and losing weight.
GENERAL GUIDELINES FOR PATIENTS WITH PERIPHERAL NERVE DISORDERS
 Collaborate with members of the interdisciplinary team, including the health care provider, physical and
occupational therapists, speech-language pathologist, and nutritionist, for care of patients with GBS
and MG.
 Refer patients with peripheral nervous system disorders to community support groups and health care
organizations, such as the Restless Legs Syndrome Foundation and the Myasthenia Gravis Foundation.
 Assess patients with GBS and MG for the risk for complications of immobility, such as pressure ulcers,
and take measures to prevent these problems.
 Provide alternatives to promote communication for patients with GBS and MG, including speaking
slowly, lip-reading, and communication boards or electronic technology.
 Assess for changes in respiratory status and muscle function for patients with GBS and MG.
 Remember that the priority for care for patients with GBS and MG is to maintain GAS EXCHANGE and
airway management.
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Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 46: Assessment of the Eye and Vision
Key Points: The priority concept in this chapter is SENSORY PERCEPTION.
ANATOMY AND PHYSIOLOGY REVIEW
The eye, in conjunction with the brain, work together to allow visual SENSORY PERCEPTION.
Vision is one of the five senses and is important for communicating with the world.
Besides being the most important sense in meeting the human need for sensation and cognition, vision
assesses surroundings and allows independence, warning of danger, appreciation of beauty, work, play,
and interactions.
Light is changed into nerve impulses in the eye, which are sent to the brain where images are fully
perceived.
Many systemic conditions as well as eye problems can affect the eye and change vision temporarily or
permanently.
Changes in the eye and vision can provide information about the patient’s general health status and
problems that might occur in self-care.
Light waves pass through the following structures on the way to the retina: cornea, aqueous humor,
lens, and vitreous body.
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 Each structure has a different density, which causes the light waves to bend or refract to some degree
and focus images on the retina.
 Six voluntary muscles rotate the eye and coordinate eye movements.
 Coordinated eye movements ensure that the retina of each eye receives an image at the same time so
only a single image is seen.
 The muscles around the eye are innervated by cranial nerves III (oculomotor), IV (trochlear), and VI
(abducens).
 The second cranial nerve, the optic nerve, is the nerve of sight, connecting the optic disc to the brain.
 Part of cranial nerve V, the trigeminal nerve, stimulates the blink reflex when the cornea is touched.
 The facial nerve (cranial nerve VII) innervates the lacrimal glands and muscles controlling eyelid
closure.
 The four eye functions that provide clear images of near and far objects are refraction, pupillary
constriction, accommodation, and convergence.
 Structural changes occur with aging.
o In the older adult, decreased eye muscle tone reduces the ability to keep gaze focused on a
single object.
o The lower eyelid may relax and fall away from the eye, called ectropion, exposing more of the
eye and leading to dry-eye symptoms.
o The lens yellows with aging, reducing the ability of the eye to transmit and focus light.
o The aging lens hardens, shrinks, and loses elasticity, resulting in loss of the ability to
accommodate.
 Other health problems, especially diabetes mellitus and hypertension, can have serious adverse effects
on vision.
 Teach patients who have these health problems about the importance of controlling blood glucose
levels and managing blood pressure to reduce the risk for vision loss.
ASSESSMENT METHODS
 Collect subjective information from the patient to determine whether problems with the eye or vision
have an impact on daily functioning.
 Immediately test the visual acuity of both eyes of any person who experiences an eye injury or any
sudden change in vision.
 Assess patient characteristics that may impact vision, including nutrition, age, family history, genetic
risks, medications, and current health.
 Wash your hands before touching a patient’s eyelids and use Contact Precautions with any patient who
has drainage from the eyes.
 If a patient has discharge from one eye, examine the eye without the discharge first.
 Teach patients who have discharge from one eye to use a tissue to wipe the drainage and discard the
tissue. Use a clean tissue on the second eye.
 Assess the blink reflex by bringing a fist quickly toward the patient’s face or expelling a syringe full of air
toward the eyes.
 Pupillary assessment involves examining each pupil separately and comparing and assessing for
accommodation.
 Vision is measured by various tests.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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o First test each eye separately, and then test both eyes together.
o Patients who wear corrective lenses are tested both without and with lenses.
o Near vision is tested for patients who have difficulty reading without using glasses or other
means of vision correction.
o Visual field testing is used to determine the degree of peripheral vision.
o Extraocular muscle function is assessed using the corneal light reflex and the six cardinal
positions of gaze.
o These tests assess smoothness of eye movements and the function of cranial nerves III, IV, and
VI.
o Visual SENSORY PERCEPTION is measured by first testing each eye separately, and then testing both
eyes together.
o Test for PERRLA, which stands for pupils equal, round, and reactive to light and
accommodation.
 A patient with changes in visual SENSORY PERCEPTION may be anxious or fearful about a possible loss of
vision.
 Patients with severe visual defects may be unable to perform activities of daily living and may need to
change their leisure activities.
 Perimetry is a commonly used test to screen the visual fields.
 Gonioscopy is a test performed when a high intraocular pressure (IOP) is found and determines
whether open-angle or closed-angle glaucoma is present.
 Laser imaging of the retina and optic nerve creates a three-dimensional view of the back of the eye.
 Computed tomography is a useful diagnostic tool for looking at the eyes, bony structures around the
eye, extraocular muscles, and tumors in the orbital space.
 Magnetic resonance imaging is useful for evaluating ocular structures and tumors, but cannot be used
to evaluate injuries involving metal in the eyes.
 Ultrasonography examines the orbit and eye with high-frequency sound waves.
o Ultrasonography is a noninvasive test that aids in the diagnosis of trauma, intraorbital tumors,
proptosis, and choroidal or retinal detachments.
 Tests used to examine specific eye structures are not needed for routine vision assessment, but may be
indicated for those with special risks or symptoms.
 Ophthalmoscopic examination allows viewing of the eye’s external and interior structures.
 Avoid using an ophthalmoscope on a confused or uncooperative patient.
 Electroretinography is the process of graphing the retina’s response to light stimulation. It is helpful in
detecting and evaluating blood vessel changes from disease or drugs.
 Explain all diagnostic procedures, restrictions, and follow-up care to the patient scheduled for tests.
 Provide opportunities for the patient and family to express their concerns about a possible change in
vision status.
 Nurses can make a difference in preserving vision and eye function by teaching all people about eye
protection methods, adequate nutrition, and the importance of regular eye examinations.
 Identify patients at risk for eye injury as a result of work environment or leisure activities.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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 Encourage all patients to wear eye protection when they are performing yard work, are working in a
woodshop or metal shop, are using chemicals, or are in any environment in which drops or particulate
matter are airborne.
 Eye and head protection should be worn during participation in sports, such as baseball, or any activity
that increases the risk for the eye being hit by objects in motion.
 Patients should avoid excessive eye rubbing, which can traumatize the delicate outer eye surfaces.
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Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 47: Care of Patients with Eye and Vision
Problems
Key Points: Priority concepts applied in this chapter are SENSORY PERCEPTION and INFECTION.
Many factors and problems can affect visual SENSORY PERCEPTION. Some conditions affecting vision may
occur gradually, such as cataracts, but others can result from an acute insult or illness.
Even with temporarily reduced vision, changes in function or lifestyle result.
CONJUNCTIVAL DISORDERS
The conjunctiva is a thin mucous membrane that covers and protects the eye.
Conjunctival blood vessels are fragile and can break with increased pressure during sneezing, coughing,
or vomiting or with hypertension, trauma, or clotting disorders.
Inflammation occurs from exposure to allergens or irritants and is not contagious.
Infectious conjunctivitis occurs with bacterial or viral INFECTION and is contagious.
The focus of nursing interventions is INFECTION control and preventing the spread of the disease to the
other eye or to other people.
Instruct the patient about the need for frequent handwashing, especially after touching the eye and
before using eyedrops.
To avoid reinfection, eye makeup, applicators, and contact lenses used at the time the infection
developed should be discarded.
Trachoma is a chronic, bilateral scarring form of conjunctivitis caused by Chlamydia trachomatis and is
the chief cause of preventable blindness in the world.
CORNEAL DISORDERS
Corneal problems may be caused by irritation or INFECTION with ulceration of the corneal surface,
degeneration of the cornea, or deposits in the cornea.
Corneal problems reduce visual SENSORY PERCEPTION and can lead to blindness.
A corneal abrasion is a scrape or scratch of the cornea, caused by a small foreign body, trauma, or
inappropriate contact lens use, that disrupts the integrity of this structure.
Bacterial, protozoal, and fungal INFECTIONS can lead to corneal ulceration, which is a deeper disruption of
the corneal epithelium, extending into the stromal layer.
A corneal ulceration is considered an emergency because the cornea has no separate blood supply, and
infections that can permanently impair vision develop rapidly.
The patient usually has pain, reduced vision, photophobia, and eye secretions.
Stress the importance of applying prescribed drugs as often as prescribed, even at night.
Keratoconus, degeneration of the corneal tissue resulting in abnormal corneal shape, can occur with
trauma or may occur as part of an inherited disorder and reduces visual SENSORY PERCEPTION.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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 Treatment for a permanent corneal disorder that obscures vision is aimed at restoring corneal clarity
and enhancing the patient’s ability to use the remaining vision.
 Keratoplasty, or corneal transplant, is the surgical removal of diseased corneal tissue and replacement
with tissue from a human donor cornea.
 For a misshaped cornea that is still clear, surgical management involves a corneal implant that adjusts
the shape of the cornea. The device approved for this procedure is the Intacs corneal ring.
o Postoperative care involves extensive patient teaching about correct technique to instill
eyedrops, use of antibiotics to prevent INFECTION, use of patches and shields, positioning to
reduce intraocular pressure, and caution against using ice.
 Complications after surgery include bleeding, wound leakage, INFECTION, and graft rejection.
 Eye donation is needed for corneal transplantation. If a deceased patient is a known eye donor, follow
these recommended steps:
o Raise the head of the bed 30 degrees.
o Instill prescribed antibiotic eyedrops.
o Close the eyes, and apply a small ice pack.
CATARACT – NEED TO KNOW
 A cataract is an opacity of the lens. With time, as lens density increases and transparency is lost, visual
SENSORY PERCEPTION is greatly reduced.
 The priority problem for the patient with cataracts is reduced visual SENSORY PERCEPTION, which is a safety
risk as activities of daily living are impacted.
 When vision is reduced to the extent that activities are affected, the surgery should be performed as
soon as possible.
 Most patients experience dramatic improvement as early as the day of surgery, but final best vision
doesn’t occur until several weeks after surgery.
 Review the complications of sharp, sudden pain in the eye, bleeding or increased discharge, lid swelling,
decreased vision, and flashes of light or floating shapes with the patient and family before discharge.
 INFECTION is a potential and serious complication.
GLAUCOMA – NEED TO KNOW
 Glaucoma is a group of ocular diseases resulting in increased intraocular pressure.
 Primary open-angle glaucoma (POAG), the most common form of primary glaucoma, is usually bilateral
and asymptomatic in the early stages.
 Primary angle-closure glaucoma, also called closed-angle glaucoma, narrow-angle glaucoma, or acute
glaucoma, is less common, has a sudden onset, and is an emergency.
 Loss of visual SENSORY PERCEPTION from glaucoma can be prevented by early detection, lifelong treatment,
and a regimen of close monitoring and follow-up care.
 Visual fields are measured to determine the extent of peripheral vision loss. In POAG, the visual fields
first show a small defect that gradually progresses to a larger field defect.
 Visual field testing by perimetry is performed, as is visualization by gonioscopy to determine whether
the angle is open or closed.
 Laser trabeculoplasty and filtering microsurgery are used when drugs for open-angle glaucoma are not
effective.
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 A sclerectomy for glaucoma involves removing a section of sclera and trabecular meshwork along with
a section of the canal of Schlemm to allow more direct drainage of aqueous humor.
 A viscocanalostomy requires removal of a section of sclera, but the main focus is artificially widening
the canal of Schlemm to improve drainage.
RETINAL DISORDERS – NEED TO KNOW
 Retinal disorders can cause progressive degeneration and lead to blindness.
 Macular degeneration is the deterioration of the macula, the area of central vision, and can be agerelated or exudative.
 Treatment aims to help the patient maximize remaining vision to maintain the ability to read, write,
recognize safety hazards, and drive.
 Dry age-related macular degeneration (AMD) has no cure. Management of dry AMD is focused on
slowing the progression of the vision loss and helping the patient maximize the remaining vision.
 This loss of visual SENSORY PERCEPTION affects independence, well-being, and quality of life. It is often the
reason an older adult leaves his or her independent living environment and moves into assisted living.
 Recent clinical trials with agents that slow or prevent new blood vessel formation, the vascular
endothelial growth factor inhibitors, has shown success in the management of wet macular
degeneration.
 A retinal hole is a break in the retina caused by trauma or aging.
 A retinal tear is a more jagged and irregularly shaped break resulting from traction.
 A retinal detachment is the separation of the retina from the epithelium.
 Treatment involves creating an inflammatory response to bind the retina and choroid together around
the break by using cryotherapy, photocoagulation, or diathermy.
 Retinitis pigmentosa is a condition in which retinal nerve cells degenerate and lead to a loss of visual
SENSORY PERCEPTION.
REFRACTIVE ERRORS - FYI
 The ability of the eye to focus images on the retina depends on the length of the eye from front to back
and the refractive power of the lens system.
 Refractive errors are caused by problems in either eye length or refraction.
REDUCED VISUAL SENSORY PERCEPTION
In general, remember the following when caring for patients with visual SENSORY PERCEPTION disorders:
 Ask the patient about vision problems in any other members of the family, because many vision
problems have a genetic component.
 Different forms of reduced vision may affect any or all aspects of vision, including color, light, image,
movement, and acuity.
 Orient the patient with reduced vision to his or her immediate surroundings, including how to call for
help and where the bathroom is located.
 Safety is a major issue for the person with reduced vision. Stress to family members not to change item
locations without input from the patient. Teach family members with vision to make these home
adaptations to increase the patient’s independence and safety.
 Identify the room of a patient with reduced visual SENSORY PERCEPTION without identifying the patient.
 Knock on the door before entering the room of a patient with reduced vision and introduce yourself.
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 Use a normal tone of voice to talk with a patient who has a visual SENSORY PERCEPTION problem and
normal hearing.
 Identify people at risk for visual SENSORY PERCEPTION impairment as a result of work environment or
leisure activities and teach them specific ways to protect the eyes.
 Encourage all adult patients older than 40 years of age to have an eye examination with measurement
of intraocular pressure every year.
 Encourage all to use polarizing sunglasses whenever outdoors in bright sunlight.
 Encourage all patients to wear eye protection when they are performing yard work, are working in a
woodshop or metal shop, are using chemicals, or are in any environment in which drops or particulate
matter is airborne.
 Teach all patients to wash their hands before and after touching the eyes.
 Avoid performing an ophthalmoscopic examination on a confused patient.
 Refer patients with visual impairment to local resources and support groups.
 Teach patients proper techniques for self-instillation of eyedrops and eye ointment.
 Stress the importance of completing antibiotic regimens for eye INFECTIONS.
 Teach patients at risk for increased intraocular pressure what activities to avoid.
 Teach patients with infections not to rub the eye to avoid infecting the other eye.
 Allow the patient and family the opportunity to express concerns.
Ignatavicius: Medical-Surgical Nursing, 8th Edition; Chapter 48: Assessment and Care of Patients with Ear
and Hearing Problems
Key Points: The priority concept applied in this chapter is SENSORY PERCEPTION.
ANATOMY AND PHYSIOLOGY REVIEW
 The ear, along with the brain, allows auditory SENSORY PERCEPTION.
 Hearing is one of the five senses important for communicating with the world, allowing the assessment
of surroundings, independence, warnings of danger, appreciation of music, work, play, and interactions
with other people.
 Ear and hearing problems are common among adults of all ages.
 Assessment of the ear and hearing is an important skill for nurses in any care environment; therefore,
an understanding of the anatomy and physiology of the ear is essential.
 Many ear and hearing problems develop over long periods of time and may be affected by drugs or
systemic health problems.
 Hearing occurs when sound is delivered through the air to the external ear canal and the temporal bone
covering the mastoid air cells. The sound waves create vibrations that are ultimately transmitted to the
cochlea, which changes the vibrations into action potentials that are conducted to the brain.
 The nerve impulses are processed and interpreted by the brain as sound.
ASSESSMENT METHODS
 All older adults should be screened for hearing acuity.
 Many scales or tools are available to assess hearing loss. However, asking, “Do you have a hearing
problem now?” may be just as helpful as these scales.
 Obtain a thorough history from the patient before performing the physical examination.
 Hearing assessment begins while observing the patient listening to and answering questions.
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 The patient’s posture and appropriateness of responses provide information about hearing acuity.
 Obtain data on demographics, personal and family history, socioeconomic status, job-related
environmental exposure to loud noises or sounds, current health problems, and the use of remedies for
ear problems.
 Personal history includes past or current manifestations of ear pain, ear discharge, vertigo, tinnitus,
decreased hearing, and difficulty understanding people when they talk or difficulty hearing
environmental noise.
 Other relevant history may include trauma, surgery, infections, ear hygiene, exposure to loud noise or
music, air travel, swimming habits, hereditary factors, other health problems, smoking, and nutritional
deficiencies.
 Ask the patient about potentially ototoxic drug history.
 Family history is important in determining genetic risk for hearing loss.
o Ask the patient about hearing problems in any other members of the family because many
hearing problems have a genetic component.
HEARING LOSS - Need To Know
 Most hearing loss as a result of a genetic mutation is seen in childhood, but some genetic problems can
lead to progressive hearing loss in adults.
 Assess current ear-related problems by asking the patient about any ear “trouble,” ear pain, or
discharge, including earwax.
 Ask about any change in hearing, such as hyperacusis (the intolerance for sound levels that do not
bother other people) or tinnitus (ringing in the ears).
 Also ask about problems with dizziness, sensation of being “off-balance,” or vertigo (sensation of
spinning movement).
 Inspection and palpation are the examination techniques used to assess the ear.
 Inspect the entire external ear for shape, location of attachment to the head, and condition, including
the condition of the visible external canal.
 Use a separate speculum cover for each ear when conducting an otoscopic examination.
 Slowly and gently introduce the otoscopic speculum into the external ear canal during assessment.
 Use Contact Precautions with any patient who has drainage from the ear canal.
 Do not perform an otoscopic examination on a confused or uncooperative patient.
 Observe the ear canal through the otoscope as you insert the speculum into the external canal to avoid
the risk of perforating the eardrum.
 Assess for lesions, foreign bodies, and the amount and consistency of cerumen and hair.
 Assess the eardrum for intactness, color, lesions, shape, and mobility.
 Assess the patient’s hearing acuity.
o If auditory SENSORY PERCEPTION is decreased, the hearing loss is categorized as:
 Conductive hearing loss, which results from physical obstruction of sound wave
transmission, such as a foreign body in the external canal, a retracted or bulging
tympanic membrane, or fused bony ossicles.
 Sensorineural hearing loss, which results from a defect in the cochlea, the eighth cranial
nerve, or the brain itself.
 Mixed conductive-sensorineural hearing loss, a profound hearing loss resulting from
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both conductive and sensorineural hearing loss.
 The patient may become irritable, frustrated, and depressed by an inability to hear and respond
appropriately.
 The inability to hear often isolates the patient from the world.
 Ask about social and work relationships to determine whether the patient is isolated and withdrawn
because of hearing problems.
 Laboratory tests generally are not of value in determining hearing acuity, but microbial culture and
antibiotic sensitivity tests can determine the causative organism in infections.
 Computed tomography (CT), with or without contrast enhancement, shows the structures of the ear in
great detail by multiple x-ray scans of the head.
 CT is especially helpful in diagnosing acoustic tumors.
 Magnetic resonance imaging is a noninvasive, nonradioactive diagnostic tool that uses a computer to
generate images and has great sensitivity to soft-tissue changes.
 Auditory brainstem-evoked response assesses hearing in patients who are unable to indicate, or are
unreliable in indicating, their recognition of sound stimuli during standard hearing tests.
 Electronystagmography (ENG) is a test that is sensitive in detecting both central and peripheral disease
of the vestibular system in the ear.
 The ENG detects and records nystagmus, or involuntary eye movements, because the eyes and ears
depend on each other for balance.
 Caloric testing is performed to evaluate the vestibular portion of the auditory nerve.
 Audiometry is the measurement of auditory SENSORY PERCEPTION.
o Frequency is the highness or lowness of tones expressed in hertz.
o Intensity of sound is expressed in decibels.
o Threshold is the lowest level of intensity at which pure tones and speech are heard by a patient
about 50% of the time.
 Pure tones are generated by an audiometer to determine hearing acuity.
 Speech reception threshold is the minimum loudness at which a patient can repeat simple words.
 Speech discrimination testing determines the patient’s ability to discriminate among similar sounds or
among words that contain similar sounds.
 Tympanometry assesses mobility of the eardrum and structures of the middle ear by systematically
changing air pressure in the external auditory canal.
DISORDERS OF THE EAR AND HEARING
Conditions Affecting the External Ear
 External otitis (swimmer’s ear) is a painful condition occurring when irritating or infective agents come
into contact with the external ear.
o Often caused by participation in water sports, it can be an allergic response or inflammation
with or without infection.
o Affected skin becomes red, swollen, and tender to touch or movement.
o Swelling of the ear canal can lead to temporary hearing loss as a result of obstruction.
 Perichondritis is an infection of the perichondrium, the tissue that supplies blood to the ear cartilage.
Infection can occur and lead to reduced blood flow to the cartilage, leading to necrosis and pinna
deformity.
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o This can occur as a complication of high helical ear piercing and may require removal of necrotic
tissue.
Conditions Affecting the Middle Ear
 Acute and chronic otitis media affects the middle ear, is painful, and can cause permanent hearing loss
if left untreated.
o Antibiotics are prescribed for infection and, if pain persists after antibiotics, a myringotomy
(surgical opening of the eardrum) is performed. This drains the middle ear fluids and relieves
the pain immediately.
 Mastoiditis (infection of the mastoid air cells) can occur with progressive otitis media. If not treated
with antibiotics, it can lead to brain abscess, meningitis, and death.
Conditions Affecting the Inner Ear
 Inner-ear conditions that impact auditory SENSORY PERCEPTION include tinnitus (continuous ringing in the
ear), dizziness, vertigo (sense of whirling or turning in space), and labyrinthitis (infection of the
labyrinth).
 Ménière’s disease can be incapacitating and has three features: tinnitus, one-sided sensorineural
auditory SENSORY PERCEPTION loss, and vertigo, occurring in attacks that can last for several days.
Conservative and surgical treatment options exist. Many patients lose hearing in the affected ear.
 An acoustic neuroma is a benign tumor of cranial nerve VIII that often damages other structures;
damage to hearing, facial movements, and sensation can occur. Removal of the tumor causes
permanent loss of auditory SENSORY PERCEPTION in the affected ear, partial facial paralysis, lack of
complete eyelid closure, and chronic dry eye.
REMINDERS FOR PATIENT EDUCATION
 Teach patients the proper way to clean the pinna and external ear canal.
 Cerumen impaction in the older adult is common, and removal of the cerumen from older adults often
improves hearing.
 Identify patients at risk for hearing impairment as a result of work environment or leisure activities.
 Encourage all patients, even if they already have a hearing impairment, to use ear protection in a loud
environment.
 Inform all patients who smoke that smoking increases the risk for development of hearing problems.
 Allow the patient the opportunity to express fear or anxiety about a change in hearing status.
 Explain all diagnostic procedures, restrictions, and follow-up care to the patient scheduled for tests.
SEIZURES AND EPILEPSY – FOR FUTURE BLOCKS
 A seizure is an abnormal, sudden, excessive, uncontrolled electrical discharge of neurons resulting in
alteration in consciousness, motor or sensory ability, or behavior.
 Seizures may be due to a pathologic condition of the brain, such as a tumor.
 Epilepsy is defined as two or more seizures experienced by a person.
 The International Classification of Epileptic Seizures recognizes three broad categories of seizure
disorders: generalized seizures, partial seizures, and unclassified seizures.
 Primary or idiopathic epilepsy is not associated with any identifiable cause.
 Secondary seizures result from an underlying brain lesion, most commonly a tumor, trauma, or
metabolic or other disorders.
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 Most seizures can be completely or almost completely controlled through the administration of
antiepileptic drugs, referred to as anticonvulsants.
 Emphasize that the drugs must not be stopped even if the seizures have stopped as the recurrence of
seizures or status epilepticus may occur.
 The actions taken during a seizure should be appropriate for the type of seizure, such as observation,
timing, turning the patient on the side to prevent aspiration and allow secretions to drain, and
removing any objects that might injure the patient.
 For a patient having a tonic-clonic or complete partial seizure, protect the patient from injury.
 Recognize that generalized seizures, such as the tonic-clonic seizure, involve both cerebral
hemispheres. Partial seizures, also called focal or local seizures, usually involve only one hemisphere.
 For patients who have had one or more seizures, place on “seizure precautions,” which includes having
oxygen and suctioning emergency equipment available, starting an IV access, and keeping the siderails
up at all times. Indicate the reasons for the siderails to meet The Joint Commission requirements.
 During a seizure, document the patient’s body movements and other assessments.
 Padded tongue blades should NEVER be inserted into the patient’s mouth because the jaw may clench
down as soon as the seizure begins!
 Status epilepticus is a medical emergency characterized by prolonged seizures lasting more than 5
minutes or repeated seizures over the course of 30 minutes. Lorazepam and diazepam are the major
drugs used for this emergency.
 Causes of status epilepticus may include withdrawal from antiepileptic drugs, alcohol or other drugs,
head trauma, chronic neurologic conditions, INFECTION, cerebral edema, and metabolic disturbances.
 Patients who cannot be managed effectively with medication may be candidates for surgery, including
vagal nerve stimulation and conventional surgical procedures.
 Emphasize to patients the importance of taking their antiseizure medications as prescribed. Instruct
patients that they can build up sensitivity to the drugs as they age.
o If sensitivity occurs, tell them they will need to have blood levels of this drug checked frequently
to adjust the dose.
o In some cases, the antiseizure effects of drugs can decline and will lead to an increase in
seizures.
o Because of this potential for “drug decline and sensitivity,” patients need to keep their
scheduled laboratory appointments.
INFECTIONS - FOR FUTURE BLOCKS
Meningitis
 The patient with an INFECTION in the head or neck has an increased risk for meningitis because of the
proximity of anatomic structures.
 Meningitis is an inflammation of the meninges surrounding the brain and spinal cord.
 Bacterial and viral organisms are most often responsible for meningitis, although fungal meningitis and
protozoal meningitis also occur.
 Viral meningitis is usually self-limiting and the patient has a complete recovery, but bacterial meningitis
is potentially life-threatening.
 Increased intracranial pressure (ICP) may occur as a result of blockage of the flow of cerebrospinal fluid
(CSF), change in cerebral blood flow, or thrombus formation.
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 Analysis of the CSF is used to diagnose meningitis.
 Patients who are older than 60 years of age, are immunocompromised, or have signs of increased ICP
usually have a computed tomography scan performed before the lumbar puncture.
 The most important nursing interventions for patients with meningitis are accurately monitoring and
documenting of their neurologic status, including vital signs and neurovascular checks. Observe for
early signs and symptoms of ICP.
 Standard Precautions are appropriate for most patients with meningitis unless the patient has a
bacterial INFECTION that is transmitted by droplets.
 Individuals ages 16 through 21 years have the highest rates of INFECTION from life-threatening Neisseria
meningococcal infection.
 The Centers for Disease Control and Prevention recommends an initial meningococcal vaccine between
ages 11 and 12 years with a booster at age 16.
 Encourage people in areas of high population density, such as college dormitories and crowded living
areas, to become immunized against meningococcal meningitis.
Encephalitis
 Encephalitis is an inflammation of the brain tissue and often the surrounding meninges, affecting the
cerebrum, the brainstem, and the cerebellum.
 Unlike in meningitis, this response does not cause exudate (pus) formation.
 A viral agent elsewhere in the body most often causes the disease, although bacteria, fungi, or parasites
may also be involved.
 Viral encephalitis can be a life-threatening INFECTION that leads to persistent neurologic problems such as
learning disabilities, epilepsy, memory loss, and fine motor deficits.
 In severe cases of encephalitis, the patient may exhibit increased ICP resulting from cerebral edema,
hemorrhage, and necrosis of brain tissue.
 The typical patient with encephalitis has a high fever and reports nausea, vomiting, and a stiff neck.
 Herpes zoster may be a cause of encephalitis, and the lesion is clinically manifested by a rash, severe
PAIN, itching, burning, or tingling in the areas innervated by these nerves.
 Assess level of consciousness as a priority in patients with encephalitis.
 Lumbar puncture and diagnostic analysis of CSF may be helpful, depending on the patient’s condition.
 Supportive nursing care and prompt recognition and treatment of increased ICP are essential
components of management.
 Drug therapy is most effective if begun early, before the patient becomes stuporous or comatose.
 No specific drug therapy is available for INFECTION by arboviruses or enteroviruses.
 Teach older adults and those with chronic illness to have influenza and pneumonia vaccines.
 Since encephalitis can be caused by certain types of bites, teach people who enjoy outdoor activities to
avoid areas where mosquitoes and ticks are likely to populate, especially near lakes and wooded areas.
If they are in contact with these areas, remind them (especially older adults) to use insect repellent and
keep skin exposure at a minimum.
HUNTINGTON DISEASE – Nice to know eventually
 Huntington disease (HD) is a chronic, hereditary illness that is transmitted as an autosomal dominant
trait at the time of conception. Refer patients with the disease for genetic counseling.
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 The triad of dominant inheritance, choreiform movements or rapid, jerky movements (in the limbs,
trunk, and facial muscles), and dementia are hallmarks of the disease.
 There is no known cure or treatment; therefore, genetic counseling is important.
 The first drug to be approved to decrease chorea associated with HD is tetrabenazine (Xenazine).
o Because of an increased risk for suicide, be sure to teach reporting early signs of depression,
including sleeplessness, decreasing appetite, and mood changes.
 Collaborate with the health care team in discharge planning and health teaching for patients who have
chronic neurodegenerative diseases.
SPINAL CORD TUMORS – FOR FUTURE BLOCKS
 Symptoms of spinal cord tumors depend on tumor location and speed of growth.
 Primary spinal cord tumors arise from the epidural vessels, spinal meninges, or glial cells of the cord.
 Spinal cord tumors occur most often in the thoracic area, but they can occur in the lumbar and cervical
areas. These tumors are classified as either primary or secondary.
 Secondary spinal cord tumors are more common. They develop as a result of a metastasis of a cancer
that originated from another part of the body. The metastasis compresses the spinal cord or nerve
roots from the outside.
 Tumors that involve the bones of the vertebral column usually occur as a result of metastasis from
other areas of the body.
 PAIN is often felt as a result of spinal cord compression, which is the most common clinical
manifestation, but it can also occur due to infiltration of the spinal tracts or irritation of the spinal roots.
 Assess the quality, severity, and intensity of the pain. In addition, ask the patient to describe factors
that worsen and relieve the pain.
 MOBILITY problems arise from weakness, clumsiness, spasticity, and hyperactive reflexes. Other
presenting signs include ataxia (staggered gait), hypotonia (decreased muscle tone), and a positive
Babinski’s sign.
 Compare bilateral responses related to SENSORY PERCEPTION, initially as a slowly progressive numbness or
tingling, PAIN, and temperature loss. The sensory deficit is further marked by a decreased touch
perception, an inability to sense vibration, and a loss of position sense.
 Routine x-ray examinations or computed tomography scans are obtained to detect a narrowing of the
spinal canal, destruction of the vertebrae, or the presence of calcification.
 Magnetic resonance imaging provides more detail of the pathologic condition of the spinal cord than
either a computed tomography scan or myelography.
 Primary management is surgery to remove as much of the tumor as possible.
o Deficits that may remain after surgery can include MOBILITY and SENSORY PERCEPTION.
o The interventions related to SEXUALITY are usually focused on education in the acute care setting.
The nurse answers questions and corrects any misinformation. Unless the nurse has had specific
training or experience in sexual counseling of people with spinal cord tumors or injuries, more
detailed questions should be directed to a sexual counselor.
o Refer patients with spinal cord cancer to appropriate resources, such as the American Cancer
Society and its support groups.
MULTIPLE SCLEROSIS – FOR FUTURE BLOCKS
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 Multiple sclerosis (MS) is a chronic autoimmune disease that affects the myelin sheath and conduction
pathway of the central nervous system and is a leading cause of neurologic disability in young adults.
 This chronic disease is characterized by periods of remission and exacerbation of an inflammatory
response that results in demyelinization.
 The four major types of MS are:
o Relapsing-remitting
o Primary progressive
o Secondary progressive
o Progressive-relapsing
 Since there is genetic predisposition, having a first-degree relative such as a parent or sibling with MS
increases a person’s risk of developing the disease.
 Electromyography may help make a differential diagnosis to rule out multiple sclerosis or amyotrophic
lateral sclerosis.
 Magnetic resonance imaging demonstrates the presence of plaques and is considered diagnostic for
MS.
 The exact cause of MS remains unknown and is very complex. Research continues on viral,
immunologic, genetic, and environmental etiologic factors. Viruses are well recognized as causes of
demyelination and INFLAMMATION.
 Ask about a history of vision, MOBILITY, and SENSORY PERCEPTION changes, all of which are early indicators of
MS.
 Symptoms are often vague and nonspecific in the early stages of the disease and may disappear for
months or years before returning. Ask about the progression of symptoms.
 Fatigue is one of the most disabling manifestations, but unlike fatigue in other patients, MS fatigue is
associated with continuous sensitivity to temperature.
 Current therapies for MS treat a dysfunctional immune system using a variety of medications, including
chemotherapy agents, to control the disease, decrease INFLAMMATION and PAIN, lessen symptoms, and
slow progression.
o Fingolimod (Gilenya) is the first oral immunomodulator approved for the management of MS.
 To maintain maximum strength, MOBILITY, function, and independence, continuity of care with an
interdisciplinary team in both the rehabilitation and home setting is necessary.
AMYOTROPHIC LATERAL SCLEROSIS – FOR FUTURE BLOCKS
 Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease, is an adult-onset upper and
lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity
eventually leading to paralysis.
 There is no known cure for ALS, but an interdisciplinary approach is used to develop an individualized
treatment plan to maintain optimum functioning.
 Monitor respiratory status carefully in patients with ALS. Patients experience respiratory failure in the
terminal stage of the disease. Consider their advance directives to assist in planning care.
 Medications for PAIN, fatigue, spasticity, excessive secretions, sleep disturbances, and other
complications are ordered.
 Implement interventions to prevent complications associated with immobility, including turning, early
ambulation or transfers out of bed, and incentive spirometry.
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 Riluzole (Rilutek) is the only drug approved by the Food and Drug Administration for use with ALS
patients and, although not a cure, has been shown to extend survival time.
 Drug therapy is prescribed for PAIN, fatigue, spasticity, excessive secretions, sleep disturbances, and
other complications as they occur.
 An exercise program is developed, and special equipment is obtained as needed to help with ADLs and
MOBILITY.
 Other interventions are directed toward preventing complications of immobility and promoting
comfort.
 The interdisciplinary health care team collaborates with the patient and family to develop an
individualized plan of care and PALLIATION of symptoms.
 Refer to hospice in the terminal stage of the disease.
GUILLAIN-BARRÉ SYNDROME– FOR FUTURE BLOCKS
 Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy that affects the
peripheral nervous system, causing progressive motor weakness and abnormal SENSORY PERCEPTION.
 An immune-mediated pathology, GBS (also called acute idiopathic polyneuritis and
polyradiculoneuropathy) is an uncommon disorder affecting middle-aged men slightly more than
women.
 Demyelination of the peripheral nerves occurs to varying degrees.
 This is an immune-mediated pathologic process wherein the immune system starts to destroy the
myelin sheath that surrounds the axons of the peripheral nerves or attacks the axons themselves.
 Symptoms typically begin in the legs and spread to the arms and upper body, referred to as an
ascending paralysis.
 Recall that patients with GBS have ascending paralysis, sensory changes, cranial nerve involvement, and
autonomic manifestations as a result of demyelination of neurons.
 Damaged sensory nerves send fewer messages to the brain, affecting the patient’s SENSORY PERCEPTION.
 Paralysis can increase in intensity until the muscles cannot be used and the patient is almost totally
immobile, sometimes requiring mechanical ventilation.
 Three stages make up the acute course: the acute or initial period of 1 to 4 weeks beginning with the
onset of the first symptoms and ending when no further deterioration occurs; the plateau period; and
the recovery phase, which coincides with remyelination and axonal regeneration.
 In general, it is self-limiting and the paralysis is temporary, but patients may experience depression
throughout the recovery period.
 No single clinical or laboratory finding confirms the diagnosis.
 An increase in cerebrospinal fluid protein level without an increase in cell count is a distinguishing
feature, but may not be noted until after 1 to 2 weeks of illness.
 Electrophysiologic studies demonstrate demyelinating neuropathy, but the degree of abnormality
found on testing does not always correlate with clinical severity.
 Plasmapheresis removes the circulating antibodies thought to be responsible for the disease.
 IV immunoglobulin has been shown to be as effective as plasmapheresis and is safer and immediately
available.
 Because respiratory function (manifested by poor GAS EXCHANGE) is often compromised, the priority
intervention is to maintain adequate respiratory function.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
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 Develop interventions that prevent complications of immobility and address deficits in self-care.
 The interventions prescribed for MOBILITY and self-management and to prevent complications depend
on the degree of motor deficit.
 Encourage maximum independence and ensure safety while walking, transferring, or changing
positions.
 Collaborate with the dietitian to develop caloric and protein intake goals to prevent malnutrition.
 Intervene with PAIN management measures, including opioids, neuroleptics, and nonpharmacologic
measures. Exercise caution when giving older adults anticholinergics.
MYASTHENIA GRAVIS – FOR FUTURE BLOCKS
 Myasthenia gravis (MG) is a chronic disease characterized by remissions and exacerbations of fatigue
and weakness primarily in muscles innervated by the cranial nerves, as well as in skeletal and
respiratory muscles.
 This autoimmune disease of the neuromuscular junction may take many forms—from mild disturbances
of the ocular muscles to a rapidly developing, generalized weakness that may lead to death from
respiratory failure.
 The priority for nursing management of the patient in myasthenic crisis is maintaining adequate
respiratory function to promote GAS EXCHANGE.
 In Eaton-Lambert syndrome, a form often observed in combination with small cell carcinoma of the
lung, the muscles of the trunk and the pelvic and shoulder girdles are most commonly affected.
 Note that patients with MG have an autoimmune disease in which muscle weakness, including ocular
symptoms, is the result of attacks on the acetylcholine receptors at neuromuscular junctions.
 An experienced clinician is able to diagnose the disease from the history and physical examination
findings.
 Most of the patients have elevated levels of acetylcholine receptor antibodies, but a negative finding
does not exclude the disease.
 Pharmacologic tests with the cholinesterase inhibitors edrophonium chloride (Tensilon) and
neostigmine bromide (Prostigmin) help to confirm diagnosis.
 Tensilon produces a temporary improvement in myasthenic crisis but worsening or no improvement of
symptoms in cholinergic crisis.
 The most common electrodiagnostic test performed to detect MG is repetitive nerve stimulation of
proximal nerves.
 Single-fiber electromyography is a newer and more sensitive form of electromyography in detecting
defects of neuromuscular transmission. This test compares the stability of the firing of one muscle fiber
with that of another fiber innervated by the same motor neuron.
 The classic presentation of MG is muscle weakness that increases when the patient is fatigued and
limits his or her mobility and ability to participate in activities.
 Management may include treating the symptoms without influencing the actual course of the disease
with anti-cholinesterases or cholinergic drugs, and therapeutic efforts for inducing remission, such as
the administration of immunosuppressive drugs or corticosteroids, plasmapheresis, and thymectomy.
 Thymectomy is most effective when performed within 2 years of onset.
o Following thymectomy, maintain adequate GAS EXCHANGE and observe for complications such as
pneumothorax or hemothorax (e.g., chest pain, shortness of breath).
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 Teach patients on cholinesterase inhibitor drugs and their families about clinical manifestations of
cholinergic and myasthenic crises.
 Teach patients which factors can worsen or exacerbate MG.
 Because respiratory compromise often occurs in myasthenic patients, encourage family members to
learn resuscitation procedures.
DISEASES OF THE CRANIAL NERVES – FOR FUTURE BLOCKS
 The cranial nerves may be affected in association with other disorders of the nervous system or as a
result of trauma.
Trigeminal Neuralgia – FOR FUTURE BLOCKS
 Trigeminal neuralgia (TN), also known as tic douloureux, is a chronic PAIN syndrome that affects the
trigeminal, or fifth, cranial nerve and entails a specific type of unilateral facial PAIN, which occurs in
abrupt, intense spasms.
 The priority for care is PAIN management, with specific interventions determined by the amount of pain
experienced.
 Drug therapy is the first choice, but surgery may be necessary.
 Usually a computed tomography scan and magnetic resonance imaging are done to determine whether
there is a reversible cause of trigeminal compression or INFLAMMATION.
 The first choice for drug therapy is carbamazepine (CBZ, Tegretol). Other drugs used may be gabapentin
(Neurontin), pregabalin (Lyrica), and baclofen (Lioresal, Kemstro). Some patients also achieve PAIN relief
with complementary therapies, such as acupuncture.
 When medical management fails or to supplement medical management, radiosurgery techniques such
as a peripheral chemical nerve block with ropivacaine or stereotactic radiation treatments with the
Gamma Knife® may be used.
 Surgical procedures include percutaneous stereotactic rhizotomy (PSR) and microvascular
decompression, and are performed by a neurosurgeon.
 After surgery for TN, perform a focused cranial nerve assessment to determine damage to the nerves,
such as cranial nerve VII.
Facial Paralysis– FOR FUTURE BLOCKS
 Facial paralysis, or Bell’s palsy, is an acute paralysis of cranial nerve VII, but may also affect the
trigeminal (cranial nerve V) and vestibulocochlear (cranial nerve VIII) nerves.
 Bell’s palsy occurs in all ages and is not seasonally related.
 The cause of Bell’s palsy is believed to be the result of INFLAMMATION triggered by a formerly dormant
herpes simplex virus type 1.
 Although controversial, corticosteroids are often used during the first week after the onset of
symptoms, and antiviral drugs may also be prescribed for 7 to 10 days.
 Mild analgesics may help relieve the pain.
 Nursing care is directed toward managing the major neurologic deficits and providing psychosocial
support.
EYELID DISORDERS - Just FYI
 Eyelid problems can be related to changes in the structure, function, or position of the eyelid and may
be impacted by aging.
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 Blepharitis, an inflammation of the eyelid edges, occurs most often in the older adult and those with
dry-eye syndrome.
 Blepharitis is controlled with eyelid care using warm, moist compresses followed by gentle scrubbing
with dilute baby shampoo.
 An entropion is the turning inward of the eyelid, causing lashes to rub against the eye. It is caused by
muscle spasms, scarring and deformity from trauma, or aging.
 Surgery corrects eyelid position either by tightening the orbicular muscles and moving the eyelid to a
normal position, or by preventing inward rotation of the eyelid.
 An ectropion is the turning outward and sagging of the eyelid, which often occurs with aging caused by
relaxation of the orbicular muscles.
 This reduces the washing action of tears, leading to corneal drying and ulceration.
 An external hordeolum is an INFECTION of sweat glands in the eyelid where the eyelashes exit from the
eyelid, resulting in redness, swelling, and tenderness. Visual SENSORY PERCEPTION is not affected.
 Treatment includes the use of warm compresses and an antibacterial ointment.
 A chalazion is an inflammation of a sebaceous gland in the eyelid, beginning with redness and
tenderness followed by a gradual painless swelling at the gland.
 Treatment includes the use of warm compresses and ophthalmic ointment.
KERATOCONJUNCTIVITIS SICCA - FYI
 Problems in the lacrimal system arise from reduced tear production, INFECTION, or inflammation.
 Keratoconjunctivitis sicca, or dry-eye syndrome, results from changes in tear composition, lacrimal
gland malfunction, or altered tear distribution.
 Dry-eye syndrome can be caused by rheumatoid arthritis, leukemia, sarcoidosis, Sjögren’s syndrome,
radiation or chemical burns, injury to cranial nerve VII, or vision-enhancing surgery.
TRAUMA - FYI
 Trauma to the eye or orbital area can result from almost any activity.
 Visual SENSORY PERCEPTION is assessed before treatment.
 A hyphema is a hemorrhage in the anterior chamber from force applied to the eye that breaks the
blood vessels.
 The patient with a hyphema is treated by bedrest in semi-Fowler’s position to use gravity as an aid in
keeping the hyphema away from the optical center of the cornea.
 Lacerations are wounds caused by sharp objects and projectiles.
 Never remove a protruding object from the eyeball, because it may be holding eye structures in place
and will need to be removed surgically.
 Patients with penetrating eye injuries have the poorest chance of retaining vision in the injured eye.
OCULAR MELANOMA - FYI
 Melanoma is the most common malignant eye tumor in adults, occurring most often in the uveal tract
among people in their 30s and 40s and associated with exposure to ultraviolet light.
 Enucleation, or surgical removal of the entire eyeball, is the most common surgery for ocular
melanoma.
Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.