Peripheral Nerve Problems

Question 1

Trigeminal Neuralgia

Answer 1

more common in women over 50

unknown cause but possibly d/t compression of blood vessels causing chronic irritation of trigeminal nerve root (CN V)

other causes: herpes, MS, infection of teeth or jaw, brain mass in cerebellum or brainstem

two types: TN1 and TN2

Question 2

TN1: Sx

Answer 2

• classic features
• abrupt onset of paroxysms of excruciating pain (burning, knife and lightning like) of lips, gums, cheek, forehead, side of nose
• eyes: pain, twitching, increased blinking, tearing
• some facial sensory loss

attacks last seconds to few minutes, unilateral

triggered by: light touch along nerve branches, chewing, teeth brushing, yawning, talking

pt may eat less, have decreased oral hygiene, isolate themselves such as with increased sleep

Question 3

TN2: Sx

Answer 3

constant aching, burning or crushing pain

Question 4

Trigeminal Neuralgia: Dx

Answer 4

tests done to r/o other Dx with similar sx:

• CT r/o lesions or vascular problems
• MRI, LP r/o MS, sinusitis, brain lesions/masses
• neuro exam, audiology exam (results will be normal)

Question 5

Trigeminal Neuralgia: Tx

Answer 5

goal is relief of pain
med do not provide permanent relief
-anti-seizure drugs (tx nerve pain and may prevent acute attack or promote remission): carbamazipine (Tegretol),
neurontin (Gabapentin)
-Tricyclic antidepressants for constant burning/aching pain: amitriptyline (Elavil), nortripyline (Pamelor)
-analgesics or opioids (effective in TN2, but not with TN1)

acupuncture
botox

surgical tx: percutaneous, open surgeries, gamma knife procedures
*outpatient usually

Question 6

Trigeminal Neuralgia: Nursing Inteventions

Answer 6

• identify triggers of what may bring it on
• monitor pain relief
• moderate environmental temps (cold temps or drafts could be triggers)
• avoid touching face
• electric razor
• teach and assist w/ oral hygiene (small, soft toothbrush)
• alternative communication to decrease talking (yawning and movement of jaw could be trigger)
• food: increase calories, easy to chew, chew on opposite side
• impairment of corneal reflex (eye shield and lubricating drops)

Question 7

Bell’s Palsy

Answer 7

• most common facial nerve disorder CN VII
• usually effects those 15-50YO
• recover in 3 weeks to 6 months
• reoccurrence are uncommon
• 1/3 have residual asymmetrical movement of facial muscles
• problem: unilateral disruption of motor branches of facial nerve causing facial paralysis. Cause is unknown but associated with reactivated herpes simplex virus leading to inflammation, edema, ischemia, and eventual demyelination of nerve creating pain and alt in sensory and motor function (usually temporary)

Question 8

Bell’s Palsy: Sx

Answer 8

• c/o rapid onset of pain around or posterior to ear usually prior to paralysis
• facial twitching
• facial numbness
• altered taste
• dry eye or mouth
• excessive tearing in eye
• hearing loss
• drooping of mouth with drooling
• inability to close eyelid (corneal abrasions)
• altered chewing, swallowing and taste

Question 9

Bell’s Palsy: Dx and Tx

Answer 9

Dx: by exclusion (MRI and CT to r/o other diseases, hx of presentation, EMG)

Tx: Meds

• corticosteroids until improvement then taper (decrease edema)
• antiviral med if d/t Herpes simplex virus: valacyclovir (Valtrex)
• analgesics for discomfort

early assessment and dx is key in effective tx

Question 10

Bell’s Palsy: Nursing Interventions

Answer 10

• analgesics
• warm compresses (herpetic lesion pain relief and increased circulation if d/t herpes simplex or zoster)
• electrical stimulation of the nerve
• physical therapy (to help maintain muscle tone)
• monitor nutrition: chew on unaffected side; oral hygiene; look for food pocketing
• dark glasses for protection and cosmetic reasons, artificial tear

Question 11

Herpes Zoster (Shingles)

Answer 11

Varicella-zoster virus (VZV) activated possibly d/t change in immune system, stress, immunosuppressed pts

Pt is contagious to those who have not had varicella or immunocompromised

Sx: linear patches of vesicles along a dermatome (nerve path); unilateral on trunk region; burning pain precedes outbreak; mild to severe pain during outbreak

Tx: antivirals; wet compresses and silver sulfadiazine (Silvadene) on lesions; analgesics

Post herpetic neuralgia - Neurontin (Gabapentin), for nerve pain

Person w/ shingles can pass the varicella-zoster virus to anyone who has not had chickenpox. VZV is present in the blisters. Once infected, the person will develop chickenpox, not shingles.

Question 12

Herpes Zoster: Complications

Answer 12

postherpetic neuralgia: in some cases, shingles pain continues long after the blisters have cleared. Occurs when damaged nerve fibers send confused and exaggerated messages of pain skin to brain.

vision loss: shingles in or around an eye can cause painful eye infections that may result in vision loss

neurological problems: depending on which nerves are affected, shingles can cause an inflammation of the brain (encephalitis), facial paralysis, or hearing or balance problems.

skin infections: if shingles blisters aren’t properly treated, bacterial skin infections may develop