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Bell’s palsy
Description
Bell’s palsy (peripheral facial paralysis, acute benign cranial polyneuritis) is a disorder characterized by inflammation of the facial nerve (CN VII) on one side of the face in the absence of any other disease, such as a stroke. Despite its good prognosis, Bell’s palsy leaves more than 8000 people a year in the United States with permanent, potentially disfiguring facial weakness.
Pathophysiology
Although the exact etiology is not known, it is believed that a viral infection such as viral meningitis or activation of herpes simplex virus 1 (HSV1), may trigger Bell’s palsy. The viral infection causes inflammation, edema, ischemia, and eventual demyelination of the nerve, creating pain and alterations in motor and sensory function.
Clinical manifestations
The onset of Bell’s palsy is often accompanied by an outbreak of herpes vesicles in or around the ear. Patients may complain of pain around and behind the ear. Additional manifestations may include fever, tinnitus, and hearing deficit.
Paralysis of the motor branches of the facial nerve typically results in a flaccidity of the affected side of the face, with drooping of the mouth accompanied by drooling. Inability to close the eyelid, with an upward movement of the eyeball when closure is attempted, is also evident.
Complications can include psychologic withdrawal because of changes in appearance, malnutrition and dehydration, mucous membrane trauma, corneal abrasions, and facial spasms and contractures.
Diagnosis of Bell’s palsy is one of exclusion. Diagnosis and prognosis are indicated by observation of the typical pattern of onset and the testing of percutaneous nerve excitability by electromyogram (EMG).
Collaborative care
Methods of treatment include moist heat, gentle massage, and electrical stimulation of the nerve. Stimulation may maintain muscle tone and prevent atrophy. Care is primarily focused on relief of symptoms, protection of the eye on the affected side, and prevention of complications.
Nursing management
Mild analgesics can relieve pain. Hot wet packs can reduce discomfort of herpetic lesions, aid circulation, and relieve pain. Tell the patient to protect the face from cold and drafts because trigeminal hyperesthesia (extreme sensitivity to pain or touch) may occur.
The change in physical appearance as a result of Bell’s palsy can be devastating. Reassure the patient that a stroke did not occur and that chances for a full recovery are good. It is important to share with the patient that most patients recover within about 6 weeks of the onset of symptoms.
Benign paroxysmal positional vertigo
Benign paroxysmal positional vertigo (BPPV) is a condition where free-floating debris in the semicircular canal causes vertigo with specific head movements, such as getting out of bed, rolling over in bed, and sitting up from lying down. BPPV causes about 50% of cases of vertigo. The debris (“ear rocks”) is composed of small crystals of calcium carbonate that may occur in the inner ear due to head trauma, infection, or the aging process. In many cases a cause cannot be found.
Symptoms are intermittent and include dizziness, vertigo, lightheadedness, loss of balance, and nausea. There is no hearing loss. The symptoms of BPPV may be confused with those of Ménière’s disease. Diagnosis is based on auditory and vestibular testing results.
Although BPPV is a bothersome problem, it is rarely serious unless a person falls. Repositioning maneuvers and procedures may help in providing symptom relief for many patients. (See Lewis et al, Medical-Surgical Nursing, ed. 9, p. 406, for a description of these procedures.)
Benign prostatic hyperplasia
Description
Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland.
Pathophysiology
Although the cause is not completely understood, it is thought that BPH results from endocrine changes associated with aging.
Clinical manifestations
Early symptoms are often minimal because the bladder can compensate for a small amount of resistance to urine flow. Symptoms gradually worsen as the degree of urethral obstruction increases. Symptoms can be divided into two groups: obstructive and irritative.
Complications
Diagnostic studies
■ Urinalysis with culture to determine the presence of infection
■ Postvoid residual urine volume to assess the degree of urine flow obstruction
■ Prostate-specific antigen (PSA) blood test to rule out prostate cancer
■ Uroflowmetry flow studies and transrectal ultrasound scan of prostate
■ Cystoscopy to visualize the urethra and bladder
Collaborative care
The goals of collaborative care are to restore bladder drainage, relieve the patient’s symptoms, and prevent or treat the complications of BPH. Treatment is generally based on the degree to which the symptoms bother the patient or the presence of complications rather than the size of the prostate. Alternatives to surgical intervention for some patients include drug therapy and minimally invasive procedures.
Conservative treatment that may be recommended for some patients with BPH is referred to as active surveillance or “watchful waiting.” When there are no symptoms or only mild ones, a wait-and-see approach is taken.
If the patient begins to have signs or symptoms that indicate an increase in obstruction, further treatment is indicated.
Drug therapy
Drugs are often used to treat BPH with variable results.
■ 5α-Reductase inhibitors reduce the size of the prostate gland. Finasteride (Proscar) blocks the enzyme needed to convert testosterone to dihydroxytestosterone, the principal intraprostatic androgen. This results in a regression of hyperplastic tissue. Dutasteride (Avodart) has the same effect as finasteride and may also be used.
Minimally invasive therapy
Minimally invasive therapies generally do not require hospitalization or catheterization and have few adverse events. Many minimally invasive therapies have shown outcomes comparable to invasive techniques. Advantages and disadvantages of the various minimally invasive and invasive treatment options are compared in Table 55-3, Lewis et al, Medical-Surgical Nursing, ed. 9, p. 1311.
Transurethral microwave thermotherapy (TUMT) is an outpatient procedure that involves the delivery of microwaves directly to the prostate through a transurethral probe. The temperature of the prostate tissue is raised to about 113° F (45° C), causing necrosis and thus relieving the obstruction.
Transurethral needle ablation (TUNA) is another outpatient procedure that increases the temperature of prostate tissue, thus causing localized necrosis. TUNA differs from TUMT in that only prostate tissue in direct contact with the needle is affected, allowing greater precision in removal of the target tissue.
There are a variety of laser procedures using different sources, wavelengths, and delivery systems. Retreatment rates are comparable to those of a transurethral resection of the prostate (TURP). The laser beam is delivered transurethrally through a fiber instrument and is used for cutting, coagulation, and vaporization of prostatic tissue. Examples of this technique include visual laser ablation, contact lasers, photovaporization, and interstitial laser coagulation.
Invasive (surgical) therapy
Invasive therapy is indicated when there is a decrease in urine flow sufficient to cause discomfort, persistent residual urine, acute urinary retention because of obstruction with no reversible precipitating cause, or hydronephrosis.
Transurethral resection of the prostate (TURP) is a surgical procedure involving removal of prostate tissue using a resectoscope inserted through the urethra. TURP has long been considered the “gold standard” surgical treatment for obstructing BPH. Although this procedure is still commonly performed, there has recently been a decrease in the number of TURP procedures because of the development of less invasive technologies.
Transurethral incision of the prostate (TUIP) is performed with the patient under local anesthesia and is indicated for men with moderate to severe symptoms and small prostates who are poor surgical candidates. TUIP has outcomes similar to those of TURP in relieving symptoms.
Nursing management
Because you will be most directly involved with the care of patients having prostatic surgery, the focus of nursing management is on preoperative and postoperative care.
Goals
Overall preoperative goals for the patient having prostatic surgery are to have restoration of urinary drainage, treatment of any urinary tract infection, and understanding of the upcoming surgery. Overall postoperative goals are that the patient will have no complications, restoration of urinary control, complete bladder emptying, and satisfying sexual expression.
Nursing diagnoses
Preoperative
Postoperative
Nursing interventions
The cause of BPH is largely attributed to the aging process. The focus of health promotion is on early detection and treatment. When symptoms of prostatic hyperplasia become evident, further diagnostic screening may be necessary.
Preoperative care.
Urinary drainage must be restored before surgery; a urethral catheter such as a coudé (curved-tip) catheter may be needed.
Postoperative care.
The plan of care should be adjusted to the type of surgery, reasons for surgery, and patient response to surgery.
Patient and caregiver teaching
Discharge planning and home care issues are important aspects of care after prostate surgery.
Bladder cancer
Description
The most frequent malignant tumor of the urinary tract is transitional cell carcinoma of the bladder, which accounts for nearly 1 in every 20 cancers diagnosed in the United States. Cancer of the bladder is most common between the ages of 60 and 70 years and is at least three times as common in men as in women.
Risk factors for bladder cancer include cigarette smoking, exposure to dyes used in the rubber and cable industries, and chronic abuse of phenacetin-containing analgesics. Individuals with chronic, recurrent renal calculi and chronic lower urinary tract infections have an increased risk of squamous cell bladder cancer. Women treated with radiation for cervical cancer, patients who received cyclophosphamide, and patients who take the diabetes drug pioglitazone (Actos) also have an increased risk for bladder cancer.
Clinical manifestations
Microscopic or gross, painless hematuria (chronic or intermittent) is the most common clinical finding. Dysuria, frequency, and urgency may also occur because of bladder irritability.
Diagnostic studies
■ When cancer is suspected, obtain urine specimens to identify neoplastic or atypical cells.
■ Ultrasound, CT, or MRI may be used to detect bladder cancer.
■ Cystoscopy and biopsy are used to confirm a diagnosis of bladder cancer.
Pathologic grading systems are used to classify the malignant potential of tumor cells, indicating a scale ranging from well differentiated to undifferentiated (anaplastic).
Nursing and collaborative management
The majority of bladder cancers are diagnosed at an early stage when the cancer is treatable. Low-stage, low-grade, superficial bladder cancers are most common and most responsive to treatment. Periodic surveillance is important as 30% of patients have tumor recurrence within 5 years and nearly 95% have recurrence by 15 years.
Surgical therapies include a variety of procedures.
Postoperative management for any of these surgical procedures includes instructions to drink large amounts of fluid each day for the first week after the procedure, avoid alcoholic beverages, use opioid analgesics and stool softeners if necessary, and take sitz baths to promote muscle relaxation and reduce urinary retention. Administer opioid analgesics for a brief period after the procedure, along with stool softeners.
Radiation therapy is used with cystectomy or as the primary therapy when the cancer is inoperable or when the patient refuses surgery. Chemotherapy drugs used in treating invasive cancer include cisplatin (Platinol), vinblastine (Velban), doxorubicin (Adriamycin), and methotrexate.
Chemotherapy with local instillation of chemotherapeutic or immune-stimulating agents can be delivered into the bladder through a urethral catheter, usually at weekly intervals for 6 to 12 weeks. Intravesical agents are instilled directly into the patient’s bladder and retained for about 2 hours. The position of the patient may be changed every 15 minutes for maximum contact in all areas of the bladder.
Bone tumors
Description
Primary bone tumors, both benign and malignant, are relatively rare in adults. They account for only about 3% of all tumors. Metastatic bone cancer in which the cancer has spread from another site is a more common problem.
Osteochondroma
Osteochondroma is the most common primary benign bone tumor. It is characterized by an overgrowth of cartilage and bone near the end of the bone at the growth plate. It is more commonly found in the long bones of the leg, pelvis, or scapula.
Osteosarcoma
Osteosarcoma is a primary malignant bone tumor that is extremely aggressive and rapidly metastasizes to distant sites. It usually occurs in the metaphyseal region of long bones of the extremities, particularly in regions of the distal femur, proximal tibia, and proximal humerus, as well as the pelvis. It is the most common malignant bone tumor affecting children and young adults and is most often associated with Paget’s disease and prior radiation.
Preoperative chemotherapy may be used to decrease tumor size before surgery. Limb-salvage surgical procedures are usually considered when there is a clear (no cancer present) 6- to 7-cm margin surrounding the lesion. Adjunct chemotherapy after surgery has increased the 5-year survival rate to 70% in patients without metastasis.
Metastatic bone cancer
Metastatic bone cancer is the most common type of malignant bone tumor. It occurs as a result of metastasis from a primary tumor. Common sites for the primary tumor include the breast, prostate, lungs, kidney, and thyroid. Metastatic bone lesions are commonly found in the vertebrae, pelvis, femur, humerus, or ribs.