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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.

■ Bell’s palsy is considered benign, with full recovery in 3 to 6 months, especially if treatment is begun immediately.

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.

■ A widened palpebral fissure (opening between the eyelids); flattening of the nasolabial fold; unilateral loss of taste; and inability to smile, frown, or whistle are also common.

■ Decreased muscle movement may alter chewing ability, and some patients may experience a loss of tearing or excessive tearing.

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.

■ Corticosteroids (prednisone) are started immediately, with best results obtained if corticosteroids are initiated before paralysis is complete. When the patient improves to the point that corticosteroids are no longer necessary, they should be tapered off over 2 weeks.

■ Because HSV is implicated in many cases of Bell’s palsy, treatment with acyclovir (Zovirax) alone or in conjunction with prednisone may be used. Valacyclovir (Valtrex) and famciclovir (Famvir) have also been used.

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.

■ Maintenance of good nutrition is important. Teach the patient to chew on the unaffected side of the mouth to avoid trapping food and to improve taste. Thorough oral hygiene must be carried out after each meal to prevent development of parotitis, caries, and periodontal disease from accumulated residual food.

■ Dark glasses may be worn for protective and cosmetic reasons. Artificial tears (methylcellulose) should be instilled frequently during the day to prevent corneal drying. Ointment and an impermeable eye shield can be used at night to retain moisture. In some patients taping the lids closed at night may be necessary to provide protection.

■ A facial sling may be helpful to support affected muscles, improve lip alignment, and facilitate eating. Vigorous massage can break down tissues, but gentle upward massage has psychologic benefits. When function begins to return, active facial exercises are performed several times per day.

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

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.

■ Dietary changes (decreasing intake of caffeine and artificial sweeteners, limiting spicy or acidic foods), avoiding medications such as decongestants and anticholinergics, and restricting evening fluid intake may result in improvement of symptoms.

■ A timed voiding schedule may reduce or eliminate symptoms, thus negating the need for further intervention.

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.

■ Patients who have an increased PSA level while taking these medications should be referred to their health care provider. The need for regular prostate cancer screening should also be discussed with the provider.

■ α-Adrenergic receptor blockers cause smooth muscle relaxation in prostate tissue, which ultimately facilitates urinary flow through the urethra. α-Adrenergic receptor blockers, such as silodosin (Rapaflo), terazosin (Hytrin), and tamsulosin (Flomax), are currently being used.

■ The combination of a 5α-reductase inhibitor (dutasteride) and an α-adrenergic receptor blocker (tamsulosin) in a single oral medication (Jalyn) is now available.

■ Erectogenic drugs such as tadalafil (Cialis) have been used in men who have symptoms of BPH alone or in combination with erectile dysfunction (ED). The drug has shown to be effective in reducing symptoms for both of these conditions.

■ Herbal preparations such as saxifrage, beta-sitosterol, Pygeum africanum, and Cernilton have shown some success in reducing symptoms of BPH. Emphasize to the patient that he should tell his health care provider about all herbal supplements that he uses.

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.

■ After the procedure, a large three-way indwelling catheter with a 30-mL balloon containing sterile water is usually inserted into the bladder to provide hemostasis and facilitate urinary drainage. The bladder is irrigated, either continuously or intermittently, for at least 24 hours to prevent obstruction from mucous threads and blood clots.

■ The outcome for 80% to 90% of patients is excellent, with marked improvements in symptoms and urinary flow rates. Postoperative complications include bleeding, clot retention, and dilutional hyponatremia associated with irrigation.

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

■ Acute pain

■ Risk for infection

Postoperative

■ Acute pain

■ Impaired urinary elimination

■ Deficient knowledge

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.

■ Some men find that ingestion of alcohol and caffeine tends to increase prostatic symptoms because of the diuretic effect that increases bladder distention.

■ Advise patients with obstructive symptoms to urinate every 2 to 3 hours or when they first feel the urge to minimize urinary stasis and acute urinary retention.

Preoperative care.

Urinary drainage must be restored before surgery; a urethral catheter such as a coudé (curved-tip) catheter may be needed.

■ Any infection of the urinary tract must be treated before surgery. Restoring drainage and encouraging a high fluid intake (2 to 3 L/day) are helpful.

■ Patients are often concerned about the impact of impending surgery on sexual function. Provide an opportunity for the patient and his partner to express their concerns.

Postoperative care.

The plan of care should be adjusted to the type of surgery, reasons for surgery, and patient response to surgery.

■ Postoperatively, bladder irrigation is typically done to remove clotted blood from the bladder and ensure drainage of urine. The bladder is irrigated either manually on an intermittent basis or more commonly as continuous bladder irrigation (CBI) with sterile normal saline solution or another prescribed solution. Monitor the inflow and outflow of the irrigant. The infusion of the continuous bladder irrigation fluid should be at a rate to keep the urine drainage light pink without clots.

■ The catheter should be connected to a closed drainage system and not disconnected unless it is being removed, changed, or irrigated. On a daily basis, cleanse the secretions that accumulate around the meatus with soap and water.

■ Blood clots are expected for the first 24 to 36 hours. However, large amounts of bright red blood in the urine can indicate hemorrhage.

■ Painful bladder spasms occur as a result of irritation of the bladder mucosa from insertion of a resectoscope, presence of a catheter, or clots leading to obstruction of the catheter. Instruct the patient not to urinate around the catheter because this increases the likelihood of spasm. If bladder spasms develop, check the catheter for clots. If present, remove the clots by irrigation so urine can flow freely. Belladonna and opium suppositories, along with relaxation techniques, are used to relieve pain and decrease spasm.

■ Sphincter tone may be poor immediately after catheter removal, resulting in urinary incontinence or dribbling. Sphincter tone can be strengthened by having the patient practice Kegel exercises (pelvic floor muscle technique). Continence can improve for up to 12 months.

■ Observe the patient for signs of postoperative infection. If an external wound is present, the area should be observed for redness, heat, swelling, and purulent drainage. Rectal procedures, such as rectal temperatures and enemas (except insertion of well-lubricated belladonna and opium suppositories), should be avoided.

■ Dietary intervention and stool softeners are important to prevent straining while having bowel movements. A diet high in fiber facilitates the passage of stool.

■ Activities that increase abdominal pressure, such as sitting or walking for prolonged periods and straining to have a bowel movement (Valsalva maneuver), should be avoided.

Patient and caregiver teaching

Discharge planning and home care issues are important aspects of care after prostate surgery.

■ Instructions include (1) caring for an indwelling catheter, if one is in place; (2) managing urinary incontinence; (3) maintaining oral fluids between 2 and 3 L/day; (4) observing for signs and symptoms of urinary tract and wound infection; (5) preventing constipation; (6) avoiding heavy lifting (more than 10 lb [more than 4.5 kg]); and (7) refraining from driving or sexual intercourse as directed by the physician.

■ Many men experience retrograde ejaculation because of trauma to the internal sphincter. Semen is discharged into the bladder at orgasm and may produce cloudy urine when the patient urinates after orgasm. Discuss these changes with the patient and his partner and allow them to ask questions and express their concerns.

■ Sexual counseling and treatment options may be necessary if erectile dysfunction becomes a chronic or permanent problem.

■ The bladder may take up to 2 months to return to its normal capacity. The patient should be instructed to drink at least 2 to 3 L of fluid per day and to urinate every 2 to 3 hours to flush the urinary tract. Teach the patient to avoid or limit the amounts of bladder irritants such as caffeine products, citrus juices, and alcohol.

■ Advise the patient to have yearly digital rectal examinations (DREs) if he has had any procedure other than complete removal of the prostate. Hyperplasia or cancer can occur in the remaining prostatic tissue.

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.

■ Transurethral resection of the bladder tumor (TURBT) is used for superficial lesions of the bladder’s inner lining. This procedure is also used to control bleeding in patients who are poor operative risks or who have advanced tumors.

■ A partial or radical cystectomy with urinary diversion is the treatment of choice when the tumor is invasive or involves the trigone (area where ureters insert into the bladder) and the patient is free from metastases beyond the pelvic area.

■ A partial cystectomy includes resection of that portion of the bladder wall containing the tumor, along with a margin of normal tissue.

■ A radical cystectomy involves removal of the bladder, prostate, and seminal vesicles in men and the bladder, uterus, cervix, urethra, and ovaries in women.

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.

■ Bacille Calmette-Guérin (BCG), a weakened strain of Mycobacterium bovis, is the treatment of choice for carcinoma in situ. When BCG fails, α-interferon, thiotepa (Thioplex), and valrubicin (Valstar) may be used.

■ After intravesical therapy most patients have irritative voiding symptoms and hemorrhagic cystitis. Encourage patients to increase daily fluid intake and to quit smoking. Assess the patient for a secondary urinary tract infection (UTI) and stress the need for routine urologic follow-up care. The patient may have fears or concerns about sexual activity or bladder function that will need to be addressed.

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.

■ Benign bone tumors are more common than primary malignant tumors. These types of tumors, which include osteochondroma, osteoclastoma, and endochroma, are often removed by surgery.

■ Primary malignant bone cancer is called sarcoma. The more common types of primary bone cancer are osteosarcoma, chondrosarcoma, Ewing’s sarcoma, and chordoma. Primary malignant tumors occur most often during childhood and young adulthood. They are characterized by their rapid metastasis and bone destruction.

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.

■ Clinical manifestations of osteochondroma include a painless, hard, and immobile mass; lower-than-normal-height for age; soreness of muscles in close proximity to the tumor; one leg or arm longer than the other; and pressure or irritation with exercise. Patients may also be asymptomatic.

■ Diagnosis is confirmed using x-ray, CT scan, and MRI.

■ No treatment is necessary for asymptomatic osteochondroma. If the tumor is causing pain or neurologic symptoms due to compression, surgical resection is usually done. Patients should have regular screening examinations for early detection of malignant transformation.

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.

■ Clinical manifestations of osteosarcoma are usually associated with a gradual onset of pain and swelling, especially around the knee. A minor injury does not cause the tumor but rather serves to bring the preexisting condition to medical attention.

■ Diagnosis is confirmed from tissue biopsy, elevation of serum alkaline phosphatase and calcium levels, x-ray, CT or positron emission tomography (PET) scans, and MRI.

■ Metastasis is present in 10% to 20% of individuals when they are diagnosed with osteosarcoma.

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.

■ Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium levels result as calcium is released from damaged bones.

■ Once a primary lesion has been identified, radionuclide bone scans are often done to detect metastatic lesions before they are visible on x-ray. Metastatic bone lesions may occur at any time (even years later) following diagnosis and treatment of the primary tumor.

■ Metastasis to the bone should be suspected in any patient who has local bone pain and a history of cancer.

■ Treatment may be palliative and consists of radiation and pain management. Surgical stabilization of the fracture may be indicated if there is a fracture or pending fracture. Prognosis depends on the primary type of cancer and if other sites of metastasis are present.

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Tags: Clinical Companion to Medical-Surgical Nursing

Oct 26, 2016 | Posted by admin in NURSING | Comments Off

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Bell’s palsy

Description

Pathophysiology

Clinical manifestations

Collaborative care

Nursing management

Benign paroxysmal positional vertigo

Benign prostatic hyperplasia

Description

Pathophysiology

Clinical manifestations

Complications

Diagnostic studies

Collaborative care

Drug therapy

Minimally invasive therapy

Invasive (surgical) therapy

Nursing management

Goals

Nursing diagnoses

Preoperative

Postoperative

Nursing interventions

Preoperative care.

Postoperative care.

Patient and caregiver teaching

Bladder cancer

Description

Clinical manifestations

Diagnostic studies

Nursing and collaborative management

Bone tumors

Description

Osteochondroma

Osteosarcoma

Metastatic bone cancer

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