Copy-of-Module-6-HNP-and-Bells-Palsy.pptx

NURSING CARE
MANAGEMENT OF
ADULT CLIENTS WITH
NEUROLOGICAL
DISTURBANCES :
HERNIATED NUCLEUS
PULPOSUS AND
BELL’S PALSY
MODULE 6

Plan of Activities
Day 1
1.Video conferencing (discussion on HNP
and Bell's Palsy)
2.Asynchronous viewing activity 1 &2
Day 2
1.Asynchronous Learning task
Infographics/Brochure making
2.Discussion Board activity
Day 3
1.Feedback on Infographics and discussion
on Skill checklist 11.11 for Skills
enhancement,
2.Summative Quiz
MODULE 6

“True or
False’’
• The normal anatomy of the spine is usually
described by dividing up the spine into three
major sections: the cervical, the thoracic,
and the lumbar spine

True
• The normal anatomy of the spine is
usually described by dividing up the
spine into three major sections:
the cervical, the thoracic, and
the lumbar spine

“True or
False’’
There are 7 cervical, 12 thoracic, 5
lumbar, 5 sacral and 4 caudal
(coccygeal) vertebrae

True
There are 7 cervical, 12 thoracic, 5
lumbar, 5 sacral and 4 caudal
(coccygeal) vertebrae

“True or
False’’
Can Deadlifting cause a herniated
disc?

True
Can Deadlifting cause a herniated
disc?

“True or
False’’
Nucleus pulposus is the inner
core of the vertebral disc. The
core is composed of a jelly-like
material that consists of mainly
water, as well as a loose network
of collagen fibers. The elastic
inner structure allows the
vertebral disc to withstand forces
of compression and torsion.

True
Nucleus pulposus is the inner
core of the vertebral disc. The core
is composed of a jelly-like material
that consists of mainly water, as
well as a loose network of collagen
fibers. The elastic inner structure
allows the vertebral disc to
withstand forces of compression
and torsion.

“True or
False’’
The facial nerve has branches
throughout both sides of the
face and controls many muscle
groups, including those in the
brow, eyelid, cheek, and lips.

True
The facial nerve has branches
throughout both sides of the face
and controls many muscle groups,
including those in the brow, eyelid,
cheek, and lips.

“True or
False’’
Bell's palsy is the most common
type of facial nerve paralysis

True
Bell's palsy is the most common
type of facial nerve paralysis

On your first RLE day at the
medical surgical ward in one of the
tertiary hospitals in Pampanga,
you were assigned to a patient by
your Clinical Instructor to a patient
at room 809, this time you are
assigned in pairs. Your Clinical
Instructor informed the group that
a brief presentation on the
designated cases will be
performed on your post
conference.
You and your partner went to the
nurse’s station and read on the
patient’s medical records. After
which, you went to the patient's
room to get the Vital Signs and do
the initial nurse patient interaction.

Mr. Muscle on his 2 nd day admission, is a
48-year-old male, married with two
children. Admitting diagnosis “to consider
Herniated Nucleus Pulposus”. He is a
power lifter for 22 years. He started his
training at the age of 16 and has won
several competitions during his prime.
History shows that he experienced back
pain on and off for more than 10 years
afforded relief by taking pain medications.
Prior to admission, patient tried to lift his
5-year-old daughter but experienced
severe lower back pain,
with tingling sensations and weakness on
his right leg seek consultation at the
Emergency Room and was advised
admission for further work up. Vital signs
are as follows: BP-140/90, PR-88bpm, RR-
24, T- 36.7C.
To prepare you for your presentation on
your post conference, during break time
you decided to read more about Herniated
Nucleus Pulposus.

Basic Spine Anatomy
Basic Spine Anatomy - YouTube

✔
✔
✔
✔
Is a condition in which part or all
of the soft, gelatinous central
portion of an intervertebral disc is
forced through a weakened part
of the disc, resulting in back pain
and nerve root irritation.
Occurs more often in men.
The 4 th and 5 th intervertebral
discs in the lumbar region are
most commonly affected.
C5-C6 or C6-C7 in cervical spine
• HNP is a medical term used to
define a spinal condition
commonly known as slipped disc
or herniated disc
Herniated
Nucleus
Pulposus (HNP)

Predisposing
Factors
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Heavy lifting or pulling and trauma.
Poor posture while lifting heavy objects.
Degeneration of the intervertebral discs
Excessive weight gain or obesity
Sedentary lifestyle with lack of physical
activities or exercises
High impact injury or sudden injury such
as motor vehicle accident; fall from a
height etc.
Occupational strain over the spine due
standing, sitting, or driving for extended
periods of time, manual labor, physical
work etc.
Excessive smoking or
alcohol consumption
Congenital predisposition/ Genetic
inheritance or family history of spinal
issue
Other underlying spine conditions or
degenerative disc diseases.

Pathophysiology
Rupture of Intervertebral Disc
Protrusion of Nucleus Pulposus
Compression of Spinal Nerves

Clinical Manifestations
∙
✔
✔
✔
✔
✔
✔
Lumbosacral disc
Back pain radiating across the buttocks and
down the leg (along sciatic nerve)
Weakness of leg and foot on affected side
Depressed or absent Achilles reflex
Muscle spasm on Lumbar region
Numbness and tingling in toes and feet.
Positive straight leg raised test; pain on leg
below the knee when leg raised from supine
position (Lasegue’s sign)

Clinical Manifestations
∙ Cervical disc
✔ Shoulder pain radiating down the arm
to hand, weakness of affected upper
extremities, paresthesias and sensory
disturbances.
• In some cases, nerve compress can
lead to symptoms such as bowel and
bladder incontinence with fever. This is
considered as a medical emergency
and needs urgent medical attention.

Diagnostic Tests/Procedure
✔
X-RAY (Lumbosacral)
✔
✔
CT Scan
MRI- (magnetic resonance
imaging) usually provides the most
accurate assessment of the lumbar
spine area, showing where a herniation
has occurred, and which nerves are
affected.

Diagnostic Tests/Procedure
MYELOGRAPHY - a type of radiographic examination that uses a
contrast medium to detect pathology of the spinal cord.

Nursing Responsibilities
Pre-Diagnostic Examination
• Ensure a signed informed consent.
• NPO for several hours /the meal prior to the
procedure is usually omitted.
• The client should be well hydrated.
• Administer enemas or laxatives as ordered
to ensure visualization of lumbar spine.
• • Administer prescribed pretest medications,
such as a sedative or diazepam (Valium).
Post –Diagnostic Examination
1.Take and record vital signs and assess
neurologic status as prescribed (at least every
4 hours) for 24 hours post examination. Record
and report any changes.
2.Assess the site of the lumbar puncture for
leakage of cerebrospinal fluid or bleeding every
4 hours. Notify the physician of leakage or
bleeding.
3.Encourage increased intake of oral fluids to
replace that withdrawn during the examination.
(help decrease a post myelogram headache).
4.Make sure that the client voids within 8 hours
after the examination, notify physician if client
has not voided for 8 hours.
5. Administer analgesics as prescribed for post
examination pain, headache, or muscle
spasms.
6. Keep the client’s head elevated at least 30
degrees (in bed or in a chair) for 12 hours, or
as ordered.
7. Resume diet if there is no nausea or
vomiting.
8.Administer prescribed medications for
nausea.
9.Do not give any phenothiazine derivatives for
48 hours (to reduce the possibility of seizures).

Diagnostic Tests/Procedure
Electromyography (EMG)- measures muscle response or electrical activity in response to a
nerve's stimulation of the muscle. The test is used to help detect neuromuscular abnormalities.
may be used to localize the specific spinal nerve roots involved

Collaborative Medical Management
∙
✔
✔
✔
✔
✔
✔
Conservative management
Bed rest on a firm mattress with bed
board
Traction (pelvic traction for low back
pain)
Local application of heat and diathermy
Use of corset for lumbosacral disk,
cervical collar for cervical disk
Physical Therapy
Prevent complications of immobility
(bed sore, incontinence)
• Pelvic traction
• Diathermy

Pharmacological/Drug therapy
1. Anti-inflammatory agents (ASA, NSAIDs, steroids)
2. Muscle relaxants
Lioresal (Baclofen)- to treat pain and certain
types of spasticity (muscle stiffness and tightness)
Maolate (Chlorphenesin Carbamate)
Flexeril (Cyclobenzaprine)
Valium (Diazepam)
Robaxin (Methacarbamol)
Norflex
Zanaflex
3. Analgesics (Tylenol)
* Epidural injections of corticosteroids if pain
becomes intolerable

Surgical Management
✔
▪
Chemonucleolysis- (less common
invasive treatment for lumbar disk
herniation.)
Chymopapain(chymodiactin) enzyme
derived from papaya plant is
introduced into the disc with a needle
to reduce size and pressure on
affected nerve root using x-ray guide.
• Used as alternative to laminectomy in
some cases. May cause severe
complications such as transverse
myelitis, allergic reactions, persistent
muscle spasm

Surgical Management
• Laminectomy- surgical excision/removal of
a part of posterior arch of vertebra and
removal of protruded disc. To relieve
compression of spinal nerve.
Nursing Intervention post op:
1.Maintain proper body alignment
Flat on Bed-lower spinal surgery
cervical spinal surgery- slight elevation of head of
bed, avoid flexion of neck and apply collar cast
2. Assess for complications- monitor sensory and
motor status q2 hours.
cervical spinal surgery- assess swallowing,
coughing, check for respiratory distress. Have
suction and tracheostomy at bedside
3.check dressing for hemorrhage, CSF leakage,
signs of infection
4., Promote comfort - use log rolling technique
when turning patient, provide analgesics as ordered
5. Assess for adequate and bladder function
6.Assist with ambulation as ordered

Surgical Management
• Spinal fusion- Fusion of spinous processes
with bone graft from iliac crest to provide
stabilization of spine and reduce the rate of
recurrence. It takes 1 year for the graft to be
stable.
Nursing interventions post op
1.Position:
a. lower spine fusion- flat on bed for the first 12
hours, then may elevate head of bed 20-30
degrees.
b. Cervical spine fusion-slightly, elevate head of
bed assist with ambulation.
2. Usually out of bed(OOB) 3-4 days post op,
apply brace before OOB
3. Provide comfort- patient my have
considerable pain from graft site
4. Advise client that brace will be needed for 4
months and corset for 1 year- no
bending,stooping,lifting for prolongrd periods for
4 months.

Surgical Management
• Microdiscectomy: Removal of
herniated or extruded fragments of
intervertebral disk material
• Partial laminectomy or laminotomy:
Creation of a hole in the lamina of a
vertebra
•

Surgical
Management
✔ Foraminotomy: Removal of the
intervertebral foramen to
increase the space for exit of a
spinal nerve, resulting in
reduced pain, compression,
and edema.

Nursing Management
The goals for the patient may include relief of pain, improved mobility, increased knowledge and
self-care ability, and prevention of complications
✔
Nursing Diagnoses
• Acute pain related to the surgical
procedure.
• Impaired physical mobility related
to the postoperative surgical
regimen
• Deficient knowledge about the
postoperative course and home
care management
• Other nursing diagnoses
• preoperative anxiety, postoperative
constipation, urinary retention
related to the surgical procedure,
and sleep pattern disturbance
related to disruption in lifestyle.
✔
✔
Potential complications may include the
following:
• Hematoma at the surgical site, resulting in cord
compression and neurologic deficit.
• Recurrent or persistent pain after surgery
Nursing Interventions:
• Relieving pain- provide comfort, give pain
medications as prescribed
• Improving mobility- apply cervical collar, back
braces
• Monitoring and managing potential
complications
• Promoting Home and community-based care.

After reading about HNP, you and
your partner relate it with your
patient’s case. Mr. Muscle is on
conservative management. He is
receiving muscle relaxant and
anti-spasmodic (Methocarbamol)
BID, on Diazepam prn to relieve him
of anxiety. Lumbosacral Xray was
done, he is due for MRI tomorrow.
He is referred to rehabilitation center
for Physical therapy. Surgery is not
yet an option this time, until course
of Physical Therapy is completed.

Asynchronous Viewing
Activity 1
• Lumbar Laminectomy
https://www.youtube.com/watch?v=gD
dqbVVFbpw
• Can a disk herniation heal by itself?
https://www.youtube.com/watch?v=84
P-r5XX7hI
• Assisting with ambulation
https://www.youtube.com/watch?v=_Q
KxQLC4rpo

10-15 mins

On your RLE duty, you are assigned to Ms. Bell, a 25-year-old
model at room 904. Receiving the handover/endorsement from
the staff nurse, you were told that she is a bit difficult to talk with
from the time of admission. Your clinical Instructor decided to
accompany you in meeting the patient and do some introductions
before leaving you to do your assessment.
As you do your nurse patient interaction, and initial VS you
noticed that Ms. Bell has facial asymmetry, drooping on the corner
of her mouth and her eyelids was noted. No weakness on both
extremities noted and no slurring of speech. She is afebrile, BP-
120/80, PR- 82, RR- 22. Ms. Bell appears sad and not
comfortable talking about her present condition. Instead, her
mother supplied you with her brief history. You were informed that
it all started while she was on her rehearsals, she felt that there is
something wrong with her face and it felt numb, her friends
noticed the facial asymmetry immediate consultation was done
and she was advised for admission for further examination and
management.
You decided to leave the room because she started crying. To
know more about the patient’s condition, thinking that Ms. Bell is
suffering from stroke, you went to the nurse’s station and read on
her medical records. Patients admitting diagnosis “Bell’s palsy”.
You then ask your clinical instructor about her diagnosis and the
following were discussed by your CI with the group

Brief review of Cranial Nerve VII
What is Facial Nerve Anatomy? - YouTube

• Name after Scottish Anatomist Charles Bell
Bell’s Palsy
• Is an acute, usually temporary, facial paresis
(or palsy) resulting from damage or trauma of
the facial nerve (CN VII).
●
●
●
It usually affects only 1 side of the face, but
both sides can be affected (rare).
the most common facial nerve disorder
Most adults with Bell palsy are younger than
45 years.
• May be a type of pressure paralysis

Bell’s Palsy
• Incidence
• It occurs equally between men
and women and can affect any
age-group.
• The peak incidence is between
ages 15 and 60 years.
• There is a high incidence during
pregnancy and in persons with
upper respiratory tract conditions
(e.g., flu, colds), obesity,
diabetes, and hypertension
• Etiology: unknown
• theories include vascular
ischemia, viral disease
(herpes simplex, herpes
zoster, epstein barr,
adenovirus,coxsackievirus,
cytomegalovirus, influenza
viruses), trauma, meningitis,
tumor, autoimmune disease,
or a combination of all of
these factors.

Pathophysiology:
Compression of the facial nerve due to
demyelination, inflammation, or ischemia
Blood supply is occluded, producing
ischemic necrosis of the nerve
The face is distorted from paralysis of the
facial muscles ( facial asymmetry);
decreased lacrimation (tearing)

Clinical Manifestations
The key feature of Bell’s palsy is the acute onset of unilateral lower motor facial weakness.
●
●
●
●
50% to 60% have pain around and behind the ear
and neck.
Most often these symptoms begin suddenly and
reach their peak within 48 to 72 hours.
o drooping of the eyelid (ptosis) and corner of
the mouth
o drooling
o facial twitching
o dryness of the eye or mouth
o facial numbness,
o altered taste.
o hearing loss
o excessive tearing in 1 eye.
Dehydration, malnutrition may be manifested due
to altered taste, difficulty in eating, and swallowing.
Psychological withdrawal because of changes in
appearance and speech difficult.

Facial Nerve Grading or House-Brackman Grading/scale

Diagnostic Procedures
1
2
3
MRI and CT can
eliminate other
causes for facial
paralysis.
Blood tests can
diagnose
infections or other
diseases.
Electromyography
(EMG) can
confirm the
presence of nerve
damage.

Nursing responsibilities
( Facial Electromyography)
1. Obtain a signed consent (may vary as per hospital policy)
2. Avoid administration of muscle relaxants, anti-cholinergics and
cholinergic agents for 3-6 days before the test.
3. Instruct the patient to abstain from smoking and drinking
caffeine-containing beverages for 3 hours before the
procedure.
4. Instruct the patient to avoid using any creams or lotions on the
day of the test.

• Medical Management
The objectives of treatment are:
●
●
●
●
To maintain the muscle tone of the face
and to prevent or minimize denervation.
The patient should be reassured that no
stroke has occurred.
Spontaneous recovery occurs within 3 to
5 weeks in most patients.
Patients should be referred to a
neurologist or otolaryngologist as soon
as possible to exclude other neurologic
conditions.
● Electrical stimulation
may be applied to the face to prevent
muscle atrophy.
• Pharmacological Management
1. Corticosteroid therapy (prednisone)
● may be prescribed to reduce
inflammation and edema; this reduces
vascular compression.
● Permits restoration of blood circulation
to the nerve.
● Early administration of corticosteroid
therapy appears to diminish the severity
of the disease, relieve the pain, and
prevent or minimize denervation.
2. Mild Analgesic Agents -To control facial pain
3. Acyclovir (Zovirax)
●
Some patients should receive an antiviral
agent in addition to the steroid therapy.

Surgical
Management
• Most patients recover with
conservative treatment.
• Surgical Exploration of Facial
Nerve- surgery may be indicated if
a tumor is suspected, for surgical
decompression of the facial nerve,
or for surgical treatment of a
paralyzed face

NURSING MANAGEMENT
1.Protection from injury
● Frequently, the eyelid does not close completely,
and the blink reflex is diminished, so the eye is
vulnerable to injury from dust and foreign particles.
Corneal irritation and ulceration may occur.
Distortion of the lower lid alters the proper
drainage of tears.
What to do:
● To prevent injury, the eye should be covered with a
protective shield at night.
● Moisturizing eye drops during the day and eye ointment
at bedtime may help prevent injury as prescribed.
● The patient can be educated to close the paralyzed
eyelid manually before going to sleep.
● Wraparound sunglasses or goggles may be worn
during the day to decrease evaporation from the eye.

NURSING MANAGEMENT
●
2.Maintaining Muscle tone and prevent muscle
atrophy.
Encourage facial exercises, such as wrinkling the
forehead, blowing out the cheeks, and whistling, may
be performed with the aid of a mirror to prevent
muscle atrophy. Massaging the face several times
daily, using a gentle upward motion, to maintain
muscle tone.
3.Exposure of the face to cold and drafts is
avoided.
4. Instruct the patient to chew on the unaffected
side.

After a brief reading and further discussion made by your Clinical
instructor, you now understand clearly what Bell’s palsy is.
The duty went on smoothly, due medications of MS. Bell was given
without difficulties and proper documentation was done. You went to
check on Ms. Bells IV line before endorsement and express your

Asynchronous
Viewing activity
2
• Angelina Jolie opens up about
struggles with Bell’s Palsy.
https://www.youtube.com/wat
ch?v=3qQEH1ON5CE
• How I healed from Bell’s palsy
https://www.youtube.com/w
atch?v=MpwcSpZwfJc
• 21 exercises for Bell’s palsy
https://www.youtube.com/wat
ch?v=amonWj6_dS8

Asynchronous Learning Task
Infographics/brochure
making
Discussion Board
Activity