Nursing Diagnosis and plan of care

A nurse working with a patient with trigeminal neuralgia may diagnose the patient with any of the following:

• Risk for suicide 
• The pain of this disease may become so unbearable that it drives a person to take their own life.
• Acute pain
• Constant or intermittent pressure on the nerve will cause bouts of unbearable pain.
• Risk for ineffective coping related to pain
• The patient may feel that they cannot take the pain, may put aside other necessary activities, and may not be able to  handle normal activities of daily living.
• Risk for activity intolerance
• Acute can can be debilitating.  Instead of participating in a healthy level of activity, patient's who suffer from trigeminal neuralgia are often doing all that they can to deal with their bouts of pain.
• Readiness for enhanced power
• A patient who has come in to be diagnosed with trigeminal neuralgia may be looking for a way to better handle and/or heal their pain and re-take control of their life.

Diagnosis	Acute pain
Related to:	Compression of trigeminal nerve by surrounding blood vessels
As evidenced by:	Patient's self-report of pain
Plan	Patient will remain pain free
Outcome	Patient will remain comfortable Patient will report no pain Patient will be aware of triggers and be able to properly manage pain Patient can describe nonanalgesic methods of pain management Patient can perform activities of daily living with ease Describe management regimen of unrelieved pain State ability to obtain sleep and rest
Nursing Intervention	Continuous assessment to determine triggers Assessment of pain level and characteristics of pain Determine patient's current medication use Steady analgesic management Develop treatment plan with patient Assess patient's knowledge of triggers and pain management Include family in teaching surrounding pain management

References:

https://evolve.elsevier.com/Resources/100530_global_0001#/content/289099256

Nursing Care

Most of the nursing care for trigeminal neuralgia is done pre- and post-operatively.  However, once a patient is diagnosed with TN, they may need some help to cope with the pain until a treatment pathway can be decided upon. TN is often referred to as 'the suicide disease' due to the fact that the extreme pain and lack of immediate signs as to the cause of the pain has caused many of those afflicted to take their own lives.  As more information is gained surrounding this affliction, that number is going down.  When the diagnosis of trigeminal neuralgia is made, a nurse may be able to help the patient with the following items:

1.  Join an online support group. - Those suffering from trigeminal neuralgia are not alone!  There are several websites in which patients can discuss their disease, ask questions, gather information on different coping mechanisms and treatments and support one another.
2.  Make a list of  positive aspects of life.  - Because the pain can be so severe, having a running list of things that add to happiness are often very helpful.  Whether it is photos of friends and families, motivational quotes, something the patient wants to learn, etc., being able to concentrate on a positive item can help these patients make it through the bouts of pain.  .
3. Keep a diary of your experiences. - This can help to suss out triggers for trigeminal neuralgia.  Maybe the pain occurs on the left side of the face every time the teeth are brushed with cold water.  Or perhaps it occurs when chewing on the right side of the mouth.  This information can help those suffering to avoid these triggers but also help their doctor to determine the best course of action.
4. Practice healthy habits. - Good health habits will lead to better health.  They may also help patients to avoid triggers or simply bear with the pain.  
5. Research TN and the treatment options. - A good knowledge base will help one who is suffering take control of their illness, and potentially, their pain.  There are many different websites which outline the disease, potential triggers and treatment options.  

A nurse can help to explain these items to someone who is suffering from trigeminal neuralgia and set them up on a path to success.  

References:

http://www.mayoclinic.org/diseases-conditions/trigeminal-neuralgia/basics/definition/con-20043802

http://fpa-support.org/trigeminal-neuralgia-support/?gclid=CjwKEAjw65GqBRCj3fLFwK2SpWoSJABa3E3cjn2QkHDjn5HYJoaSRzzt4l5rlYgXSDVIzDTLKR6uyxoC9-rw_wcB


1. Create a table to summarize the nursing care for individuals with your disease. 2. Briefly state why a particular website provides a critical collection that informs nurses. 2. Post links to that website on your blog.

Treatment

There are many people who suffer from Trigeminal Neuralgia and never have it diagnosed.  For those that do, there are a number of different treatments and procedures that can help.  These treatments fall in one of three categories: avoidance of triggers, medication or surgery.  Each of these can help to some degree.  The category chosen is likely decided upon due to the severity of the symptoms, the number of occurences of trigeminal neuralgic attack and the degree to which quality of life is hindered.  Below is a table outlining these treatments other than surgery:

Treatment	Method of action	Adverse Effects	Best for...	Cost
Avoiding Triggers	Avoiding things such as: Spicy foods Extreme hot or cold beverages Drafty or windy places	Few side effects Missing out on pleasures	People with mild or infrequent bouts of TN	Free
Medication	Anticonvulsants are the first line of treatment in TN.  This medication slows the nerve impulses that send pain.  The drug of choice is Carbamazepine.	Blurred or double vision Confusion Drowsiness Irritability Chest Pain Insomnia And many more...	People with moderate to severe episodes of TN that occur more frequently	Without insurance covering this med, the cost can be greater than $60 per month.
Complementary and Alternative Medicines	Acupuncture Biofeedback Capsaicin (active component in chili peppers) Homeopathy Nutritional Therapy etc.	Time and energy spent on these.  Adverse effects will vary.	Anyone suffering from TN who wants to try an alternative or adjuvant medicine	Widely varied range

For those suffering from severe and frequent bouts of TN, surgery may seem like a good solution.  There are several different surgeries that can be performed, as well.  The most popular surgeries are:

Surgery	Specific Procedure	Invasive?	Drawback
Microvascular Decompression (MVD)	Cushion is placed between the nerve and compressing vessel through a small incision behind the ear.	Yes	Invasive
Balloon Compression	Catheter with balloon tip is inserted through a puncture in the cheek and inflated to selectively squeeze and damage nerves which mediate light touch.	Yes	Damage to the nerve
Glycerol Injection	Glycerol is injected into the trigeminal ganglion (where the three trigeminal branches come together) and bathes the demyelinated fibers.	Mildly	Pain may return
Radiofrequency Lesioning	A needle is passed through the cheek and through an opening in the skull.  The area of the TN pain is isolated by a small electrical current and that portion of the nerve is destroyed.	Mildly	Potential destruction of surrounding nerves
Radiosurgery (GammaKnife, CyberKnife)	A head frame is attached and beams of radiation are directed to the area of the brainstem where the trigeminal nerves exit.  This causes a lesion and disrupts transmission of pain.	No	May take months for pain relief

Watch a Microvascular Decompression surgery below!

References:

http://www.healthline.com/health/cost-epilepsy-medications#Overview1

http://fpa-support.org/treatment-options-trigeminal-neuralgia/

Signs and Symptoms

What does trigeminal neuralgia feel like?

Trigeminal neuralgia is extreme facial pain.  As previously mentioned, trigeminal neuralgic pain is typically caused by a vein or artery that is putting pressure on the nerve.  The pain often occurs in repeated short bursts lasting a few seconds each but can last more than a minute.  It is described as: zapping, shooting, stabbing, lightning-burst, and excruciating.  The pain can be felt anywhere from the forehead to the jaw but is most often felt in the cheek alongside the nose or in the jaw on one side of the face.  It can be so severe that is will cause the person to cry out, wince and/or stop whatever it is they are doing. 

How does the pain start?
 
The affected area of the face becomes extremely sensitive with such minor stimulation.  This minor stimulation includes such triggers as: a light breeze, cold temperature, water from a shower, washing the face, shaving, or even eating.  The pain can occur spontaneously but is often triggered by touching certain 'trigger spots' on the face, lips, or tongue.

How long does it last?

Trigeminal neuralgic pain usually lasts only seconds but can last up to two minutes and can occur more than 100 times in a day.  The pain will resolve on its own, but reoccur often.  Even after being pain-free for an extended period of time, the pain could potentially return if a more permanent solution is tried.


References:

 http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/headache/conditions/trigeminal_neuralgia.html

http://www.merckmanuals.com/home/brain-spinal-cord-and-nerve-disorders/cranial-nerve-disorders/trigeminal-neuralgia 

 neurosurgery.ucsf.edu/index.php/pain_treatment_trigeminal_neuralgia.html

Diagnosis

Pain is defined as an unpleasant sensation related to actual or potential tissue damage.  There is a lot of room for variation in that statement.  Unpleasant?  Actual or potential?  It is difficult to diagnose pain and certainly difficult to diagnose a specific type of pain.  It is a physical sensation combined with an emotional reaction.  Basically, pain is whatever the person who is experiencing it says it is.  Trigeminal neuralgic pain is no different.  It is diagnosed based on history and current description of the symptoms by the patient.

Trigeminal neural  is often diagnosed by ruling out other diseases.  For example, shingles, TMJ and multiple sclerosis are all able to cause facial pain but specific testing can be done to determine whether or not one of these three diseases is the cause.

Sometimes, a differential diagnosis is used.  This is done by aligning specific symptoms of the current disease and determining which category they fall into.  Below is a table showing differential diagnoses between trigeminal neuralgia and atypical facial pain.

Feature Trigeminal Neuralgia  Atypical Facial Pain Prevalence Rare  Common Main location Trigeminal area  Face, neck, ear Pain duration Seconds to 2 minutes  Hours to days Character Electric jerks, stabbing  Throbbing, dull Pain intensity Severe  Mild to moderate Provoking factors Light touch, washing, shaving, eating, talking  Stress, cold Associated symptoms        None  Sensory abnormalities

It is difficult to diagnose trigeminal neuralgia.  It is a relatively rare disorder with similar symptoms to several other disorders.  The most important thing in the process of diagnosing is to remember that this person in front of us is in great pain and offering some comfort and compassion while we determine how we can help.



References:

http://www.ninds.nih.gov/disorders/trigeminal_neuralgia/detail_trigeminal_neuralgia.htm#280103236

http://emedicine.medscape.com/article/1145144-differential

WHY has this happened and WHY does it hurt?

Imagine a typical daily task such as brushing your teeth or putting on sunscreen.  Pretty uneventful, right?  Get it done, move on.  Well, now imagine having to do that task knowing that it was going to cause you excruciating pain that could last for minutes, hours, etc.  That is what those who have trigeminal neuralgia suffer from daily.  The most minimal of contact with the trigeminal nerve will change the course of their near future due to the pain that it is sure to cause them.  Here is how it works...

The trigeminal nerve is the fifth cranial nerve.  It is one pair of 12 different pairs of nerves that are attached directly to the brain.  Here is a list of the cranial nerves.  The cranial nerves are sensory only, which means that they relay information regarding the senses (smell, sight, touch, etc.) or both sensory and motor, which means that they relay sensation but also assist with movement.  The numbers are placed into the photo based on what information they carry.

1. Olfactory - smell
2. Optic - vision
3. Oculomotor - the muscles of the eye
4. Trochlear - the superior, oblique muscles of the eye
5. Trigeminal (sensory and motor) - sends sensory information from the face and mouth and motor information to the chewing muscles of the mouth (Notice how large the corresponding number is on the image!  If this nerve is the cause of pain, it unfortunately has a lot of reach.)
6. Abducens - the lacteral rectus muscles of the eye
7. Facial - muscles of facial expression, lacrimal glands (tear ducts!) and salivary glands
8. Vestibulocochlear (Acoustic) - equilibrium and hearing
9. Glossopharyngeal - throat for swallowing, posterior part of tongue, salivary glands
10. Vagus - internal organs
11. Spinal Accessory - the muscles that move head, neck and shoulders
12. Hypoglossal - muscles of the tongue

The trigeminal nerve splits into three different branches which carry information from three different areas of the face and mouth.  Here is an image of these three areas -

In a trigeminal neuralgic attack, pressure is applied directly to a part of the nerve that has lost its protective covering called its myelin sheath.  Nerves are composed of nerve cells called neurons which relay information by sending an electrical impulse up an axon, a long, thin cablelike projection.  Because the axon is sending electrical information, it is covered with a protective covering called the myelin sheath.  Myelin is only found in our nervous system and is basically insulation for the nerve cells to give protection and to allow information to travel quickly, like the protective covering of an electrical wire.

Something has damaged this protective covering in a case of trigeminal neuralgia and the nerve is exposed.  This can be caused by a number of different things.  The different causes of damage to the myelin sheath define the type of trigeminal neuralgia.  The different types of this disease are:

• TN1 (classic or tic douloureux) - This pain is caused by loss or damage to the myelin typically from pressure on the sheath from a surrounding blood vessel.  The pain occurs spontaneously and is temporary.

• TN2 - This is similar to TN1, however the pain is more chronic.

• STN (secondary symptomatic TN) - The loss of myelin sheath in this type of trigeminal neuralgia is caused by multiple sclerosis.

• PHN (post-herpetic neuralgia) - This pain is caused by a shingles outbreak on the trigeminal nerve.

• TNP (trigeminal neuropathic pain) - Neuropathic pain differs from neuralgic pain in that it is caused by damage to the nerve itself...not just the myelin sheath.  The injured nerve will send random painful signals to the brain.  It could be a result of facial trauma, ear, nose or throat surgery, a stroke, etc.

• TDP (trigeminal deafferentation pain) - This type of trigeminal pain results from a loss of the nerve, but continued pain signals...sort of like phantom limb pain.

The bottom line is that damage to the myelin sheath and exposure of the trigeminal nerve can result in an excruciating pain whenever pressure is applied to that nerve.  The pain and suffering that this disease causes to the person can be debilitating.

References:

http://www.brainfacts.org/brain-basics/neuroanatomy/articles/2012/the-neuron/

http://fpa-support.org/trigeminal-neuralgia/

How often does this disorder occur?

Trigeminal neuralgia is a rare chronic pain disorder, but one that needs to be taken seriously.  It can severely decrease the quality of life for those who are diagnosed with it.  And who are these people who are diagnosed with the disorder?  Below is an infograph outlining the incidence and prevalence of the disease in the world. 

To summarize:

• Trigeminal neuralgia is most commonly diagnosed in those over the age of 50, although it can be diagnosed as early as teenage years and there has even been a case of trigeminal neuralgia found in infancy.  
• Women are diagnosed more often than men.
• There will be a rise in number of cases that are both diagnosed and prevalent by the year 2022.  (This forecast is likely due to the changes in population as opposed to the changes in the disease itself.)

The most common cause of trigeminal neuralgia is pressure on the trigeminal nerve from a surrounding blood vessel.  It can be an outcome of multiple sclerosis, as well, if the body attacks the covering of the trigeminal nerve (the myelin sheath.)  One final and more rare cause is pressure on the trigeminal nerve from a tumor.

References:

www.ninds.nih.gov/disorders/trigeminal_neuralgia/detail_trigeminal_neuralgia.htm#280093236 

http://dana.org/Publications/GuideDetails.aspx?id=50054

http://www.prnewswire.com/news-releases/epicast-report-trigeminal-neuralgia---epidemiology-forecast-to-2022-246134431.html

What is it?

Stabbing, burning, aching, electric shock-like...these are all descriptions that have been used to refer to the pain caused by trigeminal neuralgia.  This chronic pain disorder, also known as tic douloureux, has been said to cause the most excruciating pain known to humanity.  Trigeminal neuralgia is sometimes called 'the suicide disease' because of a number of people who have taken their own lives as an alternate to living with this pain.  A person diagnosed with this disorder is often made physically and mentally incapacitated for the duration of these bouts of pain.

In the picture below, you can see that this nerve splits into three separate branches.  The nerve endings from branch 1, the uppermost branch, end in the forehead and eye area.  Branch 2 nerve endings end in the nose and upper mouth and branch 3 nerves end in the lower mouth and jaw.  These areas are where trigeminal neuralgic pain is felt.

Trigeminal neuralgia is caused by pressure on the trigeminal nerve, which innervates the face.  This pressure is often due to a blood vessel pressing on the nerve and wearing down the myelin sheath, or the insulating cover that surround nerve cells.  In some rare cases the pressure is caused by a tumor. Symptoms of trigeminal neuralgia may also appear in multiple sclerosis, which is a disease in which the body attacks the myelin sheath.

Regardless of the cause of the pressure, the pain that comes with the disorder can be unbearable and must be closely managed in order to allow those diagnosed with trigeminal neuralgia to function.

References:

http://www.ninds.nih.gov/disorders/trigeminal_neuralgia/detail_trigeminal_neuralgia.htm

http://www.mayoclinic.org/diseases-conditions/trigeminal-neuralgia/basics/definition/con-20043802

http://www.aans.org/patient%20information/conditions%20and%20treatments/trigeminal%20neuralgia.aspx