TN News: Nursing Care for Patients with TN

Possible Nursing Diagnoses for Patients with Trigeminal Neuralgia (TN):

1. Chronic/Acute pain related to disease process as evidenced by patient report, demeanor, increased blood pressure, pulse, and respiration, visible distress
2. Chronic anxiety related to chronic bouts of acute pain, as evidenced by patient report of anxiety, sleeplessness, etc.
3. Social isolation related to chronic acute bouts of pain, as evidenced by difficulty maintaining previous social relationships at school, work, in family, and friendships at former level of involvement.
4. Risk for suicide related to chronic acute bouts of pain, as evidenced by patient report of hopelessness and/or depression, suicidality; positive diagnostic assessment for depression and/or suicidality.
5. Risk for activity intolerance related to chronic pain, anxiety, fatigue, symptoms of medications used to manage disease process, as evidenced by reduced ability to perform ADLs (activities of daily living) such as shopping, driving, personal hygiene such as brushing teeth, etc.

Nursing Interventions for Acute/Chronic Pain:

1. Medication management such as administration of anti-seizure medications known to decrease symptoms of some neuralgias (eg. Gabapentin/Neurontin, etc).
2. Guided visualizations to distract patient from pain and aid in sense of calm, relaxation, safety.
3. Distraction through music therapy, art therapy, video games, movies, etc.
4. Cognitive-behavioral therapy geared towards improving coping skills of patient in dealing with bouts of chronic pain.
5. Patient and family education regarding pain management options including non-medication interventions such as visualizations, distraction, and alternative medicine.

TN News: Nursing Plans of Care for Patients with TN

1. Assess for pain and administer analgesics as prescribed
2. Provide non-medication interventions for pain such as guided visualization and distraction
3. Provide pre/post-operative care as applicable
4. Provide patient education to avoid possible aggravating factors such as use of an electric toothbrush or electric shaver, wind on face, hot or cold drinks, contact with air/water at extremes of temperature (hot or cold), etc
5. Interdisciplinary care to include not only neurovascular care but also social work, psychiatry, etc to support patient and family with the challenges of intractable pain and illness that may have no readily apparent cause
6. Referral to regular dental exams every 6 months because dental caries may be indistinguishable from bouts of pain related to TN (trigeminal neuralgia)

Sources:

Antipuesto, D. J., MN, RN. (Feb 2011). Trigeminal Neuralgia (Tic Douloureux). From Nursing Crib. Retrieved 5/23/2015 from http://nursingcrib.com/nursing-notes-reviewer/medical-surgical-nursing/trigeminal-neuralgia-tic-douloureux/

Sweet Haven Publishing Service. (2006). Lesson 38 Trigeminal Neuralgia. From Nursing Care for Neurological patients. Retrieved 5/23/2015, from http://www.waybuilder.net/sweethaven/MedTech/NurseCare/NeuroNurse01.asp?iNum=38

Trigeminal Neuralgia (Tic Douloureux). (n.d.). From Nursing Articles. Retrieved 5/23/2015 from http://studynursing.blogspot.com/2011/02/trigeminal-neuralgiatic-douloureux.html

TN News: Treatment

The primary option for treating TN (trigeminal neuralgia) is called a microvascular decompression. The surgeon approaches the brain from a small hole in the base of the skull, finds blood vessels pushing on the trigeminal nerve, and removes or re-routes the blood vessels. After this the surgeon places a teflon "cushion" between your nerve and the blood vessels. Yes, that's teflon like the non-stick coating on your pans!

Source: Understanding Trigeminal Neuralgia

Dr. Clyde provides a great explanation of microvascular decompression above. Side effects following the surgery may include facial numbness or lack of muscle tone/control in the affected region(s) of the face. The surgery is not always a success, but many people are able to find relief from their symptoms with this surgery. However it is important to note that this surgery only works if the nerve is being compressed by a blood vessel! If your pain is caused by another source, you may need to explore other treatment options.

Sources:
  Understanding Trigeminal Neuralgia (November 2, 2010). Retrieved May 10, 2015, from https://www.youtube.com/watch?v=wYpWgeC3K-s

TN News: The Symptoms

This video documentary of the experiences of Frances Shaver with TN (trigeminal neuralgia) provides an excellent firsthand description of how TN feels. People living with TN experience repeated bouts of excruciating facial pain that might be confused with dental pain or MS pain (multiple sclerosis). The best description of symptoms in this video takes place during approximately the first six minutes:

Source: The Suicide Disease

Sources:

 The Suicide Disease (December 19, 2013). (n.d.). Retrieved May 10, 2015, from https://www.youtube.com/watch?v=uzx_m-a2BJw  

TN News: How TN is diagnosed

Source: University of Virginia School of Medicine

According to a recent article in Therapeutics and Risk Management, the International Headache Society defines the diagnosis criteria for Trigeminal Neuralgia (TN) as greater than three sudden attacks of pain on one side of the face, meeting the following criteria:

• Pain occurs in region of the face with sensation supplied only by the trigeminal nerve without radiating outside of that area
• Pain that has 3/4 of the following: occurs repeatedly in attacks lasting from an instant less than a second up to 2 minutes, is extremely severe, feels like a shock of electricity or may also be described as shooting, stabbing or sharp; and occurs after ordinarily non-painful stimuli to face, like a breeze or brush of fabric, brushing teeth.

Your doctor may make a diagnosis based solely upon an interview with you where you describe your symptoms and medical history, including any dental surgeries, neuropathic pain conditions, or neurological diseases like Multiple Sclerosis. 

You may also be referred to a hospital to have imaging studies like an MRI or CT scan in hopes of locating the source of your pain. These imaging scans may also help your doctors rule out other conditions that can cause similar types of pain, including meningiomas, a type of tumor that grows from the lining of your brain.

Sources:
Advances in diagnosis and treatment of trigeminal neuralgia. Montano N, Conforti G, Di Bonaventura R, Meglio M, Fernandez E, Papacci F. Ther Clin Risk Manag. 2015 Feb 24; 11:289-99. doi: 10.2147/TCRM.S37592 eCollection 2015.

Trigeminal Neuralgia and Gamma Knife. (n.d.). Retrieved April 26, 2015, from http://www.medicine.virginia.edu/clinical/departments/neurosurgery/gammaknife/disorders/pain-page

TN News: Why and how TN hurts

Your trigeminal nerve is a cranial nerve located inside of your skull. It supplies sensation to your face as well as the ability to move your eyes. When you roll your eyes, you are using your trigeminal nerve!

When you have TN (trigeminal neuralgia), something as simple cotton swab being brushed lightly across your face can trigger a sensation of extreme pain. This pain travels from the surface of your skin to your trigeminal nerve, which carries the information (cotton swab has brushed face, here is what it feels like) to your brain. In people with TN, it seems that some kind of problem with the trigeminal nerve causes a sensation that might only cause us to sneeze or wrinkle our nose instead causes a sensation that puts us in excruciating pain.

Doctors disagree about what causes the trigeminal nerve to malfunction and cause these waves of pain. One theory is that the blood vessels near the root of the nerve are compromised in some way (by high blood pressure or build-up of gunk on the vessel walls) that reduces blood flow to the nerve, in essence starving the nerve and causing it to lose some of its protective coating (myellination). If you've ever accidentally been shocked by an electrical cord that had lost some of it's protective coating, the theory is similar. This theory is supported because there is a large amount of overlap between people with hypertension (high blood pressure) and people with TN. But why don't all people with high blood pressure get TN?

Doctors are still working on figuring out what causes TN so they can provide better treatment to patients with TN, perhaps even in time finding a cure.


Sources:
Sabalys G, Juodzbalys G, Wang HL. Aetiology and Pathogenesis of Trigeminal Neuralgia: a Comprehensive Review. URL: http://www.ejomr.org/JOMR/archives/2012/4/e2/v3n4e2ht.pdf doi: 10.5037/jomr.2012.3402

Trigeminal Neuralgia. Rudolph M. Krafft, MD, Northeastern Ohio Universities College of Medicine, Rootstown, Ohio. Am Fam Physician. 2008 May 1;77(9):1291-1296.

TN News: Who gets TN?

Estimates on the prevalence of Trigeminal neuralgia vary. According to studies cited by a recent paper published in 2013, TN is diagnosed for approximately 12.6 to 28.9 people per 100,000 every year. The disease is uncommon enough that it be very difficult for your doctor to diagnose.


TN is most common for women, and patients who have high blood pressure (hypertension), or multiple sclerosis, a chronic and debilitating disease that affect the myelin sheathes that protect your brain cells (neurons).

drawing by surrealdesirex, Trigeminal Neuralgia from deviantart.com

While TN does not cause death, it does cause excruciating pain, and was previously known by some as "suicide disease" because of the high potential for self-harm related to the experience of severe chronic pain.

So what are the options for patients with TN? There are options! Please come back next week to learn more about TN.

Sources:
 Increased risk of trigeminal neuralgia after hypertension: a population-based study. Neurology. 2011 Oct 25;77(17):1605-10. doi: 10.1212/WNL.0b013e3182343354. Epub 2011 Oct 12.

Neuropathic pain in the general population: a systematic review of epidemiological studies. 
Pain. 2014 Apr;155(4):654-62. doi: 10.1016/j.pain.2013.11.013. Epub 2013 Nov 26.

Spectrum of trigeminal neuralgia. J Ayub Med Coll Abbottabad. 2013 Jan-Jun;25(1-2):168-71.