Neurologic disorders

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Neurologic disorders

  1. 1. Nursing Care of Clients with Neurologic Disorders   Ma. Tosca Cybil A. Torres, RN, MAN
  2. 2. Outline <ul><li>Autoimmune Disorders </li></ul><ul><ul><li>Multiple Sclerosis (MS) </li></ul></ul><ul><ul><li>Myasthenia Gravis (MG) </li></ul></ul><ul><ul><li>Guillen-Barr é syndrome (GBS) </li></ul></ul><ul><li>Degenerative disorders </li></ul><ul><ul><li>Parkinson’s Disease </li></ul></ul><ul><ul><li>Huntington’s Disease </li></ul></ul><ul><ul><li>Amyotrophic Lateral Sclerosis (ALS) </li></ul></ul>
  3. 3. Multiple Sclerosis
  4. 4. Multiple Sclerosis <ul><li>Chronic demyelinating disease of the CNS associated with abnormal immune response to environmental factor </li></ul>
  5. 6. Multiple Sclerosis <ul><li>Periods of exacerbations and remissions </li></ul><ul><li>Progression of disease with increasing loss of function </li></ul><ul><li>Incidence is highest in young adults (20 – 40); onset between 20 – 50 </li></ul><ul><li>Affects females more than males </li></ul><ul><li>More common in temperate climates </li></ul><ul><li>Occurs mainly in Caucasians </li></ul>
  6. 7. Manifestations <ul><li>Fatigue </li></ul><ul><li>Optic nerve involvement: blurred vision, haziness </li></ul><ul><li>nystagmus, dysarthria,cognitive dysfunctions, vertigo, deafness </li></ul><ul><li>Weakness, numbness in leg(s), spastic paresis, bladder and bowel dysfunction </li></ul><ul><li>ataxia </li></ul><ul><li>Spasticity </li></ul><ul><li>Blindness </li></ul>
  7. 8. <ul><li>STRESS AGGRAVATES SYMPTOMS. </li></ul>
  8. 9. Collaborative Care <ul><li>Focus is on retaining optimum functioning and limiting disability </li></ul>
  9. 10. Diagnostic Tests <ul><li>Neurological exam, careful history </li></ul><ul><li>Lumbar puncture with CSF analysis: increased number of T lymphocytes; elevated level of immunoglobulin G (IgG) </li></ul><ul><li>Cerebral, spinal optic nerve MRI: shows multifocal lesions </li></ul><ul><li>Evoked response testing of visual, auditory, somatosensory impulses show delayed conduction </li></ul><ul><li>CT scan shows density of white matter or plaque formation </li></ul>
  10. 11. <ul><li>NO CURE EXISTS FOR MS </li></ul>
  11. 12. Medications <ul><li>Biologic response modifiers </li></ul><ul><ul><li>Interferon beta-1a </li></ul></ul><ul><ul><li>Interferon beta-1b </li></ul></ul><ul><ul><li>Glatiramer acetate </li></ul></ul><ul><li>Glucocorticosteroids </li></ul><ul><li>Immunosuppressants </li></ul><ul><ul><li>azathioprine (Imuran) </li></ul></ul><ul><ul><li>cyclophosphamide (Cytoxan) </li></ul></ul><ul><ul><li>methotrexate </li></ul></ul><ul><li>Muscle relaxants to treat muscle spasms </li></ul><ul><ul><li>diazepam </li></ul></ul><ul><li>Medications to deal with bladder problems: anticholinergics or cholinergics depending on problem experienced by client </li></ul>
  12. 13. Nursing Diagnoses <ul><li>Self care deficit </li></ul><ul><li>Impaired physical mobility </li></ul><ul><li>Risk for injury </li></ul><ul><li>Impaired urinary and bowel elimination </li></ul><ul><li>Impaired verbal communication </li></ul><ul><li>Risk for aspiration </li></ul><ul><li>Disturbed thought processes </li></ul><ul><li>Ineffective individual coping </li></ul><ul><li>Potential for sexual dysfunction </li></ul>
  13. 14. Nursing Care <ul><li>Monitor motor movements for interference with ADLs </li></ul><ul><li>Encourage activity balanced with rest periods </li></ul><ul><li>Assess cognitive function </li></ul><ul><li>Explain: </li></ul><ul><ul><li>Bladder training </li></ul></ul><ul><ul><li>Positioning </li></ul></ul><ul><ul><li>Avoid temperature extremes </li></ul></ul><ul><ul><li>Medication compliance </li></ul></ul><ul><ul><li>Avoid STRESS. </li></ul></ul>
  14. 15. Health Promotion <ul><li>Client needs to develop strategies to deal with fatigue, exacerbations </li></ul><ul><li>Prevention of respiratory and urinary tract infections </li></ul>
  15. 16. Home Care <ul><li>Education </li></ul><ul><li>Referral to support group and resources </li></ul><ul><li>Referral to home health agencies when condition requires </li></ul>
  16. 17. Myasthenia gravis (MG)
  17. 18. Myasthenia gravis (MG) <ul><li>Chronic autoimmune neuromuscular disorder affecting the neuromuscular joint </li></ul>
  18. 20. Myasthenia gravis (MG) <ul><li>characterized by fatigue and severe weakness of skeletal muscles </li></ul><ul><li>Occurs with remissions and exacerbations </li></ul><ul><li>Occurs more frequently in females, with onset between ages 20 – 30 </li></ul>
  19. 21. Manifestations <ul><li>Seen in the muscles that are affected: </li></ul><ul><li>Ptosis (drooping of eyelids), diplopia (double vision) </li></ul><ul><li>Weakness in mouth muscles resulting in dysarthria and dysplagia </li></ul><ul><li>Weak voice, smile appears as snarl </li></ul><ul><li>Head juts forward </li></ul><ul><li>Muscles are weak but DTRs are normal </li></ul><ul><li>Weakness and fatigue exacerbated by stress , fever, overexertion, exposure to heat; improved with rest </li></ul>
  20. 22. <ul><li>MG is purely a MOTOR disorder with no effect on sensation or coordination </li></ul>
  21. 23. Complications <ul><li>Pneumonia </li></ul><ul><li>Myasthenic Crisis </li></ul><ul><li>Sudden exacerbation of motor weakness putting client at risk for respiratory failure and aspiration </li></ul><ul><li>Manifestations: tachycardia, tachypnea, respiratory distress, dysphasia </li></ul>
  22. 24. Complications <ul><li>Cholinergic Crisis </li></ul><ul><li>Occurs with overdosage of medications (anticholinesterase drugs) used to treat MG </li></ul><ul><li>Develops GI symptoms, severe muscle weakness, vertigo and respiratory distress </li></ul><ul><li>Both crises often require ventilation assistance </li></ul>
  23. 25. Diagnostic Tests <ul><li>Physical examination and history </li></ul><ul><li>Tensilon Test: edrophonium chloride (Tensilon) administered and client with myasthenia will show significant improvement lasting 5 minutes </li></ul><ul><li>EMG: reduced action potential </li></ul><ul><li>Antiacetylcholine receptor antibody serum levels: increased in 80% MG clients; used to follow course of treatment </li></ul><ul><li>Serum assay of circulating acetylcholine receptor antibodies: if increased, is diagnostic of MG </li></ul>
  24. 26. Medications <ul><li>Anticholinesterase medications </li></ul><ul><ul><li>Pyridostigmine bromide (Mestinon) </li></ul></ul><ul><li>Immunsuppression medications including glucocorticoids </li></ul><ul><ul><li>Cyclosporineor azathioprine (Imuran) </li></ul></ul>
  25. 27. Surgery <ul><li>Thymectomy is recommended in clients <60 </li></ul><ul><li>Remission occurs in 40 % of clients, but may take several years to occur </li></ul>
  26. 28. Plasmapheresis <ul><li>Used to remove antibodies </li></ul><ul><li>Often done before planned surgery, or when respiratory involvement has occurred </li></ul>
  27. 29. Nursing Care <ul><li>Teaching interventions to deal with fatigue </li></ul><ul><li>Importance of following medication therapy </li></ul>
  28. 30. Nursing Diagnoses <ul><li>Ineffective Airway Clearance </li></ul><ul><li>Impaired Swallowing: plan to take medication to assist with chewing activity </li></ul>
  29. 31. Home Care <ul><li>Avoid fatigue and stress </li></ul><ul><li>Plan for future with treatment options </li></ul><ul><li>Keep medications available </li></ul><ul><li>Carry medical identification </li></ul><ul><li>Referral to support group, community resources </li></ul>
  30. 32. Guillain-Barr é Syndrome (GBS)
  31. 33. Guillain-Barr é Syndrome (GBS) <ul><li>Acute autoimmune inflammatory demyelinating disorder of peripheral nervous system characterized by acute onset of ascending motor paralysis </li></ul>
  32. 34. Guillain-Barr é Syndrome (GBS) <ul><li>Cause is unknown but precipitating events include GI or respiratory infection, surgery, or viral immunizations </li></ul><ul><li>80 – 90% of clients have spontaneous recovery with little or no disabilities </li></ul><ul><li>4 – 6% mortality rate, and up to 10% have permanent disabling weakness </li></ul><ul><li>20 % require mechanical ventilation due to respiratory involvement </li></ul>
  33. 35. Manifestations <ul><li>Most clients have symmetric weakness beginning in lower extremities </li></ul><ul><li>Ascends body to include upper extremities, torso, and cranial nerves </li></ul><ul><li>Sensory involvement causes severe pain, paresthesia and numbness </li></ul><ul><li>Paralysis of intercostals and diaphragmatic muscle </li></ul><ul><li>Autonomic nervous system involvement: blood pressure fluctuations, cardiac dysrhythmias, paralytic ileus, urinary retention </li></ul><ul><li>Weakness usually plateaus or starts to improve in the fourth week with slow return of muscle strength </li></ul>
  34. 36. Diagnostic Tests <ul><li>diagnosis made thorough history and clinical examination; there is no specific test </li></ul><ul><li>CSF analysis: increased protein </li></ul><ul><li>EMG: decrease nerve conduction </li></ul><ul><li>Pulmonary function test reflect degree of respiratory involvement </li></ul>
  35. 37. Medications <ul><li>supportive and prophylactic care </li></ul><ul><li>Antibiotics </li></ul><ul><li>Morphine for pain control </li></ul><ul><li>Anticoagulation to prevent thromboembolic complications </li></ul>
  36. 38. Medical management <ul><li>Tracheostomy </li></ul><ul><li>Plasmapheresis </li></ul><ul><li>Enteral feeding </li></ul><ul><li>IVIG </li></ul>
  37. 39. Nursing Diagnoses <ul><li>Ineffective breathing pattern </li></ul><ul><li>Impaired bed and physical mobility </li></ul><ul><li>Imbalanced nutrition </li></ul><ul><li>Acute Pain </li></ul><ul><li>Risk for Impaired Skin Integrity </li></ul><ul><li>Impaired Communication </li></ul><ul><li>Fear </li></ul>
  38. 40. Nursing Care <ul><li>Maintain respiratory function </li></ul><ul><li>Enhancing physical mobility </li></ul><ul><li>Providing adequate nutrition </li></ul><ul><li>Improving communication </li></ul><ul><li>Decreasing fear and anxiety </li></ul>
  39. 41. Home Care <ul><li>Clients will usually require hospitalization, rehabilitation, and eventually discharge to home </li></ul><ul><li>Client and family will need support; support groups </li></ul>
  40. 42. Degenerative Disorders
  41. 43. Parkinson’s Disease
  42. 44. Parkinson’s Disease <ul><li>Associated with decreased levels of dopamine resulting from destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia. </li></ul>
  43. 45. Parkinson’s Disease <ul><li>characterized by tremor at rest, muscle rigidity and akinesia (poor movement); cause unknown </li></ul><ul><li>Affects older adults mostly, mean age 60 with males more often than females </li></ul><ul><li>Parkinson-like syndrome can occur with some medications, encephalitis, toxins; these are usually reversible </li></ul>
  44. 46. Manifestations <ul><li>Tremor </li></ul><ul><li>at rest with pill rolling motion of thumb and fingers </li></ul><ul><li>Worsens with stress and anxiety </li></ul><ul><li>Progressive impairment affecting ability to write and eat </li></ul><ul><li>Rigidity </li></ul><ul><li>Involuntary contraction of skeletal muscles </li></ul><ul><li>Cogwheel rigidity: jerky motion </li></ul>
  45. 47. Manifestations <ul><li>Akinesia </li></ul><ul><li>Slowed or delayed movement that affects chewing, speaking, eating </li></ul><ul><li>May freeze: loss of voluntary movement </li></ul><ul><li>Bradykinesia: slowed movement </li></ul><ul><li>Posture instability </li></ul><ul><li>Involuntary flexion of head and shoulders, stooped leaning forward position </li></ul><ul><li>Equilibrium problems causing falls, and short, accelerated steps </li></ul><ul><li>Shuffling gait </li></ul>
  46. 49. Manifestations <ul><li>Autonomic nervous system </li></ul><ul><li>Constipation and urinary hesitation or frequency </li></ul><ul><li>Orthostatic hypotension, dizziness with position change </li></ul><ul><li>Eczema, seborrhea </li></ul><ul><li>Depression and dementia; confusion, disorientation, memory loss, slowed thinking </li></ul><ul><li>Inability to change position while sleeping, sleep disturbance </li></ul><ul><li>Mask-like face </li></ul><ul><li>Dysphonia </li></ul>
  47. 50. Complications <ul><li>Impaired communication </li></ul><ul><li>Falls </li></ul><ul><li>Infection related to immobility and pneumonia </li></ul><ul><li>Malnutrition related to dysphagia </li></ul><ul><li>Skin breakdown </li></ul><ul><li>Depression and isolation </li></ul>
  48. 51. Prognosis <ul><li>Slow progressive degeneration </li></ul><ul><li>Eventual debilitation </li></ul>
  49. 52. Diagnostic Tests <ul><li>No specific test for disease </li></ul><ul><li>Drug screens to determine medications or toxins causing parkinsonism </li></ul><ul><li>EEG: slowed and disorganized pattern </li></ul>
  50. 53. Medications <ul><li>Antiparkinsonian- Levodopa (Larodopa) </li></ul><ul><li>antiviral therapy- amantadine (Symmetrel) </li></ul><ul><li>anticholinergics- benztropine mesylate (Cogentin) </li></ul><ul><li>Bromocriptine (Parlodel) pergolide (Permax) inhibit dopamine breakdown </li></ul><ul><li>MAOI- selegiline (Eldepryl) </li></ul><ul><li>Antihistamine- diphenhydramine hydrochloride (Benadryl) </li></ul><ul><li>Medications may lose their efficacy; response to drugs fluctuates: “on-off” effect </li></ul>
  51. 54. Treatments <ul><li>Deep brain stimulation </li></ul><ul><li>Stereotactic procedures </li></ul><ul><li>Pallidotomy: destruction of involved tissue </li></ul><ul><li>thalamotomy: destroys specific tissue involved in tremor </li></ul>
  52. 55. Nursing Diagnoses <ul><li>Impaired Physical Mobility </li></ul><ul><li>Impaired Verbal Communication </li></ul><ul><li>Impaired Nutrition: Less than body requirements </li></ul><ul><li>Self care deficit </li></ul><ul><li>Constipation </li></ul><ul><li>Disturbed Sleep Patterns </li></ul><ul><li>Ineffective coping </li></ul>
  53. 56. Nursing Care <ul><li>Improve mobility </li></ul><ul><li>Enhance self care activities </li></ul><ul><li>Improving bowel elimination </li></ul><ul><li>Improving nutrition </li></ul><ul><li>Enhancing swallowing </li></ul><ul><li>Improving communication supporting coping abilities </li></ul>
  54. 57. Home Care <ul><li>Medication education </li></ul><ul><li>Adaptation of home environment </li></ul><ul><li>Gait training and exercises </li></ul><ul><li>Nutritional teaching </li></ul>
  55. 58. Huntington’s Disease (chorea)
  56. 59. Huntington’s Disease (chorea) <ul><li>Progressive, degenerative inherited neurologic disease characterized by increasing dementia and chorea </li></ul>
  57. 60. Huntington’s Disease (chorea) <ul><li>Cause unknown </li></ul><ul><li>Autosomal dominant genetic disorder </li></ul><ul><li>No cure </li></ul><ul><li>Usually asymptomatic until age of 30 – 40 </li></ul><ul><li>a significant reduction (volume and activity) of acetylcholine </li></ul>
  58. 61. Manifestations <ul><li>Abnormal movement and progressive dementia </li></ul><ul><li>Early signs are personality change with severe depression, memory loss; mood swings, signs of dementia </li></ul><ul><li>Increasing restlessness, worsened by environmental stimuli and emotional stress; arms and face and entire body develops choreiform movements, lurching gait; difficulty swallowing, chewing, speaking </li></ul><ul><li>Slow progressive debilitation and total dependence </li></ul><ul><li>Death usually results from aspiration pneumonia or another infectious process </li></ul>
  59. 62. Diagnostic Tests <ul><li>Genetic testing of blood </li></ul><ul><li>CT scan shows cerebral atrophy </li></ul>
  60. 63. Medications <ul><li>Antipsychotic (phenothiazines and butyrophenones) to block dopamine receptors </li></ul><ul><li>Antidepressants </li></ul>
  61. 64. Nursing Diagnoses <ul><li>Risk for injury </li></ul><ul><li>Risk for Aspiration </li></ul><ul><li>Imbalanced Nutrition: Less than body requirements </li></ul><ul><li>Impaired Skin Integrity </li></ul><ul><li>Impaired Verbal Communication </li></ul><ul><li>Disturbed thought processes </li></ul>
  62. 65. Nursing Care <ul><li>Very challenging: physiological, psychosocial and ethical problems </li></ul><ul><li>Genetic counseling </li></ul>
  63. 66. Home Care <ul><li>Referral to agencies to assist client and family, support group and organization </li></ul>
  64. 67. Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s disease
  65. 68. Amyotrophic Lateral Sclerosis (ALS) Disease of unknown cause in which there is a loss of motor neurons in the anterior horns of the spinal cord and the motor nuclei in the lower brain stem.
  66. 69. Amyotrophic Lateral Sclerosis (ALS) <ul><li>Progressive, degenerative neurologic disease characterized by weakness and wasting of muscles without sensory or cognitive changes </li></ul><ul><li>Several types of disease including a familial type </li></ul><ul><li>onset is usually between age of 40 – 60 </li></ul><ul><li>higher incidence in males at earlier ages but equally post menopause </li></ul><ul><li>Physiologic problems involve swallowing, managing secretions, communication, respiratory muscle dysfunction </li></ul><ul><li>Death usually occurs in 2 – 5 years due to respiratory failure </li></ul>
  67. 70. Manifestations <ul><li>Initial: spastic, weak muscles with increased DTRs; muscle flaccidity, paresis, paralysis, atrophy; clients note muscle weakness and fasciculations; muscles weaken, atrophy; client complains of progressive fatigue; usually involves hands, shoulders, upper arms, and then legs </li></ul><ul><li>Atrophy of tongue and facial muscles result in dysphagia and dysarthria; emotional lability and loss of control occur </li></ul><ul><li>50% of clients die within 2 – 5 years of diagnosis, often from respiratory failure or aspiration pneumonia </li></ul>
  68. 71. Diagnostic Test <ul><li>Testing rules out other conditions that may mimic early ALS such as hyperthyroidism, compression of spinal cord, infections, neoplasms </li></ul><ul><li>EMG to differentiate neuropathy from myopathy </li></ul><ul><li>Muscle biopsy shows atrophy and loss of muscle fiber </li></ul><ul><li>Serum creatine kinase if elevated (non-specific) </li></ul><ul><li>Pulmonary function tests: to determine degree of respiratory involvement </li></ul>
  69. 72. Medications <ul><li>Rilutek (Riluzole) antiglutamate </li></ul><ul><ul><li>Prescribed to slow muscle degeneration </li></ul></ul><ul><ul><li>Requires monitoring of liver function, blood count, chemistries, alkaline phosphatase </li></ul></ul>
  70. 73. Nursing Diagnoses <ul><li>Risk for Disuse Syndrome </li></ul><ul><li>Ineffective Breathing Pattern: may require mechanical ventilation and tracheostomy </li></ul>
  71. 74. Nursing Care <ul><li>Help client and family deal with current health problems </li></ul><ul><li>Plan for future needs including inability to communicate </li></ul>
  72. 75. Home Care <ul><li>Education regarding disease, community resources for health care assistance and dealing with disabilities </li></ul>
  73. 76. Creutzfeldt-Jakob disease (CJD, spongiform encephalopathy)
  74. 77. Creutzfeldt-Jakob disease <ul><li>Rapid progressive degenerative neurologic disease causing brain degeneration without inflammation </li></ul>
  75. 78. Description <ul><li>Transmissible and progressively fatal </li></ul><ul><li>Caused by prion protein: transmission of prion is through direct contamination with infected neural tissue </li></ul><ul><li>Variant form of CJD is “mad cow disease”: believed transmitted by consumption of beef contaminated with bovine form of disease </li></ul><ul><li>Pathophysiology: spongiform degeneration of gray matter of brain </li></ul>
  76. 79. <ul><li>No definitive treatment. </li></ul><ul><li>Outcome is fatal. </li></ul>
  77. 80. Manifestations <ul><li>Onset: memory changes, exaggerated startle reflex, sleep disturbances </li></ul><ul><li>Rapid deterioration in motor, sensory, language function </li></ul><ul><li>Confusion progresses to dementia </li></ul><ul><li>Terminal states: clients are comatose with decorticate and decerebrate posturing </li></ul>
  78. 81. Diagnostic Tests <ul><li>Clinical pictures, suggestive changes on EEG and CT scan </li></ul><ul><li>Similar to Alzheimers in early stages </li></ul><ul><li>Final diagnosis made on postmortem exam </li></ul>
  79. 82. Nursing Care <ul><li>Use of standard precautions with blood and body fluids </li></ul><ul><li>Support and assistance to client and family </li></ul>
  80. 83. Trigeminal neuralgia (tic douloureux)
  81. 84. Description <ul><li>Chronic disease of trigeminal nerve (cranial nerve V) causing severe facial pain </li></ul><ul><li>The maxillary and mandibular divisions of nerve are effected </li></ul><ul><li>Occurs more often in middle and older adults, females more than males </li></ul><ul><li>Cause is unknown </li></ul>
  82. 85. Manifestations <ul><li>Severe facial pain occurring for brief seconds to minutes hundreds of times a day, several times a year </li></ul><ul><li>Usually occurs unilaterally in area of mouth and rises toward ear and eye </li></ul><ul><li>Wincing or grimacing in response to the pain </li></ul><ul><li>Trigger areas on the face may initiate the pain </li></ul><ul><li>Sensory contact or eating, swallowing, talking may set off the pain </li></ul><ul><li>Often there is spontaneous remission after years, and then condition recurs with dull ache in between pain episodes </li></ul>
  83. 86. Diagnosis <ul><li>by physical assessment </li></ul>
  84. 87. Medications <ul><li>Anticonvulsants </li></ul><ul><li>carbamazepine (Tegretol) </li></ul><ul><li>phenytoin (Dilantin) </li></ul><ul><li>gabapentin (Neurotin) </li></ul>
  85. 88. Surgery <ul><li>Intractable pain may be treated by severing the nerve root: rhizotomy </li></ul><ul><li>Client may have lost facial sensation and have loss of corneal reflex </li></ul>
  86. 89. Nursing Care <ul><li>Teaching client self-management of pain </li></ul><ul><li>Maintaining nutrition </li></ul><ul><li>Preventing injury </li></ul>
  87. 90. Bell’s Palsy
  88. 91. Description <ul><li>Disorder of seventh cranial nerve and causes unilateral facial paralysis </li></ul><ul><li>Occurs between age of 20 – 60 equally in males and females </li></ul><ul><li>Cause unknown, but thought to be related to herpes virus </li></ul>
  89. 92. Manifestations <ul><li>Numbness, stiffness noticed first </li></ul><ul><li>Later face appears asymmetric: side of face droops; unable to close eye, wrinkle forehead or pucker lips on one side </li></ul><ul><li>Lower facial muscles are pulled to one side; appears as if a stroke </li></ul>
  90. 93. Prognosis <ul><li>Majority of person recover fully in few weeks to months </li></ul><ul><li>Some persons have residual paralysis </li></ul>
  91. 94. Diagnosis <ul><li>based on physical examination </li></ul>
  92. 95. Collaborative Care <ul><li>Corticosteroids are prescribed in some cases but use has been questioned </li></ul><ul><li>Treatment is supportive </li></ul>
  93. 96. Nursing Care <ul><li>Teaching client self-care: prevent injury and maintain nutrition </li></ul><ul><li>Use of artificial tears, wearing eye patch or taping eye shut at night; wearing sunglasses </li></ul><ul><li>Soft diet that can be chewed easily, small frequent meals </li></ul>

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