Neurology

Chapter 64Management of Patients with

neurologic infection, autoimmune disorders and neuropathies

Meningitis

• Pathophysiology• Meningitis– Infection/ inflammation

of the meninges

• Encephalitis– Infection/inflammation

of the brain tissue

Meningitis

Pathophysiology• Meningitis/ encephalitis • Infection • Immune response • Swelling/edema • I –ICP • Etc.

Meningitis

Is meningitis a disorder of the CNS, PNS or both?A. CNSB. PNSC. Both CNS & PNS

Meningitis

The most common bacterial pathogens are:• Haemonphili influenzai– Affected kids < 5 yrs– H influenzae vaccine (Hib)

• Streptococcus pneumoniae– Affects age 19-59

• Neisseria meningitides– Easily transmitted to others– Least lethal

Meningitis

Two ways the infectious agent can inter the meninges

• Blood stream– Most common– Usually d/t URI

• Direct extension– TBI– Invasive procedures

Meningitis

• The viral type of meningitis is usually– Self limiting– Benign

• Bacterial meningitis is potentially – Fatal

Meningitis

Clinical manifestations• Onset:– Abrupt

• General S&S– Nuchal rigidity– Positive Kernig's– Positive Brudzinski’s– Photophobia

Meningitis

Clinical Manifestations• S&S of infection– Fever– Chills

Meningitis

Clinical manifestations• S&S of I-ICP– H/A– LOC– Vomiting– Papilledema– Hydrocephalus

Meningitis

Clinical manifestations• N. Meningitidis– Rash– Petechial– Purpuric lesion– Ecchymosis

Meningitis

Clinical manifestations• Infants/young children• Seizures• High-pitched cry• Bulging fontanels

Meningitis

• Mr. Jones has encephalitis. Would you expect his signs and symptoms to be more or les severe than a person with meningitis?

A. More severeB. Less severeEncephalitis signs and symptoms are more

severe with delirium & seizures.

Meningitis

Diagnosis• Lumbar tap– C&S of CSF

• Positive Kernig’s• Positive Brudzinski

Meningitis

Treatment• Broad spectrum

antibiotics– Penicillin– Cephalosporin's

• Intrathecally• Early intervention

crucial!

MeningitisNursing interventions• Isolation

– ? Causative agent• Assessment

– V/S– Neuro check– Cranial nerve involvement– Abn sleep patterns– Behavioral changes– ABG’s– Opisthotonus

Meningitis

Nursing management• I-ICP protocol

– I&O– Quiet environment: Dark– Limit visitors– Nutrition– No constipation– Pad side rails– Emotional support – Alkalosis

MeningitisPrevention• Haemonphilus vaccine

– HiB• meningococcal conjugate

vaccine – persons aged 11 to 55 years. – designed to offer protection

against four serogroups of Neisseria meningitidis (A, C, Y, W-135), which account for approximately 70 percent of cases in the United States.

Meningitis

Complications• Thrombosis• cerebral blood flow• Brain damage• Death

Meningitis• What do bulging fontanel’s in an infant indicate?• What type of meningitis occurs most frequently

and is considered the milder form?• What are the symptoms of meningitis?• To facilitate performing the lumbar puncture, on

the patient who may have meningitis, it is best for the nurse to place the patient in what position?

• After the lumbar puncture has been performed, it is best for the nurse to do

Meningitis

• What standard vaccine is administered to infants to prevent meningitis?

• Identify the bacteria most commonly associated with meningitis

• What is the most severe form of meningitis?• What affect does meningitis have of the physiology

of the brain?• Name six signs and symptoms of bacteria meningitis• Is meningitis a disease of the CNS or PNS

Brain Abscess

Pathophysiology• A collection of

infectious material within the tissue of the brain

• Infection • I-ICP • Brain shift

Brain Abscess

2 ways infection can enter the brain

• Direct invasion • Spread from nearby

sight– Sinuses– Ears– Teeth

Tongue piercing causes brain abscess

• 13 December 2001 New Scientist • Parents now have another reason to frown on tongue

piercing - a potentially fatal brain abscess suffered by a young woman in Connecticut.

• The woman's tongue became sore and swollen two or three days after it was pierced, and she reported a foul-tasting discharge from the pierced region. The infection healed in a few days after she removed the stud from her tongue, but a month later she suffered severe headaches, fever, nausea and vomiting.

• A scan at the Yale University hospital revealed the brain abscess, which physicians drained. She recovered after six weeks of intravenous antibiotic treatment.

Brain Abscess

Clinical manifestations• I-ICP• Infection• Fever?– Sometimes– Sometimes not!

Brain Abscess

Diagnostic findings• CT• MRI

Brain Abscess

Medical Management• Antimicrobial therapy– Large IV doses

• Surgery• Anti-convulsant

Brain Abscess

Nursing management• I-ICP protocol• Neuro assessment• Safety protocol– seizures

Brain Abscess

• Who is most at risk for brain abscesses?• Describe the medical treatment for a patient

with a brain abscess?• Is a brain abscess a diseases of the CNS, PNS

or both?

Multiple Sclerosis

Pathophysiology• Autoimmune disease• Demyelination of the

myelin covering that protects the neurons of the brain and spinal cord

Multiple Sclerosis

• Demyelination– Destruction of the

myelin sheath – Impaired transmission of

nerve impulses– Both the axon & myelin

are attacked

Multiple Sclerosis

• Is multiple sclerosis a disorder of the CNS, PNS or both?

A. CNSB. PNSC. Both CNS & PNS

Multiple SclerosisEtiology / Contributing factors• Unknown cause• Men vs women

– Men < women• Age of onset

– 20-40

Multiple Sclerosis

Clinical manifestations• Usually slow, progressive disease• Relapsing-remitting course• Patient may experience remission &

exacerbation’s– Exacerbation of symptoms – Partial/full remission – Symptoms return

Multiple Sclerosis

Clinical Manifestations• Episodes of motor, visual or

sensory disturbance• Visual disturbances

– Diplopia– Blurred vision

• Paresthesia• Fatigue• Dizziness

Multiple Sclerosis

Clinical Manifestations• Emotional disturbances• Scanning speech• Incontinence• Sexual disorders• Spasticity– Muscle hypertonicity

Multiple Sclerosis

Diagnosis• MRI– Sm. Plaque– Patches

• CT scan• Lumbar puncture– Immunoglobulin

abnormalities

Multiple Sclerosis

Medical management• No cure• Goal– Delay progress

• Manage symptoms

Multiple Sclerosis

Pharmaceutical• Interferons– ABC&R

Multiple Sclerosis

Pharmaceutical• Skeletal muscle

relaxants– Baclofen/lioresal

• transmission of impulses from the spinal cord to the skeletal muscle

• spasticity

– S/E• Drowsiness, weak

Multiple Sclerosis

Pharmaceutical• Corticosteriods

– Immunosuppressants– Dexamethasone, prednisone– Action

• Decreased imflammation

– S/E• Poor wound healing• Na+ & H20 retention• glucose levels

Multiple SclerosisNursing Interventions• Individualized• B&B management• Avoid stress

– Stress– Fatigue– Extreme temp.

• Exercise• Fluids• Diet

– High roughage

Multiple Sclerosis

Complications• Pneumonia• Decubitis ulcers• Contractures• Dependency

Multiple Sclerosis

• What is the pathophysiology of MS?• Is MS a disease of the CNS, PNS, or both?• Explain what demyelination refers to.• What role does temperature play in multiple

sclerosis?• Identify 5 common signs and symptoms of

MS.

Multiple Sclerosis

• What classifications of medications are used in treating MS?

• What is the progression of multiple sclerosis• What is the most common symptom associated with

MS? When does the individual usually seed medical help?

• What can exacerbate MS?• What is a long term goal for a patient with MS?

Myasthenia GravisPathophysiology• Auto-immune

– Progressive disease– Remission & exacerbation

• Flaw in transmission of impulses from the nerve to the muscle– Neuro-muscular junction

• Most often affects the muscles regulated by the cranial nerves

Myasthenia Gravis

Pathophysiology• Specifically attacks

receptors for acetylcholine

• Prevents muscle contraction

• Progressive weakness & fatigue

Myasthenia Gravis

• Is myasthenia Gravis a disorder of the CNS, PNS or both?

A. CNSB. PNSC. Both CNS & PNS

Myasthenia GravisClinical manifestations• Onset

– Gradual• Early

– Ptosis– Diplopia

• Progressive• May be fast or slow• With or without remission

– Dysphonia– Difficulty chewing &

swallowing– Extreme muscle weakness

Myasthenia Gravis

Clinical manifestations• Resp. paralysis (Bulbar

paralysis) • Vital capacity–

• Resp. failure • Deathmosis

Myasthenia Gravis

• “Myasthenia gravis is purely a motor disorder with no effect on sensation or coordination.”

Myasthenia Gravis

Etiology• Men vs Women– Men < women

• Age 20-40• Thymus– enlarged

Myasthenia Gravis

Diagnostic exams• Positive response to

Tensilon– IV Tensilon– Prevents Acetylcholine

from being broken down– Muscle function

improves within 60 sec. & lasts 30 mins.

Myasthenia GravisTreatment• No cure• Anticholinesterase agents

– Neostigmine, Mestinon, Prostigmin, Mytelase

– Prevents the destruction of Acetylcholine, thereby increasing the muscle to nerve response and muscle strength

– S/E: Sweating, weakness, bradycardia, hypotension

Myasthenia Gravis

Treatment• Corticosteroids• Thymus– radiation

• Plasmapheresis– Plasma exchange

Myasthenia Gravis

Nursing interventions• Planned activities• Avoid stress• Rest periods• Resp. baseline– Tidal volume– Vital capacity– Inspiratory force

Myasthenia Gravis

Nursing interventions• Do not administer

barbiturates, tranquilizers, muscle relaxants, morphine etc.

• Eye care

Myasthenia Gravis

Complications• Myasthenic crisis• Caused by– Not enough med.– Stress

• S&S– Rapid onset of weakness

– Resp. distress

• Treatment– Medication

• IV or IM

– Resp. support• Intubation• PEEP• Suction

– NG tube

Myasthenia Gravis

Complications• Cholinergic crisis• Caused by– Too much med.

• S&S– Rapid onset of weakness

– Resp. distress

• Treatment– Hold medication– Resp. support

• Intubation• PEEP• Suction

– NG tube

Myasthenia Gravis

• How can you tell the difference between Myasthenic crisis and a Cholinergic crisis?– Tensilon test– If they respond to tensilon with increased muscle

strength…• Myasthenic Crisis• They need more medications

– If they respond to the tensilon with increased muscle weakness…• Cholinergic crisis• Hold medications

Myasthenia Gravis

• What can cause a cholinergic crisis?• What are the S&S of a cholinergic crisis?• What is the treatment of a cholinergic crisis?• MG is a disorder of the CNS, PNS or both?• What are the clinical manifestations of MG• How do you confirm the diagnosis of MG?

Myasthenia Gravis

• Myasthenic crisis is caused by what?• What are the S&S of a Myasthenic crisis?• What is the treatment of a Myasthenic crisis?• What is the difference between MG and MS?

(besides the letter G&S)• When you give a Tensilon test how would you

know if they were under medicated?• What meds are used to treat MG?

Guillain-Barre Syndrome

Pathophysiology• Autoimmune disease• The myelin sheath of

the spinal and cranial nerves are destroyed by diffuse inflammatory reaction

Guillain-Barre Syndrome

Is Guillain-Barre Syndrome a disorder of the CNS, PNS or Both?

A. CNSB. PNSC. Both CNS and PNS

Guillain-Barre Syndrome

Pathophysiology• Demyelination– Axon atrophy– Starts distal nerves

• Remyelination– Slow– Descending pattern

Guillain-Barre Syndrome

Pathophysiology• Sudden attack on

myelin • Inflammation • Axon damaged • Paralysis / paresis • Remyelination

• If cell body (soma) NOT destroyed – Recovery

• If sell body (soma) IS destroyed – Some degree of

permanent disability

Guillain-Barre Syndrome

• Etiology• Unknown• In most patients it is

preceded by viral infection

• Men vs. Women– =

Guillain-Barre SyndromeClinical manifestations• Onset

– Abrupt• Symmetrical paresis that

progresses to paralysis• Begins with lower

extremities – Paresthesias– Weakness– Dyskinesia– Paralysis

Guillain-Barre Syndrome

Clinical manifestations• Progresses upward• Resp failure• Bulbar weakness• Recovery

Guillain-Barre Syndrome

Diagnostic exam• CSF– Increased protein

• EEG– Slowing of nerve

conduction

Guillain-Barre Syndrome

Treatment• Considered a medical

emergency• Mechanical ventilation• Immunosuppressant• Anti-coagulants• Plasmapheresis

Guillain-Barre Syndrome

Nursing interventions• Respiratory function• ROM• TED hose• Nutrition• Communication• Anxiety

Guillain-Barre Syndrome

Complications• Resp. failure• PE• Anxiety

Guillain-Barre Syndrome

• What is the pathophysiology of GB?• What is demyelination?• Is GB a disorder of the CNS, PNS or both?• What are the S&S of GB?• What are the initial symptoms of GB?• What is the outcome of GB?• What are the complications associated with GB?

Trigeminal Neuralgia

• AKA – Tic Douloueux

• Pathophysiology – Condition of CN 5– Neuralgia =

• Nerve pain

Trigeminal Neuralgia

Clinical manifestation• Pain occurs when

trigger points are stimulated, causing periods of intense pain and facial twitching

• Begins and ends suddenly

• Worst pain known!

Trigeminal Neuralgia

Clinical Manifestations

•PAIN!!!– Sudden– Stabbing– Burning– Knife-like

Trigeminal Neuralgia

Etiology• Unknown• Men vs Women– Men < women

• Age of onset – 50’s

• Dental work

Trigeminal Neuralgia

Diagnostic exams• Hx• MRI

Trigeminal Neuralgia

Treatment• Anticonvulsants– Examples

• Tegretol• Dilantin

– Action• transmission of nerve

impulse

– S/E• Drowsiness

Trigeminal Neuralgia

• Nerve block– Alcohol and phenol

injected into the nerve– Destroys the nerve –

temporarily

• Surgery

Trigeminal Neuralgia

Nursing Interventions• Goal

– Relieve pain

• Avoid Triggers– Hot & cold foods– Draft areas– Brushing teeth– Chewing food

• Self-care deficit• Depression• Suicide

Trigeminal Neuralgia

Complications• Paralysis• Infection

Trigeminal Neuralgia

• What cranial nerve is involved with trigeminal neuralgia?

• What is the primary nursing diagnosis with a patient with Trigeminal Neuralgia?

• What can trigger Trigeminal neuralgia?• That is Tic Douloureux?• What is Dilantin? What are the side effects of

Dilantin?• What are the S&S is Trigeminal neuralgia?• What is the treatment for trigeminal neuralgia?

Bell’s Palsy

Pathophysiology• Inflammation of CN -7• Resulting in weakness

or paralysis of one side of the face

• Usually resolve in 2-8 weeks

Bell’s Palsy

Clinical Manifestations• Facial pain that radiates

to the eye & ear• eye tearing • Speech difficulties• Distortion of the face• Diminished blink reflex

Bell’s Palsy

Etiology• Unknown

Bell’s Palsy

Medical Treatment• Corticosteriods• Eye drops• Analgesics

Bell’s Palsy

Nursing interventions• Eye care– Patch– Drops

• Moist heat to face• Massage• Electric stim

Bell’s Palsy

• What cranial nerve is involved with Bell’s palsy?

• What is the primary nursing diagnosis with a patient with Bell’s palsy?

• What can trigger Bell’s palsy?• What are the S&S is Bell’s palsy?• What is the treatment for Bell’s palsy?