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Neurology Chapter 64 Management 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. CNS B. PNS C. 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 i 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 severe B. Less severe Encephalitis 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! Meningitis Nursing 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 Meningitis Prevention • 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 • i 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. CNS B. PNS C. Both CNS & PNS Multiple Sclerosis Etiology / 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 • i transmission of impulses from the spinal cord to the skeletal muscle • i spasticity – S/E • Drowsiness, weak Multiple Sclerosis Pharmaceutical • Corticosteriods – Immunosuppressants – Dexamethasone, prednisone – Action • Decreased imflammation – S/E • Poor wound healing • Na+ & H20 retention • h glucose levels Multiple Sclerosis Nursing 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 Gravis Pathophysiology • 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. CNS B. PNS C. Both CNS & PNS Myasthenia Gravis Clinical 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 – i • 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 Gravis Treatment • 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. CNS B. PNS C. 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 Syndrome Clinical 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 • i 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 • h 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?
