Download Chapter 64 Management of Patients with Neurologic Infections

Meningitis
 Inflammation of the membranes and the fluid space surrounding the
brain and spinal cord
 Types
 Septic due to bacteria (Streptococcus pneumoniae, Neisseria
meningitidis)
 Aseptic due viral infection, lymphoma, leukemia, or brain abscess
 N. meningitidis is transmitted by secretions or aerosol contamination
and infection is most likely in dense community groups such as college
campuses
 Manifestations include headache, fever, changes in LOC, behavioral
changes, nuchal rigidity (stiff neck), projectile vomiting, positive
Kernig's sign, positive Brudzinski’s sign, and photophobia, ? seizure.
Kernig’s Sign
When the patient is lying with the thigh flexed on the
abdomen, the leg cannot be completely extended
Brudzinski’s Sign
When the patient's neck is flexed (after ruling out cervical trauma or injury),
flexion of the knees and hips is produced; when the lower extremity of one side is
passively flexed, a similar movement is seen in the opposite extremity
Assessment and Diagnostic Findings
 Bacterial culture and Gram staining of CSF and blood
are key diagnostic tests (Fischbach, 2002).
 The presence of polysaccharide antigen in CSF further
supports the diagnosis of bacterial meningitis
Medical Management
 Prevention by vaccination against Haemophilus
influenzae and S. pneumoniae for all children and all
at-risk adults
 Early administration of high doses of appropriate IV
antibiotics (should cross BBB) for bacterial meningitis
 Dexamethasone
 Treatment dehydration, shock, and seizures
Nursing Management
 Frequent/continual assessment including VS and LOC
 Protect patient form injury related to seizure activity
or altered LOC
 Monitor daily weight, serum electrolytes, urine
volume, specific gravity, and osmolality
 Prevent complications associated with immobility
 Infection control precautions
 Supportive care
 Measures to facilitate coping of patient and family
Brain Abscess
 Collection of infectious material within brain tissue
 Risk is increased in immunocompromised patient
 Prevent by treating otitis media, mastoiditis, sinusitis,
dental infections, and systemic infections promptly
 Manifestations may include headache that is usually
worse in the morning, fever, vomiting, neurologic
deficits, signs and symptoms of increased ICP
 Diagnosis by MRI or CT
 CT-guided aspiration is used to identify the causative
organisms
Brain Abscess
 Medical management
 Control ICP
 Drain abscess
 Administer appropriate antibiotic therapy. Corticosteroids
may be used to treat cerebral edema
 Nursing management
 Frequent and ongoing neurologic assessment and of
responses to treatment
 Assure patient safety and protect from injury
 Provide supportive care
Encephalitis
 Acute, inflammatory process of the brain tissue
 Causes include viral infections (herpes simplex [HSV]), vector-borne viral
infections (West Nile, St. Louis), and fungal infections
 Manifestations may include headache, fever, confusion, changes in LOC;
rash, flaccid paralysis, Parkinson-like movements
 Medical management
 Acyclovir for HSV infection, amphotericin and/or other antifungal
agents for fungal infection
 Nursing management
 Frequent and ongoing assessment
 Supportive care
Multiple Sclerosis (MS)
 A progressive immune-related demyelination disease of
the CNS
 Clinical manifestations vary and have different patterns
 Frequently, the disease is relapsing and remitting, has
exacerbations and recurrences of symptoms including
fatigue, weakness, numbness, difficulty in coordination,
loss of balance, pain, and visual disturbances
 Medical management
 Disease-modifying therapies; interferon -1a and interferon
-1b, glatiramer acetate (Copaxone), and IV
methylprednisolone
 Symptom management of muscle spasms, fatigue, ataxia,
bowel and bladder control
Process of Demyelination
Clinical Manifestations
 Has a relapsing remitting (RR) course. With each
relapse, recovery is usually complete.
 Quadriparesis, cognitive dysfunction, visual loss.
 Fatigue, depression, weakness, numbness, difficulty in
coordination, loss of balance, and pain. Visual
disturbances due to lesions in the optic nerves or their
connections may include blurring of vision, diplopia
(double vision), patchy blindness (scotoma), and total
blindness.
 Spasticity (muscle hypertonicity) of the extremities
Multiple Sclerosis treatment
 No cure exists for MS
 Treatment directed toward to relieving the patient's
symptoms and provide continuing support.
 Immunosuppressive agents
Myasthenia Gravis
 Autoimmune disorder affecting the myoneural junction
 Antibodies directed at acetylcholine at the myoneural
junction impair transmission of impulses
 Manifestations
 Myasthenia gravis, a motor disorder
 Initially symptoms involve ocular muscles; diplopia and ptosis
 Weakness of facial muscles, swallowing and voice impairment
(dysphonia), generalized weakness, weakness affects all the
extremities and the intercostal muscles, resulting in
decreasing vital capacity and respiratory failure.
Myasthenia Gravis
Normal ACh receptor site
ACh receptor site in
myasthenia gravis
Medical Management
 Pharmacologic therapy
 Cholinesterase inhibitor: pyrostigmine bromide
(Mestinon)
 Immunomodulating therapy
 Plasmapheresis
 Thymectomy
Guillain-Barré Syndrome
 Autoimmune disorder with acute attack of peripheral
nerve myelin
 Rapid demyelination may produce respiratory failure and
autonomic nervous system dysfunction with CV
instability
 Most often follows a viral infection
 Manifestations are variable and may include weakness,
paralysis, paresthesias, pain, and diminished or absent
reflexes starting with the lower extremities and
progressing upward; tachycardia; bradycardia;
hypertension; or hypotension
Guillain-Barré Syndrome
 Medical management
 Requires intensive care management with continuous
monitoring and respiratory support
 Plasmapheresis used to reduce circulating antibodies
 Recovery rates vary, but most patients recover
completely
Bell’s Palsy
 Facial paralysis due to unilateral
inflammation of the 7th cranial
nerve
 Manifestations—unilateral facial
muscle weakness or paralysis with
facial distortion, increased
lacrimation, and painful
sensations in the face, may have
difficulty with speech and eating
 Most patients recover completely
in 3–5 weeks and the disorder
rarely recurs.
Management
 Medical
 Corticosteroid therapy may be used to reduce
inflammation and diminish severity of the disorder.
 Nursing
 Provide and reinforce information and reassurance that
stroke has not occurred.
 Protection of the eye from injury; cover eye with shield
at night, instruct patient to close eyelid, use of eye
ointment, sunglasses.
 Facial exercises and massage to maintain muscle tone.