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Management of Patients
With Neurologic Infections,
Autoimmune Disorders,
and Neuropathies
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Copyright © 2008 Lippincott Williams & Wilkins.
Infectious Neurologic Disorders
• Meningitis
• Brain abscesses
• Encephalitis
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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 to 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
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• Manifestations
Meningitis
– Headache, fever (earliest)
– Changes in LOC
– behavioral changes
– nuchal rigidity (stiff neck)
– positive Kernig's sign, positive Brudzinski’s sign
– photophobia
– Petechial or purpuric rash in N. menigitidis
– Seizures
– Shock and death in fulminant cases
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Kernig’s Sign
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Brudzinski’s Sign
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Medical Management
• Diagnosis via LP and CSF culture; presentation
• Prognosis depends on causative organism, severity
of infection and timeliness of treatment
• Prevention by vaccination against H. influenzae and
S. pneumoniae for all children and at-risk adults
• Early administration of high doses of appropriate IV
antibiotics for bacterial meningitis
• Dexamethasone to decrease ICP
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• Treatment dehydration, shock, and seizures
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Nursing Management
• Conduct frequent/continual assessment including VS
and LOC
– Monitor for s/sx of increasing ICP, shock, hyperthemia
• Protect patient form injury related to seizure activity
or altered LOC
• Measures to prevent increased ICP
• Monitor daily weight, serum electrolytes, urine
volume, specific gravity, and osmolality
• Prevent complications associated with immobility
• Take infection control precautions (for at least 24 hr)
– Oral and nasal secretions infectious
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Nursing Management
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Antibiotic administration
Pain management
Aggressive fever management
Facilitate patient and family coping
Supportive care
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Brain Abscess
• Collection of infectious material within brain tissue
(usually bacteria)
• Risk is increased in immunocompromised patient
• Prevent by treating otitis media, mastoiditis,
sinusitis, dental infections, and systemic infections
promptly
• Manifestations include headache that is usually
worse in the morning, fever, vomiting, neurologic
deficits, and signs and symptoms of increased ICP
• Diagnosis by MRI or CT
• CT-guided aspiration is used to identify the
causative organisms
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Brain Abscess (cont.)
• Medical management
– Control ICP
– Surgical management - drain abscess
– Administer appropriate antibiotic therapy; corticosteroids
may be used to treat cerebral edema
• Nursing management
– Conduct frequent and ongoing neurologic assessment
and responses to treatment
– Ensure patient safety and protect him from injury
– Monitor serum lytes and glucose
– Provide supportive care
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Encephalitis
• Acute, inflammatory process of the brain tissue
• Causes include:
– viral infections (herpes simplex [HSV], cytomegalovirus)
– vector-borne viral infections (West Nile, St. Louis)-via bite
– fungal infections
• Manifestations include focal neuro symptoms, headache,
fever, confusion, changes in LOC, seizures, vector-borne
rash, flaccid paralysis, and Parkinson-like movements
• Medical management
– Acyclovir for HSV infection
– Mainly supportive care of viral infections: control seizures and
ICP
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– Amphotericin and/or other antifungal agent for fungal infection
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Encephalitis
• Nursing Management
– Ongoing neuro assessment to monitor progression of disease
and for increasing ICP
– Prevention of seizures, appropriate care if they occur
– Administer prescribed treatments
• Monitor for adverse reactions, including liver/kidney profiles
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Calm, comfortable atmosphere
Pain management
Family support
Public education re: prevention of arboviral encephalitis
• Avoid mosquito bites: insect repellents with DEET, remove standing
water, appropriate clothing
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Autoimmune Neurological
Disorders
• Multiple sclerosis
• Myasthenia gravis
• Guillain-Barré
syndrome
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Multiple Sclerosis (MS)
• A progressive, degenerative immune-related
demyelination disease of the CNS (destruction
of myelin sheaths that insulate axons)
– Myelin is replaced with scar tissue
– Flow of nerve impulses is interrupted
• Usual onset age 15-50
• Clinical manifestations vary and have different
patterns
– Relapsing Remitting (RR) 80-85%
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Multiple Sclerosis (MS)
• Insidious onset
• Often, the disease relapses and remits,
exacerbates, and symptoms recur including:
fatigue (87%), weakness, numbness, difficulty
in coordination (ataxia), loss of balance,
neuropathic pain, and visual disturbances (esp.
diplopia, scotoma)
• Bowel and bladder problems
• Spasticity of the extremities
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Multiple Sclerosis
• Diagnosis
– MRI (plaques in the CNS), electrophoresis of CSF
• Medical management
– Goal of therapy are to delay progression of disease, manage
chronic symptoms and exacerbations
– Disease-modifying therapies: beta- interferon (Betoseron,
Avonex), glatiramer acetate (Copaxone)
• Administered SC; should be started early in disease
– IV methylprednisolone for acute exacerbations
– Symptom management of muscle spasms
(baclofen,benzodiazepine, tizanidine) fatigue
(antidepressants), ataxia (beta blockers), bowel (fiber, stool
softeners), bladder (cholinergics or anticholinergics - depends
on problem)
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Multiple Sclerosis
• Nursing management
– Teaching regarding triggers of exacerbation
– Preventing immobility
• When it does occur, preventing complication
– Education regarding medication
– Emphasizing good nutrition
• High protein diet with vitamin supplementation
• High fiber to prevent constipation
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Process of Demyelination
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Multiple Sclerosis CT Scan and
MRI
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Types and Courses of Multiple
Sclerosis
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Myasthenia Gravis
• Autoimmune disorder affecting the neuromuscular
junction, characterized by varying degrees of
weakness in the voluntary muscles
– Women>men; thymus gland
• Antibodies directed at acetylcholine at the
myoneural junction impair transmission of impulses
• Manifestations
– Myasthenia gravis is a motor disorder
– Initially, symptoms involve ocular muscles, causing
conditions such as diplopia and ptosis
– Weakness of facial muscles, swallowing and voice
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Williams & Wilkins.
impairment (dysphonia),
generalized
weakness
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Myasthenia Gravis (cont.)
Normal ACh receptor site
ACh receptor site in
myasthenia gravis
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Mysathenia Gravis
• Acetylcholinesterase inhibitor test (Tensilon test)
• Acetylcholinesterase inhibitor stops the
breakdown of Ach, thereby increasing
availability
• Following administration of IV Tensilon, facial
weakness and ptosis resolve for 3 minutes
– This represents a positive test and confirms
diagnosis
– Also aids in diagnosis of cholinergic crisis - Tensilon
will worsen symptoms
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Medical Management
• Pharmacologic therapy
– Cholinesterase inhibitor: pyrostigmine and neostigmine
- inhibits Ach breakdown
 Adverse reactions
– Immunosuppressants reduce antibody production
• Plasmapheresis - remove antibody-containing
plasm
• Thymectomy - may lead to partial/full remission
• **Many medications are contraindicated in
patients with MG, including various antibiotics, CV
drugs, psychotropic drugs**
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Myasthenic crisis
Cholinergic crisis
• Caused by
• Result of disease
overmedication with
exacerbation or a
cholinesterase inhibitors
precipitating event, most
• Severe muscle weakness
commonly a respiratory
with respiratory and
infection
bulbar weakness
• Severe generalized muscle
• Hypersalivation and
weakness with respiratory
diarrhea
and bulbar weakness
• Patent may develop
• Patient may develop
respiratory compromise
respiratory compromise
and failure
failure
• Atropine to treat
bradycardia or resp 26
distress
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Management of Myasthenic
Crisis
• Patient instruction in signs and symptoms of
myasthenic crisis and cholinergic crisis
• Ensuring adequate ventilation; intubation and
mechanical ventilation may be needed
• Assessment and supportive measures include:
– Ensure airway and respiratory support
– Take ABGs, serum electrolytes, I&O, and daily weight
– If patient cannot swallow, nasogastric feeding may be
required
– Avoid sedatives and tranquilizers
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Myasthenia Gravis
• Nursing Management
– Patient and family teaching
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Medication management (SE, schedule, adherence)
Strategies to conserve energy
Risk of aspiration
Factors that promote exacerbations
– Stress, illness, medications, high temperature
• Recognition of symptoms of crisis
– Management of crisis
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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; rarely
vaccine
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Guillain-Barré Syndrome
• Characterized by ascending weakness
• Manifestations are variable and include
weakness, paralysis, paresthesias, pain,
diminished or absent reflexes starting with the
lower extremities and progressing upward,
bulbar weakness, cranial nerve symptoms,
tachycardia, bradycardia, hypertension, or
hypotension
• Plateau often includes respiratory failure
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Guillain-Barré Syndrome (cont.)
• Medical management
– Requires intensive care management with continuous
monitoring and respiratory support
– Plasmapheresis and IVIG are used to reduce
circulating antibodies
• May reduce course of disease
– Management of cardiovascular effects of autonomic
dysfunction
• Recovery rates vary but most patients recover
completely - may take up to 2 years
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Nursing Process—Assessment of
the Patient With Guillain-Barré
Syndrome
• Conduct ongoing assessment with emphasis on
early detection of life-threatening complications of
respiratory failure, cardiac dysrhythmias, and
deep vein thrombosis
• Monitor for changes in vital capacity and negative
inspiratory force
• Assess VS frequently/continuously including
continuous monitoring of ECG
• Encourage patient and family coping
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Nursing Process—Diagnosis of
the
Patient With Guillain-Barré
Syndrome
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Ineffective breathing pattern
Impaired gas exchange
Impaired physical mobility
Imbalanced nutrition
Impaired verbal communication
Fear
Anxiety
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Collaborative Problems/Potential
Complications
• Respiratory failure
• Autonomic dysfunction
• Deep vein thrombosis
(DVT)
• Pulmonary embolism
• Urinary retention
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Nursing Process—Planning the
Care of the Patient With GuillainBarré Syndrome
• Major goals include:
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Improved respiratory function
Increased mobility
Improved nutritional status
Effective communication
Decreased fear and anxiety
Effective patient and family coping
Absence of complications
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Interventions
• Enhance physical mobility and prevent DVT
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Support limbs in a functional position
Perform passive ROM at least twice daily
Initiate position changes at least every 2 hours
Provide elastic compression hose and/or sequential
compression boots
– Provide adequate hydration
• Administer IV and parenteral nutrition as
prescribed
• Carefully assess swallowing and gag reflex and
take measures to prevent aspiration
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Interventions (cont.)
• Develop a plan for communication
individualized to patient needs
• Decrease fear and anxiety
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Provide information and support
Provide referral to support group
Implement relaxation measures
Maintain positive attitude and atmosphere to
promote a sense of well-being
– Implement diversional activities
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Cranial Nerve Disorders
• Trigeminal neuralgia (tic
douloureux)
• Bell’s palsy
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Trigeminal Neuralgia (Tic
Douloureux)
• Condition of the 5th cranial nerve characterized by
paroxysms of pain
– Most commonly occurs in the 2nd and 3rd branches of this
nerve; vascular compression and pressure is the probable
cause
• Occurs more often in persons in their 50s and 60s, in
women, and in persons with multiple sclerosis
• Pain can occur with any stimulation such as washing
face, brushing teeth, eating, or a draft of air
• Patients may avoid eating, neglect hygiene, and may
even isolate themselves to prevent attacks
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Distribution of the
Trigeminal Nerve Branches
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Medical Management
• Antiseizure medications such as
carbamazepine (Tegretol), gabapentin
(Neurontin), phenytoin, or the
antispasmodic medication baclofen
(Lioresal)
• Surgical treatment
– Microvascular decompression of the
trigeminal nerve
– Radiofrequency thermal coagulation
– Percutaneous balloon microcompression
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Nursing Interventions
• Patient teaching related to pain prevention and
treatment regimen
• Measures to reduce and prevent pain; avoidance of
triggers
• Care of the patient experiencing chronic pain
• Measures to maintain hygiene: washing face, oral
care
• Strategies to ensure nutrition: soft food, chew on
unaffected side, and avoid hot and cold food
• Recognize and provide interventions to address
anxiety, depression, and insomnia
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Bell’s Palsy
• Facial paralysis due to unilateral inflammation of
the 7th cranial nerve
– Cause unknown; viral, autoimmune, vascular theories
• Manifestations: unilateral facial muscle
weakness or paralysis with facial distortion,
increased lacrimation, painful sensations in the
face, and possible difficulty with speech and
eating
• Most patients recover completely in 3 to 5
weeks, and the disorder rarely recurs
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Management
• Medical
– Corticosteroid therapy may be used to reduce
inflammation and diminish severity of the disorder
• Nursing
– Provide and reinforce information and reassure patient
that a stroke has not occurred
– Protect the eye from injury, cover the eye with a shield at
night, and instruct the patient to close the eyelid, use eye
ointment, and wear sunglasses
– Implement facial exercises and massage to maintain
muscle tone
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