Chapter 64 Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies

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 Nursing 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.

Normal ACh receptor site Myasthenia Gravis ACh receptor site in myasthenia gravis Normal ACh receptor site

Medical Management Pharmacologic therapy Plasmapheresis Thymectomy 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 Nursing 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.