Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies

Infectious Neurologic Disorders Meningitis Brain abscesses Encephalitis

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

Meningitis Manifestations 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

Kernig’s Sign

Brudzinski’s Sign

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 Treatment dehydration, shock, and seizures

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

Nursing Management Antibiotic administration Pain management Aggressive fever management Facilitate patient and family coping Supportive care

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

Brain Abscess (cont.) Medical management Nursing 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

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 Amphotericin and/or other antifungal agent for fungal infection

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 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

Autoimmune Neurological Disorders Multiple sclerosis Myasthenia gravis Guillain-Barré syndrome

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%

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

Multiple Sclerosis Diagnosis Medical management 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)

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

Process of Demyelination

Multiple Sclerosis CT Scan and MRI

Types and Courses of Multiple Sclerosis

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 impairment (dysphonia), generalized weakness

Myasthenia Gravis (cont.) ACh receptor site in myasthenia gravis Normal ACh receptor site

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

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**

Myasthenic crisis Cholinergic crisis Caused by overmedication with cholinesterase inhibitors Severe muscle weakness with respiratory and bulbar weakness Hypersalivation and diarrhea Patent may develop respiratory compromise and failure Atropine to treat bradycardia or resp distress Result of disease exacerbation or a precipitating event, most commonly a respiratory infection Severe generalized muscle weakness with respiratory and bulbar weakness Patient may develop respiratory compromise failure

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

Myasthenia Gravis Nursing Management Patient and family teaching 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

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

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

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

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

Nursing Process—Diagnosis of the Patient With Guillain-Barré Syndrome Ineffective breathing pattern Impaired gas exchange Impaired physical mobility Imbalanced nutrition Impaired verbal communication Fear Anxiety

Collaborative Problems/Potential Complications Respiratory failure Autonomic dysfunction Deep vein thrombosis (DVT) Pulmonary embolism Urinary retention

Nursing Process—Planning the Care of the Patient With Guillain-Barré Syndrome Major goals include: Improved respiratory function Increased mobility Improved nutritional status Effective communication Decreased fear and anxiety Effective patient and family coping Absence of complications

Interventions Enhance physical mobility and prevent DVT 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

Interventions (cont.) Develop a plan for communication individualized to patient needs Decrease fear and anxiety 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

Cranial Nerve Disorders Trigeminal neuralgia (tic douloureux) Bell’s palsy

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

Distribution of the Trigeminal Nerve Branches

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

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

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

Management Medical Nursing 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