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

2. 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.

3. Kernig’s Sign
When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Process of Demyelination

13. 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

14. Multiple Sclerosis treatment
No cure exists for MS
Treatment directed toward to relieving the patient's symptoms and provide continuing support.
Immunosuppressive agents

15. 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.

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

17. Medical Management Pharmacologic therapy Plasmapheresis Thymectomy
Cholinesterase inhibitor: pyrostigmine bromide (Mestinon)
Immunomodulating therapy
Plasmapheresis
Thymectomy

18. 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

19. 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

20. 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.

21. 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.