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

2. Infectious Neurologic Disorders
Meningitis
Brain abscesses
Encephalitis

3. 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

4. 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

5. Kernig’s Sign

6. Brudzinski’s Sign

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. Autoimmune Neurological Disorders
Multiple sclerosis
Myasthenia gravis
Guillain-Barré syndrome

15. 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%

16. 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

17. 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)

18. 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

19. Process of Demyelination

20. Multiple Sclerosis CT Scan and MRI

21. Types and Courses of Multiple Sclerosis

22. 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

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

24. 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

25. 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**

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

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

35. 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

36. 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

37. 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

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

39. 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

40. Distribution of the Trigeminal Nerve Branches

41. 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

42. 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

43. 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

44. 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