Neurologic Infections, Autoimmune Disorders, and Neuropathies

Infectious Neurologic Disorders

• Meningitis

• Brain abscesses

• Various types of Encephalitis

• Creutzfeldt–Jakob disease (CJD)

• Variant Creutzfeldt–Jakob disease (vCJD)

Meningitis (what is it, Manifestations)

• Inflammation of the meninges, which cover and protect the brain and spinal cord

• Two main types classified as:

  • Septic caused by bacteria (Streptococcus pneumoniae, Neisseria meningitidis)

    • N. meningitidis is transmitted by secretions or aerosol contamination, and infection is most likely in dense community groups, such as college campuses and military bases

  • Aseptic caused by viral infection secondary to cancer or a weak immune system

• Pathophysiology: Organism crosses BBB and proliferates in the CSF

• Manifestations of Meningitis: headache, fever, chills, nuchal rigidity (stiff and painful neck), positive Kernig sign, positive Brudzinski sign, and photophobia; rash (skin lesions ranging from petechial rash w purpuric lesions to large ecchymosis); changes in LOC, behavioral changes in older adults; seizures

Medical management of Meningitis

• Prevention by meningococcal vaccine

  • Youth @ 11 to 12 years of age w a booster at 16

• Early administration of high doses of appropriate IV antibiotics (Penicillin G w cephalosporins) for bacterial meningitis

• If exposed, then treat w antimicrobial chemoprophylaxis (rifampin, ciprofloxacin, or ceftriaxone) within 24 hours after exposure

• Dexamethasone (Decadron)

• Treatment for dehydration, shock, and seizures

Nursing management of Meningitis

• Frequent or continual assessment, including VS and LOC

• Pain and fever management

• Protect patient from injury related to seizure activity or altered LOC

  • Hyperthermia: worried about seizures

• 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

Encephalitis

• Acute, inflammatory process of the brain tissue

• Causes: viral infections (herpes simplex virus [HSV] is most common in the US), vector-borne viral infections (West Nile, St. Louis), and fungal infections

• Manifestations: headache, fever, confusion, hallucinations; vector borne-rash, flaccid paralysis, Parkinson-like movements

• Medical management: Acyclovir for HSV infection, amphotericin or other antifungal agents for fungal infection

• Nursing management: Frequent and ongoing neuro assessment; supportive care

• Diagnostic tests: spinal tap (checking CSF), EEG (also used for seizure)

Multiple Sclerosis (MS)

• A progressive immune-related demyelinating disease of the CNS

  • Destruction of myelin sheath (the fatty and protein material that surrounds certain nerve fibers in the brain and spinal cord)

• Clinical manifestations: vary w different patterns

  • Relapsing and remitting: 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 β- 1a and interferon β-1b, glatiramer acetate, and IV methylprednisolone

    • targets immune system; flu like symptoms leukakine increased LFTs, h/a, deprssion & skin necrosis

    • Still need to be on steriod so would switch to PO predison (rather then IV) → tapered started slow → supress immune,, supresses adrenal, mood swings, weight gain, electrolyte imblalence etc.

  • Symptom management of muscle spasms, fatigue, ataxia, bowel and bladder control

How is patient with Multiple Sclerosis assessed

Neurologic deficits

Secondary complications

Impact of disease on physical, social, and emotional

function and on lifestyle

Patient and family coping

What are the Nursing interventions of patient with Multiple Sclerosis?

• Use a collaborative approach

• Coordinate and refer as needed to health care services: social services, speech therapy, physical therapy, counseling services, home care services, and so on

• Activity and rest

  • Program of activity and daily exercise

  • Relaxation, coordination exercises, walking, muscle- stretching exercises

  • Avoid very strenuous activity and extreme fatigue

• Bowel and bladder control

  • Instruction or administration of prescribed medications

  • Voiding schedule

  • Bowel training program

  • Adequate fluid and fiber to prevent constipation

• Reinforce and encourage swallowing instructions

• Strategies to reduce risk of aspiration

• Memory aides, structured environment, and daily routine to enhance cognitive function

• Interventions to minimize stress

• Maintenance of temperate environment—air conditioning to avoid excessive heat and avoidance of exposure to extreme cold

• Use assistive devices and modifications for home care management and independence in ADLs

• Support of coping

Myasthenia Gravis

• Autoimmune disorder where antibodies directed at acetylcholine receptor sites impair transmission of impulses at the myoneural junction

• Characterized by varying degrees of weakness of voluntary muscles (purely motor disorder) → Blocks messaging

• Manifestations: variable; ocular (diplopia and ptosis); generalized (weakness of facial muscles, swallowing and voice impairment (dysphonia), generalized weakness)

Medical management of Myasthenia Gravis

• Directed at improving function and reducing and removing circulating antibodies

• Pharmacologic therapy

  • Anticholinesterase medications and immunosuppressive therapy

  • Intravenous immune globulin (IVIG) → S/E; h/a, migraine, & flu like symptoms

• Therapeutic plasma exchange - plasmapheresis

• Thymectomy (removal of the thymus gland)

• No cure for myasthenia gravis

Differenciate between Myasthenic Crisis & Cholinergic Crisis

• Get O2 stat, respiratory support → avoid sedatives and tranquilizers to prevent resp. issues

Myasthenic Crisis

• Result of disease exacerbation or precipitating event, most commonly a respiratory infection

• Severe generalized muscle weakness with respiratory and bulbar weakness

• Patient may develop respiratory compromise/failure

Cholinergic Crisis

• Caused by overmedication with cholinesterase inhibitors

• Severe muscle weakness with respiratory and bulbar weakness

• Patient may develop respiratory compromise and failure

Guillain- Barre Syndrome

• Autoimmune disorder with acute attack of peripheral nerve myelin

  • Rapid segmental demyelination of peripheral nerves producing ascending weakness w dyskinesia (inability to execute voluntary movements), hyporeflexia, and paresthesia (pins and needles sensation) → symptoms from feet up

  • Rapid demyelination may produce respiratory failure and autonomic nervous system dysfunction with CV instability

• Most often follows a viral infection

• Manifestations: variable; weakness, paralysis, paresthesia, pain, and diminished or absent reflexes,; bulbar weakness; cranial nerve symptoms; tachycardia; bradycardia; hypertension; or hypotension

Medical Management of Guillain- Barre Syndrome

• A medical emergency b/c of rapid progression

• Requires intensive care management with continuous monitoring and respiratory support

• Therapeutic plasma exchange and IVIG are used to reduce circulating antibodies

• Recovery rates vary, but most patients recover completely

How is patient with Guillain- Barre Syndrome assessed?

• Ongoing assessment with emphasis on early detection of life-threatening complications of respiratory failure, cardiac dysrhythmias, and deep vein thrombosis (DVT)

• Monitor for changes in vital capacity and negative inspiratory force

• Assess VS frequently or continuously, including continuous monitoring of ECG

• Patient and family coping

What are the nursing interventions for patient with Guillain- Barre Syndrome assessed?

• Enhancing physical mobility and prevention of DVT

  • Support limbs in functional position

  • Passive ROM at least twice daily

  • Frequent position changes at least every 2 hours

  • Elastic compression hose or sequential compression boots

  • Adequate hydration

• Administer IV and parenteral nutrition as prescribed

• Carefully assess swallowing and gag reflex and take measures to prevent aspiration

• Develop a plan for communication individualized to patient needs

• Decreasing fear and anxiety

  • Provide information and support

  • Referral to support group

  • Relaxation measures

  • Maintain positive attitude and atmosphere to promote a sense of well-being

  • Diversional activities

Cranial nerve disorders (diagram)

Trigeminal Neuralgia (Tic Douloureux)

• Condition of the fifth cranial nerve characterized by paroxysms of pain → extreme

  • Most commonly occurs in the second and third branches of this nerve

• Vascular compression and pressure is the probable cause

• Occurs more often in the fifth and sixth decades and in women and persons with MS

• 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 even isolate themselves to prevent attacks

Medical management of Trigeminal Neuralgia

• Anticonvulsant agents (carbamazepine-tegratol) for pain- (4-12)

  • Take with food, watch serum levels for toxicity, nausea, dizziness, drowsiness, aplastic anemia

  • SJS- Steven johnsons syndrome: severe skin and mucous membrane reactions, typically triggered by medications or infections. It begins with flu-like symptoms followed by a painful red/purple rash that blisters and causes the skin to peel, affecting less than 10% of the body surface area. → use suncreen, more used as anticonvulsent rather then mood stabilizer

  • Hepatotoxic & teratogenic

  • Check serium sodium, LFT, CBC (serious blood disorders)

  • What are the nursing considerations: avoid grapefruit juice, affect birth control, report signs of infection (agranulocytosis), use sunscreen

• Gabapentin and antispasmodic (baclofen) → good for nerve pain

• Phenytoin as adjunctive therapy

• Surgical treatment

  • Microvascular decompression of the trigeminal nerve

  • Radiofrequency thermal coagulation

  • Percutaneous balloon microcompression

What are the nursing interventions for Trigeminal Neuralgia?

• Patient education 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, avoid hot and cold food

• Recognize and provide interventions to address anxiety, depression, and insomnia

Bell’s Palsy

• Facial paralysis caused by unilateral inflammation of the seventh 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 to 5 weeks, and the disorder rarely recurs

How is Bell’s Palsy management?

• Medical

  • Corticosteroid therapy may be used to reduce inflammation and edema

• 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 and sunglasses

  • Facial exercises and massage to maintain muscle tone