copyright © 2008 lippincott williams & wilkins. 1 management of patients with neurologic...

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Copyright © 2008 Lippincott Williams & Wilkins.

Management of Patients

With Neurologic Infections, Autoimmune Disorders,

and Neuropathies

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Infectious Neurologic Disorders

• Meningitis

• Brain abscesses

• Encephalitis

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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

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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

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Kernig’s Sign

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Brudzinski’s Sign

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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

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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

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Nursing Management

• Antibiotic administration

• Pain management

• Aggressive fever management

• Facilitate patient and family coping

• Supportive care

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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

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Brain Abscess (cont.)• Medical 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

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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

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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

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Autoimmune Neurological Disorders

• Multiple sclerosis

• Myasthenia gravis

• Guillain-Barré syndrome

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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%

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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

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Multiple Sclerosis• Diagnosis

– 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)

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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

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Process of Demyelination

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Multiple Sclerosis CT Scan and MRI

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Types and Courses of Multiple Sclerosis

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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

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Myasthenia Gravis (cont.)

ACh receptor site in myasthenia gravis

Normal ACh receptor site

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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

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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**

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Myasthenic crisis Cholinergic crisis

• 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

• 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

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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

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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

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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

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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

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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

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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

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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

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Collaborative Problems/Potential Complications

• Respiratory failure

• Autonomic dysfunction

• Deep vein thrombosis (DVT)

• Pulmonary embolism

• Urinary retention

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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

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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

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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

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Cranial Nerve Disorders

• Trigeminal neuralgia (tic douloureux)

• Bell’s palsy

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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

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Distribution of the Trigeminal Nerve Branches

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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

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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

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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

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Management• Medical

– 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

copyright © 2008 lippincott williams & wilkins. 1 management of patients with neurologic...

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