Transcript Neurology - Porterville College

Neurology
Chapter 64
Management of Patients with
neurologic infection, autoimmune
disorders and neuropathies
Meningitis
• Pathophysiology
• Meningitis
– Infection/ inflammation
of the meninges
• Encephalitis
– Infection/inflammation
of the brain tissue
Meningitis
Pathophysiology
• Meningitis/ encephalitis 
• Infection 
• Immune response 
• Swelling/edema 
• I –ICP 
• Etc.
Meningitis
Is meningitis a disorder of the CNS, PNS or both?
A. CNS
B. PNS
C. Both CNS & PNS
Meningitis
The most common bacterial pathogens are:
• Haemonphili influenzai
– Affected kids < 5 yrs
– H influenzae vaccine (Hib)
• Streptococcus pneumoniae
– Affects age 19-59
• Neisseria meningitides
– Easily transmitted to others
– Least lethal
Meningitis
Two ways the infectious agent can inter the
meninges
• Blood stream
– Most common
– Usually d/t URI
• Direct extension
– TBI
– Invasive procedures
Meningitis
• The viral type of
meningitis is usually
– Self limiting
– Benign
• Bacterial meningitis is
potentially
– Fatal
Meningitis
Clinical manifestations
• Onset:
– Abrupt
• General S&S
–
–
–
–
Nuchal rigidity
Positive Kernig's
Positive Brudzinski’s
Photophobia
Meningitis
Clinical Manifestations
• S&S of infection
– Fever
– Chills
Meningitis
Clinical manifestations
• S&S of I-ICP
–
–
–
–
–
H/A
i LOC
Vomiting
Papilledema
Hydrocephalus
Meningitis
Clinical manifestations
• N. Meningitidis
–
–
–
–
Rash
Petechial
Purpuric lesion
Ecchymosis
Meningitis
Clinical manifestations
• Infants/young children
• Seizures
• High-pitched cry
• Bulging fontanels
Meningitis
•
Mr. Jones has encephalitis. Would you
expect his signs and symptoms to be more
or les severe than a person with meningitis?
A. More severe
B. Less severe
Encephalitis signs and symptoms are more
severe with delirium & seizures.
Meningitis
Diagnosis
• Lumbar tap
– C&S of CSF
• Positive Kernig’s
• Positive Brudzinski
Meningitis
Treatment
• Broad spectrum
antibiotics
– Penicillin
– Cephalosporin's
• Intrathecally
• Early intervention
crucial!
Meningitis
Nursing interventions
• Isolation
– ? Causative agent
• Assessment
–
–
–
–
–
–
–
V/S
Neuro check
Cranial nerve involvement
Abn sleep patterns
Behavioral changes
ABG’s
Opisthotonus
Meningitis
Nursing management
• I-ICP protocol
–
–
–
–
–
–
–
–
I&O
Quiet environment: Dark
Limit visitors
Nutrition
No constipation
Pad side rails
Emotional support
Alkalosis
Meningitis
Prevention
• Haemonphilus vaccine
– HiB
• meningococcal conjugate
vaccine
– persons aged 11 to 55 years.
– designed to offer protection
against four serogroups of
Neisseria meningitidis (A, C, Y,
W-135), which account for
approximately 70 percent of
cases in the United States.
Meningitis
Complications
• Thrombosis
• i cerebral blood flow
• Brain damage
• Death
Meningitis
•
•
•
•
•
What do bulging fontanel’s in an infant indicate?
What type of meningitis occurs most frequently
and is considered the milder form?
What are the symptoms of meningitis?
To facilitate performing the lumbar puncture, on
the patient who may have meningitis, it is best for
the nurse to place the patient in what position?
After the lumbar puncture has been performed, it
is best for the nurse to do
Meningitis
• What standard vaccine is administered to infants to
prevent meningitis?
• Identify the bacteria most commonly associated with
meningitis
• What is the most severe form of meningitis?
• What affect does meningitis have of the physiology
of the brain?
• Name six signs and symptoms of bacteria meningitis
• Is meningitis a disease of the CNS or PNS
Brain Abscess
Pathophysiology
• A collection of
infectious material
within the tissue of the
brain
• Infection 
• I-ICP 
• Brain shift
Brain Abscess
2 ways infection can enter
the brain
• Direct invasion
• Spread from nearby
sight
– Sinuses
– Ears
– Teeth
Tongue piercing causes brain abscess
• 13 December 2001 New Scientist
• Parents now have another reason to frown on tongue piercing
- a potentially fatal brain abscess suffered by a young woman
in Connecticut.
• The woman's tongue became sore and swollen two or three
days after it was pierced, and she reported a foul-tasting
discharge from the pierced region. The infection healed in a
few days after she removed the stud from her tongue, but a
month later she suffered severe headaches, fever, nausea and
vomiting.
• A scan at the Yale University hospital revealed the brain
abscess, which physicians drained. She recovered after six
weeks of intravenous antibiotic treatment.
Brain Abscess
Clinical manifestations
• I-ICP
• Infection
• Fever?
– Sometimes
– Sometimes not!
Brain Abscess
Diagnostic findings
• CT
• MRI
Brain Abscess
Medical Management
• Antimicrobial therapy
– Large IV doses
• Surgery
• Anti-convulsant
Brain Abscess
Nursing management
• I-ICP protocol
• Neuro assessment
• Safety protocol
– seizures
Brain Abscess
•
•
•
Who is most at risk for brain abscesses?
Describe the medical treatment for a patient
with a brain abscess?
Is a brain abscess a diseases of the CNS, PNS
or both?
Multiple Sclerosis
Pathophysiology
• Autoimmune disease
• Demyelination of the
myelin covering that
protects the neurons of
the brain and spinal
cord
Multiple Sclerosis
• Demyelination
– Destruction of the
myelin sheath 
– Impaired transmission of
nerve impulses
– Both the axon & myelin
are attacked
Multiple Sclerosis
•
Is multiple sclerosis a disorder of the CNS,
PNS or both?
A. CNS
B. PNS
C. Both CNS & PNS
Multiple Sclerosis
Etiology / Contributing factors
• Unknown cause
• Men vs women
– Men < women
• Age of onset
– 20-40
Multiple Sclerosis
Clinical manifestations
• Usually slow, progressive disease
• Relapsing-remitting course
• Patient may experience remission &
exacerbation’s
– Exacerbation of symptoms 
– Partial/full remission 
– Symptoms return
Multiple Sclerosis
Clinical Manifestations
• Episodes of motor, visual or
sensory disturbance
• Visual disturbances
– Diplopia
– Blurred vision
• Paresthesia
• Fatigue
• Dizziness
Multiple Sclerosis
Clinical Manifestations
• Emotional disturbances
• Scanning speech
• Incontinence
• Sexual disorders
• Spasticity
– Muscle hypertonicity
Multiple Sclerosis
Diagnosis
• MRI
– Sm. Plaque
– Patches
• CT scan
• Lumbar puncture
– Immunoglobulin
abnormalities
Multiple Sclerosis
Medical management
• No cure
• Goal
– Delay progress
• Manage symptoms
Multiple Sclerosis
Pharmaceutical
• Interferons
– ABC&R
Multiple Sclerosis
Pharmaceutical
• Skeletal muscle
relaxants
– Baclofen/lioresal
• i transmission of
impulses from the spinal
cord to the skeletal
muscle 
• i spasticity
– S/E
• Drowsiness, weak
Multiple Sclerosis
Pharmaceutical
• Corticosteriods
– Immunosuppressants
– Dexamethasone, prednisone
– Action
• Decreased imflammation
– S/E
• Poor wound healing
• Na+ & H20 retention
• h glucose levels
Multiple Sclerosis
Nursing Interventions
• Individualized
• B&B management
• Avoid stress
– Stress
– Fatigue
– Extreme temp.
• Exercise
• Fluids
• Diet
– High roughage
Multiple Sclerosis
Complications
• Pneumonia
• Decubitis ulcers
• Contractures
• Dependency
Multiple Sclerosis
•
•
•
•
•
What is the pathophysiology of MS?
Is MS a disease of the CNS, PNS, or both?
Explain what demyelination refers to.
What role does temperature play in multiple
sclerosis?
Identify 5 common signs and symptoms of
MS.
Multiple Sclerosis
• What classifications of medications are used in
treating MS?
• What is the progression of multiple sclerosis
• What is the most common symptom associated with
MS? When does the individual usually seed medical
help?
• What can exacerbate MS?
• What is a long term goal for a patient with MS?
Myasthenia Gravis
Pathophysiology
• Auto-immune
– Progressive disease
– Remission & exacerbation
• Flaw in transmission of
impulses from the nerve to
the muscle
– Neuro-muscular junction
• Most often affects the
muscles regulated by the
cranial nerves
Myasthenia Gravis
Pathophysiology
• Specifically attacks
receptors for
acetylcholine 
• Prevents muscle
contraction 
• Progressive weakness &
fatigue
Myasthenia Gravis
•
Is myasthenia Gravis a disorder of the CNS,
PNS or both?
A. CNS
B. PNS
C. Both CNS & PNS
Myasthenia Gravis
Clinical manifestations
• Onset
– Gradual
• Early
– Ptosis
– Diplopia
• Progressive
• May be fast or slow
• With or without remission
– Dysphonia
– Difficulty chewing &
swallowing
– Extreme muscle weakness
Myasthenia Gravis
Clinical manifestations
• Resp. paralysis (Bulbar
paralysis)
• Vital capacity
– i
• Resp. failure 
• Deathmosis
Myasthenia Gravis
• “Myasthenia gravis is purely a motor disorder
with no effect on sensation or coordination.”
Myasthenia Gravis
Etiology
• Men vs Women
– Men < women
• Age 20-40
• Thymus
– enlarged
Myasthenia Gravis
Diagnostic exams
• Positive response to
Tensilon
– IV Tensilon
– Prevents Acetylcholine
from being broken down
– Muscle function
improves within 60 sec.
& lasts 30 mins.
Myasthenia Gravis
Treatment
• No cure
• Anticholinesterase agents
–
–
–
Neostigmine, Mestinon,
Prostigmin, Mytelase
Prevents the destruction of
Acetylcholine, thereby
increasing the muscle to
nerve response and muscle
strength
S/E: Sweating, weakness,
bradycardia, hypotension
Myasthenia Gravis
Treatment
• Corticosteroids
• Thymus
– radiation
• Plasmapheresis
– Plasma exchange
Myasthenia Gravis
Nursing interventions
• Planned activities
• Avoid stress
• Rest periods
• Resp. baseline
– Tidal volume
– Vital capacity
– Inspiratory force
Myasthenia Gravis
Nursing interventions
• Do not administer
barbiturates,
tranquilizers, muscle
relaxants, morphine etc.
• Eye care
Myasthenia Gravis
Complications
• Myasthenic crisis
• Caused by
– Not enough med.
– Stress
• S&S
– Rapid onset of weakness

– Resp. distress
• Treatment
– Medication
• IV or IM
– Resp. support
• Intubation
• PEEP
• Suction
– NG tube
Myasthenia Gravis
Complications
• Cholinergic crisis
• Caused by
– Too much med.
• S&S
– Rapid onset of weakness

– Resp. distress
• Treatment
– Hold medication
– Resp. support
• Intubation
• PEEP
• Suction
– NG tube
Myasthenia Gravis
• How can you tell the difference between Myasthenic
crisis and a Cholinergic crisis?
– Tensilon test
– If they respond to tensilon with increased muscle
strength…
• Myasthenic Crisis
• They need more medications
– If they respond to the tensilon with increased muscle
weakness…
• Cholinergic crisis
• Hold medications
Myasthenia Gravis
•
•
•
•
•
•
What can cause a cholinergic crisis?
What are the S&S of a cholinergic crisis?
What is the treatment of a cholinergic crisis?
MG is a disorder of the CNS, PNS or both?
What are the clinical manifestations of MG
How do you confirm the diagnosis of MG?
Myasthenia Gravis
•
•
•
•
Myasthenic crisis is caused by what?
What are the S&S of a Myasthenic crisis?
What is the treatment of a Myasthenic crisis?
What is the difference between MG and MS?
(besides the letter G&S)
• When you give a Tensilon test how would you
know if they were under medicated?
• What meds are used to treat MG?
Guillain-Barre Syndrome
Pathophysiology
• Autoimmune disease
• The myelin sheath of
the spinal and cranial
nerves are destroyed by
diffuse inflammatory
reaction
Guillain-Barre Syndrome
Is Guillain-Barre Syndrome a disorder of the
CNS, PNS or Both?
A. CNS
B. PNS
C. Both CNS and PNS
Guillain-Barre Syndrome
Pathophysiology
• Demyelination
– Axon atrophy
– Starts distal nerves
• Remyelination
– Slow
– Descending pattern
Guillain-Barre Syndrome
Pathophysiology
• Sudden attack on
myelin 
• Inflammation 
• Axon damaged 
• Paralysis / paresis 
• Remyelination 
• If cell body (soma) NOT
destroyed 
– Recovery
• If sell body (soma) IS
destroyed 
– Some degree of
permanent disability
Guillain-Barre Syndrome
• Etiology
• Unknown
• In most patients it is
preceded by viral
infection
• Men vs. Women
–=
Guillain-Barre Syndrome
Clinical manifestations
• Onset
– Abrupt
• Symmetrical paresis that
progresses to paralysis
• Begins with lower
extremities
–
–
–
–
Paresthesias
Weakness
Dyskinesia
Paralysis
Guillain-Barre Syndrome
Clinical manifestations
• Progresses upward
• Resp failure
• Bulbar weakness
• Recovery
Guillain-Barre Syndrome
Diagnostic exam
• CSF
– Increased protein
• EEG
– Slowing of nerve
conduction
Guillain-Barre Syndrome
Treatment
• Considered a medical
emergency
• Mechanical ventilation
• Immunosuppressant
• Anti-coagulants
• Plasmapheresis
Guillain-Barre Syndrome
Nursing interventions
• Respiratory function
• ROM
• TED hose
• Nutrition
• Communication
• Anxiety
Guillain-Barre Syndrome
Complications
• Resp. failure
• PE
• Anxiety
Guillain-Barre Syndrome
•
•
•
•
•
•
•
What is the pathophysiology of GB?
What is demyelination?
Is GB a disorder of the CNS, PNS or both?
What are the S&S of GB?
What are the initial symptoms of GB?
What is the outcome of GB?
What are the complications associated with GB?
Trigeminal Neuralgia
• AKA
– Tic Douloueux
• Pathophysiology
– Condition of CN 5
– Neuralgia =
• Nerve pain
Trigeminal Neuralgia
Clinical manifestation
• Pain occurs when
trigger points are
stimulated, causing
periods of intense pain
and facial twitching
• Begins and ends
suddenly
• Worst pain known!
Trigeminal Neuralgia
Clinical Manifestations
•PAIN!!!
–
–
–
–
Sudden
Stabbing
Burning
Knife-like
Trigeminal Neuralgia
Etiology
• Unknown
• Men vs Women
– Men < women
• Age of onset
– 50’s
• Dental work
Trigeminal Neuralgia
Diagnostic exams
• Hx
• MRI
Trigeminal Neuralgia
Treatment
• Anticonvulsants
– Examples
• Tegretol
• Dilantin
– Action
• i transmission of nerve
impulse
– S/E
• Drowsiness
Trigeminal Neuralgia
• Nerve block
– Alcohol and phenol
injected into the nerve
– Destroys the nerve –
temporarily
• Surgery
Trigeminal Neuralgia
Nursing Interventions
• Goal
– Relieve pain
• Avoid Triggers
–
–
–
–
Hot & cold foods
Draft areas
Brushing teeth
Chewing food
• Self-care deficit
• Depression
• Suicide
Trigeminal Neuralgia
Complications
• Paralysis
• Infection
Trigeminal Neuralgia
•
•
•
•
•
•
•
What cranial nerve is involved with trigeminal
neuralgia?
What is the primary nursing diagnosis with a
patient with Trigeminal Neuralgia?
What can trigger Trigeminal neuralgia?
That is Tic Douloureux?
What is Dilantin? What are the side effects of
Dilantin?
What are the S&S is Trigeminal neuralgia?
What is the treatment for trigeminal neuralgia?
Bell’s Palsy
Pathophysiology
• Inflammation of CN -7
• Resulting in weakness
or paralysis of one side
of the face
• Usually resolve in 2-8
weeks
Bell’s Palsy
Clinical Manifestations
• Facial pain that radiates
to the eye & ear
• h eye tearing
• Speech difficulties
• Distortion of the face
• Diminished blink reflex
Bell’s Palsy
Etiology
• Unknown
Bell’s Palsy
Medical Treatment
• Corticosteriods
• Eye drops
• Analgesics
Bell’s Palsy
Nursing interventions
• Eye care
– Patch
– Drops
• Moist heat to face
• Massage
• Electric stim
Bell’s Palsy
•
•
•
•
•
What cranial nerve is involved with Bell’s
palsy?
What is the primary nursing diagnosis with a
patient with Bell’s palsy?
What can trigger Bell’s palsy?
What are the S&S is Bell’s palsy?
What is the treatment for Bell’s palsy?