Chapter 48 LPN

Central Nervous System Infections

• Infectious agents access the central nervous system through various routes
• A depressed immune system from factors like steroid use, chemotherapy, radiation, or malnutrition, increases vulnerability to these infections

Routes of Entry for CNS Infections

• Bloodstream: Infections can spread through the bloodstream
• Insect bites: Insects can carry and transmit infectious agents
• Otitis media: Middle ear infections may spread to the CNS
• Direct extension: Infections can spread from nearby areas
• Fractures: Frontal or facial bone fractures can provide entry
• Cerebrospinal fluid: Contamination of CSF can introduce infection
• Dural tear: Tears in the dura mater can allow entry
• Poor technique: Non-sterile procedures can introduce pathogens
• Nose or mouth: Some pathogens enter through the nasal or oral passages
• In utero: Infections can be contracted during gestation.
• Vaginal and Amniotic Fluid: Infection from the vagina, or from contaminated amniotic fluid during gestation
• Meningococcus Meningitis: A route of entry that directly introduces the bacteria into the meninges
• Rubella: A viral infection that, in some cases, can lead to CNS involvement

Meningitis Etiology and Pathophysiology

• Meningitis involves inflammation of the membranes (meninges) surrounding the brain and spinal cord
• It is caused by bacterial or viral infections
• Any microorganism entering the body can potentially cause meningitis
• Bacterial meningitis spreads through direct contact with respiratory discharge
• Aseptic or Viral meningitis is more common, rarely serious, presenting with flu-like symptoms, resolving within two weeks
• Common bacteria causing meningitis are Neisseria meningitidis, Streptococcus pneumoniae, Group B Streptococcus, and Haemophilus influenzae type b (Hib)
• Hib has decreased due to current vaccine standards
• Bacterial infection often starts in the upper respiratory tract
• Bacteria enters the blood, invades the CNS, inflames the meninges, and increases intracranial pressure (ICP)
• Vessel occlusion and necrosis can occur in the brain
• Meningitis can temporarily or permanently affect cranial nerve function

Cranial Nerves Affected by Meningitis

• III, IV, VI: Manifests as ocular palsies, unequal/sluggish pupils
• VII: Manifests as facial weakness
• VIII: Manifests as deafness and vertigo

Meningitis Prevention

• Vaccines are available for some pathogens. Hib vaccinations start in infancy
• Streptococcus pneumoniae vaccine is recommended for those 65+, and those with chronic medical conditions
• Two doses of meningococcal vaccine (MCV4) are recommended for adolescents, at ages 11-12 and 16
• High-risk groups advised to get vaccinated: college freshmen (dorms), U.S. military recruits, communal living, compromised immunity, lab personnel, travelers to areas where meningococcal disease is common

Meningitis Prophylactic Treatment

• Prophylactic treatment is recommend for individuals with significant exposure to meningitis
• Antimicrobials like rifampin (Rifadin), quinolones, or sulfonamides, are used to eradicate the organism from the nasopharynx

Meningitis Signs and Symptoms

• Severe headaches are the most common symptom, caused by tension on blood vessels and irritation of the dura
• Symptoms include stiff neck, change in consciousness, photophobia, and nausea
• Meningococcal meningitis may present petechiae
• Nuchal rigidity (pain and stiffness when neck is moved) results from spasm of extensor neck muscles
• Positive Kernig and Brudzinski signs
• Kernig's sign involves flexing the hip and attempting to extend the knee.
• Brudzinski's sign: Positive when neck flexion causes hips and knees to flex
• Nausea and vomiting are caused by irritation of brain tissue and increased ICP

Learning Tip

• Kernig, bend the knee, and Brudzinski lift the back of the head

Meningitis Word Building

• Meningitis indicates membranous covering of the brain plus an inflammation
• Photophobia: photo - light, and phobia - Fear or intolerance

Meningitis Encephalopathy

• Encephalopathy presents as mental status changes of short attention span, poor memory, disorientation, difficulty following commands and misinterpreting environmental stimuli
• Late signs include lethargy and seizures

Meningitis Complications

• Resolution depends on quick and effective treatment
• Viral meningitis usually has no lasting effects
• Bacterial meningitis can be fatal
• Cranial nerve damage can leave a patient blind or deaf
• Seizures can continue after the acute phase
• Cognitive deficits range from memory impairment to learning disabilities

Meningitis Diagnostic Tests

• Lumbar puncture is the most informative test
• Viral Meningitis CSF: Is characterized by clear, normal glucose level and protein level, with increased WBC, and no bacteria
• Bacterial Meningitis CSF: Is turbid because of elevated WBC, with bacteria identified by Gram stain and culture
• Sensitivity tests helps identify the best antibiotic
• Bacteria use CSF glucose which lowers the glucose level
• Protein is elevated in the CSF
• MRI or CT scans can evaluate complications

Meningitis Therapeutic Measures

• Vancomycin and cephalosporins are antibiotics used for bacterial meningitis
• Confirm that the antibiotic the patient receives is the best choice
• Symptom management is the same for viral or bacterial cases
• Antipyretics (acetaminophen) control fever; use a cooling blanket
• Avoid excessive cooling to prevent shivering, which increases metabolic demand for oxygen and glucose
• Analgesics lessen head and neck pain
• Corticosteroids and anti-inflammatory agents are given to decrease cerebral swelling
• Antiemetic medications control nausea and vomiting
• Meningococcal meningitis should be placed in droplet isolation for the first 24 hours of administering medication

Meningitis Nursing Care

• A quiet and dark environment lessens stimulation for headaches or photophobia
• Focus on keeping patients from harming themselves
• Educate the family about symptoms and treatment goals

Encephalitis Pathophysiology

• Encephalitis is brain tissue inflammation, which causes nerve cell damage, edema, and necrosis.
• Leads to neurologic findings in affected areas
• Brain hemorrhage can occur, leading to increased ICP and potential brain herniation

Encephalitis Etiology

• Viruses are the most common cause
• Can be related to time of year and geographic location
• West Nile virus is carried by ticks or mosquitoes
• Systemic viral infections like infectious mononucleosis or mumps can spread to the brain
• Herpes simplex virus (HSV) is the most common non-insect-borne viral cause
• Those with HSV type 1 have a dormant state
• Cold sores are responsible for the virus.
• Communicable diseases, fever, and stress can activate the viral infection

Encephalitis Signs and Symptoms

• Symptoms like headache, malaise, nausea, vomiting, and fever develop over several days, similar to many viral infections
• Additional symptoms include nuchal rigidity, confusion, decreased level of consciousness (LOC), seizures, photophobia, ataxia, abnormal sleep patterns, and tremors, and hemiparesis

Encephalitis Word Building

• Encephalopathy: encephalo-brain + pathy-illness
• Encephalitis: encephalo–brain + itis-inflammation
• Hemiparesis: hemi–one side + paresis-partial paralysis

Meningitis Summary

• Signs and Symptoms*
• Nuchal rigidity
• Positive Kernig and Brudzinski signs
• Fever
• Photophobia
• Petechial rash on skin and mucous membranes
• Encephalopathy
• No appetite or thirst
• Severe headache
• Diagnostic Tests*
• Lumbar puncture (CSF analysis, C&S)
• Complete blood count (CBC)
• C&S nose & throat
• Therapeutic Measures*
• Antimicrobials (if bacterial)
• Seizure precautions
• Antipyretics
• Pain management
• Reduction of environmental stimuli
• Education
• Complications*
• Seizures
• Increased intracranial pressure
• Hearing loss
• Vision impairment
• Cognitive defects
• Priority Nursing Diagnoses*
• Hyperthermia
• Risk for acute confusion
• Self-care deficit
• Acute or chronic pain
• Risk for injury
• Impaired physical mobility

Encephalitis Progression and Complications

• Herpes encephalitis leads to brain edema and necrosis, commonly in the temporal lobes, increasing ICP and brain herniation
• Delayed or absent treatment can result in death or disability
• Complications include cognitive disabilities, personality changes, seizures, motor deficits, and blindness
• Changes in cognition and personality are stressful for family
• Monitor the patients physical ability when considering discharge plans
• Home care, therapy, daycare or long-term care are all options

Encephalitis Diagnostics and Treatment

• CT scan, MRI, lumbar puncture (CSF), and EEG are used to diagnose
• CSF analysis typically shows increased WBCs and protein, normal glucose
• Blood breakdown from hemorrhage presents as a yellow CSF
• Viral serology helps identify and guide treatment
• No specific treatment is available for insect-borne encephalitis
• Manage symptoms and neurologic issues to reduce complications and improve survival
• Administer anticonvulsants, antipyretics, and analgesics
• Corticosteroids reduce cerebral swelling
• Sedatives can help with irritability
• Antiviral medications like acyclovir (Zovirax) are used, especially with HSV

Increased Intracranial Pressure (ICP)

• Skull is a rigid compartment containing brain, blood, CSF
• Normal ICP is 0-15 mm Hg, fluctuating with normal physiological changes
• Increased ICP: Increase in one component that isn't accompanied by a decrease in another
• Patients with any pathological intracranial condition are at risk
• Common causes: brain trauma, hemorrhage, brain tumors
• Detecting changes in neurologic status allows intervention to prevent permanent brain damage
• Consequences depend on the severity of elevation and the speed in which the intracranial pressure increases
• Slow tumor growths can have significantly increased ICP before noticeable symptoms
• Subarachnoid hemorrhage can cause a sudden sharp increase in ICP
• CSF can be shunted into the spinal subarachnoid space
• Hyperventilation constricts cerebral blood vessels
• Temporary mechanisms will compensate for ICP increase.
• Compensation decreases because there is an increase in blood going to the brain because of severity

Signs and Symptoms

• Restlessness, irritability, and decreased LOC (cerebral cortex function impaired)
• Hyperventilation causes vasoconstriction as the body attempts to compensate (if not intubated)
• Oculomotor nerve compression results in diminished reactivity and dilation of the pupil, and the pupil stops reacting to light
• The compression continues and the brain tissue exerts pressure on the opposite side of the brain from the injury, both pupils will then be fixed and dilated
• Cushing triad is a late sign: bradycardia, decreased respirations, arterial hypertension (increasing systolic blood pressure while diastolic blood pressure remains the same) and the result of it widening the pulse pressure
• ICP is significantly increased at the time that symptoms start

Monitoring

• ICP monitoring allows early detection of changes in the pressure on the brain before changes in symptoms are seen

• Catheter placement in a ventricle of the brain, the cerebral parenchyma, or the subdural/subarachnoid space is a common treatment method to monitor ICP in adults

• Anesthetizing the scalp and drilling a burr hole are often required

• External ventricular drainage is when the catheter is placed in one of the lateral ventricles

• Pressure can be reduced by monitoring and draining CSF

• Occlusion of the catheter by blood in the CSF and difficulty that it allows. Subarachnoid Bolt

• communication with the subarachnoid space

• Ease of Puncture

• Occlusion of the sensor portion of the bolt with brain tissue will occlude the sensor

• Intraparenchymal monitor is placed directly into brain tissue

• Some physicians believe this type of monitor most accurately reflects the actual situation within the skull Cannot be used to drain CSF and can become occluded by brain tissue

• Patients with ICP monitors are cared for in the ICU with aggressive nursing care

• Patients can be mechanically ventilated, and are generally pharmacologically paralyzed and sedated

• The nurse provides education and emotional support for the family members

ICP - Nursing Process for Communicable or Inflammatory Disorders

• Collaborate for a complete history from the patient and from family members
• Physical examination must include all body systems because neurologic impairment affects the entire person
• Following the initial examination, serial neurologic remain important to detect and report changes promptly
• Monitor pupil response, LOC, and vital signs. Also monitor headache on a pain scale or the Pain Assessment in Advanced Dementia (PAINAD) scale if necessary
• Glasgow Coma Scale or The FOUR Score Coma Scale are tools to use

ICP Signs and Symptoms

• Vomiting
• Headache
• Dilated pupil on affected side
• Hemiparesis or hemiplegia
• Decorticate/decerebrate posturing
• Decreasing of consciousness
• Increasing systolic blood pressure
• Increasing then decreasing pulse rate
• Rising temperature

Nursing Care for Communicable or Inflammatory Neurological Disorders

• Use antipyretics, tepid sponge baths, or cooling blankets to control fever
• Determine patient's ability to perform ADLs
• Manage pain with medications and comfort measures
• Control nausea and vomiting
• Maintain seizure precautions
• Report any changes of LOC to the RN or health-care provider (HCP)

Interventions for Seizures

• Pad side rails of hospital bed with commercial pads or bath blankets folded over and pinned in place

• Keep call light within reach

• Assist patient when ambulating

• Keep suction and oral airway at bedside

• Nursing Care During a Seizure*

• Stay with the patient

• Do not restrain the patient

• Protect from injury (move nearby objects)

• Loosen tight clothing

• Turn to side when able to prevent occlusion of airway or aspiration

• Suction if needed

• Monitor vital signs when able

• Be prepared to assist with breathing if necessary

• Base teaching on the patients LOC and status

• If not able to be active the focus of teaching is family members

Measures to Prevent Increased Intracranial Pressure

• A Rationale Is Stated With Each

• Head of bed at 30 degrees

• Avoid flexing neck, keep head and neck in midline

• Administer antiemetics and antitussives as necessary to prevent vomiting and cough

• Administer stool softeners

• Minimize suctioning, oxygenate first and limit suction passes to one or two

• Avoid hip flexion

• Prevent unnecessary noise, startle

• Noxious stimuli

• Space care activities

Headaches - Types, Migraines, Tension and Cluster

• Most headaches are transient events that do not indicate a serious pathological condition
• If headaches are recurrent, persistent, or increasing in severity, the patient should undergo a neurologic evaluation

Types of Headaches

• Three types include: primary, secondary, and cranial neuralgias, central and primary facial pain and other headaches

Migraine Headaches

• A neurologic disorder involving brain chemicals and pathways in the brain
• A trigger stimulates a release of chemicals and causes an inflammatory response resulting in overstimulation of the trigeminal nerve that is painful
• May or may not involve an aura, such as vision changes, tingling, that precedes an attack
• The tendency to develop migraine headaches is often hereditary
• Frequently begin in childhood or adolescence and are more common in women
• Stress, hormone, not eating, barometric pressure, irregular sleep, smells, pain, , bright light, and alcohol can all be common triggers

Major Types

• Migraine with and without aura
• Four phases: Prodromal, aura, headache, and resolution
• Prodromal Phase: Irritability, sleepiness, food craving
• Aura Stage: Visual disturbances, speaking difficulty, numbness or tingling
• Descriptors of Migraine Pain: Throbbing, boring, viselike, and pounding
• Pain: Usually one side of the head
• Noise and light worsen the headache, leading patients to find a dark, quiet environment

Treatment

• Can be treated prophylactically or with an acute episode
• Prophylactic Treatment: Patients that typically experience one or more per week
• Botox (botulinum toxin) can treat headaches 15 or more days a month, injected into specific areas of the head and neck around pain fibers stimulate release of the inflammatory chemicals, repeated every 3 months
• Lifestyle changes can help prevent migraines
• Routine mealtimes
• Good sleep habits
• Daily exercise
• Avoidance of triggers
• Dietary restrictions (if triggers that are foods)

Medications

• NSAIDs such as naproxen (Naprosyn, Aleve)
• A vasoconstrictor (Ergot [Cafergot]) is effective if taken before the vessel walls become edematous, usually within 30 to 60 minutes of headache onset
• Serotonin receptor sites, vasoconstricting action work at sites, Triptans, such as sumatriptan (Imitrex) and zolmitriptan (Zomig)
• Treximet- Combines naproxen and sumatriptan
• Habit-forming opioids are the last resort

Tension/Muscle Contraction Headaches

• Scalp, cervical, and upper thoracic muscles contraction cause tension headaches
• Cycle of muscle tension, muscle tenderness, and further muscle tension that can or cannot be associated with vasodilation of cerebral arteries
• Premenstrual syndrome or anxiety, emotional distress, or depression are potential associations
• Symptoms gradually develop
• Pressure, aching, steady, and tight are other ways

Treatment

• Before psychosocial reasons are attributed must rule out physical causes with relaxation techniques , yoga/stretching exercises, massage of the affected muscles, rest, localized heat application, nonopioid analgesics, and appropriate counseling

Cluster Headaches

• Vascular disturbance, stress, anxiety, and emotional distress all proposed causes of cluster headaches. During time span of days to weeks they tend to occur in clusters
• Months or even years can pass, alcohol consumption may worsen episodes
• Begins suddenly(typically at night), Throbbing and excruciating
• Unilateral affecting eye, nose, and forehead
• Bloodshot teary look

Treatment

• A quiet, dark environment and cold compresses can lessen the intensity of the pain
• NSAIDs or tricyclic antidepressants may be prescribed.

Diagnosis of Headaches

• History and symptoms
• Rule out other causes for headaches

To Rule out other causes:

• MRI/CT Scans
• Skull x-ray
• Arteriogram
• EEG
• Cranial nerve testing, and lumbar puncture to test CSF

The WHAT’S UP

• A mnemonic that helps provide useful information regarding headaches

• W-Where is the pain

• H-How does the headache feel?

• A-Aggravating or alleviating factors

• T-Timing

• S-Severity of pain

• U-Useful data such as associated symptoms such as nausea, vomiting, or bloodshot eyes?

• P- Perception of the headache and does it interfere with their life? And had a previously evaluation?

Nursing Diagnosis, planning, implementation

• Acute Pain related to physiological mechanisms of headache

• Prevented or controlled by patients statements

• Can identify, reduce, or eliminate aggravating factors by documenting factors in a headache diary with triggers and symptoms. Identification of triggers can help the patient lessen the frequency and intensity of attacks.

• Use alleviating techniques such as warm or cold compresses, biofeedback, or stress reduction. treatment of the headache and provides a sense of control Relaxation exercises or simple stretching can reduce tension

• Dark room and rest to reduce stimulation during a migraine

Seizure Disorder

• Can indicate epilepsy or other neurologic disorders such as a brain tumor or meningitis
• Epilepsy is a recurrent seizure activity

Pathophysiology

• Instability of the neuron cell membrane allows abnormal electrical discharges to occur
• Seizures can be classified as partial or generalized
• Partial Seizures:*
• Seizures begin on one side of the cerebral cortex
• Electrical discharge and spreads
• Generalized Seizures:*
• Characterized by the cerebral hemispheres

Etiology

• Acquired:*

• Traumatic brain injury and anoxic events

• Idiopathic*

• Signs and symptoms of seizures begin related to areas in the brain*

• Aura

• Sitting or lying down to minimize risk of injury

• Repetitive, purposeless behaviors are called automatisms, a classic symptom of partial seizures*

• A dreamlike state while picking at clothing, chewing, or smacking lips

• Patients may be labeled as mentally ill

• The patient does not lose consciousness simple partial Seizures if consciousness is lost and is called complex partial

• Paresthesias opposite the seizure focus arising from, parietal lobe

• Visual disturbances in occipital lobe

• Movements on the opposite side of the body that originate in motor cortex and often begin in the arm and hand that spreads to the leg and face

• Recovery is the Postical period

• Following a partial seizure, the phase may be no more than a few minutes of

Generalized Seizures

• Affect the entire brain

• Absence seizures*

• Petit main seizures, occur mostly in children Consistence of staring and last several seconds

• Tonic-clonic seizures*

• Grand Mal Loss of consciousness, The tonic phase which is the last 30 to 60 seconds which the patient falls down, Pupils fixed and dilated

• Jaw clenched Temporally breathing stops

• Clonic Phase*

• Contraction and relaxions Limb move forefully Often incontinent Cause bleeding If the patient strikes furniture or walls from biting the lips or tongue

• Postictal period usually is longer after tonic-clonic seizures. Sleep deeply and report headaches

• Diagnostic Tests: CT, MRI, PET, SPECT, and EEG

• Therapeutic Measure:*

• Underlying Correct the cause in that area as a treat Prevent seizures

• Start with one medication increase

• Anticonvulsants

• Kidney and Liver monitored

• Surgical Intervention*

• The the area is resected to prevent

• The seizures are unable to find success is unable

• Trained to have a sent of smell

• To identify and assess of epilepsy is extensive and multistage

Emergency Care

• Prime objective is to prevent injury
• The patient’s teeth into that side
• To make sure the mouth is ready for their oral

•Word Building

• Post After and Ictal Seizure

• MedClass Action*

• Discharge neurons that The spreading of neurons

• Monitor blood cell counts

• Do not crush medications

• Can injectable

• Side Effect:* suicidal ideation, retention

• Can give retinitis Pigmentosa

• Phenytoin (Dilantin)*

• Level at 10 to 20

• Have care for their gums

General Nursing

• Valproic Level which is 100MCG/Ml

• The benzo class is is -Amino inhibitory for central

• Patient Perspective:*

• Padding the patients to seizure their is you usually can care for them

• A nurse’s role is to not stay on or hold on which is not natural Is to is exhausting

• Status Epilepticus:*

• This an medical emergency

• Abruplty stop therapy

• IV diazepam:*

• Is carefully for this

• Psycho effects:*

• Remind them their license

• Encourage a for

• Never put any that patients

TBI facts

• A major cause of death and disability

• Can come trauma

• Falls and the younger gender

• Classified several back and Forth

Classified to injury

Rotational injuries

The brain and are damage to the system

• Types Brain*

• Headache and Dizziness

• Contusion- Bruising the tissue

• Hematoram Subdural one side

• A progressive Course system due brain And blood

• Ct scan assess more and more

• The injuries to assess more

• Osmotic with and eliminate

• Maintain and monitor

• Herniation* And the brain stem is to help Prevent damage

• The is used to control

• Diadbetes Insipidus*

• Causes a low fluid release and

• Data Collection* And the scales

Nursing Process for the Patient

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