Lecture 16, 17 - Neurologic Infections, Autoimmune, Degenerative (2020-2021) PDF

Adult Care Nursing II/ Theory Lecture number: 16 Management of Patients with Neurologic Infections: Meningitis; Brain Abscess & Encephalitis Dr Abdallah Alwawi  Meningitis  Meningitis is an inflammation of the meninges, which cover and protect t...

Adult Care Nursing II/ Theory Lecture number: 16 Management of Patients with Neurologic Infections: Meningitis; Brain Abscess & Encephalitis Dr Abdallah Alwawi  Meningitis  Meningitis is an inflammation of the meninges, which cover and protect the brain & spinal cord. Caused by Bacteria, Virus & Fungus...  Types A. Septic caused by Bacteria (Streptococcus Pneumoniae, Neisseria (N) meningitidis). B. Aseptic caused by viral infection, or secondary to cancer or having a weakened immune system, such as lymphoma, leukemia, HIV, or brain abscess. N. Meningitidis is transmitted by secretions or aerosol contamination, & infection is most likely in dense community groups such as college campuses, military installations. 2  Clinical Manifestations – Meningitis Throbbing Headache & Fever Neck immobility: Stiff and painful neck (Nuchal rigidity) Positive Kernig’s Sign: when patient is lying with thigh flexed on the abdomen, the leg cannot be completely extended, when the hip is flexed to 90 degrees Positive Brudzinski’s Sign: when the patient neck is flexed, flexion of the knees & hips is produced. Photophobia (extreme sensitivity to light). A rash can be a striking feature of N. meningitidis infection 3 Clinical Manifestations – Meningitis 4 Other Clinical Manifestations – Meningitis Disorientation & memory impairment Behavioral manifestation Lethargy Confusion &  responsiveness Seizures & increased ICP Decreased in LOC 5  Diagnostic Findings History & Clinical presentation Physical Exam Lumber Puncture: Bacterial culture & gram staining of CSF & blood CSF for WBC, protein, glucose WBC count CT: to detect shift in brain contents MRI 6 7  Medical Management Prevention by vaccination against (Haemophilus influenzae & S. pneumoniae) for all children & all at-risk adults. Prevention by meningococcal vaccination for adolescents & high-risk groups. Early administration of high doses of appropriate IV Antibiotics for bacterial meningitis within 30 min of hospital arrival. Dexamethasone (Decadron) Treatment for dehydration, shock, and seizures (by using anticonvulsant medications)  Nursing Management Infection control precautions until 24hr after Antibiotic Frequent or continual assessment, including neurologic status, vital signs and LOC. Protect patient form injury related to seizure activity or altered LOC. Monitor daily weight, serum electrolytes, urine volume, specific gravity, and osmolality. Prevent complications associated with immobility. Supportive care, assisting with getting rest in a quiet, darkened room. Pain management & treat elevated temperature. Hydrate the patient either orally or IV. Measures to facilitate coping of patient and family.  Brain Abscess Collection of infectious material within brain tissue. Risk is increased in immunocompromised patients. Prevent by treating otitis media, mastoiditis, sinusitis, dental infections, and systemic infections promptly. Manifestations may include headache that is usually worse in the morning, fever, vomiting, neurologic deficits, signs and symptoms of increased ICP. Diagnosis by MRI or CT CT-guided aspiration is used to to drain the abscess identify the causative organisms.  Brain Abscess  Medical Management Control ICP Drain abscess Administer appropriate Antibiotic therapy; Corticosteroids may be used to treat cerebral edema.  Nursing Management Frequent and ongoing neurologic assessment and responses to treatment Assure patient safety and protect from injury Provide supportive care  Encephalitis Acute, inflammatory process of the brain tissue. Causes include viral infections (herpes simplex [HSV]), vector-borne viral infections (The main vector in North America: mosquito) (West Nile, St. Louis), and fungal infections. Manifestations may include headache fever, confusion, changes in LOC; 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 assessment Supportive care  Adult Care Nursing II/ Theory Lecture number: 17 Management of Patients with Autoimmune Neurologic Disorders: Multiple Sclerosis & Myasthenia Gravis Dr Abdallah Alwawi  Multiple Sclerosis (MS) MS is an immune-mediated, progressive demyelinating disease of the (CNS). Demyelination refers to the destruction of myelin sheath (fatty & protein material that surrounds nerve fibers),which results in impaired transmission of nerve impulses. The age of peak onset 25-35 years. Affect Women more than Men. Frequently, the disease is relapsing-remitting (RR) Course 85%. ‫نوبات من الشدة‬ Has exacerbations and recurrences of symptoms. 14  Types and characteristics of MS 1. Relapsing-remitting (RR) MS is characterized by clearly acute attacks with full recovery or with sequelae and residual deficit upon recovery. Periods between disease relapses are characterized by lack of disease progression. 2. Primary progressive MS is characterized by disease showing progression of disability from onset, without plateaus and temporary minor improvements. 3. Secondary progressive MS begins with an initial RR course, followed by progression of variable rate, which may also include occasional relapses and minor remissions. 4. Progressive-relapsing MS shows progression from onset but with clear acute relapses with or without recovery 15 Types and courses of multiple sclerosis (MS)  Process of Demyelination Most frequently affected areas are: Optic nerves, Cerebrum, Brainstem, Cerebellum, Spinal cord.  Etiology The cause of MS is an area of ongoing research. Auto immune activity results in demyelination.  Autoimmune o T-cells activate against myelin  Viral o Specific viral protein not yet identified o Viral infections known to provoke relapses  Risks Factors: genetic factors, smoking, lack of Vitamin D. 19  Clinical Manifestations of MS Clinical  Spasticity & Pain manifestations vary  Visual and have different disturbances: patterns.  Blurring of vision  Fatigue  Diplopia  Depression  Total blindness  Weakness  Tremors  Numbness  Heat intolerance  Ataxia (Difficulty in coordinating  Bladder dysfunction movement)  Loss of balance 20 21  Diagnostics Findings of MS MRI is the primary diagnostic tool: (based on the presence of multiple plaques in the CNS) Electrophoresis of CSF Increased immunoglobulin concentration in > 90% of patients Immunoglobulin G index (CSF/serum) elevated Blood and urine 22 Abnormal MRI—Cerebral Hemispheres 23  Medical Management No cure exists for Multiple Sclerosis (MS) Treatment is indicated to relieve patients symptoms (Symptomatic). Symptom management of muscle spasms, fatigue, ataxia, bowel and bladder control. 24  Medical Management  Pharmacologic Therapy: Interferon -1a and Interferon -1b, Glatiramer acetate (Copaxone), and IV Methylprednisolone Avoid hot temperature, treatment of depression and anemia, Physical & occupational therapy help control fatigue. 25  Nursing Diagnoses Impaired bed and physical mobility related to weakness, muscle paresis, spasticity, increased weight Risk for injury related to sensory and visual impairment Impaired urinary elimination (urgency, frequency, incontinence), constipation, and bowel incontinence related to nervous system dysfunction Impaired verbal communication and risk for aspiration related to cranial nerve involvement Chronic confusion related to cerebral dysfunction Ineffective coping related to uncertainty of course of MS Impaired home maintenance management related to physical, psychological, and social limits imposed by MS Ineffective sexuality pattern related to lesions or psychological reaction  Nursing Interventions Promoting Physical Mobility Preventing Injury Enhancing Bowel and Bladder control: o Instruction or administration of prescribed medications o Voiding schedule o Bowel training program o Adequate fluid and fiber to prevent constipation Enhancing communication and managing swallowing difficulties Strategies to reduce risk of aspiration Preventing complications of immobility Strengthening coping mechanisms Improving home management: assisting eating devices, raised toilet seat, bathing aids, modified clothing, air conditioning.  Nursing Care of Client with MS  Promoting Physical Mobility: Activity & Rest Program of activity and daily exercise & ROM Relaxation, coordination exercises, walking, muscle- stretching exercises. Avoid very strenuous activity and extreme fatigue Daily Exercises: walking, swimming  Warm packs to relief muscle spasticity  Advice patient to take frequent short rest period Improving self care abilities & Proper skin care Optimize nutrition as long as possible Teach effective coping methods Provide psychological support   Myasthenia Gravis An autoimmune disorder affecting the myoneural junction and is characterized by varying degrees of weakness of the voluntary muscles. Antibodies directed at Acetylcholine at the myoneural junction impair transmission of impulses to voluntary muscles. The Thymus gland is believed to be the site of antibody production. More common in Women than Men.  Myasthenia Gravis ACh receptor Normal ACh receptor site in site Myasthenia Gravis  Clinical Manifestation  Myasthenia gravis, a motor disorder.  Weakness of ocular muscles causes diplopia, ptosis (drooping of the eyelids).  Weakness of facial muscles, neck & throat (bulbar symptoms):difficult to talk, chew, swallow and hold up the head.  Generalized weakness.  Dysphonia (voice impairment).  Dysphagia, difficulty chewing, weight loss and choking during meals & aspiration.  Respiratory muscles affected: resulting in decrease vital capacity & respiratory failure.  Bowel and bladder sphincter weakness.  Diagnostic Findings  Acetylcholinesterase inhibitor test (Tensilon test) Tensilon; short -acting anticholinesterase (Edrophonium Chloride) given IV shows immediate improvement in muscle strength (5 minutes). Acetylcholine receptor antibodies titers are elevated. MRI may show enlarged Thymus gland (Acetylcholine receptor antibody production) 32  Diagnostic Findings  The ice test: an ice pack is held over the eyes of patient for 1 minute, the ptosis should temporarily resolve. 33  Medical Management Pharmacologic Therapy Cholinesterase Inhibitor: by inhibiting the breakdown of acetylcholine and increasing the relative concentration of available acetylcholine at the neuromuscular junction. E.g., Pyrostigmine bromide (Mestinon) Immunomodulating therapy: Corticosteroids & Immunosuppressant (Imuran & Cyclosporine) Plasmapheresis: plasma exchange Surgical Management: Thymectomy 34  Complications of Myasthenia Gravis  Myasthenia Crisis: too little Acetylcholine: Exacerbation of the disease process, usually precipitated by infection. Severe generalized muscle weakness with respiratory and bulbar weakness that may result in respiratory failure.  Cholinergic Crisis: too much Acetylcholine: Caused by overmedication with Cholinesterase Inhibitors. Severe muscle weakness with respiratory and bulbar weakness. Patient may develop respiratory failure. Endotracheal intubation and mechanical ventilation may be needed. 35  Nursing Management Patient & family education about signs and symptoms of myasthenic crisis and cholinergic crisis, medication management, energy conservation, & prevention of complications. Monitor for respiratory complications Physical and occupational therapy Rest periods Tape the eyes closed for short intervals, & regularly instill artificial tears  Aspiration Precautions: Administer meds 30 minutes before meals to optimize muscle strength Small frequent meals & soft food Rest before meals Sit upright during meals 36