Mod 3_Ch 64 Management of Patients with Neurologic Infections PDF

Chapter 64 Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 64 Learning Objectives Copyright © 2022 Wolters Kluwer · All Rights Reserved Copyright © 2...

Chapter 64 Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 64 Learning Objectives Copyright © 2022 Wolters Kluwer · All Rights Reserved Copyright © 2022 Wolters Kluwer · All Rights Reserved Infectious Neurologic Disorders Meningitis Brain abscesses Various types of encephalitis Creutzfeldt–Jakob disease (CJD) Variant Creutzfeldt–Jakob disease (vCJD) Copyright © 2022 Wolters Kluwer · All Rights Reserved Meningitis  Inflammation of the meninges, which cover and protect the brain and spinal cord  Two main types: bacterial and viral  Classified: o Septic caused by bacteria (Streptococcus pneumoniae, Neisseria meningitidis) o Aseptic caused by viral infection secondary to cancer or a weak immune system  N. meningitidis is transmitted by secretions or aerosol contamination, and infection is most likely in dense community groups such as college campuses  Manifestations include headache, fever, changes in LOC, behavioral changes, nuchal rigidity (stiff neck), positive Kernig sign, positive Brudzinski sign, and photophobia Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? Meningitis is an inflammation of the pia mater, the arachnoid, and the cerebrospinal fluid-filled subarachnoid space. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 True Rationale: Meningitis is an inflammation of the pia mater, the arachnoid, and the cerebrospinal fluid-filled subarachnoid space. Copyright © 2022 Wolters Kluwer · All Rights Reserved Kernig Sign Copyright © 2022 Wolters Kluwer · All Rights Reserved Brudzinski Sign Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 What is a positive Kernig sign? A. Extreme sensitivity to light B. Any attempts at flexion of the head are difficult because of spasms in the muscles of the neck C. When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended D. When the patient’s neck is flexed, flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 C. When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended Rationale: Photophobia is common with meningitis and is extreme sensitivity to light. Nuchal rigidity is any attempt at flexion of the head is difficult because of spasms in the muscles of the neck. Kernig sign is when the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. Brudzinski sign is when the patient’s neck is flexed, flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity. Copyright © 2022 Wolters Kluwer · All Rights Reserved  Medical Management of Meningitis  Prevention by meningococcal vaccine to youth 11 to 12 years of age; booster at 16. First-year college students and members of the military  Early administration of high doses of appropriate IV antibiotics for bacterial meningitis o Dexamethasone Why? (review dosing)  People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin, ciprofloxacin, or ceftriaxone  Treatment for dehydration and shock (fluid and volume expanders), and seizures (anticonvulsant meds) o Monitor for signs of increasing signs of ICP  Decreasing LOC/focal motor deficits  Monitor for signs of sepsis  Abrupt onset of high fever, shock, DIC, purpura Copyright © 2022 Wolters Kluwer · All Rights Reserved  Nursing Management of Meningitis  Critically ill patients; work with collaborative care team  Frequent or continual assessment, including VS and LOC  Pain and fever management (how?)  Protect patient from injury related to seizure activity or altered LOC  Monitor daily weight, serum electrolytes, urine volume, specific gravity, and osmolality  Prevent complications associated with immobility  Infection control precautions o Review labs  Supportive care o Rest in quiet, controlled, darkened room  Measures to facilitate coping of patient and family Copyright © 2022 Wolters Kluwer · All Rights Reserved  Brain Abscess Collection of infectious material within brain tissue Bacteria is the most common causative organism Prevent by treating otitis media, rhinosinusitis Manifestations may include headache that is usually worse in the morning, fever, vomiting, neurologic deficits, signs and symptoms of increased ICP o As the abscess expands, symptoms of increased ICP such as decreasing LOC and seizures occur Diagnosis by MRI or CT, CT-guided aspiration is used to identify the causative organisms Copyright © 2022 Wolters Kluwer · All Rights Reserved  Medical and Nursing Management of Brain Abscess  Medical management: treatment is based on o Controlling increased ICP o Draining the abscess o Administer appropriate antibiotic therapy directed at the abscess (based on culture and sensitivity and started asap); corticosteroids may be used to treat cerebral edema (inflammation) and, anticonvulsants to treat seizures  Nursing management (review chart 64.1) o Frequent and ongoing neurologic assessments o Administer medications o Assess response to treatment o Provide supportive care, assess family’s ability to cope Copyright © 2022 Wolters Kluwer · All Rights Reserved Encephalitis  Acute, inflammatory process of the brain tissue  Causes include viral infections (herpes simplex [HSV]), vector-borne viral infections (West Nile, St. Louis), and fungal infections  EEG, CSF, MRI, LP (PCR-standard for early diagnosis)  Manifestations may include headache, fever, confusion, hallucinations; vector borne—rash, flaccid paralysis, Parkinson-like movements  Medical management o Acyclovir for HSV infection, amphotericin or other antifungal agents for fungal infection-up to 3 weeks  Nursing management o Frequent and ongoing neurologic assessment o Dim lights, reduce noise and visitors, cluster cares, administer analgesic agents, cautious use of opioids o Monitor labs-renal function with antivirals o Supportive care Copyright © 2022 Wolters Kluwer · All Rights Reserved  Creutzfeldt–Jakob Disease and Variant Creutzfeldt–Jakob Disease  Rare, degenerative infectious, transmissible spongiform encephalopathies (TSEs)  TSEs are caused by prions: small proteinaceous particles that are smaller than viruses and resistant to sterilization  The disease is not spread by casual contact; vCJD may be contracted through ingestion of infected beef through prions and may be infected for many years prior to ingestion  Manifestations include affective, sensory, motor, and cognitive impairments (behavioral changes, sensory disturbances, limb pain, muscle spasms, rigidity, dysarthria, incoordination, cognitive impairment, and sleep disturbances  Tests include EEG, MRI, immunologic assessment  No effective treatment; progressive and fatal within one year of symptom onset  Nursing management o Prevention of disease transmission; blood and body fluid precautions  Use of disposable instruments whenever possible o Supportive and palliative care, hospice  Psychological and emotional support Copyright © 2022 Wolters Kluwer · All Rights Reserved Autoimmune Nervous System Disorders Multiple sclerosis (MS) Myasthenia gravis Guillain–Barré syndrome Copyright © 2022 Wolters Kluwer · All Rights Reserved Process of Demyelination Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #3 Is the following statement true or false? Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the peripheral nervous system. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 False Rationale: Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the central nervous system, not the peripheral nervous system Copyright © 2022 Wolters Kluwer · All Rights Reserved  Myasthenia Gravis #1  Autoimmune disorder affecting the myoneural junction indicating varying degrees of weakness of voluntary muscles  Antibodies directed at acetylcholine at the myoneural junction impair transmission of impulses  Manifestations o Two clinical types-ocular and generalized o Initially symptoms involve ocular muscles; diplopia and ptosis o Weakness of facial muscles, swallowing and voice impairment (dysphonia), generalized weakness  Generalized weakness affects all extremities and may involve the intercostal muscles, resulting in decreasing vital capacity and respiratory failure.  When this occurs, the patient is in a myasthenic crisis  Tests o Acetylcholinesterase inhibitor test (atropine on hand to manage potential side effects) o Ice test for those with cardiac or asthma issues Copyright © 2022 Wolters Kluwer · All Rights Reserved Myasthenia Gravis #2 Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #4 Is the following statement true or false? Myasthenia gravis is an autoimmune attack on the peripheral nerve myelin. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #4 False Rationale: Myasthenia gravis is an autoimmune disorder affecting the myoneural junction and is characterized by varying degrees of weakness of the voluntary muscles. Guillain–Barré syndrome is an autoimmune attack on the peripheral nerve myelin. Copyright © 2022 Wolters Kluwer · All Rights Reserved  Medical Management of Myasthenia Gravis  Directed at improving function and reducing and removing circulating antibodies  Education of energy conservation, coordinate medications with mealtimes to prevent aspiration, softer foods to prevent choking  Impaired vision-taping of the eyes may be needed to prevent corneal damage  Pharmacologic therapy o No overall cure o Anticholinesterase medications and immunosuppressive therapy (corticosteroids) o Intravenous immune globulin (IVIG)  Therapeutic plasma exchange  Thymectomy (removal of thymus gland) Copyright © 2022 Wolters Kluwer · All Rights Reserved  Myasthenic Crisis Cholinergic Crisis  Result of disease exacerbation or precipitating Caused by event, most commonly a overmedication with respiratory infection cholinesterase inhibitors  Severe generalized muscle weakness with respiratory Severe muscle and bulbar weakness weakness with  Weak respiratory muscles do respiratory and bulbar not support inhalation d/t an weakness inadequate cough/impaired gag reflex Patient may develop  Patient may develop respiratory compromise respiratory compromise and failure failure  May need intubation/nutritional support Copyright © 2022 Wolters Kluwer · All Rights Reserved Management of Myasthenic and Cholinergic Crisis  Patient education in signs and symptoms of myasthenic crisis and cholinergic crisis  Ensuring adequate ventilation; intubation and mechanical ventilation may be needed  Assessment and supportive measures o Measures to ensure airway and respiratory support  Ongoing respiratory assessment is essential o ABGs, serum electrolytes, I&O, and daily weight o Chest physiotherapy to mobilize secretions o If patient cannot swallow, nasogastric feeding may be required o Avoid sedatives and tranquilizers as they aggravate hypoxia and hypercapnia and can cause respiratory and cardiac depression. Copyright © 2022 Wolters Kluwer · All Rights Reserved  Guillain–Barré Syndrome #1  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 usually 1-3 weeks prior, maximum weakness varies, peak severity within 2-4 weeks  Manifestations are variable and may include weakness, paralysis, paresthesia, pain, and diminished or absent reflexes, starting with the lower extremities and progressing upward symmetrically (ascending); bulbar weakness; cranial nerve symptoms; tachycardia; bradycardia; hypertension; or hypotension  Any residual symptoms are permanent and reflect axonal damage from demyelination Copyright © 2022 Wolters Kluwer · All Rights Reserved Guillain–Barré Syndrome #2 Medical management o Rapid progression o Medical emergency o Requires intensive care management with continuous monitoring and respiratory support d/t weakened respiratory muscles  Intubation/suction o Therapeutic plasma exchange and IVIG are used to reduce circulating antibodies Recovery rates vary, but most patients recover completely Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment of the Patient with Guillain– Barré Syndrome 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved  Collaborative Problems and Potential Complications of the Patient with Guillain– Barré Syndrome Respiratory failure o Bulbar weakness/suctioning Autonomic dysfunction (BP/HR) DVT Pulmonary embolism Urinary retention Communication Nutrition Anxiety Pressure injuries/physical mobility Copyright © 2022 Wolters Kluwer · All Rights Reserved Planning and Goals for the Patient with Guillain–Barré Syndrome Major goals include: o Improved respiratory function o Increased mobility o Improved nutritional status o Effective communication o Decreased fear and anxiety o Effective patient and family coping o Absence of complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Guillain–Barré Syndrome #1 Enhancing physical mobility and prevention of DVT o Support limbs in functional position o Passive ROM at least twice daily o Frequent position changes at least every 2 hours o Elastic compression hose or sequential compression boots o Adequate hydration Administer IV and parenteral nutrition as prescribed Carefully assess swallowing and gag reflex and take measures to prevent aspiration Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Guillain–Barré Syndrome #2 Develop a plan for communication individualized to patient needs Decreasing fear and anxiety o Provide information and support o Referral to support group o Relaxation measures o Maintain positive attitude and atmosphere to promote a sense of well-being o Diversional activities Copyright © 2022 Wolters Kluwer · All Rights Reserved  Multiple Sclerosis  A progressive immune-related demyelination disease of the CNS  Clinical manifestations vary and have different patterns o 4 main clinical forms o Geographic factors higher prevalence in northern colder latitudes)  MS may occur at any age, but the age of peak onset is between 20 and 50 years; it affects women three times more than men  Frequently, the disease is relapsing and remitting; has exacerbations and recurrences of symptoms, including fatigue, weakness, numbness, difficulty in coordination, loss of balance, pain, and visual disturbances Copyright © 2022 Wolters Kluwer · All Rights Reserved  Multiple Sclerosis  Medical management o Disease-modifying therapies; interferon -1a and interferon -1b, glatiramer acetate, and IV methylprednisolone-treatment based on sxs o No cure, only management of symptoms o Symptom management of muscle spasms (Baclofen, benzos), fatigue (amantadine, pemoline, or dalfampridine), ataxia (beta blockers), bowel and bladder control (anticholinergic agents, alpha-adrenergic blockers, antispasmodic agents)  Visual disturbances, pain, risk for UTI (increase fluid intake)  Risks for osteoporosis for perimenopausal women  Shorter lifespan  Course may follow many different patterns with remissions and treatments Copyright © 2022 Wolters Kluwer · All Rights Reserved  Planning and Goals for the Patient with Multiple Sclerosis  Monitor for: o Neurologic deficits o Secondary complications o Impact of disease on physical, social, and emotional function and on lifestyle o Patient and family coping o Promotion of physical mobility o Avoidance of injury o Achievement of bowel and bladder continence o Promotion of speech and swallowing mechanisms o Improvement in cognitive function o Development of coping strengths o Improved home maintenance o Adaptation to sexual function Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Multiple Sclerosis #1 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 o Program of activity and daily exercise o Relaxation, coordination exercises, walking, muscle-stretching exercises o Avoid very strenuous activity and extreme fatigue Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Multiple Sclerosis #2 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 Reinforce and encourage swallowing instructions Strategies to reduce risk of aspiration Memory aides, structured environment, and daily routine to enhance cognitive function Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Multiple Sclerosis #3  Interventions to minimize stress  Individualized educational plan of physical, occupational, speech-language therapy, rehabilitation combined with emotional support to manage depression, pain, fatigue, and other symptoms  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 o Increase level of physical activity and overall sense of well-being o Prevent falls o Manage fatigue o Strengthen coping mechanisms o Monitor complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Cranial Nerve Disorders Refer to Table 64-3 Trigeminal neuralgia (tic douloureux) Bell’s palsy Copyright © 2022 Wolters Kluwer · All Rights Reserved  Trigeminal Neuralgia (Tic Douloureux)  Condition of the fifth cranial nerve characterized by paroxysms of pain  Pain ends as abruptly as it starts and is described as a unilateral shooting and stabbing or burning sensation.  The unilateral nature of the pain is an important feature  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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Distribution of the Trigeminal Nerve Branches Copyright © 2022 Wolters Kluwer · All Rights Reserved Medical Management of Trigeminal Neuralgia Anticonvulsant agents such as carbamazepine (taken w/meals) o Monitor labs for toxicity (know side effects) Gabapentin and antispasmodic such as baclofen Phenytoin as adjunctive therapy Surgical treatment o Microvascular decompression of the trigeminal nerve o Radiofrequency thermal coagulation o Percutaneous balloon microcompression Copyright © 2022 Wolters Kluwer · All Rights Reserved  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 Copyright © 2022 Wolters Kluwer · All Rights Reserved  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  Affects ages 15-45  Objectives of treatment are to maintain the muscle tone of the face and to prevent or minimize denervation  *know difference between stroke sxs and Bell’s Palsy* Copyright © 2022 Wolters Kluwer · All Rights Reserved Distribution of the Facial Nerve Copyright © 2022 Wolters Kluwer · All Rights Reserved Management of Bell’s Palsy  Medical o Corticosteroid therapy may be used to reduce inflammation and diminish severity of the disorder o Early administration of corticosteroid therapy, started within 72 hours of symptom onset, is highly effective in diminishing the severity of the disease, relieving the pain, and preventing or minimizing denervation o Pain controlled with analgesics  Nursing o Provide and reinforce information and reassurance that stroke has not occurred o Protection of the eye from injury; cover eye with shield at night, instruct patient to close eyelid, use of eye ointment and sunglasses o Facial exercises and massage to maintain muscle tone o Avoid exposure to cold or drafts Copyright © 2022 Wolters Kluwer · All Rights Reserved Questions?? 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