NURS 4410
NEURO- CHAPT 69 & 70
LECTURE VERSION
Spring 2019
Alfred State
Marilyn J. Oggeri MSN, RN
MANAGEMENT OF PATIENTS
WITH NEUROLOGICAL
INFECTIONS, AUTOIMMUNE
DISORDERS, & NEUROPATHIES
/ ONCOLOGICAL OR
DEGENERATIVE
1
NEUROLOGICAL DISORDERS
LEARNING OBJECTIVES
16. Differentiate among the primary causes,
collaborative care, and nursing
management of meningitis, brain abscesses,
encephalitis, Creutzfieldt-Jacob disease, MS,
Myasthenia Gravis, Guillian-Barre, Cranial
Nerve Disorders, Brain / Spinal tumors,
Parkinson’s, Huntington’s, MD
2
INFECTIOUS NEUROLOGIC DISORDERS
1. Meningitis
2. Brain abscesses
3. Encephalitis
4. Creutzfeldt-Jakob disease and variant
Creutzfeldt-Jakob disease
QUESTION
Is the following statement true or false?
Meningitis is an inflammation of the pia mater,
the arachnoid, and the cerebrospinal fluid–
filled subarachnoid space.
ANSWER
True
Meningitis is an inflammation of the pia mater,
the arachnoid, and the cerebrospinal fluid–
filled subarachnoid space.
QUESTION
What is a positive Kernig’s 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.
ANSWER
C. When the patient is lying with the thigh flexed on the abdomen,
the leg cannot be completely extended.
Photophobia is common with meningitis and is extreme sensitivity
to light. Nuchal rigidity is any attempts at flexion of the head are
difficult because of spasms in the muscles of the neck.
Kernig’s sign is when the patient is lying with the thigh flexed on the
abdomen, the leg cannot be completely extended.
Brudzinski’s 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.
KERNIG’S SIGN
BRUDZINSKI’S SIGN
MENINGITIS
1. Inflammation of the membranes and the fluid space surrounding the brain
and spinal cord
2. Types
1. Septic caused by bacteria (Streptococcus pneumoniae, Neisseria
meningitidis)
2. Aseptic caused by viral infection, lymphoma, leukemia, or brain
abscess
3. N. meningitidis is transmitted by secretions or aerosol contamination, and
infection is most likely in dense community groups such as college campuses
4. Manifestations include headache, fever, changes in LOC, behavioral
changes, nuchal rigidity (stiff neck), positive Kernig's sign, positive Brudzinski’s
sign, and photophobia
MEDICAL MANAGEMENT
1. Prevention by vaccination against Haemophilus influenzae and S.
pneumoniae for all children and all at-risk adults
2. Prevention by meningococcal vaccination for adolescents and highrisk groups
3. Early administration of high doses of appropriate IV antibiotics for
bacterial meningitis
4. Dexamethasone (steroid)
5. Treatment dehydration, shock, and seizures
NURSING MANAGEMENT
1. Frequent or continual assessment, including VS and LOC
2. Protect patient form injury related to seizure activity or altered LOC
3. Monitor daily weight (look at fluid shifts), serum electrolytes, urine
volume, specific gravity, and osmolality
4. Prevent complications associated with immobility
5. Infection control precautions
6. Supportive care
7. Measures to facilitate coping of patient and family
BRAIN ABSCESS
1. Collection of infectious material within brain tissue
2. Risk is increased in immunocompromised patients
3. Prevent by treating otitis media, mastoiditis, sinusitis, dental infections,
and systemic infections promptly
4. Manifestations may include headache that is usually worse in the
morning, fever, vomiting, neurologic deficits, signs and symptoms of
increased ICP
5. Diagnosis by MRI or CT
6. CT-guided aspiration is used to identify the causative organisms
BRAIN ABSCESS (CONT’D)
8. Medical management
1. Control ICP
2. Drain abscess
3. Administer appropriate antibiotic therapy; corticosteroids
may be used to treat cerebral edema
9. Nursing management
1. Frequent and ongoing neurologic assessment and of
responses to treatment
2. Assure patient safety and protect from injury
3. Provide supportive care
ENCEPHALITIS
1. Acute, inflammatory process of the brain tissue
2. Causes include viral infections (herpes simplex [HSV]), vector-borne viral
infections (West Nile, St. Louis), and fungal infections
3. Manifestations may include headache fever, confusion, changes in
LOC; vector borne—rash, flaccid paralysis, Parkinson-like movements
4. Medical management
1. Acyclovir for HSV infection, amphotericin or other antifungal agents
for fungal infection
5. Nursing management
1. Frequent and ongoing assessment
2. Supportive care
CREUTZFELDT-JAKOB DISEASE AND
VARIANT CREUTZFELDT-JAKOB DISEASE
1. Rare, degenerative infectious, transmissible spongiform
encephalopathies (TSEs)
2. TSEs are caused by prions: small proteinaceous particles that are
smaller than viruses and resistant to sterilization
3. The disease is not spread by casual contact; vCJD may be
contracted through ingestion of infected beef.
4. Manifestations include affective, sensory, motor, and cognitive
impairments.
5. No effective treatment; progressive and fatal
6. Nursing management
1. Prevention of disease transmission; blood and body fluid
precautions
2. Supportive care
AUTOIMMUNE NEUROLOGIC DISORDERS
1. Multiple sclerosis (MS)
2. Myasthenia gravis
3. Guillain-Barré syndrome
QUESTION
Is the following statement true or false?
Multiple sclerosis is an immune-mediated, progressive
demyelinating disease of the peripheral nervous
system.
ANSWER
False
Multiple sclerosis is an immune-mediated, progressive
demyelinating disease of the central nervous system,
not the peripheral nervous system.
MULTIPLE SCLEROSIS
1. A progressive immune-related demyelination disease of the CNS
2. Clinical manifestations vary and have different patterns
3. 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
4. Medical management
1. Disease-modifying therapies; interferon -1a and interferon -1b,
glatiramer acetate (Copaxone), and IV methylprednisolone
2. Symptom management of muscle spasms, fatigue, ataxia, bowel
and bladder control
PROCESS OF DEMYELINATION
TYPES AND COURSES OF MULTIPLE SCLEROSIS
QUESTION
Is the following statement true or false?
Myasthenia gravis is an autoimmune attack on the
peripheral nerve myelin.
ANSWER
False
Guillain–Barré syndrome is an autoimmune attack on the peripheral
nerve myelin. Myasthenia gravis is an autoimmune disorder affecting
the myoneural junction and is characterized by varying degrees of
weakness of the voluntary muscles.
NURSING PROCESS: THE CARE OF THE PATIENT WITH
MULTIPLE SCLEROSIS—ASSESSMENT
1.Neurologic deficits
2. Secondary complications
3. Impact of disease on physical, social, and emotional
function and on lifestyle
4. Patient and family coping
NURSING PROCESS: THE CARE OF THE PATIENT
WITH MULTIPLE SCLEROSIS—DIAGNOSES
1. Impaired physical mobility
2. Risk for injury
3. Impaired bowel and bladder function
4. Impaired verbal communication
5. Disturbed thought processes
6. Ineffective coping
7. Impaired home maintenance
8. Potential sexual dysfunction
NURSING PROCESS: THE CARE OF THE PATIENT WITH
MULTIPLE SCLEROSIS—PLANNING
1.Major goals may include
1. Promotion of physical mobility
2. Avoidance of injury
3. Achievement of bowel and bladder continence
4. Promotion of speech and swallowing mechanisms
5. Improvement in cognitive function
6. Development of coping strengths
7. Improved home maintenance
8. Adaptation to sexual function
INTERVENTIONS
1, Use a collaborative approach
2. Coordinate and refer as needed to health care
services: social services, speech therapy, physical
therapy, counseling services, home care services, and
so on
3. Activity and rest
1. Program of activity and daily exercise
2. Relaxation, coordination exercises, walking,
muscle-stretching exercises
3. Avoid very strenuous activity and extreme fatigue
INTERVENTIONS (CONT’D)
1. Bowel and bladder control
1. Instruction or administration of prescribed
medications
2. Voiding schedule
3. Bowel training program
4. Adequate fluid and fiber to prevent constipation
2. Reinforce and encourage swallowing instructions
3. Strategies to reduce risk of aspiration
4. Memory aides, structured environment, and daily
routine to enhance cognitive function
INTERVENTIONS (CONT’D)
1. Interventions to minimize stress
2. Maintenance of temperate environment—air
conditioning to avoid excessive heat and avoidance of
exposure to extreme cold
3. Use assistive devices and modifications for home care
management and independence in ADLs
4. Support of coping
MYASTHENIA GRAVIS
1. Autoimmune disorder affecting the myoneural junction
2. Antibodies directed at acetylcholine at the myoneural junction impair
transmission of impulses
3. Manifestations
1. a motor disorder
2. Initially symptoms involve ocular muscles: diplopia (double vision)
and ptosis (eyelid drooping)
3. Weakness of facial muscles, swallowing and voice impairment
(dysphonia), generalized weakness
MYASTHENIA GRAVIS (CONT’D)
Normal ACh receptor site
ACh receptor site in
myasthenia gravis
MEDICAL MANAGEMENT
1. Pharmacologic therapy
1. Cholinesterase inhibitor: pyrostigmine bromide (Mestinon)
2. Immunomodulating therapy
2. Plasmapheresis
3. Thymectomy
MYASTHENIC CRISIS
VS
CHOLINERGIC CRISIS
1. Result of disease exacerbation or
precipitating event, most commonly
a respiratory infection
2. Severe generalized muscle
weakness with respiratory and
bulbar weakness
3. Patient may develop respiratory
compromise/failure
4. Caused by overmedication
with cholinesterase inhibitors
5. Severe muscle weakness with
respiratory and bulbar weakness
(motor neuron impairment of
Cranial nerves 9-12)
6. Patent may develop respiratory
compromise and failure
MANAGEMENT OF MYASTHENIC CRISIS
1. Patient education in signs and symptoms of myasthenic crisis
and cholinergic crisis
2. Ensuring adequate ventilation; intubation and mechanical
ventilation may be needed.
3. Assessment and supportive measures
1. Measures to ensure airway and respiratory support
2. ABGS, serum electrolytes, I&O, and daily weight
3. If patient cannot swallow, nasogastric feeding may be
required
4. Avoid sedatives and tranquilizers
NURSING PROCESS: THE CARE OF THE
PATIENT WITH MYASTHENIA GRAVIS
1. Focus on patient and family education
2. Medication education and management
3. Energy conservation
4. Strategies to help with ocular manifestations
5. Prevention and management of complications and
avoidance of crisis
6. Measures to reduce risk of aspiration
7. Avoidance of stress, infections, vigorous physical
activity some medications, and high environmental
temperatures
GUILLAIN-BARRÉ SYNDROME
1. Autoimmune disorder with acute attack of peripheral nerve myelin
2. Rapid demyelination may produce respiratory failure and autonomic
nervous system dysfunction with CV instability
3. Most often follows a viral infection
4. Manifestations are variable and may include weakness, paralysis,
paresthesias, pain, and diminished or absent reflexes, starting with the
lower extremities and progressing upward; bulbar weakness; cranial
nerve symptoms; tachycardia; bradycardia; hypertension; or
hypotension
GUILLAIN-BARRÉ SYNDROME (CONT’D)
5. Medical management
1. Requires intensive care management with continuous
monitoring and respiratory support
2. Plasmapheresis and IVIG are used to reduce circulating
antibodies
**Recovery rates vary, but most patients recover completely
NURSING PROCESS: THE CARE OF THE PATIENT
WITH GUILLAIN–BARRÉ SYNDROME— ASSESSMENT
1. Ongoing assessment for with emphasis on early detection of
life-threatening complications of respiratory failure, cardiac
dysrhythmias, and deep vein thrombosis (DVT)
2. Monitor for changes in vital capacity and negative inspiratory
force
3. Assess VS frequently or continuously, including continuous
monitoring of ECG
4. Patient and family coping
NURSING PROCESS: THE CARE OF THE PATIENT
WITH GUILLAIN-BARRÉ SYNDROME—DIAGNOSES
1. Ineffective breathing pattern
2. Impaired gas exchange
3. Impaired physical mobility
4. Imbalanced nutrition
5. Impaired verbal communication
6. Fear
7. Anxiety
COLLABORATIVE PROBLEMS AND
POTENTIAL COMPLICATIONS OF GUILLAINBARRE SYNDROME
1. Respiratory failure
2. Autonomic dysfunction
3. DVT
4. Pulmonary embolism
5. Urinary retention
NURSING PROCESS: THE CARE OF THE PATIENT
WITH GUILLAIN-BARRÉ SYNDROME—PLANNING
Major goals include
1. Improved respiratory function
2. Increased mobility
3. Improved nutritional status
4. Effective communication
5. Decreased fear and anxiety
6. Effective patient and family coping
7. Absence of complications
INTERVENTIONS
1. Enhancing physical mobility and prevention of DVT
1. Support limbs in functional position
2. Passive ROM at least twice daily
3. Frequent position changes at least every 2 hours
4. Elastic compression hose or sequential compression
boots
5. Adequate hydration
2. Administer IV and parenteral nutrition as prescribed
3. Carefully assess swallowing and gag reflex and take
measures to prevent aspiration
INTERVENTIONS (CONT’D)
1. Develop a plan for communication individualized to patient
needs
2. Decreasing fear and anxiety
1. Provide information and support
2. Referral to support group
3. Relaxation measures
4. Maintain positive attitude and atmosphere to promote a
sense of well-being
5. Diversional activities
CRANIAL NERVE DISORDERS
1. Refer to Table 69-2
2. Trigeminal neuralgia (tic douloureux)
3. Bells’ palsy
TRIGEMINAL NEURALGIA
(TIC DOULOUREUX)
1. Condition of the fifth cranial nerve characterized by
paroxysms of pain
2. Most commonly occurs in the second and third
branches of this nerve. Vascular compression and
pressure is the probable cause.
3. Occurs more often in the fifth and sixth decades and
in women and persons with MS
4. Pain can occur with any stimulation such as washing
face, brushing teeth, eating, or a draft of air.
5. Patients may avoid eating, neglect hygiene, and even
isolate themselves to prevent attacks.
DISTRIBUTION OF THE TRIGEMINAL NERVE BRANCHES
MEDICAL MANAGEMENT
1. Antiseizure medications such as carbamazepine (Tegretol),
gabapentin (Neurontin), phenytoin, or antispasmodic
medication baclofen (Lioresal)
2. Surgical treatment
1. Microvascular decompression of the trigeminal nerve
2. Radiofrequency thermal coagulation
3. Percutaneous balloon microcompression
NURSING INTERVENTIONS
1. Patient education related to pain prevention and treatment
regimen
2. Measures to reduce and prevent pain; avoidance of triggers
3. Care of the patient experiencing chronic pain
4. Measures to maintain hygiene: washing face, oral care
5. Strategies to ensure nutrition; soft food, chew on unaffected
side, avoid hot and cold food
6. Recognize and provide interventions to address anxiety,
depression, and insomnia
BELL’S PALSY
1. Facial paralysis caused by unilateral inflammation of the
seventh cranial nerve
2. Manifestations: unilateral facial muscle weakness or
paralysis with facial distortion, increased lacrimation (tears),
and painful sensations in the face; may have difficulty with
speech and eating
3. Most patients recover completely in 3 to 5 weeks, and the
disorder rarely recurs.
DISTRIBUTION OF THE FACIAL NERVE (#7)
MANAGEMENT
1. Medical
1. Corticosteroid therapy may be used to reduce
inflammation and diminish severity of the disorder.
2. Nursing
1. Provide and reinforce information and reassurance that
stroke has not occurred.
2. Protection of the eye from injury; cover eye with shield at
night, instruct patient to close eyelid, use of eye ointment and
sunglasses.
3. Facial exercises and massage to maintain muscle tone
BRAIN & SPINAL CORD TUMORS
1.Brain Tumors
1. Classified by location and histology characteristics (what kind of cells the
tumor is made up of)
2. Symptoms depend on the location and size of the lesion and its
compression on the nearby structures
3. Dx with CTs, MRIs, PET scans, EEGs, Bx, Spinal Tap
4. Rx depends on type location and accessibility of the tumor
1. Surgery – goal is to remove tumor WITHOUT ↑ neuro s&s OR ↓ s&s by
decompression.
2. Radiation Rx
3. Chemotherapy
4. Pharmacological Rx for s&s control
2. Spinal Cord Tumors
1. Classified by their anatomic relation to the spinal cord
2. Manifestations include pain, weakness, loss of motor or sensory or
reflexes
2. Rx depends on type of tumor and location
PARKINSON’S DISEASE
1.Slow, progressive neurologic movement disorder associated with decreased
levels of dopamine
2.Manifestations:
1.Cardinal: tremor, rigidity, bradykinesia/akinesia, postural instability
2.Autonomic: sweating, drooling, flushing, orthostatic hypotension, gastric and
urinary retention
3.Dysphagia
4.Psychiatric changes: depression, anxiety, dementia, delirium, hallucinations
3.Treatment directed toward controlling symptoms and maintaining functional
independence.
1.Pharmacologic treatment (Levodopa, Table 70-1)
2.Surgical procedures
1.Stereotactic Procedures; thalamotomy, pallidotomy
3.Neural transplantation
4.Ongoing research
HUNTINGTON’S DISEASE
1. A chronic progressive hereditary disease that results
in choreiform( rapid, jerky, involuntary, purposeless)
movements and dementia
2.Transmitted as an autosomal dominant trait
3. Pathology involves premature death of cells in the
striatum of the basal ganglia (control of movement)
and the cortex (thinking, memory, perception,
judgment)
4.Refer to Chart 70-5
5.Treatment is aimed at s&s relief.
AMYOTROPHIC LATERAL SCLEROSIS (ALS)
1. “Lou Gehrig disease”
2. Loss of motor neurons in the anterior horn of
the spinal cord and loss of motor nuclei of
the lower brainstem
3. Manifestations
1. Progressive weakness and atrophy of
muscles, cramps, twitching, and lack of
coordination
2. Spasticity, deep tendon reflex brisk and
overactive
3. Difficulty speaking, swallowing, breathing
MUSCULAR DYSTROPHIES
1. Incurable disorders characterized by progressive
weakening and wasting of skeletal and voluntary
muscles
2. Most are inherited disorders
3. Duchenne muscular dystrophy is the most common and
inherited as a sex-linked trait (influences males. Women
carry it but their sons get it)
4. Common characteristics:
1. Varying degrees of muscle wasting and weakness
2. Abnormal elevation in serum levels of muscle enzymes
REFERENCES
Hinkle, J., Cheever, K., Brunner & Suddarth’s Textbook of
Medical-Surgical Nursing, 14th Edition, LWW, 2018
Oggeri, M.J. Neuro 4410 2018 Lectures/PPT, Alfred State College
Oggeri, M.J. , Shepard, T., Neuro 4410 2017 Focus on Head InjuryIICP Lecture /PPT, Alfred State College
Oggeri, M.J. , Shepard, T., Neuro 4410 2017 Head Injury and
Spinal Injury Lecture/PPT, Alfred State College
Oggeri, M.J., Neuro 3310 2017 Neuro Assessment Lecture/PPT,
Alfred State College
Shepard, T., 4410, 2017 Back Pain & Spinal Injury Lecture/PPT,
Alfred State College
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