Neurology

1
Neurology

• Chapter 64
• Management of Patients with neurologic infection,
  autoimmune disorders and neuropathies

2
Meningitis

• Pathophysiology
• Meningitis
• Infection/ inflammation of the meninges
• Encephalitis
• Infection/inflammation of the brain tissue

3
Meningitis

• Pathophysiology
• Meningitis/ encephalitis ?
• Infection ?
• Immune response ?
• Swelling/edema ?
• I ICP ?
• Etc.

4
Meningitis

• Is meningitis a disorder of the CNS, PNS or both?
• CNS
• PNS
• Both CNS PNS

5
Meningitis

• The most common bacterial pathogens are
• Haemonphili influenzai
• Affected kids lt 5 yrs
• H influenzae vaccine (Hib)
• Streptococcus pneumoniae
• Affects age 19-59
• Neisseria meningitides
• Easily transmitted to others
• Least lethal

6
Meningitis

• Two ways the infectious agent can inter the
  meninges
• Blood stream
• Most common
• Usually d/t URI
• Direct extension
• TBI
• Invasive procedures

7
Meningitis

• The viral type of meningitis is usually
• Self limiting
• Benign
• Bacterial meningitis is potentially
• Fatal

8
Meningitis

• Clinical manifestations
• Onset
• Abrupt
• General SS
• Nuchal rigidity
• Positive Kernig's
• Positive Brudzinskis
• Photophobia

9
Meningitis

• Clinical Manifestations
• SS of infection
• Fever
• Chills

10
Meningitis

• Clinical manifestations
• SS of I-ICP
• H/A
• i LOC
• Vomiting
• Papilledema
• Hydrocephalus

11
Meningitis

• Clinical manifestations
• N. Meningitidis
• Rash
• Petechial
• Purpuric lesion
• Ecchymosis

12
Meningitis

• Clinical manifestations
• Infants/young children
• Seizures
• High-pitched cry
• Bulging fontanels

13
Meningitis

• Mr. Jones has encephalitis. Would you expect his
  signs and symptoms to be more or les severe than
  a person with meningitis?
• More severe
• Less severe
• Encephalitis signs and symptoms are more severe
  with delirium seizures.

14
Meningitis

• Diagnosis
• Lumbar tap
• CS of CSF
• Positive Kernigs
• Positive Brudzinski

15
Meningitis

• Treatment
• Broad spectrum antibiotics
• Penicillin
• Cephalosporin's
• Intrathecally
• Early intervention crucial!

16
Meningitis

• Nursing interventions
• Isolation
• ? Causative agent
• Assessment
• V/S
• Neuro check
• Cranial nerve involvement
• Abn sleep patterns
• Behavioral changes
• ABGs
• Opisthotonus

17
Meningitis

• Nursing management
• I-ICP protocol
• IO
• Quiet environment Dark
• Limit visitors
• Nutrition
• No constipation
• Pad side rails
• Emotional support
• Alkalosis

18
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. 

19
Meningitis

• Complications
• Thrombosis
• i cerebral blood flow
• Brain damage
• Death

20
Meningitis

• What do bulging fontanels 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

21
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

22
Brain Abscess

• Pathophysiology
• A collection of infectious material within the
  tissue of the brain
• Infection ?
• I-ICP ?
• Brain shift

23
Brain Abscess

• 2 ways infection can enter the brain
• Direct invasion
• Spread from nearby sight
• Sinuses
• Ears
• Teeth

24
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.

25
Brain Abscess

• Clinical manifestations
• I-ICP
• Infection
• Fever?
• Sometimes
• Sometimes not!

26
Brain Abscess

• Diagnostic findings
• CT
• MRI

27
Brain Abscess

• Medical Management
• Antimicrobial therapy
• Large IV doses
• Surgery
• Anti-convulsant

28
Brain Abscess

• Nursing management
• I-ICP protocol
• Neuro assessment
• Safety protocol
• seizures

29
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?

30
Multiple Sclerosis

• Pathophysiology
• Autoimmune disease
• Demyelination of the myelin covering that
  protects the neurons of the brain and spinal cord

31
Multiple Sclerosis

• Demyelination
• Destruction of the myelin sheath ?
• Impaired transmission of nerve impulses
• Both the axon myelin are attacked

32
Multiple Sclerosis

• Is multiple sclerosis a disorder of the CNS, PNS
  or both?
• CNS
• PNS
• Both CNS PNS

33
Multiple Sclerosis

• Etiology / Contributing factors
• Unknown cause
• Men vs women
• Men lt women
• Age of onset
• 20-40

34
Multiple Sclerosis

• Clinical manifestations
• Usually slow, progressive disease
• Relapsing-remitting course
• Patient may experience remission exacerbations
• Exacerbation of symptoms ?
• Partial/full remission ?
• Symptoms return

35
Multiple Sclerosis

• Clinical Manifestations
• Episodes of motor, visual or sensory disturbance
• Visual disturbances
• Diplopia
• Blurred vision
• Paresthesia
• Fatigue
• Dizziness

36
Multiple Sclerosis

• Clinical Manifestations
• Emotional disturbances
• Scanning speech
• Incontinence
• Sexual disorders
• Spasticity
• Muscle hypertonicity

37
Multiple Sclerosis

• Diagnosis
• MRI
• Sm. Plaque
• Patches
• CT scan
• Lumbar puncture
• Immunoglobulin abnormalities

38
Multiple Sclerosis

• Medical management
• No cure
• Goal
• Delay progress
• Manage symptoms

39
Multiple Sclerosis

• Pharmaceutical
• Interferons
• ABCR

40
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

41
Multiple Sclerosis

• Pharmaceutical
• Corticosteriods
• Immunosuppressants
• Dexamethasone, prednisone
• Action
• Decreased imflammation
• S/E
• Poor wound healing
• Na H20 retention
• h glucose levels

42
Multiple Sclerosis

• Nursing Interventions
• Individualized
• BB management
• Avoid stress
• Stress
• Fatigue
• Extreme temp.
• Exercise
• Fluids
• Diet
• High roughage

43
Multiple Sclerosis

• Complications
• Pneumonia
• Decubitis ulcers
• Contractures
• Dependency

44
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.

45
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?

46
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

47
Myasthenia Gravis

• Pathophysiology
• Specifically attacks receptors for acetylcholine
  ?
• Prevents muscle contraction ?
• Progressive weakness fatigue

48
Myasthenia Gravis

• Is myasthenia Gravis a disorder of the CNS, PNS
  or both?
• CNS
• PNS
• Both CNS PNS

49
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

50
Myasthenia Gravis

• Clinical manifestations
• Resp. paralysis (Bulbar paralysis)?
• Vital capacity
• i
• Resp. failure ?
• Deathmosis

51
Myasthenia Gravis

• Myasthenia gravis is purely a motor disorder
  with no effect on sensation or coordination.

52
Myasthenia Gravis

• Etiology
• Men vs Women
• Men lt women
• Age 20-40
• Thymus
• enlarged

53
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.

54
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

55
Myasthenia Gravis

• Treatment
• Corticosteroids
• Thymus
• radiation
• Plasmapheresis
• Plasma exchange

56
Myasthenia Gravis

• Nursing interventions
• Planned activities
• Avoid stress
• Rest periods
• Resp. baseline
• Tidal volume
• Vital capacity
• Inspiratory force

57
Myasthenia Gravis

• Nursing interventions
• Do not administer barbiturates, tranquilizers,
  muscle relaxants, morphine etc.
• Eye care

58
Myasthenia Gravis

• Complications
• Myasthenic crisis
• Caused by
• Not enough med.
• Stress
• SS
• Rapid onset of weakness ?
• Resp. distress

• Treatment
• Medication
• IV or IM
• Resp. support
• Intubation
• PEEP
• Suction
• NG tube

59
Myasthenia Gravis

• Complications
• Cholinergic crisis
• Caused by
• Too much med.
• SS
• Rapid onset of weakness ?
• Resp. distress

• Treatment
• Hold medication
• Resp. support
• Intubation
• PEEP
• Suction
• NG tube

60
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

61
Myasthenia Gravis

• What can cause a cholinergic crisis?
• What are the SS 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?

62
Myasthenia Gravis

• Myasthenic crisis is caused by what?
• What are the SS of a Myasthenic crisis?
• What is the treatment of a Myasthenic crisis?
• What is the difference between MG and MS?
  (besides the letter GS)
• When you give a Tensilon test how would you know
  if they were under medicated?
• What meds are used to treat MG?

63
Guillain-Barre Syndrome

• Pathophysiology
• Autoimmune disease
• The myelin sheath of the spinal and cranial
  nerves are destroyed by diffuse inflammatory
  reaction

64
Guillain-Barre Syndrome

• Is Guillain-Barre Syndrome a disorder of the CNS,
  PNS or Both?
• CNS
• PNS
• Both CNS and PNS

65
Guillain-Barre Syndrome

• Pathophysiology
• Demyelination
• Axon atrophy
• Starts distal nerves
• Remyelination
• Slow
• Descending pattern

66
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

67
Guillain-Barre Syndrome

• Etiology
• Unknown
• In most patients it is preceded by viral
  infection
• Men vs. Women

68
Guillain-Barre Syndrome

• Clinical manifestations
• Onset
• Abrupt
• Symmetrical paresis that progresses to paralysis
• Begins with lower extremities
• Paresthesias
• Weakness
• Dyskinesia
• Paralysis

69
Guillain-Barre Syndrome

• Clinical manifestations
• Progresses upward
• Resp failure
• Bulbar weakness
• Recovery

70
Guillain-Barre Syndrome

• Diagnostic exam
• CSF
• Increased protein
• EEG
• Slowing of nerve conduction

71
Guillain-Barre Syndrome

• Treatment
• Considered a medical emergency
• Mechanical ventilation
• Immunosuppressant
• Anti-coagulants
• Plasmapheresis

72
Guillain-Barre Syndrome

• Nursing interventions
• Respiratory function
• ROM
• TED hose
• Nutrition
• Communication
• Anxiety

73
Guillain-Barre Syndrome

• Complications
• Resp. failure
• PE
• Anxiety

74
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 SS of GB?
• What are the initial symptoms of GB?
• What is the outcome of GB?
• What are the complications associated with GB?

75
Trigeminal Neuralgia

• AKA
• Tic Douloueux
• Pathophysiology
• Condition of CN 5
• Neuralgia
• Nerve pain

76
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!

77
Trigeminal Neuralgia

• Clinical Manifestations
• PAIN!!!
• Sudden
• Stabbing
• Burning
• Knife-like

78
Trigeminal Neuralgia

• Etiology
• Unknown
• Men vs Women
• Men lt women
• Age of onset
• 50s
• Dental work

79
Trigeminal Neuralgia

• Diagnostic exams
• Hx
• MRI

80
Trigeminal Neuralgia

• Treatment
• Anticonvulsants
• Examples
• Tegretol
• Dilantin
• Action
• i transmission of nerve impulse
• S/E
• Drowsiness

81
Trigeminal Neuralgia

• Nerve block
• Alcohol and phenol injected into the nerve
• Destroys the nerve temporarily
• Surgery

82
Trigeminal Neuralgia

• Nursing Interventions
• Goal
• Relieve pain
• Avoid Triggers
• Hot cold foods
• Draft areas
• Brushing teeth
• Chewing food
• Self-care deficit
• Depression
• Suicide

83
Trigeminal Neuralgia

• Complications
• Paralysis
• Infection

84
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 SS is Trigeminal neuralgia?
• What is the treatment for trigeminal neuralgia?

85
Bells Palsy

• Pathophysiology
• Inflammation of CN -7
• Resulting in weakness or paralysis of one side of
  the face
• Usually resolve in 2-8 weeks

86
Bells Palsy

• Clinical Manifestations
• Facial pain that radiates to the eye ear
• h eye tearing
• Speech difficulties
• Distortion of the face
• Diminished blink reflex

87
Bells Palsy

• Etiology
• Unknown

88
Bells Palsy

• Medical Treatment
• Corticosteriods
• Eye drops
• Analgesics

89
Bells Palsy

• Nursing interventions
• Eye care
• Patch
• Drops
• Moist heat to face
• Massage
• Electric stim

90
Bells Palsy

• What cranial nerve is involved with Bells palsy?
• What is the primary nursing diagnosis with a
  patient with Bells palsy?
• What can trigger Bells palsy?
• What are the SS is Bells palsy?
• What is the treatment for Bells palsy?