Neurological Disorders

• Pressure-          60-150 mm H20
• WBC-               0-8 per ul
• Protein-           14-45 mg/dl
• Glucose-          45-75 mg/dl
• Appearance-     Clear and colorless

*if pink/red tinged --> sub-arachnoid hemorrhage 

Meningitis

• Bacteria
• Viruses
• Fungi
• Chemicals

• ***Go into detail with symptom analysis
• *CRANIAL NERVES/ Autonomic NS
• Seizures?
• Dizziness/vertigo?
• Vision problems?
• Muscle weakness?
• Abnormal sensations?

Assess: thought content, emotional status, cranial nerves, LOC, motor system, balance/coordination, reflexes, etc…

• upper respiratory tract
• 

Droplet Precautions

• Adhesions- (hydrocephalus)
• Vasculitis- (stroke)
• Encephalitus- (cerebral edema/increased ICP)

100

Bacterial (septic)

• Strep. pneumoniae
• Meisseria meningitidis

Hemophilus influenza

Enteroviruses

Arboviruses

Human immunodeficiency virus (HIV)

Herpes Simplex virus (HSV)

Candida albicans, Histoplasmosis capsulatum

•Inflammatory response, ↑CSF, ↑ICP

•If the brain parenchyma involved → cerebral edema and further ↑ICP

Blood Brain Barrier

•Meningeal irritation

• •Nuchal rigidity (stiff neck) --
• Any attempts at flexion of the head are difficult because of spasms in the muscles of the neck. Usually, the neck is supple, and the patient can easily bend the head and neck forward.

• •Positive Kernig’s--
• Patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended...When Kernig’s sign is bilateral, meningeal irritation is suspected 

• *Brudzinski’s --
• Patient’s neck is flexed (after ruling out cervical trauma or injury), 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. Brudzinski’s sign is a more sensitive indicator of meningeal irritation than Kernig’s sign.

•Photophobia (extreme sensitivity to light), fever, H/A, N/V, ↓LOC, ↑ICP

•Meningococcus- rash, petechiae

Bacterial Meningitis

(Streptococcus pneumoniae and Neisseria meningitidis)

• Viral Meningitis
• (enteroviruses)

Dense (college campuses, military installations)

Tobacco use and viral upper respiratory infection -- increase the amount of droplet production

Otitis media and mastoiditis -- the bacteria can cross the epithelial membrane and enter the subarachnoid space.

People with immune system deficiencies are also at greater risk for development of bacterial meningitis

•Most common- ↑ICP

•CN alterations

•Noncommunicating hydrocephalusà caused by adhesions (scar tissue that blocks blood flow and pressure/fluid continues to build)

•Waterhouse-Friderichsen syndrome/DICà disseminated intravascular coagulation (widespread hemorrhages)…patient will begin to bleed out of every place…SHOCK…patient will die

...visual impairment, deafness, seizures, paralysis, hydrocephalus, and septic shock.

H/A and Fever

• •Cryptococcal meningitis is the most common fungal infection of the central nervous system in patients with AIDS. Patients may experience headache, nausea, vomiting, seizures, confusion, and lethargy. Treatment consists of IV administration of amphotericin B followed by fluconazole. Maintenance therapy with fluconazole may be necessary to prevent relapse.
• • Some patients who are immunosuppressed develop few if any symptoms because of blunted inflammatory responses; others develop atypical features.
• • Onset of fever, headache, nausea, and malaise most often occur over a few weeks. Only 25% of patients present with stiff neck and photophobia.

• Lyme disease is a multisystem inflammatory process caused by the tick-transmitted spirochete Borrelia burgdorferi.
• • Neurologic deficits are seen in later stages (stages 2 or 3). Stage 2 occurs with the start of a characteristic rash or 1–6 months after the rash has disappeared.
• • Neurologic comorbidities include aseptic meningitis, chronic lymphocytic meningitis, and encephalitis.
• • Cranial nerve inflammation, including Bell’s palsy and other peripheral neuropathies, is common.
• • Stage 3 (the chronic form of the disease) begins years after the initial tick infection and is characterized by arthritis, skin lesions, and neurologic abnormalities.
• • Most patients with stage 2 and 3 Lyme disease are treated with IV antibiotics, usually ceftriaxone or penicillin G.
• • Meningeal and systemic symptoms begin to improve within days, although other symptoms, such as headache, may persist for weeks.

CT scan, MRI

• CT -- (assesses ICP and hydrocephalus)
• MRI
• Bacterial (nasal) culture and Gram-Staining of CSF-- (allows for rapid identification of the causative bacteria and initiation of appropriate antibiotic therapy)
• X-ray- (may be able to trace back
• to sinus infection)

• Older age
• HR > 120 bpm
• Decreased Glasgow Coma Scale Score
• Cranial nerve palsies
• Positive Gram stain 1 hour after presentation to the hospital

• CULTURES!
• (have done within 20 min of arrival, then start antibiotic therapy)

• WBC- 1000/ul
• Protein- >500 mg/dL
• Glucose- low < 45 mg/dL
• Turbid color
• (if pink/red  tinged -- indication of hemorrhage)

Assess Pt. LOC and ability to handle procedures, look for papiledema, assess any neurodeficit, assess history of CNS disorders

Medical emergency

• Placed on respiratory isolation (any discharge is considered infectious)…droplet
• precautions

• MENINGOCOCCAL MENINGITIS IS
• CONTAGIOUS- don’t take any risks…educate family!

• Collect Cultures FIRST, then start antibiotics
• (Most commonly prescribed- Penicillin G and Cephalosporins)

•Resolve infection

•Control discomfort/Pain management

•Decrease stimuli-- getting rest in dark, quiet room

•Family at bedside/family education

•Seizure precautions

•Cooling blanket/Antipyretics for fevers

•Fluids

• •IVF
• *Frequent neurological monitoring and vital signs

Protecting the patient from injury secondary to seizure activity or altered LOC

Monitoring daily body weight; serum electrolytes; and urine volume, specific gravity, and osmolality, especially if syndrome of inappropriate antidiuretic hormone (SIADH) is suspected


Preventing complications associated with immobility, such as pressure ulcers and pneumonia

• COMMON: (given IV within 30 min of arrival)
• Penicillin G
• Cephalosporins

• •Decadron- decreases inflammation
• (Beneficial as adjunct therapy in the treatment of acute bacterial meningitis and in pneumococcal meningitis if it is administered 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days. Research suggests that dexamethasone improves the outcome in adults and does not increase the risk of gastrointestinal bleeding)

• •Antipyretics-
• (used for fever, ↑ cerebral edema, and seizures)

•Analgesics

•Antiseizure meds

• •Diuretics- Mannitol-
• (reduces cerebral edema)

**some patients will not go home right away depending on the severity of disease

• •Nutrition
• (High protein, high calorie foods in small, frequent feedings)

• •Progressive ROM exercises and Warm Baths
• (for muscle rigidity)

•Gradual progression of activity

•Adequate rest & sleep

•Assessment of long term sequelae– (hearing, CN damage, seizures, long term med therapy, etc....

Dementia, Seizures, Deafness, Hemiplegia, Hydrocephalus.  Should also assess vision, hearing, cognitive skills, and motor and sensory abilities. Infants may have silient sequelae that are not apparent until they start to school and have learning and behavioral problems)

•Family support

Vaccinations: 2011 guidelines from CDC- youth 11-12yrs, booster at 16

• People who have been in close contact with anyone who has bacterial meningitis should be treated with prophylactic antibiotics.
• Rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin).

Early and vigorous treatment of resp. and ear infections is very important.

100-180

200-500

<250

>200

0-5

100-5000

50-1000

>20

fluid volume expanders

Phenytoin

• Respiratory Support
• (Insertion of a cuffed endotracheal tube- or tracheotomy- and mechanical ventilation to maintain adequate tissue oxygenation)

• Treat Symptoms
• Prevent increased Intracranial Pressure

• LP (lymphocytosis)
• *NO organisms in culture!

Adults and Children

Neonates

Encephalitis

Fever, Headache, Confusion, and Hallucinations. Focal neurologic symptoms reflect the areas of cerebral inflammation and necrosis and include fever, headache, behavioral changes, focal seizures, dysphasia, hemiparesis, and altered LOC

• Lumbar Puncture (CSF)
• CT
• MRI
• EEG
• CAT scan
• Brain imaging
•   PCRà specific DNA/RNA
• (standard test for early diagnosis of HSV 1 encephalitis. PCR identifies the deoxyribonucleic acid (DNA) bands of HSV-1 in the CSF. The validity of PCR is very high between the 3rd and 10th days after symptom onset)

•Mosquito Program

•HSV- most severe form of viral encephalitis; Zovirax, Vira-A

•Seizures- antiseizure meds

•Cerebral edema- Mannitol and Decadron

***Antiviral agents, either acyclovir (Zovirax) or ganciclovir (Cytovene), are the medications of choice in the treatment for HSV. Early administration of antiviral agents (usually well tolerated) improves the prognosis associated with HSV-1 encephalitis

•Antimicrobial therapy- corticosteroids to decrease pressure

•I&D

•Management of sx- providing comfort

dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents.

Symptom

Clothing that provides coverage and insect repellents containing 25% to 30% diethyltoluamide (DEET) should be used on exposed clothing and skin in high-risk areas to decrease mosquito and tick bites. Remaining indoors at dawn and dusk when mosquito activity is highest is recommended. Screens should be in good repair in the home, and standing water should be removed. All cases of arboviral encephalitis must be reported to the local health department

Creutfeldt-Jakob Disease (CJD) and Variant Creutzfeldt-Jakob Disease (vCJD)

(results from the ingestion by humans of prions in infected meat)

behavioral changes, sensory disturbance, and limb pain, Muscle spasms and rigidity, dysarthrias incoordination, cognitive impairment, and sleep disturbances follow. Patients with sporadic CJD present with mental deterioration, ataxia, and visual disturbance. Memory loss, involuntary movement, paralysis, and mutism occur as the disease progresses

Brain Abscess

• Similar to meningitis and encephalitis-
• H/A, fever, N/V, ↑ ICP, focal sx

CT and MRI

Agnosia

Aneurysm

Aphasia

Apraxia

Dysphagia

Expressive Aphasia

15-20 minutes

• Be alert to the following signs and symptoms of brain abscess:
• Frontal Lobe
• Hemiparesis (weakness on one side of the body) Expressive aphasia (inability to express oneself) Seizures, Frontal headache
• Temporal Lobe
• Localized headache, Changes in vision, Facial weakness, Receptive aphasia (inability to understand language)
• Cerebellar 
• Occipital headache, Ataxia (inability to coordinate movements) Nystagmus (rhythmic, involuntary movements of the eye)

controlling increased ICP, draining the abscess, and providing antimicrobial therapy directed at the abscess and the main source of infection

Ceftriaxone, which will be adjusted based on the culture and sensitivity results

• Antibiotics (ceftriaxone)
• Corticosteroids
• Anti-seizure

• blood glucose and serum potassium levels
• Normal Glucose= 70-100
• Potassium- 3.5-5.5

Both Hemispheres of the brain

Epilepsy

• Tonic-Clonic
• Absence Seizures
• Myoclonic Seizure
• Atonic Seizure

Atypical Absence

Myoclonic

Atonic

head injury!

< 1 min

• Prodromal- activity that precedes a seizure
• Aura- sensory warning of seizure
• Ictal- Full seizure state
• Post-Ictal- period of recovery after seizure

Assess Breathing

apnea (10-20 sec), muscle stiffening

• Contraction and Relaxation (jerking 30-40 sec)
• Cyanosis
• Increases Saliva
• Biting
• Incontinence

No memory of Seizure

motor and sensory

Temporal Lobe

Automatisms (occur with complex partial seizure)

• Detailed Health History (helps if family is present to give detailed info in what happens when the pt has a seizure)
• EEG (electroencephalogram) -- electrical activity of brain waves
• Serum Lab Studies

• Teach pt that the test is painless
• No electrical shocks are given
• Avoid caffeine and stimulants
• Determine if antiseizure drugs or tranquilizing meds need to be held prior to test

Resume all meds after test

Assist pt to wash electrode gel out of hair

24

CBC, Liver and Renal function, Urinalysis

CT or MRI

Status epilepticus

STOP SEIZURES!!!

Brain Damage

NO driving

• IV Valium
• IV Ativan

• Nystagmus
• Drowsiness,
• Rash,
• Slowness,
• Liver/Kidney Disorders,
• Bone Marrow Depression

10-20

Pt will need to have lab work done regularly to monitor levels for therapeutic range

ORAL CARE (gingival hyperplasia)

Kepra

• Tegretol- 
• skin rash, blood dyscrasias, hepatitis

• Klonopin-
• Hepatotoxicity, thrombocytopenia, bone marrow failure, ataxia

• Zarontin
• Skin rash, blood dyscrasias, hepatitis, systemic lupus erythematosus

• Felbatol
• Aplastic anemia, hepatotoxicity

• Neurontin
• Leukopenia, hepatotoxicity

• Lamictal
• Severe rash (Stevens-Johnson syndrome)

Keppra

• Trileptal
• Hepatotoxicity

• Luminal
• Skin rash, anemia

• Dilantin
• Gingival Hyperplasia, 

• Mysoline
• Rash

Gabitril

• Topamax
• Nephrolithiasis

• Depakote
• Hepatotoxicity, skin rash, blood dyscrasias, nephritis

• Zonegran
• Leukopenia, hepatotoxicity

• Foci Removal
• Vagal Nerve Stimulation -- interrupts the neurons firing that would normally cause the abnormal brain activity