WEEK 11 NCM 116
NURSING CARE OF CLIENTS WITH NEUROLOGIC INFECTIONS
AND NEUROPATHIES
MENINGITIS
- Inflammation of the membranes and the fluid space
surrounding the brain and the spinal cord
- REMEMBER: meninges wrap around the brain and
spinal cord so they are in close contact with these
tissues
- Cause:
o Bacteria
o Viruses – most common: Enteroviruses
o Fungi
- Classification
o Septic
▪ Caused by bacteria
▪ Bacterial in nature
o Aseptic
▪ Caused by viruses
▪ Secondary due to a weakened
immune system
▪ Any meningitis not caused by
bacteria Once the pathogen enters the subarachnoid space, it can
▪ More common go to the meninges in three different ways, either
hematogenously, direct contiguous spread, iatrogenic
Common Causative Agents of Bacterial Meningitis (Arranged means or causes.
by most common cause)
Neonates Children Adults Elderly (>65) Hematogenous spread – bacteria enters meninges through
(<3 months) the blood and cross blood-brain barrier; pathogens from a
Group B Streptococcu Streptococ Streptococc distant nidus cross BBB
Streptococc s cus us
us pneumoniae pneumonia pneumoniae Direct contiguous spread – through traumatic injury;
(pneumococc e pathogens from an adjacent structure spread directly to
us) meninges. Example: skull fracture
Escherichia Neisseria Neisseria Neisseria
coli meningitidis meningitidi meningitidis Iatrogenic – Surgery to the cranium or spine
(meningococ s
cus) Once these pathogens enter, it will activate the immune
Listeria Haemophilus (these 2 Listeria system. The activation of the immune system will lead to
monocytoge influenzae organisms monocytoge an increase in the cytokines. The increase in the cytokine or
nes type B (less cause 80% nes cytokine production will lead to four primary effects.
common now of cases)
with the 4 Primary Effects
advent od 1. Increase blood-brain barrier permeability
the HiB 2. Alter cerebral blood flow
vaccination) 3. Increase leukocyte adherence to capillary
Most common is Streptococcus Pneumoniae endothelium
4. Increase reactive oxygen species
These four effects can lead to further changes
Changes:
1. Changes in CSF Flow and composition
2. Damage to the brain tissue to spinal cord tissue at
the same time increasing ICP and cerebral edema
All will lead to the clinical presentation of meningitis
,WEEK 11 NCM 116
Opening Elevated Usually Variable Variable
CLINICAL MANIFESTATIONS pressure normal
WBC ≥1,000 per <100 per variable Variable
- Initial symptoms: Fever and headache mm3 mm3
o Usually >38 C Cell Predominanc Predominanc Predomina Predomina
o Fever remains throughout entire period of differenti e of PMNs* e of nce of nce of
the disease al lymphocytes lymphocyte lymphocyt
+ s es
- Nuchal rigidity or neck immobility Protein Mild to Normal to elevated Elevated
- Photophobia – cannot tolerate bright light marked elevated
- Rash – Neisseria meningitidis; already suspect elevation
meningococcemia CSF-to- Normal to Usually low Low
serum marked normal
- Seizures
glucose decrease
- Decreased LOC ratio
- Positive Kernig’s and Brudzinki’s sign CSF Cerebrospinal fluid
PMNs Polymorphonucleocytes
* Lymphocytosis present 10% of the time
+ PMNs may predominate early in the course
PREVENTION
- Meningococcal Conjugated Vaccine
Kernig’s sign o 1st Dose: 11-12 years old
Allow patient to lie supine and then flex the thigh of the o Booster: 16 years old
patient and attempt to extend the leg. Usually, these o Usually for neisseria meningitidis
patients are unable to completely extend leg due to pain - Prophylaxis
o For those with exposure
Brudzinki’s Sign o Given within 24 hours
First, make sure that the patient does not have any cervical o Rifampin, Ciprofloxacin, Ceftriaxone
trauma or spinal injury. When you try to flex the neck of o Given to those exposed to the patient with
the patient, there will be accompanying flexion of the meningitis because this is highly infectious
knees and the hips. When the lower extremity of one side is o Ensures that those with close contact will
passively flexed, a similar movement is seen on the not develop meningitis
opposite extremity. MORE SENSITIVE FOR MENINGEAL
IRRITATION BUT STILL ILLICIT BOTH. MEDICAL MANAGEMENT
- Success depends on timeliness of the antibiotics
ASSESSMENT AND DIAGNOSTIC FINDINGS o How fast the antibiotics were given or how
- Goal: To identify the causative agent promptly the patient was brought to the
o Later on, whatever the causative agent is, it hospital for treatment
will also determine the specific treatment - Penicillin G + Cephalosporins (Ceftriaxone)
that is needed o Given IV within 30 minutes of hospital
- CT Scan – to detect shift in brain contents or arrival
herniation - Dexamethasone
- Blood culture – hematogenous spread o Adjunct therapy
- Lumbar/Spinal Tap/Puncture – to test CSF: o Given 15 minutes prior to 1st dose of
o 1st tube – test for protein and glucose antibiotics then every 6 hours for 4 days
o 2nd tube – for gram stain and culture o Given to decrease inflammation
o 3rd Tube – for cell count - Anticonvulsant medications – if the patient develops
o 4th tube (optional) – for special test seizure
o ** 3 is the minimum - IV Fluids – to maintain fluid balance
NURSING MANAGEMENT
- Infection precautions until 24 hours after 1st dose of
antibiotics or ceftriaxone
- Pain management
- Decreased environmental stimuli – because patient
is at risk for seizures
- Antipyretics and cooling blankets – continuous fever
Test Bacterial Viral Fungal Tubercu - Injury protection during seizures
lar
, WEEK 11 NCM 116
- Patient and family education – because this disease - Seizures
is a critical disease
Temporal Lobe:
PIT STOP - Changes in vision
Among children and adults, Streptococcus pneumoniae - Facial weakness
what is the most common - Localized headache
causative agent of meningitis? - Receptive aphasia – inability to understand language
How many tubes are needed 1st tube – test for protein and
when getting CSF samples? glucose Cerebellar Abscess:
What is the use of each tube? 2nd tube – for gram stain and - Ataxia – inability to coordinate movements
culture
- Nystagmus – rhythmic involuntary movements of the
3rd Tube – for cell count
4th tube (optional) – for eye
special test - Occipital headache – headache in the posterior
portion of the skull
BRAIN ABSCESS
- Rare in immunocompetent people MEDICAL MANAGEMENT
o If this happens in immunocompetent - Goals:
people, these people usually have a history o Control ICP – Mannitol IV (osmotic diuretic;
of otitis media or ear infection or have a decrease the ICP)
history of rhinosinusitis o Drain the abscess – surgical
- Collection of infectious material within the brain o Give antibiotics (to address causative
tissue agent), corticosteroids (decrease
- Most common cause: bacteria inflammation), and anticonvulsants
- Other causes: surgery, head injury, and tongue
piercings NURSING MANAGEMENT
- Assess neuro status, ICP, and LOC
- Administer medications
When you talk about the vascular supply of your tongue,
- Assess response to treatment
your tongue has a venous drainage that will lead to the
- Provide supportive care
brain. Infection to tongue piercings can lead to brain
- Provide patient safety – disoriented; risk for seizures
abscess
PIT STOP
What is the most common Bacteria
cause of brain abscesses?
What medication is given to Mannitol IV
decrease the ICP?
ENCEPHALITIS
- Acute inflammatory process of the brain tissue
- May or may not have accompanying meningitis
- May be classified according to:
o Chronicity: Acute, Subacute, Chronic
MANIFESTATIONS o Etiology:
- Headaches worse in the morning ▪ Non-infectious
- Fever – because this is infectious in nature ▪ Infectious: Viral, Bacterial, Fungal
- Decreased LOC
- Seizures Because of its close contact with the meninges, sometimes
encephalitis and meningitis may occur together. However,
ASSESSMENT it is not always true that when you have encephalitis, you
Assessing for Brain Abscesses will have meningitis.
Be alert to the following signs and symptoms of brain
abscess: Types:
- Herpes Simplex Encephalitis
Frontal Lobe: - Arthropod Borne Encephalitis
- Expressive aphasia – inability to express oneself - Fungal Encephalitis
- Frontal headache - Variant Creutzfeldt-Jakob Disease
- Hemiparesis – weakness on one side of the body
NURSING CARE OF CLIENTS WITH NEUROLOGIC INFECTIONS
AND NEUROPATHIES
MENINGITIS
- Inflammation of the membranes and the fluid space
surrounding the brain and the spinal cord
- REMEMBER: meninges wrap around the brain and
spinal cord so they are in close contact with these
tissues
- Cause:
o Bacteria
o Viruses – most common: Enteroviruses
o Fungi
- Classification
o Septic
▪ Caused by bacteria
▪ Bacterial in nature
o Aseptic
▪ Caused by viruses
▪ Secondary due to a weakened
immune system
▪ Any meningitis not caused by
bacteria Once the pathogen enters the subarachnoid space, it can
▪ More common go to the meninges in three different ways, either
hematogenously, direct contiguous spread, iatrogenic
Common Causative Agents of Bacterial Meningitis (Arranged means or causes.
by most common cause)
Neonates Children Adults Elderly (>65) Hematogenous spread – bacteria enters meninges through
(<3 months) the blood and cross blood-brain barrier; pathogens from a
Group B Streptococcu Streptococ Streptococc distant nidus cross BBB
Streptococc s cus us
us pneumoniae pneumonia pneumoniae Direct contiguous spread – through traumatic injury;
(pneumococc e pathogens from an adjacent structure spread directly to
us) meninges. Example: skull fracture
Escherichia Neisseria Neisseria Neisseria
coli meningitidis meningitidi meningitidis Iatrogenic – Surgery to the cranium or spine
(meningococ s
cus) Once these pathogens enter, it will activate the immune
Listeria Haemophilus (these 2 Listeria system. The activation of the immune system will lead to
monocytoge influenzae organisms monocytoge an increase in the cytokines. The increase in the cytokine or
nes type B (less cause 80% nes cytokine production will lead to four primary effects.
common now of cases)
with the 4 Primary Effects
advent od 1. Increase blood-brain barrier permeability
the HiB 2. Alter cerebral blood flow
vaccination) 3. Increase leukocyte adherence to capillary
Most common is Streptococcus Pneumoniae endothelium
4. Increase reactive oxygen species
These four effects can lead to further changes
Changes:
1. Changes in CSF Flow and composition
2. Damage to the brain tissue to spinal cord tissue at
the same time increasing ICP and cerebral edema
All will lead to the clinical presentation of meningitis
,WEEK 11 NCM 116
Opening Elevated Usually Variable Variable
CLINICAL MANIFESTATIONS pressure normal
WBC ≥1,000 per <100 per variable Variable
- Initial symptoms: Fever and headache mm3 mm3
o Usually >38 C Cell Predominanc Predominanc Predomina Predomina
o Fever remains throughout entire period of differenti e of PMNs* e of nce of nce of
the disease al lymphocytes lymphocyte lymphocyt
+ s es
- Nuchal rigidity or neck immobility Protein Mild to Normal to elevated Elevated
- Photophobia – cannot tolerate bright light marked elevated
- Rash – Neisseria meningitidis; already suspect elevation
meningococcemia CSF-to- Normal to Usually low Low
serum marked normal
- Seizures
glucose decrease
- Decreased LOC ratio
- Positive Kernig’s and Brudzinki’s sign CSF Cerebrospinal fluid
PMNs Polymorphonucleocytes
* Lymphocytosis present 10% of the time
+ PMNs may predominate early in the course
PREVENTION
- Meningococcal Conjugated Vaccine
Kernig’s sign o 1st Dose: 11-12 years old
Allow patient to lie supine and then flex the thigh of the o Booster: 16 years old
patient and attempt to extend the leg. Usually, these o Usually for neisseria meningitidis
patients are unable to completely extend leg due to pain - Prophylaxis
o For those with exposure
Brudzinki’s Sign o Given within 24 hours
First, make sure that the patient does not have any cervical o Rifampin, Ciprofloxacin, Ceftriaxone
trauma or spinal injury. When you try to flex the neck of o Given to those exposed to the patient with
the patient, there will be accompanying flexion of the meningitis because this is highly infectious
knees and the hips. When the lower extremity of one side is o Ensures that those with close contact will
passively flexed, a similar movement is seen on the not develop meningitis
opposite extremity. MORE SENSITIVE FOR MENINGEAL
IRRITATION BUT STILL ILLICIT BOTH. MEDICAL MANAGEMENT
- Success depends on timeliness of the antibiotics
ASSESSMENT AND DIAGNOSTIC FINDINGS o How fast the antibiotics were given or how
- Goal: To identify the causative agent promptly the patient was brought to the
o Later on, whatever the causative agent is, it hospital for treatment
will also determine the specific treatment - Penicillin G + Cephalosporins (Ceftriaxone)
that is needed o Given IV within 30 minutes of hospital
- CT Scan – to detect shift in brain contents or arrival
herniation - Dexamethasone
- Blood culture – hematogenous spread o Adjunct therapy
- Lumbar/Spinal Tap/Puncture – to test CSF: o Given 15 minutes prior to 1st dose of
o 1st tube – test for protein and glucose antibiotics then every 6 hours for 4 days
o 2nd tube – for gram stain and culture o Given to decrease inflammation
o 3rd Tube – for cell count - Anticonvulsant medications – if the patient develops
o 4th tube (optional) – for special test seizure
o ** 3 is the minimum - IV Fluids – to maintain fluid balance
NURSING MANAGEMENT
- Infection precautions until 24 hours after 1st dose of
antibiotics or ceftriaxone
- Pain management
- Decreased environmental stimuli – because patient
is at risk for seizures
- Antipyretics and cooling blankets – continuous fever
Test Bacterial Viral Fungal Tubercu - Injury protection during seizures
lar
, WEEK 11 NCM 116
- Patient and family education – because this disease - Seizures
is a critical disease
Temporal Lobe:
PIT STOP - Changes in vision
Among children and adults, Streptococcus pneumoniae - Facial weakness
what is the most common - Localized headache
causative agent of meningitis? - Receptive aphasia – inability to understand language
How many tubes are needed 1st tube – test for protein and
when getting CSF samples? glucose Cerebellar Abscess:
What is the use of each tube? 2nd tube – for gram stain and - Ataxia – inability to coordinate movements
culture
- Nystagmus – rhythmic involuntary movements of the
3rd Tube – for cell count
4th tube (optional) – for eye
special test - Occipital headache – headache in the posterior
portion of the skull
BRAIN ABSCESS
- Rare in immunocompetent people MEDICAL MANAGEMENT
o If this happens in immunocompetent - Goals:
people, these people usually have a history o Control ICP – Mannitol IV (osmotic diuretic;
of otitis media or ear infection or have a decrease the ICP)
history of rhinosinusitis o Drain the abscess – surgical
- Collection of infectious material within the brain o Give antibiotics (to address causative
tissue agent), corticosteroids (decrease
- Most common cause: bacteria inflammation), and anticonvulsants
- Other causes: surgery, head injury, and tongue
piercings NURSING MANAGEMENT
- Assess neuro status, ICP, and LOC
- Administer medications
When you talk about the vascular supply of your tongue,
- Assess response to treatment
your tongue has a venous drainage that will lead to the
- Provide supportive care
brain. Infection to tongue piercings can lead to brain
- Provide patient safety – disoriented; risk for seizures
abscess
PIT STOP
What is the most common Bacteria
cause of brain abscesses?
What medication is given to Mannitol IV
decrease the ICP?
ENCEPHALITIS
- Acute inflammatory process of the brain tissue
- May or may not have accompanying meningitis
- May be classified according to:
o Chronicity: Acute, Subacute, Chronic
MANIFESTATIONS o Etiology:
- Headaches worse in the morning ▪ Non-infectious
- Fever – because this is infectious in nature ▪ Infectious: Viral, Bacterial, Fungal
- Decreased LOC
- Seizures Because of its close contact with the meninges, sometimes
encephalitis and meningitis may occur together. However,
ASSESSMENT it is not always true that when you have encephalitis, you
Assessing for Brain Abscesses will have meningitis.
Be alert to the following signs and symptoms of brain
abscess: Types:
- Herpes Simplex Encephalitis
Frontal Lobe: - Arthropod Borne Encephalitis
- Expressive aphasia – inability to express oneself - Fungal Encephalitis
- Frontal headache - Variant Creutzfeldt-Jakob Disease
- Hemiparesis – weakness on one side of the body
