Common neurologic disorders

Below are several common neurologic disorders, along with their causes, pathophysiology, signs and symptoms, diagnostic test findings, treatments, and nursing interventions.

Common neurologic disorders: Meningitis

In meningitis, infection (bacterial or otherwise) causes inflammation of the brain and spinal meninges that can involve all three meningeal membranes: dura mater, arachnoid, and pia mater.

What causes it

  • Bacteremia, especially due to pneumonia, empyema, osteomyelitis, or endocarditis
  • Other infections, such as sinusitis, otitis media, encephalitis, or myelitis
  • Brain abscess, usually caused by Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, or Escherichia coli
  • Head injury, such as skull fracture, penetrating head wound, or neurosurgery
  • Virus or other organism (aseptic meningitis) (See Recognizing aseptic meningitis.)

Common neurologic disorders

 

What to look for

  • Fever, chills, malaise
  • Headache, vomiting
  • Signs of meningeal irritation, such as nuchal rigidity, positive Brudzinski’s and Kernig’s signs (see Important signs of meningitis), exaggerated and symmetrical deep tendon reflexes, or opisthotonos
  • Seizures
  • Delirium, deep stupor, and coma

Common neurologic disorders

 

What tests tell you

Typically, CSF testing and positive Brudzinski’s and Kernig’s signs establish the diagnosis:

  • Look for elevated CSF pressure, high CSF protein levels and, possibly, low glucose levels.
  • CSF culture and sensitivity tests usually identify the infecting organism unless it’s a virus. The Xpert EV test identifies the enterovirus in CSF.

How it’s treated

Treatment includes antibiotic therapy (if the cause is bacterial) and vigorous supportive care. Usually, the patient receives I.V. antibiotics for 2 or more weeks, followed by oral antibiotics. Other prescribed drugs may include:

  • digoxin (Lanoxin) to control arrhythmias
  • mannitol (Osmitrol) to decrease cerebral edema
  • an anticonvulsant or a sedative to reduce restlessness
  • acetaminophen (Tylenol) to relieve headache and fever

Culture club

Supportive measures include bed rest and measures to prevent dehydration. If nasal cultures are positive, isolation is necessary. Any coexisting conditions, such as endocarditis and pneumonia, are treated as well.

What to do

  • Assess the patient’s neurologic function often and watch for deterioration. Be especially alert for a temperature increase up to 102º F (38.9º C), deteriorating LOC, onset of seizures, and altered respirations, all of which may signal an impending crisis.

Finding fluid equilibrium

  • Monitor the patient’s fluid balance. Make sure he consumes enough fluids to prevent dehydration, but avoids fluid overload to decrease the risk of cerebral edema. Measure his central venous pressure, and record intake and output accurately.
  • Position the patient carefully to prevent joint stiffness and neck pain. Turn him often, according to a planned positioning schedule. Help with ROM exercises.
  • Maintain adequate nutrition and elimination.

Keep it quiet…

  • Maintain a quiet, comfortable environment. If necessary, darkening the room can help reduce photophobia.
  • Relieve headache with a nonopioid analgesic, such as acetaminophen, as ordered. (Opioids interfere with accurate neurologic assessment.)

…and strictly aseptic

  • Use strict aseptic technique when treating the patient with a head wound or skull fracture.
  • Provide reassurance and support. The patient may be frightened by his illness and the need for frequent lumbar punctures. If he’s disoriented or confused, calm and reorient him as often as needed. Reassure the family that the delirium and changes in behavior caused by meningitis usually disappear during recovery. However, if a severe neurologic deficit appears permanent, refer the patient to a rehabilitation program as soon as the acute phase of the illness has passed.
  • Evaluate the patient’s progress. If treatment is succeeding, the patient will be pain-free and his LOC will be normal. He’ll maintain adequate hydration and nutrition and his blood pressure, heart rate, and respiratory rate will remain within normal limits. (See Meningitis teaching tips.)

Meningitis teaching tips

  • Teach the patient and his family about the illness and expected recovery. The family may need to receive prophylactic antibiotics.
  • Teach the patient and his family how to help prevent meningitis by seeking proper medical treatment for chronic sinusitis or other chronic infections.
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Common neurologic disorders: Multiple sclerosis

MS is a major cause of chronic disability in young adults. It results from progressive demyelination of the white matter of the brain and spinal cord and is characterized by exacerbations and remissions. The prognosis varies. MS may progress rapidly, disabling patients by early adulthood or causing death within months of onset. Fortunately, however, 70% of all patients lead active, productive lives with long periods of remission.

What causes it

The exact cause is unclear; however, current theories suggest that it may be caused by an autoimmune response to a slow-acting or latent viral infection or by environmental or genetic factors.

Pathophysiology

In MS, axon demyelination and nerve fiber loss occur in patches throughout the CNS, inducing widely disseminated and varied neurologic dysfunction.

What to look for

Accurate diagnosis requires evidence of multiple neurologic exacerbations and remissions. Signs and symptoms, which can vary considerably, include:

  • vision disturbances, such as optic neuritis, diplopia, ophthalmoplegia, and blurred vision
  • sensory impairment such as paresthesia
  • muscle dysfunction, such as weakness, paralysis ranging from monoplegia to quadriplegia, spasticity, hyperreflexia, intention tremor, and gait ataxia
  • urinary disturbances, such as incontinence, frequency, urgency, and frequent infections
  • emotional lability, such as mood swings, irritability, and euphoria
  • associated signs, such as poorly articulated speech and dysphagia.

What tests tell you

Because of the difficulty inherent in establishing a diagnosis, some patients may undergo years of periodic testing and close observation. These tests may help diagnose MS:

  • In one-third of all patients, EEG shows nonspecific abnormalities.
  • Lumbar puncture reveals CSF with elevated gamma globulin fraction of immunoglobulin G, but normal total protein levels. An elevated CSF gamma globulin level is significant only when serum gamma globulin levels are normal. It reflects hyperactivity of the immune system due to chronic demyelination. Oligoclonal bands of immunoglobulin can be detected when CSF gamma globulin is examined by electrophoresis.

Common neurologic disordersEvoking a reaction

  • Evoked potential studies demonstrate slowed conduction of nerve impulses in 80% of patients.
  • A CT scan may reveal lesions within the brain’s white matter.

Common neurologic disorders: Legions with lesions

  • MRI is the most sensitive method of detecting lesions and is also used to evaluate disease progression. Lesions are present in more than 90% of all patients undergoing this test.

How it’s treated

The aim of treatment is to shorten exacerbations and relieve neurologic deficits to help the patient maintain as normal a lifestyle as possible. Drug therapy and other measures can achieve these goals.

Common neurologic disorders: Medicate, don’t exacerbate

Methylprednisolone (Medrol) is commonly prescribed during acute exacerbations to reduce CNS inflammation. Other typically used corticosteroids include dexamethasone, prednisone, betamethasone (Celestone), and prednisolone (Prelone). For relapsing MS, glatiramer acetate (Copaxone) may be prescribed to reduce the frequency of attacks. Interferon beta-1a (Avonex) or interferon beta-1b (Betaseron) are effective in reducing disability progression and in decreasing the frequency of exacerbations.

In conjunction with corticosteroids, the practitioner may prescribe:

  • fluoxetine to combat depression
  • baclofen (Lioresal) or dantrolene (Dantrium) to relieve spasticity
  • oxybutynin (Ditropan) to relieve urine retention and minimize frequency and urgency.

Common neurologic disorders: Support to cut short

During acute exacerbation, treatment routinely calls for:

  • bed rest
  • physical therapy and massages
  • measures to prevent fatigue
  • meticulous skin care to prevent pressure ulcers
  • bowel and bladder training (if necessary)
  • antibiotic treatment of bladder infection
  • counseling

What to do

  • Nursing interventions focus on maintaining mobility, ensuring proper nutrition, and controlling pain during exacerbations.
  • Form a care plan based on the patient’s abilities and symptoms.
  • Help with physical therapy and provide massages, relaxing baths, and other measures that promote comfort.
  • Assist with active, resistive, and stretching exercises to maintain muscle tone and joint mobility, reduce spasticity, improve coordination, and boost morale.
  • Encourage emotional stability by helping the patient establish a daily routine that maintains optimal functioning. Let the patient’s tolerance regulate the level of daily activity. Encourage daily physical exercise and regular rest periods to prevent fatigue.
  • Watch for drug therapy adverse effects. (See MS teaching tips.)

MS teaching tips

  • Teach the patient and family about the chronic course of the disease. Explain that exacerbations are unpredictable and will require physical and emotional adjustments.
  • Emphasize the need to avoid stress, infections, and fatigue and to maintain independence by finding new ways to perform daily activities.
  • Explain the value of a well-balanced, nutritious diet that contains sufficient fiber.
  • Evaluate the need for bowel and bladder training and provide instruction, as needed.
  • Encourage adequate fluid intake and regular urination.
  • Teach the patient the correct use of suppositories to help establish a regular bowel schedule.
  • Refer the patient and family to the National Multiple Sclerosis Society for more information.
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