INFLAMMATORY DISORDERS
Brain Abscess
A brain abscess is a collection of pus that may result from an infection of the ears, mastoid, sinus, or skull. It can also directly result from brain surgery. If left untreated, the encapsulated pus pocket eventually ruptures and spreads, causing further abscesses and meningitis, infection of the meninges.
Findings associated with a brain abscess mimic those of a brain tumor. The person may also experience a fever if the primary infection site is still infected. Those with brain abscesses are at risk for cICP and seizures, as well as spread of the infection. Surgical treatment is necessary to drain the abscess. Massive doses of IV antibiotics are given preopera-tively and postoperatively. The person may be left with some brain damage or may be completely cured.
Meningitis
Meningitis is an inflammation of the meninges, the membranes that cover the brain and the spinal cord. Bacteria, viruses, fungi, or other microorganisms can cause meningitis. Brain damage, hearing loss, disabilities, and death are known to occur more often with bacterial meningitis than with viral meningitis. Meningitis can be a secondary infection caused by microorganisms which have traveled to the meninges from nearby structures, such as the sinuses or the middle ear. The bloodstream also may carry the infection as sepsis. The causative organism is often related to age and children are particularly susceptible. Prevention of many causes of meningitis is available via immunizations against preventative infections.
Meningitis can be a contagious infection. Direct contact with respiratory secretions can transmit the organism from one person to another. People living in close proximity to others, children and caregivers in daycare centers, and individuals who have contact with another person’s secretions (as in kissing) are most at risk for meningitis. Specific highrisk groups include refugees, military personnel, college students living in dormitories, and infants and young children. People who are exposed to active or passive tobacco smoke are also at risk.
Nursing Alert The best protection for healthcare providers against meningitis is thorough and frequent handwashing.
Vaccines are available for Streptococcus pneumoniae, Neisseria meningitides, and Haemophilus influenzae type b, which cause most of the cases of bacterial-related meningitis. S. pneumonia is commonly called pneumonococcal meningitis. N. meningitidis is also known as meningococcal meningitis and is particularly contagious. N. meningitidis has an incubation period of 2-10 days, which is pertinent because the causative organisms are present in the throat as well as in the CSF.
Viral meningitis, also known as aseptic meningitis, may resolve without specific treatment. Many types of viruses can be causative agents of meningitis, such as the enterovirus, herpesvirus, and the mumps virus. The illness lasts 7-10 days, and the person generally recovers without disability. The client needs bed rest, good hydration, and adequate nutrition. Analgesics for headache and fever may provide symptomatic relief. Antiviral medications may be useful.
Signs and Symptoms
Signs and symptoms of meningitis usually appear abruptly. Symptoms of viral and bacterial meningitis are often the same. Many symptoms are due to tICP.
Signs and symptoms include fever, chills, severe headache, nausea and vomiting, nuchal rigidity (stiff neck), and irritability. A change in LOC is present. Two neurologic signs are present: positive Kernig’s sign and positive Brudzinski’s sign (Fig. 78-5). Photophobia (intolerance to light) and pain when the eyes move from side to side occur. The affected person may have seizures. A petechial purpuric rash is also possible. Opisthotonos, an acute spasm in which the body is bowed forward, with the head and heels bent backward, is often present. Children have tense or bulging fontanels and a high-pitched cry.
Diagnostic Tests
Meningitis is diagnosed based on a general neurologic examination that includes two special neurologic signs:
FIGURE 78-5 · Signs of meningeal irritation. (A) Kernig’s sign. (B) Brudzinski’s sign.
• Kernig’s sign: The client lies on the back and brings one leg up so that the hip and knee are both flexed at 90 degrees. He or she then straightens the knee (the sole of the foot toward the ceiling). Pain or resistance indicates meningeal and spinal root inflammation. Kernig’s sign is considered a positive indicator of meningitis (Fig. 78-5A).
• Brudzinski’s sign: The client lies on the back and brings the head forward toward the chest. Pain or resistance indicates meningeal irritation, arthritis, or a neck injury. If the person responds by flexing the hips and knees, meningeal inflammation is indicated. Brudzinski’s sign is also considered a positive indicator of meningitis (Fig. 78-5B).
Medical Treatment
When a diagnosis of meningitis is suspected, an LP is done. A culture and sensitivity test of CSF may be ordered to determine the causative organism. The client is given antibiotics.
If it is possible to identify the causative organism, the physician prescribes large doses of antibiotics that have been identified as effective in treating the specific organism. Antibiotics are highly effective in treating bacterial meningitis. If the infection is exceedingly virulent, drugs may prove useless, and the person may die. Sometimes, nerves of sight and hearing are damaged.
Nursing Considerations
Provide nursing care with the awareness that the person is critically ill. Transmission-based Precautions are likely, especially in the early days of meningitis. The person is generally placed on seizure precautions. Side rails should be raised and padded for the client’s protection. Elevate the head of the bed to at least 30 degrees, unless otherwise ordered. Monitor the client’s LOC. Keep the environment subdued, both in visual and auditory sensations (e.g., do not turn on bright over-the-bed lighting and do speak quietly in the room). Minimize traffic in and out of the room.
Carefully monitor the person’s respiratory status; endotracheal intubation may be necessary if the client’s respiratory status deteriorates. A hypothermia blanket and antipyretic medications may be ordered for high fever. Analgesics may be given for pain. Give IV fluids and nourishing liquids, as ordered. Tube feedings or TPN may be necessary.
Caution caregivers and the client not to flex the individual’s neck because doing so can obstruct venous flow and increase ICP. The client should also avoid acute hip flexion because it can cause increased intra-abdominal and intratho-racic pressures. These increased pressures interfere with cerebral blood vessel drainage and cause tICP. Caregivers need to be aware that the individual may become confused and disoriented at times. Repeating instructions and closely monitoring the client’s status are important.
Nursing Alert Specific nursing care of individuals with trauma or infection of the brain’s structures is required. A quiet atmosphere, minimal light, and patience are all fundamental interventions. The family must be aware of any specific environmental or personal limitations (e.g., isolation procedures, seizure precautions), or changes in the level of awareness.
Encephalitis
Encephalitis is an inflammation of the white and gray matter of the brain. It may be associated with meningitis. Encephalitis is caused by a virus, bacteria, or chemicals (such as in lead poisoning). It is characterized by the destruction of nerve cells. It may follow vaccination or a viral infection, such as measles. Encephalitis seems to be more prevalent after influenza epidemics. Mosquitoes and ticks are common vectors.
Some types of viral encephalitis are more lethal than others. The death rate varies from 5% to 70%, depending on the infection’s cause. Many people who recover from encephalitis are left with mental changes, seizure disorders, or parkinsonian symptoms, all of which become increasingly disabling.
Signs and Symptoms
Encephalitis can attack suddenly, causing violent headache, fever, nausea, vomiting, and drowsiness. The person may show muscular weakness, tremors, or visual disturbances.
Medical Treatment
No drug for the specific treatment of encephalitis has been found. Treatment is similar to the care of a client with meningitis.
Nursing Considerations
Nursing care focuses on reducing fever and maintaining a quiet environment. Warm, moist packs may be ordered to relieve muscle spasms. Tube feedings or TPN is necessary for clients who are unresponsive. If acute respiratory distress occurs, endotracheal intubation and mechanical ventilation may be required.
The client with encephalitis is subject to seizures. Side rails should be in place. Hospital policy may require a signed release when side rails are used. The family needs instructions for safety to prevent injury. The family also needs to be aware that the client may exhibit mental changes such as irritability and confusion.
Guillain-Barré Syndrome
Guillain-Barré syndrome is an autoimmune disorder of the peripheral nervous system. It may also be called acute febrile, acute idiopathic, or infectious polyneuritis. In Guillain-Barré syndrome, antibodies start to destroy the myelin sheath of peripheral nerves. When the sheath is damaged, it cannot transmit nerve signals to the muscles. The muscles atrophy and become paralyzed. Paresthesia (tingling sensation) develops; the nerves cannot transmit sensory messages such as pain, heat, or texture.
Guillain-Barré syndrome is considered rare. It occurs in both males and females and can occur at any age. A viral illness, such as a respiratory or gastrointestinal infection, typically precedes the onset of Guillain-Barré. Surgery and vaccinations also have been identified as triggers of the disorder.
Signs and Symptoms
After a nonspecific febrile illness, onset is often sudden. However, 3-4 weeks may pass before signs and symptoms develop. Symmetrical pain and weakness follow. The syndrome usually begins in the lower extremities, ascends, and may progress to total paralysis. Disability ranges from muscle weakness to total body paralysis. Vital functions, such as breathing, heart rate, and blood pressure, can be compromised. Eventually, the progression of the disease stops and stabilizes. The client generally then begins a gradual recovery.
Diagnosis
Diagnosis is made after obtaining a careful history and review of systems. No differential diagnostic procedure or laboratory test exists. An LP may be done, possibly revealing increased protein levels in CSF.
Treatment
Some success has resulted from two types of treatments: plasmapheresis and injection of high-dose immunoglobulins. However, the effects of both are temporary. Plasmapheresis may be helpful because it removes the antibodies that are destroying the myelin sheaths. Immunoglobulin therapy may be effective because it provides normal support to an immune system that is under abnormal attack.
Steroid therapy is controversial because, although it may reduce symptoms, steroids have significant nonbeneficial side effects that can effect the client’s overall health.
Nursing Considerations
The nurse must keep in mind that this client has an excellent chance of total or nearly total recovery. Therefore, excellent nursing care is necessary to prevent permanent damage. Emergency interventions, such as endotracheal intubation and mechanical ventilation, may be necessary when the respiratory muscles fail.
Maintenance of muscle function is required to prevent atrophy and skeletal deformities. Nursing interventions, such as providing passive range-of-motion exercises and working with physical therapy, are very important from the very beginning of the diagnosis. Adequate nutrition may necessitate tube feedings or TPN. Family and other caregivers will need instruction in ROM exercises, skin care, positioning, and ADL.
Recovery is usually slow, lasting weeks, months, or years, depending on the severity of symptoms. Emotional support is essential. This condition is frightening for the client and family. If the acute phase of the disease is correctly managed, however, recovery is often complete.
Acute Transverse Myelitis
Acute transverse myelitis is an inflammatory condition affecting the spinal cord. It results from inflammation or destruction of the myelin of the spinal cord neurons. The person experiences impaired bowel and bladder function, generalized weakness of the extremities, and loss of sensation.
Acute transverse myelitis has several causes. If the disease is diagnosed as postinfectious, it usually begins 5-20 days after a viral infection. The cause may also be related to collagen- vascular disease, syphilis, or human immunodeficiency virus or acquired immunodeficiency syndrome (HIV/AIDS). Prognosis varies; some individuals recover fully, and others do not.
Nursing Considerations
Nursing care for the client with acute transverse myelitis involves supportive and preventive measures. Be alert for urinary retention, constipation, skin breakdown, thrombus formation, and other complications of immobility.
HEAD TRAUMA
Trauma to the brain is a common cause of motor and sensory symptoms, including brain damage, coma, and paralysis. Normally, the skull’s thick bones, as well as the tough outer membrane of the meninges (the dura), protect the brain. In addition, CSF acts as a shock absorber. However, violent blows to the head can cause several kinds of injury to the brain and skull. A major complication of head trauma is increased pressure within the brain. Numerous factors can cause swelling including hemorrhage, or an inflammatory process. Head injuries may be the cause of seizures and epilepsy later in life.
Nursing Alert Serious symptoms can appear up to several days after a head injury Observe the client carefully.
Increased Intracranial Pressure
Intracranial pressure (ICP) is the pressure that the brain, blood, and CSF exert inside the cerebrospinal cavity. Normally, ICP is 4-13 mm Hg. If one of the normal contents of the cranial or spinal cavity (e.g., brain tissue, blood, or CSF) increases in size, volume, or shape, pressure increases. This increase in pressure can cause the delicate structures to be moved, damaged, or destroyed.
The increase in pressure is caused by the limited space within a rigid bony skull, leaving little or no room for expansion because of brain edema, hemorrhage, or increased amounts of CSF. Examples of conditions that may lead to tICP include head injury, brain tumor, CNS infection, brain surgery, stroke, and hydrocephalus. Normal body functions, such as straining at stool (the Valsalva maneuver) and coughing, may increase ICP.
Sustained ICP over 15-20 mm Hg is called increased intracranial pressure (tICP). It is an abnormal and dangerous condition. The first consequence of tICP is venous compression, resulting in a decrease in blood flow to the brain. This results in cerebral hypoxia or cellular hypoxia. Brain cells are extremely sensitive to levels of oxygen. Neuron tissue death will begin within 4-6 minutes if oxygen is not supplied.
An elevation in ICP can occur suddenly and progress rapidly. Usually, tICP begins on one side of the brain, although both sides quickly become involved. Early detection and treatment are vital before complications occur (see In Practice: Data Gathering in Nursing 78-2). The earliest and most important sign of tICP is any change in LOC.
ICP Monitoring
In special circumstances of tICP, devices that are surgically inserted into the brain can monitor the levels of ICP. The most common monitor is the intraventricular catheter. Other monitors include the subarachnoid (subdural) bolt (or screw), intraparenchymal bolt (fiberoptic), and epidural sensor (least invasive). The neurosurgeon places the devices under strict sterile technique, using the information that these devices relay via computer to determine the plan of care (Fig. 78-6). The clients are generally in an intensive care unit (ICU), and trained ICU nurses monitor the ICP pressures as part of nursing care. Medications, and possibly surgical interventions, are calculated based on the results of ICP monitoring. Mannitol (Osmitrol) is an osmotic diuretic specifically ordered by the physician to lower ICP caused by swelling.
IN PRACTICE: DATA GATHERING IN NURSING 78-2
SIGNS OF INCREASED INTRACRANIAL PRESSURE (ICP)
• Any change in level of consciousness (loss of consciousness, lethargy, confusion, seizures)
• Any change in sensory-motor function (slowed reflexes, slowed response time, restlessness, ataxia, aphasia, slowed speech)
• Headache, which becomes progressively worse, or is aggravated by movement
• Change in eye signs or vision (change in pupil size, unequal pupils, slowed or no response to light, inability to follow examiner’s finger difficulty seeing)
• Change in vital signs (pulse <60 or > 100, increased blood pressure, widening of pulse pressure, increased or lowered body temperature)
• Change in respirations or evidence of respiratory distress (occurs late—caused by pressure on brain stem)
• tICP recorded on a monitoring device
• Nausea and vomiting (especially projectile vomiting)
• Urinary incontinence
• Bulging fontanels (in infant); elevation of bone segments
• Sudden changes in condition
• Leakage of cerebrospinal fluid (CSF) (clear yellow or pinkish) from nose or ear
Nursing Alert Report any break in an ICP monitoring system to the physician immediately The system must remain sterile. Never move the client’s head up or down without specific orders from the physician.
The intraventricular catheter (ventriculostomy) may also be used to drain CSF to relieve pressure. The drained CSF can then be sent for laboratory analysis.
