Inflammatory Brain Disorder

Inflammatory Brain Disorder 150 150 Tony Guo

Inflammatory Brain Disorder

  • Most common inflammatory conditions of the brain and spinal cord
    • Brain abscesses
    • Meningitis
    • Encephalitis 
      • 10% to 30% mortality rate
      • Long-term neurologic deficits among survivors

Bacterial meningitis

  • Acute inflammation of meningeal tissue surrounding brain and spinal cord
    • Usually occurs in fall, winter, or early spring
      • Often secondary to viral respiratory disease
  • Mandatory reporting to CDC
  • Mortality rate near 100% if untreated

Etiology and pathophysiology

  • Leading causes of bacterial meningitis
    • Streptococcus pneumoniae 
    • Neisseria meningitidis
      • Replaced Hemophilus as flu vaccine emerged
      • Organisms enter CNS through upper respiratory tract or bloodstream
      • May enter through skull wounds or fractured sinuses
  • Inflammatory response
    • Increase CSF production
    • Purulent secretions spread to other areas of brain through CSF
    • Cerebral edema and increased ICP become problematic
      • If process extends into parenchyma 
      • If concurrent encephalitis is present

Clinical manifestation

  • Key signs of meningitis
    • Fever
    • Severe headache
    • Nausea, vomiting
    • Nuchal rigidity 
  • Coma associated with poor prognosis 
    • Occurs in 5% to 10% of cases
  • Other symptoms that may be present
    • Photophobia
    • Decreased LOC
    • Signs of increased Intracranial pressure
      • Seizures occur in 1/3 of all cases
      • Headache worsens 
      • Vomiting and irritability may occur

Complications

  • Increased ICP
    • Major cause of altered mental status
  • Residual neurologic dysfunction
    • Cranial nerves III, IV, VI, VII, or VIII can become dysfunctional
    • Sequelae varies by cranial nerve
  • Optic nerve (CN II) compressed by ↑ ICP
    • Papilledema with possible blindness
  • Ocular movements affected with irritation to nerves III, IV, and VI
    • Ptosis
    • Unequal pupils
    • Diplopia
  • CN V irritation 
    • Sensory loss and loss of corneal reflex
  • Inflammation of CN VII 
    • Facial paresis 
  • Irritation of CN VIII 
    • Tinnitus, vertigo, deafness
    • Hearing loss may be permanent
  • Hemiparesis, dysphagia, hemianopsia 
  • Suspect the following if above do not resolve 
    • Cerebral abscess, subdural empyema, subdural effusion, or persistent meningitis
  • Acute cerebral edema may cause
    • Seizures
    • CN III palsy
    • Bradycardia
    • Hypertensive coma
    • Death

Diagnostic studies

  • Blood culture
  • CT scan and  MRI
  • Diagnosis verified 
    • Lumbar puncture 
    • Analysis of CSF (for protein, WBC, and glucose)
    • Specimens of secretions are cultured to identify causative organism
    • Gram-stain to detect bacteria
  • Neutrophils are predominant WBC in CSF 
  • X-rays of skull

Interprofessional care

  • Bacterial meningitis is a medical emergency
  • Rapid diagnosis crucial
    • Patient  usually critical when health care is initiated
    • Antibiotic therapy instituted before diagnosis is confirmed

Nursing Assessment

  • Initial assessment should include
    • Vital signs
    • Neurologic assessment
    • Fluid intake and output
    • Evaluation of lungs and skin

Nursing diagnosis

  • Decreased intracranial adaptive capacity related to decreased cerebral perfusion or increased ICP
  • Risk for ineffective cerebral tissue perfusion related to reduction of blood low and cerebral edema
  • Hyperthermia related to infection
  • Acute pain related to headache and muscle aches

Planning

  • Overall Goals
    • Return to maximal neurologic functioning
    • Resolve the infection
    • Control pain and discomfort

Nursing implementation

  • Health Promotion
    • Vaccinations for pneumonia and influenza
    • Meningococcal vaccines
      • MCV4 (Meningococcal conjugate vaccine), MPSV4 (Meningococcal polysaccharide vaccine), Serogroup B
    • Early, vigorous treatment of respiratory tract and ear infections
    • Prophylactic antibiotics for anyone exposed to bacterial meningitis
      • Bacterial meningitis is a medical emergency. Rapid diagnosis based on history and physical examination is crucial because the patient is usually in a critical state when health care is sought. When meningitis is suspected, antibiotic therapy is instituted after the collection of specimens for cultures, even before the diagnosis is confirmed.  
  • Acute Care
    • Revolve around the nursing diagnoses of
      • Decreased intracranial adaptive capacity
      • Risk for ineffective cerebral perfusion
      • Increased fever
      • Acute pain
    • Close observation and assessment
    • Provide relief for head and neck pain
    • Position for comfort
    • Darkened room and cool cloth over eyes for photophobia
    • Minimize environmental stimuli
    • Provide safety
  • Observe and record seizures
    • Prevent injury
    • Administer antiseizure medications 
  • Vigorously manage fever
    • Fever increases cerebral edema and the frequency of seizures
    • Neurologic damage may result from high, prolonged fever
  • Assess for dehydration
    • Evaluate fluid intake and output
    • Compensate for diaphoresis in replacement fluids
  • Maintain therapeutic blood levels of antibiotics
  • Respiratory isolation until cultures are negative (Droplet precautions)
  • Ambulatory Care
    • Provide for several weeks of convalescence
    • Increase activity as tolerated
      • Stress adequate nutrition
      • Encourage adequate rest and sleep
    • Progressive ROM exercises and warm baths for muscle rigidity
    • Ongoing assessment for recovery of vision, hearing, cognitive skills, motor and sensory abilities
    • Tend to signs of anxiety and stress of family and caregivers

Evaluation

  • Patient will
    • Demonstrate appropriate cognitive function
    • Be oriented to person, place, and time
    • Maintain body temperature within normal range
    • Report satisfaction with pain control

 

  • As a nurse, since bacterial meningitis is very contagious and potentially a fatal infection, Universal precautions should ALWAYS be in place – you have the right to implement more conservative care (respiratory isolation) at any time as a professional nurse.

 

Viral Meningitis

  • Most common causes are enterovirus, arbovirus, HIV, and HSV
    • Most often spread through direct contact with respiratory secretions
  • Usually presents as headache, fever, photophobia, and stiff neck
    • Fever may be moderate or high
  • Diagnostic testing of CSF
    • Rapid diagnosis with Xpert EV test
      • Sample of CSF is evaluated for enterovirus
      • Results available within hours
    • PCR to detect viral-specific DNA/RNA
  • Treat with antibiotics after obtaining diagnostic sample but before receiving test results
    • Symptomatic management 
    • Disease is self-limiting
    • Full recovery expected

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