17.2 Acute Disorders of the Nervous System

Pathophysiology

Brain tumors involve genetic, molecular, and cellular changes, which contribute to abnormal cell proliferation in the central nervous system or brain. When cells do not experience apoptosis, which is the normal, controlled process of cell death, cancer may occur. Cancer cells have uncontrolled division and produce additional abnormal cells when they duplicate. These cells are undifferentiated and may compress blood vessels and vasculature. They also outgrow their own vasculature and sometimes develop new vasculature, while releasing toxins to surrounding tissues.

Cancers, including brain tumors, are varied and have different causes. Medical professionals are not certain what causes brain tumors, but typically, brain tumors result in genetic and molecular alterations, abnormal cell proliferation, angiogenesis (the formation of new blood vessels), infiltration and compression of normal body tissues, obstruction of CSF flow, and abnormal immune response.

Genetic and molecular alterations in oncogenes and tumor suppressor genes play an integral part in brain tumor onset. Typically, proto-oncogenes enable cells to stay alive by growing and dividing properly. Their work is complemented by that of tumor suppressor genes, which control cell divisions, while also repairing DNA errors and forcing cells to die when they reach the end of their lifespan. If patients experience DNA alterations that affect the functioning of proto-oncogenes and tumor suppressor genes, brain tumors may result. When a proto-oncogene becomes mutated, it is known as an oncogene.

One goal of cancer research is to determine the triggers that turn on oncogenic genes and turn off tumor suppressor genes. Research has identified contributing factors, including obesity, poor diet, stress, and smoking.

Types of Brain Tumors

Brain tumors include several types of benign and malignant growths. The benign tumors include the following (American Association of Neurological Surgeons [AANS], n.d.):

• meningioma—the most common type of benign intracranial tumor. As their name suggests, meningiomas begin growing in the meninges around the brain and spinal cord.
• schwannoma—common type of benign brain tumor found in adults. Schwannomas are found near nerves and may displace a nerve rather than invading it. Although schwannomas are benign, they can be serious health threats, even causing death, if they exert too much pressure on nerves and/or the brain.
• pituitary adenoma—also common, this type of benign tumor begins in the pituitary gland. Typically, pituitary adenomas affect individuals in their 30s and 40s, although children may have them.
• craniopharyngioma—typically arises from the pituitary gland and becomes embedded deep in the brain near critical structures. Patients with craniopharyngiomas usually need hormone replacement therapy, even though these tumors are benign.
• chordoma—rare, slow-growing tumor that generally occurs in individuals between the ages of 50 and 60. Typically, chordomas are found at the base of the skull or in the lower spine.
• gangliocytoma—rare tumor that involves the neoplastic nerve cells, which are nervous system cells that have become cancerous, and typically occurs in young adults.
• glomus tumor—rare tumor that occurs in the head and neck, often near the jugular vein.

The more serious brain tumors are malignant. The most common type of malignant brain tumor is a glioma, produced from the brain’s glial cells. A glial cell is a supporting cell that provides nourishment to neurons. The different types of malignant brain tumors include the following (AANS, n.d.):

• astrocytoma—common type of glioma that grows from astrocytes. An astrocyte is a star-shaped glial cell that forms part of the brain’s supportive tissue. Typically, astrocytomas form in the brain’s cerebrum and can occur in individuals of all ages.
• glioblastoma multiforme (GBM)—the most invasive of the glial tumors. GBMs tend to be comprised of multiple types of cells, including astrocytes and oligodendrocytes, and they tend to grow quickly, spreading to other tissues. GBMs typically affect individuals between ages 50 to 70 and tend to occur in men more than women. For individuals who have a GBM, the prognosis is usually poor.
• medulloblastoma—typically occurs in children, affecting the cerebellum, and tends to be high-grade. Medulloblastomas usually respond to chemotherapy and radiation, making them more treatable than some brain tumors.
• ependymoma—less common brain tumor that occurs when the ependymal cells that line the ventricular system experience a neoplastic transformation, which occurs when oncogenes are activated while tumor suppressor genes are inactivated.
• oligodendroglioma—occurs in the cells that produce the brain’s myelin, which insulates the brain’s wiring.

Clinical Manifestations

Brain tumor symptoms vary according to the tumor’s location, size, and growth rate. Generally, all brain tumors cause headaches. Other common symptoms include vertigo, nausea, fatigue, and changes in appetite. Additional manifestations, depending on the part of the brain affected by the tumor, include the following (Mayo Clinic, 2023a):

• Frontal lobe tumors tend to cause personality changes, disinterest in normal activities, forgetfulness, balance issues, and difficulty walking.
• Parietal lobe tumors, in the upper middle section of the brain, typically cause issues with the senses, including hearing and vision problems.
• Occipital lobe tumors, in the back of the brain, may cause vision problems, including blindness.
• Temporal lobe tumors, on the lower sides of the brain, may cause memory loss as well as issues with the senses, such as tasting or smelling something that does not exist.

Assessment and Diagnostics

As with other medical issues, to assess a brain tumor, nurses and other health-care professionals should first obtain the patient’s medical history. This history should identify whether patients could be at risk for a brain tumor because of factors such as obesity, age, family history, and certain radiation exposure. It should also determine whether patients are exhibiting symptoms of a brain tumor, such as frequent headaches and nausea. Patients should receive a physical examination to check their vision, hearing, speech patterns, coordination, and other physical behavior, including the patient’s ability to walk. The examination should also include an assessment of the patient’s deep tendon reflexes.

Nursing Care of the Patient with Brain Tumors

Brain tumors, whether benign or malignant, are critical conditions requiring nursing care tailored to address the patient’s needs based on the grade of their tumor. By recognizing the cues of brain tumors, nurses can help to identify patients with a brain tumor. Nurses also need to understand how to provide effective nursing care to patients with a brain tumor.

Evaluation of Nursing Care for Patients with Brain Tumors

The desired outcomes for patients with brain tumors include the successful removal of brain tumors if possible. For patients who must learn to live with their brain tumors, the desired outcome is to relieve symptoms and restore as much quality of life as possible. For patients whose brain tumors are terminal, the desired outcome is to help patients navigate end-of-life challenges. Examples of successful outcomes for patients with brain tumors include pain that is satisfactorily controlled, physical therapy that results in a decreased risk for falls, and range of motion exercises that restore or sustain the patient’s mobility.

Medical Therapies and Related Care

Treatment strategies for brain tumors depend on whether the tumor is benign or malignant, the grade of the tumor, its location and size, and the patient’s health. Common treatments for tumors may include the following:

• Surgical procedures
  • craniotomy—involves removing a bone flap from the skull to access a tumor
  • neuroendoscopy—uses an endoscopy to enter the skull through small holes and access a tumor
  • laser ablation—uses heat to destroy tumor cells
  • laser interstitial thermal therapy—uses a laser inserted through a tiny incision in the skull to kill tumor cells
• Radiation therapy
• Chemotherapy drugs to kill existing cancer cells and inhibit the growth of new cancer cells
• Immunotherapy to strengthen immunity by recognizing and destroying cancerous cells as soon as they appear

Pathophysiology

The exact cause of GBS remains unknown, but people who develop GBS often experience respiratory illness or diarrhea in the days, or even weeks, before they develop GBS. GBS may follow infection with Campylobacter jejuni or influenza viruses such as H1N1, and on rare occasions, vaccinations for the flu may lead to the development of GBS (Centers for Disease Control and Prevention, 2023). Surgeries can also trigger GBS, which occurs when an immune response damages myelin sheaths or nerve axons of peripheral nerves, causing muscle weakness, especially in the arms and legs. This muscle weakness may affect other bodily functions, such as swallowing and breathing (muscles in the throat and diaphragm are affected), and some patients with GBS may have difficulty walking. Some patients with GBS experience near complete paralysis.

GBS comes in different forms. The four primary types of GBS include the following:

• acute inflammatory demyelinating polyradiculoneuropathy (AIDP)—most common form of GBS characterized by muscle weakness that begins in the lower parts of the body and spreads upward
• Miller Fisher syndrome (MFS)—begins with paralysis in the eyes
• acute motor axonal neuropathy (AMAN)—characterized by paralysis and the loss of reflexes but the senses remain intact
• acute motor-sensory axonal neuropathy (AMSAN)—characterized by sensory deficiencies as well as a loss of reflexes and motor weakness

Clinical Manifestations

The symptoms typical of GBS include the following:

• muscle weakness progressing upward from feet to the hands and head
• tingling and weakness from lower body to upper body
• loss of deep tendon reflexes
• progressive paralysis from legs to respiratory muscles
• pain and aching of limbs
• difficulty speaking and swallowing
• autonomic dysfunction of heart rate, temperature, and bowels
• cranial nerve disorders causing blurred and double vision
• paresthesia, which is abnormal sensations such as burning, prickling, and tingling

In addition, because GBS affects patients’ nerves and bodily functioning, patients with GBS may experience breathing difficulties, blood pressure and heart issues, blood clots, bladder and bowel dysfunction including incontinence, and pressure injury as the condition progresses.

Assessment and Diagnostics

To assess and diagnose GBS, nurses and other health-care professionals should review a patient’s medical history and conduct a physical examination that focuses on GBS symptoms, such as vision problems, muscle weakness, paralysis, and loss of reflexes. If GBS is suspected based on the physical examination findings, medical tests to confirm the diagnosis may include a lumbar puncture, nerve conduction study, and/or electromyography (EMG).

Nursing Care of the Patient with Guillain-Barré Syndrome

GBS is a serious condition that requires emergency medical treatment and hospitalization. Without immediate care, patients with GBS are more likely to experience long-term effects, such as muscle weakness, pain in the limbs, and difficulty with balance and coordination. Some patients with GBS may even die without medical treatment.

Prioritizing Hypotheses, Generating Solutions, and Taking Action

Because GBS is a serious condition that requires immediate care, prioritize GBS as critical and provide emergency interventions. Once the patient is stable, collaborate with the patient’s health-care team members to address GBS symptoms, which may include loss of reflexes, muscle weakness, and difficulty speaking and swallowing. The actions that nurses should take to treat patients with GBS may include the interventions in Table 17.5.

Evaluation of Nursing Care for the Patient with Guillain-Barré Syndrome

The desired outcome for patients with GBS is recovery that results in a fully functioning peripheral nervous system. Ideally, patients with GBS should also not have lingering symptoms, such as fatigue, numbness, or weakness. Table 17.6 provides more specific details about evaluating outcomes for patients with GBS.

Medical Therapies and Related Care

Many patients with GBS are treated with intravenous immunoglobulin therapy (IVIG). This process provides patients with healthy antibodies intravenously. IVIG modulates immune response and decreases inflammation by blocking damaged antibodies in the patient’s body. Plasma exchange (plasmapheresis) is another treatment regimen often used for patients with GBS. This procedure removes harmful antibodies by replacing old plasma with fresh plasma taken from another source, such as a donor.

Pathophysiology

Meningitis can affect anyone, including children, but people with weakened immune systems are at greater risk. People who live in crowded conditions, such as dormitories, military barracks, or immigration camps have a higher risk of contracting meningitis. Also, those who have not been fully immunized are more likely to contract meningitis. Children are eligible to receive their initial meningococcal vaccination at age 10, with a booster at age 15. When there is an outbreak of infected individuals, exposure can elevate the risk for those who are not fully immune. Head injuries, such as skull fractures, and surgical procedures that break the protective barriers of the meninges increase the risk of introducing a pathogen into the meninges. In addition, people who travel to areas with a higher prevalence of meningitis risk contracting it (National Institute of Neurological Disorders and Stroke [NINDS], 2024).

Clinical Manifestations

The symptoms of meningitis are varied and range in intensity depending on severity of the case. Common clinical manifestations include sudden onset fever, severe headache, neck stiffness, photophobia, which is an increased sensitivity to light, and phonophobia, which is an aversion to loud noises.

If the infection progresses, patients may experience neurological symptoms, such as altered mental status, confusion, difficulty focusing, irritability, and seizures. Individuals who have bacterial meningitis may exhibit additional symptoms such as hearing loss and a skin rash associated with Neisseria meningitidis pathogens. They may also experience petechiae, which are round spots on the skin caused by bleeding in the skin; they may be red, brown, or purple. Typically, symptoms in patients with viral meningitis are less severe than in patients with bacterial meningitis (Figure 17.5).

Figure 17.5 Clinical manifestations of meningitis include sensory symptoms, skin, and musculoskeletal changes. (credit: modification of “Symptoms of Meningitis” by Mikael Häggström/Wikimedia Commons, Public Domain)

Assessment and Diagnostics

Meningitis can be diagnosed through blood tests, lumbar punctures of CSF, and imaging with CT scans or MRIs. When assessments of patient’s medical history and symptoms indicate that the patient may have meningitis, nurses or other health-care professionals should draw samples of blood and/or cerebrospinal fluid for laboratory testing. They may also order CT scans of the sinuses or chest or MRI scans of the head.

Nursing Care of the Patient with Meningitis

Meningitis is a serious disease that can be deadly for some patients. Thus, patients with meningitis need immediate medical attention. Nursing care should focus on treating the bacterial and/or viral infection that has caused meningitis and should strive to relieve patients’ symptoms, such as fever and pain.

Recognizing Cues and Analyzing Cues

To recognize the cues of meningitis, nurses should obtain the patient’s medical history and determine if the patient is at risk for meningitis and has symptoms of meningitis. Nurses should check patients for skin rashes and petechiae. In addition, a physical examination may reveal a positive Brudzinski’s sign or a positive Kernig’s sign. A positive Brudzinski’s sign occurs when pressure applied to the pubic symphysis elicits a reflex hip and knee flexion and abduction of the leg (Stribos & Jones, 2023). To elicit Kernig’s sign, the patient is kept in a supine position, the hip and knee is flexed to a right angle, and then the knee is slowly extended by the examiner. The appearance of resistance or pain during extension of the patient’s knee beyond 135 degrees constitutes a positive Kernig’s (Karl et.al., 2022) (Figure 17.6). If the physical examination indicates the patient may have meningitis, patients should receive testing, such as blood tests and lumbar punctures, to confirm the diagnosis. Meningitis is contagious. Thus, when drawing blood from patients with meningitis, nurses should take necessary precautions, such as wearing appropriate PPE equipment such as gloves and face masks.

Figure 17.6 The (left) Brudzinski’s and (right) Kernig’s signs can be indicative of meningitis. (credit: attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Evaluation of Nursing Care for the Patient with Meningitis

The successful treatment of meningitis should result in the removal of infection and alleviation of symptoms such as fever, headache, and neck stiffness. Patients should no longer experience issues such as seizures, photophobia, or phonophobia. If the treatment is not prompt, the patient is at risk for long-term issues, such as permanent nerve damage or hearing loss.

Medical Therapies and Related Care

Immunizations are essential in protecting against various forms of meningitis. Although vaccination schedules differ by country, they most often target specific pathogens associated with meningitis, such as Hemophilus influenzae, Neisseria meningitidis or Streptococcus pneumoniae. Patients with bacterial meningitis are more likely to require hospitalization, whereas those with viral meningitis may be treated as outpatients and provided supportive care while they remain at home. Patients who experience permanent damage from meningitis, such as nerve damage, may need long-term care such as anti-inflammatory medications and physical therapy.