INFECTIOUS DISEASES OF THE CNS
NCM 112: MEDICAL SURGICAL NURSING
TETANUS (LOCKJAW)
→ Caused by Clostridium tetani which produces
potent exotoxin with prominent systemic
neuromuscular efforts manifested by
generalized spasmodic contractions of the
skeletal musculature
○ Caused by endotoxins from Cl. tetani
(cone-shape bacteria)
○ Opistotonus > arching of the back
→ Fatal up to 60% of immunized persons, usually
within 10 days of onset
○ DPT vaccine (diphtheria, pertussis
(whooping cough), and tetanus)
→ When symptoms develop within 3 days, the
prognosis is poor
→ Incubation Period
○ ADULT: 3 days to 3 weeks
○ NEONATE: 3 to 30 days
→ Etiologic Agent: Cl. Tetani
○ Anaerobic, gram (+) with round
terminal spore with slender body giving
a drumstick appearance (bacteria)
○ Toxins released by the Cl. Tetani
一 TETANOSPASMIN > responsible
for muscle spasm
一 TETANOLYSIN > responsible for
destruction of RBC (tissue
hypoxia > necrosis > prone to
bleeding > hypovolemic shock)
→ Sources of infection
○ Animal and human feces. Organism
that are found in the intestinal wall of
herbivorous animals, including man
○ Soil and dust (farmers are susceptible)
○ Plaster of paris (stabilizes fracture),
unsterile sutures, pins, rusty materials,
and scissors
一 (Before) Endemic in newborns >
unsanitary use of scissors for
cord cutting > Voiceless cries
because of muscle spasm
(larynx)
→ Mode of Transmission
○ Direct inoculation > dust, soil or
animal excreta
一 Used as a bioweapon in WWII
→ Avenues for entrance of the organism
○ Rugged traumatic wounds and burns
○ Umbilical stump in newborn > home
deliveries (mothers without tetanus
toxoid immunizations)
○ Unrecognized wounds (cleaning of the
ears with sharp materials)
○ Dental extraction, circumcision and ear
piercing (unsterilized equipment)
MANIFESTATIONS
→ NEONATE
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August 20, 2021
Preliminary Term
○ Feeding and sucking difficulty
一 Spasm of larynx and facial
muscles
一 NGT or OGT
○ Excessive crying, most of the time
voiceless crying
○ An attempt to suck results in spasm
and cyanosis
○ Fever due to infection and dehydration
○ Jaw becomes so stiff that the baby
cannot suck or swallow
○ Tonic or rigid muscular contraction l,
spasm or convulsions provoked by
stimuli
一 Limit external stimulus
(isolated)
○ Cyanosis and pallor
一 Endotoxin destroys RBC
○ May end with flaccidity, exhaustion and
death
→ OLDER CHILDREN AND ADULT
○ If tetanus remains localized, signs of
onset are spasm and increase muscle
tone near the wound
一 Wound is edematous
一 If it becomes systemic
indications include
○ Hypertonicity, hyperactive deep tendon
reflexes, tachycardia, profuse sweating,
low grade fever, and painful involuntary
muscle contractions
○ Neck and facial muscle rigidity
(Trismus) (!)PATHOGNOMONIC SIGN
○ Grinning expression (Risus
Sardonicus) (!)PATHOGNOMONIC SIGN
○ Boardlike abdomen / abdominal
rigidity
一 Constipation > No peristaltic
movement
○ Opisthotonos (arching of the back)
○ Tonic convulsion for several
minutes-may result in cyanosis and
sudden death due to asphyxiation
○ Laryngospasm > accumulation of
secretions in the lower airway resulting
to respiratory distress (involvement of
respiratory muscles)
○ Fracture of the vertebrae > severe
spasm, yielding to coma and death
一 In mild cases, after weeks,
spasm gradually diminish in
frequency and severity with
trismus (last symptoms to
disappear)
一 In fatal cases, death usually
occurs during the first 10 days
of the disease
COMPLICATIONS
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INFECTIOUS DISEASES OF THE CNS
NCM 112: MEDICAL SURGICAL NURSING
→ Laryngospasm and involvement of respiratory
muscle
○ Hypostatic pneumonia
○ Hypoxia pneumonia
○ Hypoxia due to laryngospasm
decreased o2 supply to tissue
○ Atelectasis (failure of respiration to
function)
○ Pneumothorax (lungs full of secretions)
一 Suctioning
→ Due to trauma
○ Laceration of tongue and buccal
mucosa
○ Intramuscular hematoma
○ Fracture of the spine and ribs dt
prolong opisthotonos
→ Septicemia or generalized infection
TREATMENT
→ Specific
○ Within 72 hours after punctures wound,
the patient should receive ATS (anti
tetanus serum), TAT (tetanus antigen
toxoid) or TIG (tetanus
immunoglobulin)
一 Especially with no DPT vaccine
一 If patient is vaccinated or not
serums will be given is
suspected for tetany
○ Tetanus toxoid 0.55 cc IM given in
standard schedule
○ Pen G Na to control infection
一 Broad sodium antibiotic
○ Muscle relaxant to control muscle
spasm and muscle rigidity
→ Non specific
○ O2 inhalation
一 Assistance in breathing
○ Feed thru NGT
○ Tracheostomy
一 For severe respiratory distress
○ Adequate F&E and caloric intake
一 Anemia and hemorrhage
NURSING MANAGEMENT
→ Avoidance of external stimulation
○ Limit visitors
○ TV light may trigger spasms or gadgets
○ Avoid touching the patient > ask
permission > gentle touches
→ Prevention from further injury
→ Maintain adequate airway
→ Provide cardiac monitoring
→ Maintain IV line for medication and emergency
care
○ IM administration may trigger spasms
→ Carry out efficient wound care
→ Avoid contractures and pressure > pressure
sores
→ Watch out for urinary retention
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August 20, 2021
Preliminary Term
○ Normal: 30cc/hr
→ Close monitoring on VS and muscle tone
→ Provision of optimum comfort measure
PREVENTION AND CONTROL
→ Active immunization with tetanus toxoid for
adult
→ DPT for babies and children
→ Early consultation and adequate wound care
after injury
RABIES (HYDROPHOBIA / LYSSA)
→ Specific, acute, viral infection communicated
to man by saliva of an infected animal
→ All of your fears will manifest
→ Lyssa > Latin for rage and furry
→ Etiologic Agent
○ RHABDOVIRUS
一 Bullet-shaped filterable virus
with strong affinity to the CNS
一 Sensitive to sunlight, UV light,
ether, formalin, mercury, and
nitric acid > easier to kill outside
the body
一 Resistant to phenol, merthiolate,
and common antibacterial
agents
→ Incubation Period
○ 1 week - 7 ½ months in dogs
○ 10 days - 15 years in human
○ Depending on the following factors
一 Distance of bite to the brain
● SITUATION: Much better
to be bitten in parts that
are distal to the brain
(foot/legs)
一 Extensiveness
一 Species of animal
一 Richness of blood supply
一 Resistance of the host
→ Period of Communicability
○ 3 - 5 days before onset of the
symptoms until entire course of illness
一 Isolation of PX due to aggressive
tendencies
MANIFESTATIONS
→ PRODROMAL / INVASION PHASE
○ Fever, anorexia, malaise, sore throat,
copious salivation, lacrimation,
perspiration, irritability,
hyperexcitability, apprehensiveness,
restlessness, drowsy, mental
depression, melancholy and insomnia
○ Pain or tingling sensation at the
original site and different body parts
○ Sensitive to light sound and tmp
○ Anesthesia numbness burning
→ EXCITEMENT / NEUROLOGICAL PHASE
○ Excitation, apprehension, and even
terror
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INFECTIOUS DISEASES OF THE CNS August 20, 2021
NCM 112: MEDICAL SURGICAL NURSING Preliminary Term
○ Delirium associated with nuchal → Confinement for 10 - 14 days of any dog that
rigidity, involuntary twitching or has bitten a person
generalized convulsions → Laboratory facilities for observation and
○ Maniacal behavior, eyes are fixed and diagnosis
glossy, skin is cold and clammy → Public education, especially children, in
○ Severe and painful spasm of the avoiding and reporting all animals that
muscle of the mouth, pharynx, and appears sick
larynx, on attempt to swallow water or MENINGOCOCCAL INFECTION: MENINGITIS
food or even the mere sight of water → Cerebrospinal Fever
○ Aerophobia > fear of air → Inflammation of the meninges of the brain and
○ Difficulty in swallowing causes frothy spinal cord as a result of viral and bacterial
saliva to drool from the patient’s mouth infection
○ Marked restlessness, → Meningeal Membrane
anxiety,apprehension, CN dysfunction ○ Dura mater
that causes ocular palsies, strabismus ○ Arachnoid
○ Death may occur during the episode of ○ Pia mater
spasm or cardiac/respiratory failure → Etiologic Agent:
○ If patient survives, patient deteriorates ○ Pneumococcus
rapidly and enters to the terminal ○ Staphylococcus
phase ○ Streptococcus
→ TERMINAL / PARALYTIC PHASE ○ Tubercle bacillus
○ Quiet and unconscious ○ Neisseria meningitidis
○ Loss of bowel and urinary control (meningococcal)
○ Spasm ceases with progressive 一 Most of the epidemics of
paralysis meningitis
○ Tachycardia, labored, irregular 一 Cause primary pneumonia,
respiration purulent conjunctivitis,
○ Death occurs due to respiratory endocarditis, sinusitis, and
paralysis, circulatory collapse or heart genital infections
failure → Incubation period: 1 - 10 days
DIAGNOSTIC PROCEDURES → MOT:
→ Virus isolation from saliva or throat ○ Respiratory droplets
→ Fluorescent rabies antibody (FRA) > most ○ Direct invasion through otitis media
definitive (for children > blood is drawn to test for
○ Opening of the brain (post mortem) the source of infection)
○ Presence of negri bodies in the dog’s ○ May also follow skull fracture,
brain penetrating head wound, lumbar
TREATMENT puncture or ventricular shunting
procedures
→ Wash wounds and scratches with soap and
○ Viral meningitis > compilation of
running water for at least 3 minutes
existing viral infection (unresolved)
→ Tetanus toxoid if needed
→ Tetanus antiserum infiltrate around the wound DIAGNOSTIC PROCEDURES
or given IM after negative skin test → Lumbar Puncture (CSF Analysis)
→ Anti-rabies vaccine ○ Diagnostic Purpose
○ All kinds may be given all together 一 Obtain CSF (clear, no order, and
NURSING MANAGEMENT not cloudy)
一 X-ray of the spinal canal and
→ Isolate the patient
cord
→ Emotional and spiritual support
○ Therapeutic purposes
→ Optimum comfort
一 Reduce ICP by CSF extraction
→ Darken the room and provide quiet
一 Introduce serum and other
environment
medications
→ Not be bathed > Hydrophobic
一 Inject anesthetic agent
→ Secure IV lines > wrapped the hands
→ Gram staining > type of bacteria and virus
→ Concurrent and terminal disinfection
○ Petechiae is smeared for analysis
→ Monitoring for cardiac and respiratory function
→ Smear and blood culture
PREVENTION AND CONTROL → Smear from petechiae
→ Vaccination of all dogs → Urine culture

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INFECTIOUS DISEASES OF THE CNS
NCM 112: MEDICAL SURGICAL NURSING
TYPES OF MENINGITIS: ASEPTIC
→ Benign syndrome
○ HA, fever, projectile vomiting, and
meningeal symptoms
○ Fever up to 40 C, alterations in
consciousness (drowsiness, confusion,
stupor)
→ (!)PATHOGNOMONIC SIGN > Meningeal
irritation
○ Characterized by
一 Stiff neck
一 Opisthotonos
一 (+) Brudzinski’s sign
● Flat on bed and lift the
head and the extremities
will flex
一 (+) Kernig’s Sign
● Flat on bed and lift one
leg then it will flex or
pain is present or leg
stay flexed for a period of
time
一 Exaggerated and symmetrical
deep tendon reflexes
一 Sinus arrhythmia, irritability,
photophobia, diplopia, and other
visual problems
● Infection can go down
the heart
● Diplopia (increased ICP >
brainstem si
compressed down > optic
chiasm is blocked
一 Delirium, deep stupor and coma
一 Signs of ICP
● Bulging fontanel in
infants
● Nausea and vomiting
(projectile)
● Severe frontal headache
● Blurring of vision
● Alteration in sensorium
COMPLICATIONS
→ Subdural effusion
○ Clogged subdural space
→ Hydrocephalus
○ Accumulation of CSF (in children >
fontanelles)
→ Deaf - mutism
○ Compression of optic and auditory
nerve
→ Blindness of either one or both eyes
→ Otitis media and mastoiditis
→ Pneumonia and bronchitis
TREATMENT
→ If left untreated it has a mortality rate of
70-100%
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August 20, 2021
Preliminary Term
→ Treatment includes appropriate antibiotic
therapy and supportive care management
→ Usually IV antibiotics are given for 2 weeks
and followed by oral antibiotics such as:
○ Ampicillin
○ Cephalosporin (Ceftriaxone)
○ Aminoglycosides
→ Digitalis glycoside (digoxin) to control
arrhythmias
→ Mannitol to decrease cerebral edema
○ Monitor the I&O (urine output)
increased urine
→ Anticonvulsant/sedative to reduce
restlessness and convulsions
→ Acetaminophen to relieve to relieve to relieve
HA and fever
TYPES OF MENINGITIS: ACUTE MENINGOCOCCEMIA
→ Most common among children, ages 6 months
to 5 years
→ Incubation period: 3 - 4 days
→ Following the incubation period of 3-4 days,
invades the bloodstream, the joints, the skin,
the adrenal glands, the lungs, without
involving the meninges
→ Starts with nasopharyngitis followed by
sudden onset of spiking grade fever with
chills, nausea, vomiting, malaise and HA
○ Assess pattern of fever and other
symptoms > colds and sore throat
(initial symptom)
→ Petechial, purpuric, or ecchymotic
hemorrhages scattered over the entire body
and mucous membrane, which could be due to
acute vasculitis followed by suppurative
necrosis and hemorrhage into the dermal
connective tissues
→ Adrenal lesions starts to bleeds into the
medulla which extends to the cortex
○ The combination of the dermal
manifestations and adrenal medullary
hemorrhage is known as the
waterhouse-friderichsen syndrome
(!)PATHOGNOMONIC SIGN
○ Waterhouse-friderichsen syndrome
一 Rapid development of petechiae
to purpuric & ecchymotic spots
associated with shock
→ The condition runs a short course and is
usually fatal. This frequently occurs in
fulminant type of meningococcemia
MANAGEMENT
→ Asses neurologic condition of the patient
○ Observe the patient's LOC and check for
signs of increased ICP manifested by:
一 Plucking at bed covers
一 Projectile vomiting
一 Seizures, changes in motor
functions and VS
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INFECTIOUS DISEASES OF THE CNS
NCM 112: MEDICAL SURGICAL NURSING
○ WOF deterioration of patients
condition, which maybe signal for an
impending crisis
○ WOF adverse reaction of antibiotics and
other drugs. Avoid IV infiltration and
phlebitis
○ Maintain adequate nutrition and
elimination
一 Avoid dark colored foods
○ Ensure patient’s comfort
○ Monitor fluid balance
一 Maintain adequate fluid intake
to avoid dehydration, but avoid
fluid overload because of the
danger of cerebral edema
一 Measure central venous
pressure and intake and output
○ Position the patient carefully to prevent
joint stiffness and neck pain
一 Turn him often to sides to avoid
pressure sores and respiratory
complications
一 Assists with ROM, passive and
active range of motion
○ Provide reassurance and support to the
patient and the family
一 Follow strict aseptic techniques
when treating patients with
head wounds or skull fractures
一 Isolation is necessary especially
if nasal culture is positive
PREVENTION
→ Vaccines available to protect against certain
types of meningitis > Pneumococcal vaccine
→ Chronic sinusitis > can go up > importance of
proper and prompt medical treatment and
diagnosis
POLIOMYELITIS (INFANTILE PARALYSIS /
HEINE-MEDIN DISEASE)
→ Characterized by changes in CNS which may
result in pathologic reflexes, muscle spasm
and paresis or paralysis
○ Destroys tissues and myelin sheath >
loss of sensation > atrophy
→ Lower motor neurons and it is because of
anterior horn involvement that is named
“Anterior poliomyelitis”
→ Etiologic agent
○ Caused by a filterable virus, polio
virtual “legio debilitans”
○ 3 strains of viruses, and as far as it is
known, the disease affects man alone:
一 Brunhilde
一 Lansing
一 Leon
→ Incubation period
○ 7-21 days for paralytic cases with a
repeated range of 3-35 days
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August 20, 2021
Preliminary Term
→ Period of communicability
○ 3 days- 3 months
○ Most contagious during the first few
days of active disease, and possibly for
3-4 days before
→ Mode of transmission
○ Direct contact
○ Person to person transmission
○ Indirectly through contaminated
articles and flies-contaminated water,
food and utensils
→ Predisposing causes
○ Age
一 About 60% of patients are under
10 years of age
○ Sex
一 Males are more prone than
female (ratio of 3:2 ) death >
higher in males
○ Heredity
一 Poliomyelitis is not heredity
○ Environment and hygienic conditions
一 The rich are more often to
spread than the poor (due to
lifestyle)
一 Excessive work, strain, marked
overexertion
TYPES OF POLIOMYELITIS: ABORTIVE TYPE
→ Accounts to about 4-8% of all causes
→ Does not invade the central nervous system
○ Flu-like symptoms and lower lumbar
pain
→ Headache and sore throat
→ Slight or moderate fever
→ Occasional vomiting
→ Lower lumbar pain
→ The patient usually recovers within 72 hours
and in most cases, the disease passes
unnoticed
TYPES OF POLIOMYELITIS: PRE-PARALYTIC OR
MENINGITIS TYPE
→ Usual type
→ All the above signs + spasms
→ Patient manifest higher temperature, more
severe headache, restlessness, vomiting,
anorexia, lethargy
→ Pain and spasm of the muscle of the
hamstring, pain at the neck and back
→ Changes in deep and superficial reflexes
→ Pain in the neck, back, arms, legs, and
abdomen
→ Inability to place the head in between the
knees
→ Positive pandy’s test
○ One drop of CSF sample (collected from
the patient by lumbar puncture
technique), is added to about 1ml of
Pandy's solution
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INFECTIOUS DISEASES OF THE CNS
NCM 112: MEDICAL SURGICAL NURSING
○ The turbid appearance signifies the
presence of elevated levels of globulin
protein in the CSF and is regarded as
positive Pandy's reaction
→ Transient paresis may occur
→ Lasts for about a week, with meningeal
irritation persisting for about 2 weeks
PARALYTIC
→ The above signs and symptoms
→ Paralysis occurs
→ Less tendon reflexes
→ (+) Kernig and Brudzinski
(!)PATHOGNOMONIC SIGN
○ Kernig
○ Brundzinski
→ Weakness of the muscles (muscles becomes
smaller)
→ Hypersensitivity to touch
→ There is usually urine retention, constipation
and abdominal discomfort
○ High fiber and water intake
SPINAL PARALYTIC
→ Paralysis occurs in muscle innervated by
motor neurons of the spinal cord
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August 20, 2021
Preliminary Term
→ Characterized by as asymmetry, scattered
flaccid paralysis on one or both lower
extremities
→ Autonomic involvement manifested by
excessive sweating
→ Respiratory difficulty
BULBAR PARALYTIC
→ Usually has a rapid development and more
serious type
→ Attacked motor neuron, affecting the medulla.
It weakens the muscles supplied by the cranial
nerves especially the 9th (glossopharyngeal)
and the 10th (vagus)
→ Paralysis of the facial, pharyngeal, and
ocular muscles
→ Hypothalamic dysfunction as manifested by
impaired temperature regulation
→ Encephalitic manifestation > 30%of patients
manifested by facial weakness, dysphagia,
difficulty in chewing, inability to swallow or
expel saliva, regurgitation of food through
nasal passages and dyspnea
BULBOSPINAL PARALYTIC
→ Involvement of the neurons both the
brainstem and the spinal cord
→ Could be permanent
COMPLICATIONS
→ Respiratory failure
→ Circulatory collapse
→ Electrolyte imbalance
→ Bacterial infection
→ Urinary problems r/t retention or paralysis of
the urinary bladder
→ Abdominal distention (boardlike > spasms)
DIAGNOSTIC PROCEDURE
→ Isolation of the virus from throat washings or
swab early in the disease
→ Stool culture throughout the disease
→ Culture form the cerebrospinal
TREATMENT
→ Analgesics > HA, back pain and leg spasm
○ Morphine is contraindicated >
respiratory suppression
→ Moist heat application > reduce muscle spasm
and pain
→ Bed rest is necessary
→ Paralytic polio requires rehabilitation using
physical therapy, brace, corrective shoes and
in some cases, orthopedic surgery
NURSING MANAGEMENT
→ Carry out enteric isolation
→ Observe the patient carefully for signs of
paralysis and other neurologic disease
→ Perform a neurological assessment at least
once a day > but don’t demand any vigorous
muscular activity
6
INFECTIOUS DISEASES OF THE CNS August 20, 2021
NCM 112: MEDICAL SURGICAL NURSING Preliminary Term
→ Check BP regularly especially in bulbar
poliomyelitis
→ Watch out for fecal impaction due to
dehydration and immobility > give sufficient
fluids and high iber to ensure adequate diet
→ Prevention of pressure sores. Provide good skin
care. Reposition the patient frequently, and
keep the bed dry
→ To prevent the spread to the disease, wash
hands every after contact with patient
→ Apply hot packs affected limb to relieve pain
and muscle shortening
→ Dispose excreta and vomits properly
→ Provide emotional support for the px and
family
→ Maintain good personal hygiene, particularly
oral and skin care
PREVENTION AND CONTROL
→ Immunization > oral polio vaccine
→ Proper disposal of GIT secretions
→ Enteric isolation
→ Implementation of standard precautions
→ Sanitation of the premises and proper food
handling to avoid contamination by flies
should be strictly observed
→ Avoid overcrowding

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