Prince Sultan Military College for Health Sciences

8/14/2019 Prince Sultan Military College for Health Sciences

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Prince Sultan military college for health

sciences .

Meningitis

Prepared by:

MAHA AL-BLUI , ASHWAQ AL-HABODAL ,TAHANI

AL-ATAWI, AMNAH AL-SHEHRI.

BSN BR-B


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INTRODUCTION :

Meningitis

Is the inflammation of the meninges , the membrane lining the

brain and spinal cord. Pathogenic organisms cross the blood

brain barrier, invade the sub arachnoid space and cause an

inflammatory response.

Etiology :The organism responsible formeningitis is viruses or bacteria, it

is according to age:-

1- From birth 2month:- E-coli, streptococcus group B.

2- From 3months 3years:- Haemophilus influenza,

streptococcus pneumonia, Neisseria meningitis.

3- From 3 16years:- Streptococcus pneumonia, Neisseriameningitis.


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Altered physiology:

1- Bacterial meningitis is almost always preceded by upper

respiratory tract infection, Complicated by bacteremia.

2- Bacteria in the circulating blood invade the spinal fluid.

3- Also bacterial meningitis may occur as an extension of a local

bacterial infection (otitis media, mastoiditis or sinusitis).

4- Also bacteria may also gain direct entry through (penetrating

wound, surgery, spinal bifida, anatomic abnormality).

5- Infective process result in :- inflammation, tissue damage.


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Clinical Manifestations :-

A- Signs and symptoms are variable depending on:-1- patients age.2- Etiological agent.3- Duration of illness.

1- Neonates:-

1- Irritability.2- Lethargy.3- Vomiting.4- Lack of appetite.5- Seizures.6- High pitched cry.

7- Fever or hypothermia.8- Diarrhea, poor tone, lack of movement.9- Jaundice, cyanosis and weight loss


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Infant 2years old:- Similar to neonate also:-

1- Neck rigidity.

2-Positive Brudzinskis and Kerning's signs.

Brudzinskis Sign :-To elicit Brudzinskis sign place the patient supine position andflex the head upward. Resulting flexion of hips, knees, andankles with neck flexion indicates meningeal irritation.

Kerning's Sign :-Again place the patient into supine position, Keeping one legstraight, flex the other hip and knee to a bent knee to a 90-degree angle. Slowly extend the lower leg.

3-Children over 2years old:- Initial symptoms:-

1- Vomiting.2- Headache.3- Lethargy.


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Diagnosis

Blood tests and imagingCBC , CRP , BLOOD CULTURE .

The most important test in identifying or ruling out meningitis is

analysis of the cerebrospinal fluid through lumbar puncture

(LP, spinal tap) .However, lumbar puncture is contraindicated

if there is a mass in the brain (tumor or abscess) or theintracranial pressure (ICP) is elevated, as it may lead to brain

herniation . CT or MRI is required before LP .
http://en.wikipedia.org/wiki/Lumbar_puncturehttp://en.wikipedia.org/wiki/Intracranial_pressurehttp://en.wikipedia.org/wiki/Brain_herniationhttp://en.wikipedia.org/wiki/Brain_herniationhttp://en.wikipedia.org/wiki/Brain_herniationhttp://en.wikipedia.org/wiki/Brain_herniationhttp://en.wikipedia.org/wiki/Intracranial_pressurehttp://en.wikipedia.org/wiki/Lumbar_puncture


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The treatment of TB meningitis is isoniazid, rifampicin,

pyrazinamide and ethambutol for two months,followed by isoniazid and rifampicin alone for a

further ten months. Steroids are always used in the

first six weeks of treatment (and sometimes for

longer). A few patients may require

immunomodulatory agents such as thalidomide.

Treatment must be started as soon as there is a

reasonable suspicion of the diagnosis. Treatment

must not be delayed while waiting for confirmation of

the diagnosis. Hydrocephalus occurs as acomplication in about a third of patients with TB

meningitis and will require a ventricular shunt.


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PATIENTS PROFILE

Name: HIND,ALAJMIDate of Birth: October 8, 1999

Birthplace: RIYADH

Age: 11 years old

Sex: Female

ADMITTING HISTORY

This is a case of an 11 year old, female patient who was

admitted at KAAP Hospital with chief complaints of fever, headache

and vomiting .


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21 days : fever, low grade, tolerable headache and vomiting

14 days: patient had a fever; 13 days PTA: (+) High grade fever

39C, vomiting, colds.

8 days : patient complains of pain on nape area with neck rigidity and

headache, fever, no convulsion.

5 days : dizziness, anorexia, with pain at her back characterized as

pricking sensation..

Tramadol, Metoclopromide, were given.


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Diagnostic Evaluation :-

1- CBC :- Elevated leukocyte.

2- Blood Culture :- Streptococcus pneumoniae3- Lumbar Puncture with CSF :- Low glucose levels, high protein

levels.

4- MRI / CT .

5- Platelet count.6- Urine analysis.

7- Skull and chest X-ray.

8- Serum electrolytes:- Hyponatremia.


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Treatment :

(Cefotaxime 1 grams IV q12h

dexamethasone (0.4mg/kg q12h

Vancomycin 1 gram IV OD

IVF normal saline 10ml/kg.


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PHYSICAL ASSESSMENT

GS: weak looking, conscious, coherent Skin: (-) jaundice, (-) pallor, (-) cyanosis Respiratory

SCE, (-) retractions, (-) crackles, no wheezes AP: no murmur Heart: Normal Rate Regular Rhythm, (-) murmurs Abdomen: no mass palpated, no tenderness GUT: Unremarkable Extremities: no atrophy noted

Neuro: (+) neck rigidity (+) brudzinkis sign

(+) kernigs sign

(-) babinski reflex Vital Signs:

B/P= 90/70 PR=76 RR=18 T=38 OC


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Final diagnosis : Meningitis .

FAMILY HISTORY

FATHER MOTHER

DIABETES (-) (-)

HYPERTENSION (-) (-)

ASTHMA (-) (-)


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Anatomy and physiology

Central Nervous System

The central nervous system (CNS) is the largest part of

the nervous system, and includes the brain and spinal

cord. The spinal cavity holds and protects the spinal

cord, while the head contains and protects the brain. The

CNS is covered by the meninges, a three layered

protective coat. The brain is also protected by the skull,

and the spinal cord is also protected by the vertebrae.


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The meninges , is thesystem of membraneswhich envelops thecentral nervous system.The meninges consist of

three layers: the duramater, the arachnoidmater, and the piamater.The primary function ofthe meninges and of the

cerebrospinal fluid is toprotect the centralnervous system.


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Nursing Assessment :-

1- Obtain a history of recent infection, such as upper respiratory

infection.

2- Assess neurological status and vital signs.3- Evaluate for signs of meningeal irritation.

Nursing Diagnoses :-

1- Hyperthermia related to the infectious process and cerebral

edema.Goal :-

Reduce Fever.

Interventions :-

1- Administer antibiotics in time to maintain optimal blood levels.

2- Monitor temperature continuously, and administer antipyretics as

ordered.

3- Institute other cooling measures, such as a hypothermia blanket.


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Risk for fluid volume deficit related to fever and decrease fluid intake.Goal :-Maintain fluid balance.Intervention :-1- Prevent IV fluid overload, which may worsen cerebral edema.2- Monitor intake and output.3- Monitor Central Venus Pressure.

3- Altered cerebral tissue perfusion related to infectious process and cerebraledema.Goal :-Enhancing cerebral perfusion.

Intervention :-1- Assess level of conscious, vital signs, and neurological parameters.2- Maintain a quite, calm environment to prevent agitation, which may causean increased Intra Cranial Pressure.3- Prepare patient for a lumbar puncture for CSF evaluation, and repeat spinaltap.4- Notify the health care provider of signs of deterioration:- (increasing

temperature, decreasing level of conscious, seizure activity, or alteredrespirations).


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Pain related to meningeal irritation.Goal :-Reducing pain.Intervention :-

1- Administer analgesics; monitor for response and adverse reactions.Avoid narcotics, which may mask a decreasing level of conscious.2- Darken the room if photophobia is present.3- Assess with position of comfort for neck stiffness, and turn patientslowly and carefully with head and neck in alignment.

5-Impaired physical mobility related to prolonged bed rest.Goal :-Promoting return to optimal level of functioning.Intervention :-1- Implement rehabilitation interventions after admission (ex:- turning,

positioning)2- Progress from passive to active exercises based on the patientneurologic status.


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Patient Education :-

1- Advice close contacts of the patient with meningitis that

prophylactic treatment may be indicated; they should check with their

health care providers or the local public health department.2- Encourage the patient to follow medication regimen as directed to

fully eradicate the infectious agent.

3- Encourage follow up and prompt attention to infection in future.

4- Practice measures that will prevent the transmission of infection:-

1- Place child in isolation until at least 24hours .2- Practice careful hand washing technique.

3- Personnel with infection should avoid contact with infant.

4- Teach parents and other visitors proper hand washing.

5- Maintain sterile technique.

5-Let parents to visit their child and express their feeling.

6-Be aware for signs and symptoms of complications.


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