Download Meningitis

Management of Patients with
Neurologic Dysfunction
Meningitis
Chapter 64
1
Learning Objectives
• Describe the pathophysiology, clinical
manifestations, and medical and nursing
management of Meningitis.
• Use the nursing process as a framework for
care of patients with Meningitis.
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Meningitis
• Meningitis is an inflammation of the lining
around the brain and spinal cord caused by
bacteria or viruses (Iggulden, 2006).
• Meningitis can be the primary reason a patient is
hospitalized or can develop during
hospitalization and is classified as septic or
aseptic.
• Septic meningitis is caused by bacteria.
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Meningitis
• In aseptic meningitis, the cause is viral or secondary
to lymphoma, leukemia, or human
immunodeficiency virus (HIV).
• Factors that increase the risk of bacterial meningitis
include tobacco use and viral upper respiratory
infection, because they increase the amount of
droplet production.
• Otitis media and mastoiditis increase the risk of
bacterial meningitis, because the bacteria can cross
the epithelial membrane and enter the
subarachnoid space.
• People with immune system deficiencies are also at
greater risk for development of bacterial meningitis.
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Pathophysiology
• Meningeal infections generally originate in one of
two ways: through the bloodstream as a
consequence of other infections or by direct
spread, such as might occur after a traumatic
injury to the facial bones or secondary to invasive
procedures.
• N. meningitidis concentrates in the nasopharynx
and is transmitted by secretion or aerosol
contamination.
• Bacterial or meningococcal meningitis also occurs
as an opportunistic infection in patients with
acquired immunodeficiency syndrome (AIDS) and
as a complication of Lyme disease (Chart 64-1).
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Pathophysiology
• Once the causative organism enters the
bloodstream, it crosses the blood–brain barrier and
proliferates in the cerebrospinal fluid (CSF).
• The host immune response stimulates the release of
cell wall fragments and lipopolysaccharides,
facilitating inflammation of the subarachnoid and pia
mater.
• Because the cranial vault contains little room for
expansion, the inflammation may cause increased
intracranial pressure (ICP).
• CSF circulates through the subarachnoid space,
where inflammatory cellular materials from the
affected meningeal tissue enter and accumulate.
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Pathophysiology
• The prognosis for bacterial meningitis depends on
the causative organism, the severity of the infection
and illness, and the timeliness of treatment.
• Acute fulminant presentation may include adrenal
damage, circulatory collapse, and widespread
hemorrhages (Waterhouse-Friderichsen syndrome).
• This syndrome is the result of endothelial damage
and vascular necrosis caused by the bacteria.
• Complications include visual impairment, deafness,
seizures, paralysis, hydrocephalus, and septic shock.
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Clinical Manifestations
• Headache and fever are frequently the initial
symptoms.
• Neck mobility: A stiff and painful neck (nuchal
rigidity) can be an early sign and any attempts at
flexion of the head are difficult because of spasms
in the muscles of the neck.
• Photophobia (extreme sensitivity to light): This
finding is common, although the cause is unclear.
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Clinical Manifestations
• Positive Kernig’s sign: When the patient is
lying with the thigh flexed on the abdomen,
the leg cannot be completely extended (Fig.
64-1).
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Clinical Manifestations
• Positive Brudzinski’s sign: When the patient’s neck is flexed (after
ruling out cervical trauma or injury), flexion of the knees and hips
is produced; when the lower extremity of one side is passively
flexed, a similar movement is seen in the opposite extremity (see
Fig. 64-1).
• Brudzinski’s sign is a more sensitive indicator of meningeal
irritation than Kernig’s sign.
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Clinical Manifestations
• A rash can be a striking feature of N. meningitidis infection.
• Skin lesions develop ranging from a petechial rash with
purpuric lesions to large areas of ecchymosis.
• Disorientation and memory impairment are common early in
the course of the illness.
• As the illness progresses, lethargy, unresponsiveness, and
coma may develop.
• Seizures .
• ICP increases secondary to diffuse brain swelling or
hydrocephalus,
• The initial signs of increased ICP include decreased level of
consciousness and focal motor deficits.
• If ICP is not controlled, Brain stem herniation is a lifethreatening event that causes cranial nerve dysfunction and
depresses the centers of vital functions, such as the medulla.
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Assessment and Diagnostic Findings
• A computed tomography (CT) scan or magnetic
resonance imaging (MRI) scan is used to detect a
shift in brain contents (which may lead to
herniation) prior to a lumbar puncture.
• Bacterial culture and Gram staining of CSF and
blood are key diagnostic tests.
• CSF studies demonstrate low glucose, high protein
levels, and high white blood cell count (Mazzoni, et
al., 2006).
• Gram staining allows for rapid identification of the
causative bacteria and initiation of appropriate
antibiotic therapy (van de Beek, et al., 2006).
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Prevention
• the meningococcal conjugated vaccine be given to adolescents entering
high school and to college freshmen living in dormitories.
• education addressing meningococcal meningitis and the availability of
vaccination so that families can make informed decisions.
• People in close contact with patients with meningococcal meningitis
should be treated with antimicrobial chemoprophylaxis using rifampin
(Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium
(Rocephin).
• Therapy should be started within 24 hours after exposure because a
delay in the initiation of therapy limits the effectiveness of the
prophylaxis.
• Vaccination should also be considered as an adjunct to antibiotic
chemoprophylaxis for anyone living with a person who develops
meningococcal infection.
• Vaccination against H. influenzae and S. pneumoniae should be
encouraged for children and at-risk adults.
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Medical Management
• early administration of an antibiotic that crosses the blood–
brain barrier into the subarachnoid space in sufficient
concentration to halt the multiplication of bacteria.
• Vancomycin hydrochloride in combination with one of the
cephalosporins (eg, ceftriaxone sodium, cefotaxime sodium) is
administered intravenously (IV) (van de Beek, et al., 2006).
• Dexamethasone (Decadron) has been shown to be beneficial
as adjunct therapy in the treatment of acute bacterial
meningitis and in pneumococcal meningitis if it is administered
15 to 20 minutes before the first dose of antibiotic and every 6
hours for the next 4 days.
• Dehydration and shock are treated with fluid volume
expanders.
• Seizures, which may occur early in the course of the disease,
are controlled with phenytoin (Dilantin).
• Increased ICP is treated as necessary.
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Nursing Management
• The patient’s safety and well-being depend on sound nursing
judgment.
• Neurologic status and vital signs are continually assessed.
• Pulse oximetry and arterial blood gas values are used to
quickly identify the need for respiratory support if increasing
ICP compromises the brain stem.
• Insertion of a cuffed endotracheal tube (or tracheotomy) and
mechanical ventilation may be necessary to maintain
adequate tissue oxygenation.
• Blood pressure (usually monitored using an arterial line) is
assessed for incipient shock, which precedes cardiac or
respiratory failure.
• Rapid IV fluid replacement may be prescribed, but care is
taken to prevent fluid overload.
• measures are taken to reduce body temperature as quickly as
possible.
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Nursing Management
• Protecting the patient from injury secondary to
seizure activity or altered LOC
• Monitoring daily body weight; serum electrolytes;
and urine volume, specific gravity, and osmolality,
especially if syndrome of inappropriate antidiuretic
hormone (SIADH) is suspected
• Preventing complications associated with
immobility, such as pressure ulcers and pneumonia
• Instituting infection control precautions until 24
hours after initiation of antibiotic therapy (oral and
nasal discharge is considered infectious)
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Nursing Management
• Because the patient’s condition is often critical and
the prognosis guarded, the family needs to be
informed about the patient’s condition.
• Periodic family visits are essential to facilitate
coping of the patient and family.
• An important aspect of the nurse’s role is to support
the family and assist them in identifying others who
can be supportive to them during the crisis.
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CRITICAL THINKING EXERCISES
• A 19-year-old college student is admitted with
suspected meningitis6.
• Identify two assessment parameters that indicate
meningitis?
• What interventions would be included in your plan
of care to protect the patient from injury?
• The patient’s family has many questions about the
disease and their risk of contracting meningitis.
Develop a teaching plan that would describe
meningitis and prophylactic therapy for the
patient’s family and close contacts.
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