Ch. 36 Meningitis

Question 1

Meningitis

Answer 1

inflammation of meninges, thin covering around the brain and spinal cord

Question 2

Risk factors

Answer 2

• Living in close proximity
• College dormitories
• Military barracks
• Prisons
• Poor countries not vaccinated against mumps
• Very old or very young

Question 3

Acute meningitis

Answer 3

indicates bacterial cause

Question 4

CSF pleocytosis

Answer 4

markedly increased WBCs with acute meningitis

Question 5

What happens with CSF with meningitis?

Answer 5

increased turbidity of CSF, leading to sluggish flow which can lead to increased ICP leading to herniation

Question 6

Viral meningitis

Answer 6

aseptic form, most commonly caused by enterovirus, HSV, herpes zoster, mumps, and measles

Question 7

Clinical Manifestations

Answer 7

Fever
Headache
Altered mental status
Photophobia
Chills
Nausea
Vomiting
Nuchal rigidity 
Opisthotonos 
Faint petechial rash which can develop into DIC
Rhinorrhea

Question 8

Opisthotonos

Answer 8

severe hyperextension of the head with arching of the back

Question 9

What type of precaution should pt be placed on?

Answer 9

Seizure

Question 10

Diagnosis and what is special about one of them

Answer 10

• Lumbar puncture
• Head CT - for those with new onset of seizures and ALOC require head CT before lumbar puncture b/c higher risk of herniation

Question 11

What is recorded during lumbar puncture and what is tested?

Answer 11

• Opening pressure at time of the puncture is recorded

- Test for glucose, protein, WBC, gram stain, and culture

Question 12

What is special about lumbar puncture and pts with DM?

Answer 12

may have higher serum glucose so serum glucose is drawn at time of puncture

Question 13

That is the rule of thumb for CSF glucose level?

Answer 13

2/3 that of serum glucose

Question 14

Bacterial meningitis levels of:

• Glucose
• Protein
• WBC
• Microbiology

Answer 14

• Glucose: <40
• Protein: higher than 100
• WBC: 100-500
• Microbiology: Gram +

Question 15

Viral meningitis levels of:

• Glucose
• Protein
• WBC
• Microbiology

Answer 15

• Glucose: Normal
• Protein: Normal to slightly H
• WBC: 10-300
• Microbiology: viral isolation

Question 16

Medication TX of meningitis

Answer 16

• before confirmation from microbiological data, broad spectrum ABX are given
• 14-21 days of ABX
• Long term IV access due to long term ABX therapy

Question 17

Complications of meningitis

-and what med can be used?

Answer 17

Increase ICP

• Use dexamethasone
• Also at risk for DI and SIADH

Question 18

Brudzinski Sign

Answer 18

involuntary flexion of the hips in response to passive flexion of the neck with the patient in a supine position

Question 19

Kernigs Sign

Answer 19

pain in the back of the leg [hamstring] and resistance to movement when the leg is flexed at the hip and then straightened at the knee

Question 20

Nursing Diagnosis

Answer 20

Disturbed sensory perception related to meningeal irritation
• Activity intolerance related to pain and fatigue
• Ineffective coping related to the complexity of the treatment regimen to manage meningitis

Question 21

Nursing assessment: Neuro Status

Answer 21

Because of the risk of increased ICP secondary to increased turbidity of CSF, frequent neurological assessments are essential to recognize subtle signs. Changes in level of consciousness are the earliest sign of increased ICP and should be reported immediately to the healthcare provider.

Question 22

Nursing Assessment: Sign of meningeal irritation

Answer 22

The inflammatory process in the meninges causes pain upon movement of the neck, and the patient guards the neck. In the patient with a positive Brudzinski’s sign, there is involuntary flexion of the hips in response to passive flexion of the neck with the patient in a supine position (ensure no cervical spine injury prior to attempting). To assess the Kernig’s sign, the nurse starts with the patient’s hip and knee flexed at a 90-degree angle and then slowly extends (do not force) the knee. Pain behind the knee and repeated pain bilaterally are indicative of a positive sign.

Question 23

Nursing assessment: VS

Answer 23

Elevated temperature develops secondary to the infectious process. If increased ICP develops, the blood pressure increases with widening pulse pressure and decrease in heart rate.

Question 24

Nursing assessment: Fluid balance

Answer 24

Monitor blood pressure for signs of hypo/hypertension and heart rate. If the patient develops SIADH, fluid is retained and there may be an increase in blood pressure. With DI the patient has an increased output of dilute urine and is at risk for hypovolemia, hypotension, and tachycardia.

Question 25

Nursing assessment: Headache

Answer 25

The inflammation of the meninges may lead to headache.

Question 26

Nursing assessment: Cranial nerve

Answer 26

with particular attention to CNs 3, 4, and 6 The eye on the affected side can deviate down and out because of a dilated, light-fixed pupil.

Question 27

Nursing assessment: CSF result

Answer 27

Treatment of meningitis, particularly bacterial infections, is directed to the specific organism that is isolated in the CSF sample.

Question 28

Nursing assessment: daily weight

Answer 28

Changes in fluid volume status correspond to changes in body weight

Question 29

Nursing assessment: Renal function

Answer 29

Many antibiotics are cleared by the kidneys, so increases in blood urea nitrogen and creatinine may demonstrate damage to the renal system.

Question 30

Nursing assessment: Vascular assessment

Answer 30

In the patient who develops DIC, there may be increased bleeding as well as decreased peripheral perfusion.

Question 31

Nursing actions

Answer 31

• Administer IV fluids The patient may have changes in fluid volume status related to increased fluid loss with elevated temperature or development of diabetes insipidus.
• Administer antibiotics as ordered Antibiotics should be initiated without delay, and antibiotics that require therapeutic dosing should be monitored judiciously to facilitate their therapeutic goals.
• Decrease environmental stimuli Dim the lights, exposure to bright lights from windows (patients may be photo sensitive); and provide quiet environment as these may exacerbate associated with meningitis.
• Maintain head of bed elevated to 30 degrees This position increases venous outflow and may decrease intracranial pressure that may be elevated due to turbidity of the CSF.
• Pain management Because of associated headache, it is important to implement pharmacological and nonpharmacological interventions to promote patient comfort.
• Implement transmission precautions Standard precautions are maintained for all patients. Include droplet precautions (bacterial meningitis per hospital policy). • Maintain normothermia via antipyretic, cooling baths, and cooling blankets Decreases metabolic activity and decreases CNS oxygen demand

Question 32

Pt teaching

Answer 32

• Importance of follow-up appointments Recovery from meningitis may take weeks to months and requires frequent assessment and evaluation by the healthcare provider.
• Importance of taking full course of antibiotics Extended antibiotic therapy may be indicated to lessen the chances of reoccurrence of the infectious process.

Question 33

Nursing Management – Evaluating care outcomes

Answer 33

• Neurologically stable – no signs of pain or stiff neck
• Hemodynamically stable – good BP, HR, blood sugar normal
• Knowledgeable of signs of recurrent infection – S/S of when they actually had it; may not remember the s/s b/c of how late they came to the hospital
• Compliance of antibiotic therapy