Chapter 28: Meningitis (Children)

Question 1

Meningitis

Answer 1

inflammation of the structures in the central nervous system (CNS) caused by an infectious process

• can develop at anytime during childhood
• can be septic or aseptic

Question 2

The meninges

Answer 2

composed of three membranes that cover the brain and protect it from injury and infection: the dura mater, arachnoid mater, and the pia mater
>these structures house arterioles, venules, and cerebrospinal fluid that protects, bathes, and provides chemical functional support for the brain and its contents

Question 3

Septic Meningitis is Caused by?

Answer 3

a bacterial pathogen
-streptococcus pneumoniae, Neisseria meningitidis, Escherichia coli, or Haemophilus influenzae type B
-is a result of bacterial dissemination from a nasopharyngeal or a hematological inoculation
>the pathogen migrates into the cerebrospinal fluid and imbeds in the subarachnoid space; the body reacts to the infiltration with a severe inflammatory response and white blood cell proliferation (rapid increase in numbers)
-systemic septicemia, surgical procedures involving the CNS, a penetrating wound, otitis media, sinusitis, cellulitis of the scalp or facial structure, dental caries, pharyngitis, and orthopedic diseases and procedures are antecedent events leading to bacterial meningitis
-in CSF analysis, increased in CSF protein, and decrease in glucose; pressure may be increased and cloudy

Question 4

Aseptic Meningitis is caused by?

Answer 4

a known or unknown viral agent typically presenting at peak seasonal viral illness intervals in the fall and winter

Question 5

Cerebral Spinal Fluid Analysis

Answer 5

a lumbar puncture is performed to collect cerebrospinal fluid (CSF)

• normal CSF is clear and colorless
• in infections, pressure may be increased, and appear cloudy
• increases in CSF protein and decreases in glucose are seen in bacterial meningitis

Question 6

Signs and Symptoms

Answer 6

may initially appear mildly ill with general vague or subtle signs:

• fever
• headache
• stiff neck
• lethargy and/or irritability
• nausea and/or vomiting

Question 7

Diagnosis

Answer 7

• review of current illness with specific information regarding duration of symptoms, ill contacts in the family or school setting, seizures, loss of sleep or weight, anorexia, emesis, behavioral changes, and immunization status
• complete blood count (CBC) reveals elevated WBC count and any clotting deficiencies
• a disseminated intravascular coagulation panel is collected to rule out a coagulation disorder when the child presents with petechial hemorrhage, shock, and meningococcemia
• blood cultures obtained to identify potential hematological origin
• lumbar puncture performed for CSF analysis
• chemistry and cell counts
• gram stain for bacterial or viral diagnosis

Question 8

Meningitis diagnosis is primarily based on what?

Answer 8

results of the lumbar puncture

Question 9

Classic Findings on examination for a child suspected with Meningitis?

Answer 9

-positive Kernig’s sign
-Brudzinski’s sign
>these exams indicate meningeal irritation resulting in hyperreactive reflexes

Question 10

Kernig’s Sign

Answer 10

-conducted with the child lying supine with the hips flexed
-as the nurse straightens the leg, the child either cries out or resists the leg extension
-if the child experiences pain behind the knee as the knee is fully extended, this is an abnormal finding
>bilateral increased resistance and pain on extension of the knee is a positive Kernig’s sign and may indicate meningeal irritation

Question 11

Brudzinski’s Sign

Answer 11

-is conducted with the child lying flat
-the nurse attempts to raise the head toward the child’s chest and place the chin on the chest; if there is pain or resistance, the child immediately flexes the hip and knee
>if the child exhibits flexion of the hips and knees when the nurse performs the maneuver, meningeal inflammation may be present

Question 12

Prevention

Answer 12

-the pneumococcal conjugate vaccine is a routine childhood immunization that is effective at preventing pneumococcal meningitis
>recommendations for the meningococcal vaccination include children age 2 and older with immunodeficiency and those under 21 who have not been vaccinated

Question 13

Nursing Care

Answer 13

• assessing neurological status every 2 to 4 hours
• LOC, use of a pediatric Glasgow Coma Scale, pupil response, and overall activity provides clues to neurological status (e.g. increase in intracranial pressure [ICP] or response to antibiotic or fluid therapy)
• droplet precautions

Question 14

How to monitor ICP in small infants

Answer 14

subjectively monitored by palpating the anterior fontanelle while the patient is lying supine
>if the fontanelle is tense and bulging, this may suggest increased ICP, particularly combined with photophobia, irritability, a high-pitched cry, anorexia, and emesis
>infants with open fontanelles and an enlarging head circumference during post meningitis infection may indicate hydrocephalus and must be monitored
-to prevent additional increased ICP, the child’s room is kept quiet, dim, and without loud or noxious visual, auditory, or olfactory stimuli

Question 15

What to do with the child with an increasing head size and symptoms of increased ICP?

Answer 15

requires radiological evaluation: CT or MRI

Question 16

How to Prevent additional increased ICP?

Answer 16

the child’s room is kept quiet, dim, and without loud noxious visual, auditory, or olfactory stimuli

Question 17

Medical Care

Answer 17

• the onset of seizure activity associated with meningitis is managed medically; seizure precautions are maintained
• child with meningitis may develop new onset seizures and is treated with anti-convulsant therapy
• child is kept NPO until nausea and vomiting has been resolved
• comfort care: dim room, antipyretic therapy for fever management, nutrition as tolerated, and emotional and social support
• care for malaise: massage, NSAIDs, warm baths, and rest
• treatment varies on viral or bacterial; viral treatment is supportive; bacterial treatment with IV antibiotics
• household members and others who have come in contact with someone diagnosed with meningococcal meningitis are advised to take antibiotics to prevent becoming infected

Question 18

Surgical Care

Answer 18

usually delayed in a child with acute brain infection unless ICP and cerebral edema is compromising outcomes

Question 19

Education/ Discharge

Answer 19

• educate family and child about the disease, preventing injury, and early detection of complications
• explain long-term parenteral access is maintained with a peripherally inserted central catheter (PICC), and IV antibiotics can be continued at home with assistance of a home health nurse