Unit 1: Meningitis Flashcards
Meningitis
an inflammation of the meninges, the thin covering around the brain and spinal cord
- acute or chronic
- increased in settings where people live in close proximity (college dormitories, military barracks, and prisons)
Causes of Meningitis
- bacterial infection
- viral infection
- fungal infection
- aseptic meningitis
- secondary to traumatic injury or transmission of organisms during surgery or from invasive procedures or device
- can be caused by pericarditis (inflammation of the pericardium in the heart) and myocarditis (inflammation of heart muscle); assessment of heart murmurs and echocardiograms help r/o these causes
- other causes: infection from a cochlear implant, conjunctivitis, and exposure to animals and animal bites
Acute Meningitis
- bacterial cause
- clinical manifestations occurring in hours to days
- CSF pleocytosis (increased WBC in CSF)
- the inflammatory process within the meninges leads to increased turbidity of CSF; sluggish flow of CSF; lead to increased ICP
- acute = medical emergency
- bacterial more severe than viral
Chronic Meningitis
- onset of symptoms during weeks to months
- duration of symptoms longer than 4 weeks
Causes of Bacterial Infection
- d/t local infection from the skin, upper respiratory infection, or from GI/GU tracts
- occur secondary to traumatic injury or transmission of organisms during surgery, or from an invasive procedure or device
- can be caused by pericarditis and myocarditis; assessment of heart murmurs and echocardiograms help r/o these causes
Causes of Viral Infection
-herpes simplex virus, herpes zoster, mumps, and measles
Why is Meningitis a medical Emergency?
b/c the increased turbidity and sluggish flow of CSF can lead to increased ICP
-while ICP increases, herniation of the brain can occur b/c of displacement of brain tissue, CSF, and compression of blood vessels, culminating in severe brain damage, coma, and death
Viral Meningitis
- self-limiting form
- causes cell necrosis or results in enzymatic or neurotransmitter alterations depending on pathogen and cells involved
Clinical Manifestations of Meningitis
- fever (infections)
- headache
- altered mental status
- photophobia (light sensitivity)
- chills
- nausea
- vomiting
- nuchal rigidity and opisthodomos d/t meningeal irritation
- Brudzinski’s and Kernig’s sign
nuchal rigidity
neck stiffness
opisthodomos
severe hyperextension of the head w/ arching of the back
Clinical Manifestations of Meningeal Irritataion
- Nuchal rigidity (neck stiffness)
- Opisthodomos (severe hyperextension of the head w/ arching of the back)
Presentation of meningococcal meningitis
-faint petechial rash can develop; which can develop into disseminated intravascular coagulation (DIC)
Brudzinski’s Sign
as the neck is fixed, there is stretch on the inflamed meninges and the knees flex involuntarily to decreased the pain caused by the stretching of the meninges
Kernig’s Sign
as the hip and knee are flexed and then straightened, there is pain in the hamstring secondary to scratching of the inflamed meninges
What is the Hallmark of Diagnosis Meningitis?
examination of CSF via lumbar puncture
Lumbar Puncture
the opening pressure at the time of the lumbar puncture is recorded, and specimens are tested for glucose, protein, WBC, gram stain and culture
-suspicion for space-occupying lesions, new onset seizures and those w/ moderate to severe altered LOC require CT of the head before the procedure b/c they are at higher risk for herniation
What the examination of Lumbar Puncture (CSF) results look like
- decreased glucose (bacteria thriving; eats sugar up)
- increased protein
- increased WBC
- a gram stain and culture is done to identify the organism
Normal Cerebrospinal Fluid Exam
- Glucose: 50-75 mg/dl
- Protein: 14-40 mg/dl
- WBC: 0-5; lymphocytes
- Microbiology: negative
Bacterial Meningitis Cerebrospinal Fluid Exam
- Glucose: less than 40 mg/dl
- Protein: higher than 100 mg/dl
- WBC: 100-500 w/ more than 80% polymorphonuclear (PMN) lymphocytes
- Microbiology: gram stain and cultures (+) for specific pathogen
Medical Management of Meningitis
- Lumbar Puncture (LP)
- CT of the Head (before LP; risk for herniation)
- 14 to 21 days of antibiotic treatment (bacterial meningitis)
Medications
on basis of initial assessment and presumptive diagnosis, and before confirmation from microbiological data, Broad-spectrum antibiotics are initiated
- tx requires 14 to 21 days of antibiotics
- long-term IV access (peripherally inserted central line [PICC] or other central venous access) initiated b/c of need for long-term antibiotics
Complications of Meningitis
- Increased ICP
- Reduction of hearing loss (caused by H influenzae)
- Seizure activity
- Risk for syndrome of antidiuretic hormone (SIADH) and Diabetes Insipidus (DI)
Complication of Meningitis: Increased ICP
- life-threatening
- early signs are identified during neurological exam; requiring frequent assessments
Nursing Management: Assessment + Analysis
clinical manifestations are r/t irritation and inflammation of the meninges that surround the brain and spinal cord -Change in LOC -Fever -Headache -Photophobia -Nausea/Vomiting -Rhinorrhea (runny nose) -Nuchal Rigidity -Brudzinski's Sign -Kernig's Sign >Neurological exam = most significant nursing intervention in the care of a patient w/ meningitis
Nursing Diagnoses
- Disturbed sensory perception r/t meningeal irritation
- Activity intolerance r/t pain and fatigue
- Ineffective Coping r/t the complexity of the treatment regimen to manage meningitis
Nursing Assessments
- Neurological Assessment: Look for S/S of meningeal irritation (nuchal rigidity, opisthodomos, Brudzinski’s sign, Kernig’s sign)
- Vital Signs
- Fluid Balance
- Headache
- Cranial Nerve Assessment (CN III, CN IV, and CN VI)
- CSF results
- Daily Weight
- Renal Function
- Vascular Assessment
Assessments: Neurological Assessment
b/c of the risk of increased ICP secondary to increased turbidity of CSF
- essential to recognize subtle signs
- changes in LOC is earliest sign of increased ICP; be reported immediately
- also Look for S/S of meningeal irritation (nuchal rigidity, opisthodomos, Brudzinski’s sign, Kernig’s sign)
Assessment: Vital Signs
- elevated temperature develops secondary to the infectious process
- if increased ICP develops, the blood pressure increased w/ widening pulse pressure and decrease in HR
Assessment: Fluid volume
- monitor blood pressure for signs of hypo/hypertension and HR
- if develops SIADH, fluid is retained and there may be an increased in BP
- W/ diabetes insipidus (DI), the patient has an increased output of dilute urine and is at risk for hypovolemia, hypotension, and tachycardia
Assessments: Headache
inflammation of meninges may lead to headache
Assessment: Cranial Nerve Assessment (CN III, CN IV, CN VI)
the eye on the affected side can deviate down and out b/c of a dilated, light-fixed pupil
CN III, IV, and VI
- CN III (Oculomotor): pupillary constriction
- CN IV (Trochlear): eyes look down toward nose
- CN VI: (Abducens) eyes move to the sides; look toward ears
Cerebrospinal Fluid (CSF) Results
-treatment of meningitis (bacterial) is directed to the specific organism that is isolated on the CSF sample
Assessment: Daily Weight
changes in fluid volume status correspond to changes in body weight
Assessment: Renal Function
many antibiotics are cleared by the kidneys
-increases of BUN and Creatinine may demonstrate damage to the renal system
Assessment: Vascular Assessment
in patients who develop DIC, there may be increased bleeding; decreased peripheral perfusion
-may see rash on patient; petechiae
Nursing Actions
- Administer IV fluids
- Administer Antibiotics as ordered
- Decrease Environmental Stimuli
- Maintain HOB elevated to 30 degrees
- Pain Management
- Transmission Precautions
- Maintain Normothermia
Nursing Actions: Administer IV Fluids
may have change in fluid volume status r/t increased fluid loss w/ elevated temperatures (fever from infection), or development of diabetes insipidus (increased urine output)
Nursing Actions: Administer Antibiotics as ordered
- antibiotics initiated w/o delay
- antibiotics that require therapeutic dosing should be monitored to facilitate their therapeutic goal
Nursing Actions: Diminish Environmental Stimuli
- dim the lights, exposure to bright lights from windows (may be photosensitive)
- quiet environment
Nursing Actions: Maintain HOB elevated to 30 degrees
increases venous outflow and may decrease ICP that may be elevated d/t turbidity of CSF
Nursing Actions: Pain Management
b/c of associated headaches, implement pharmacological and nonpharmacological interventions to promote patient comfort
Nursing Actions: Transmission Precautions
- standard precautions are maintained for all patients
- droplet precautions (bacterial meningitis)
Nursing Actions: Maintain Normothermia
- decreases metabolic activity and decreases CNS oxygen demand
- antipyretics, cooling baths, cooling blankets
Nursing Teachings
- Importance of follow-up appointments
- Importance of taking full course of antibiotics
Importance of follow up appointments
-recovery from meningitis may take weeks to months and requires frequent assessment and evaluation
Importance of taking full course of antibiotics
extended antibiotic therapy may be indicated to lessen the chances of reoccurrence of the infectious process
Evaluating Care Outcomes
- management of meningitis requires eradication of the infectious organism
- during acute phase, pt chief complaints are pain, neck stiffness, and photophobia
- definitive interventions focus on antibiotic therapies and comfort measures
- antipyretics for fever
- monitoring for increased ICP
- at discharge the patient will be neurologically and hemodynamically stable; knowledgeable of signs of recurrent infection and increased ICP to seek emergent treatment; compliance with antibiotic therapy
