MENINGITIS

DEFINITION

Meningitis is the inflammation of the piamater,the arachnoid and the cerebrospinal fluid filled subarachnoid space. Meningitis is classified as septic or aseptic. Septic meningitis is caused by bacteria. Aseptic meningitis is caused by virus or secondary to lymphoma,leukemia or human immune deficiency virus(HIV)
 

CAUSATIVE ORGANISMS

The most common cause of septic meningitis is Streptococcus pneumonia and Neisseria meningitides.Hemophilus influenza was once considered as the common cause of infection in children.

RISK FACTORS

The risk factors includes increased use of tobacco,viral upper respiratory tract infection,ottitis media.Mastoiditis increases the risk of bacterial meningitidis.People with immune system disorders are also at greater risk for bacterial meningitidis.

PATHOPHYSIOLOGY

  • Meningeal infections generally orginates in one of the two ways,through the blood stream as a consequence of other infections,or by direct spread ie..after a traumatic injury to the facial bone or secondary to invasive procedures.
  • Neisseria Meningitidis concentrates in the nasopharynx and is transmitted by secretion or aerosol contamination.Bacterial or Meningococcal Meningitis also occurs as an opportunistic infectionin patients with AIDS and also as a complication of AIDS.

FLOW CHART REPRESENTATION

1. Due to the etiological factors.
2. Meningeal irritations occurs through the blood stream as a consequence of other infections or by direct method ie by traumatic injury to the facial bone or secondary to invasive procedures.
3. Once the organism enters the blood stream, it crosses the blood brain barrier and proliferates the CSF.
4. The host immune response stimulates the release of cell wall fragments and lipopolysacchrides.
5. Stimulates the release of cell wall fragments and lipo polysaccharides.
6. The cranial vault contains little room for expansion,the inflammation will cause increased ICP.
7. CSF circulates through the subarachnoid space where infected cellular material from the affected meningeal tissue enters and accumulates
8. Meningitis occurs and CSF studies demonstrates decreased glucose,increased protein levels and increased white blood cell count.

PROGNOSIS

The prognosis of the bacterial meningitis depends on the causative organism,the severity of infection and illness and and the timeliness of the treatment.Acute fulminant presentation may include adrenal damage,circulatory collapse and widespread haemorrhages.This syndrome is the result of endothelial damage and vascular necrosis caused by bacteria.

COMPLICATIONS

Visual impairment,deafness,seizures,paralysis,hydrocephalus and septic shock.

CLINICAL MANIFESTATIONS

  • Throbbing headache as a result of meningeal irritation
  • Fever
  • Nuchal rigidity-This is an early sign,any attempt at the flexion of the head is difficult because of the spasms of the muscles of the neck.Forceful flexion causes severe pain.
 
  • Positive Kernigs sign-When the patient is lying with the thigh flexed on the abdomen,the leg cannot be completely extended.
 
  • Positive Brudzinski S sign-When the patient s neck is flexed(after ruling out cervical trauma or injury),flexion of the knees and the hips is produced,when the lower extremity of one side is passively flexed,a similar movement is seen in the opposite extremity.Brudzinski s sign is a more sensitive indicator of meningeal irritation than Kernig s sign.
  • Photophobia(extreme sensitivity to light)
  • Skin rashes are common in N Meningitidis infection.Skin lesions ranges from petechial rash with purpuric rash with purpuric lesions to large areas of ecchymosis.
  • Disorientation and memory impairment,as disease progresses lethargy,unresponsiveness and coma.
  • Seizures in adults withS pneumonia meningitis as a result of irritation in the brain.
  • ICP increases resulting in decreased level of consciousness and focal motor deficits If ICP is not controlled the uncus of the temporal lobe may herniated through the tentorium,causing pressure on the brain stem.Brain stem herniation is a life threatening complication that causes cranial nerve dysfunction and depresses the centres of vital function such as medulla.
  • Septicemia,high grade fever and extensive purpuric lesions(over the face and extremities)Shock
  • Signs and symptoms of disseminated intravascular coagulopathy

ASSESSMENT AND DIAGNOSTIC FINDINGS

  • History collection and Physical examination
 
  • Bacterial culture and Gram staining of the CSF and blood(The presence of polysaccharide antigen in the CSF confirms the diagnosis of bacterial meningitis)

PREVENTION

  • Vaccination against meningitis.
  • People in contact with the patient should be treated with antimicrobial chemoprophylaxis using Rifampin(Rifadin),Ciprofloxacin Hydrochloride(Cipro) or Cefriaxone sodium(Rocepin)Treatment should be initiated within 24 hours of the exposure because delay in the initiation can result in the limitation in the effectiveness of the prophylaxis.
  • Vaccination against H influenza and S pneumonia should be encouraged in children and in high risk adults.

MEDICAL MANAGEMENT

  • Pencillin antibiotics(eg:ampicillin,piperacillin)or one of the cephalosporin(eg:cefriaxone sodium,cefotaxime sodium)is used vancomycin hydrochloride alone or a combination with Rifampicin is used.
  • High doses of appropriate antibiotics are given.
  • Dexamethasone for the treatment of acute bacterial meningitis and in Pneumococcal meningitis if it is given 15-20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days
  • Dehydration and shock is treated with fluid volume expanders
  • Seizures is controlled with Phenytoin(Dilantin)
  • Increased ICP should be treated.

NURSING MANAGEMENT

  • Patient will be acutely ill so most of the treatment measures are collaborative with the physician,respiratory therapist and other members of the health care team.
  • Neurological status and vital signs are continuously assessed.
  • Pulse oxymetry and ABG is analyzed
  • Insertion of an endotracheal tube and mechanical ventilation to maintain adequate tissue oxygenation.
  • Arterial blood pressures are monitored to assess for shock which precedes cardiac and respiratory failure.
  • Fluid replacement is needed but care must be taken to prevent fluid overload.
  • Protect the patients from injury secondary to seizure activity or altered level of consciousness.
  • Monitoring daily body weight,serum electrolytes and urine volume,specific gravity and osmilality especially if syndrome of inappropriate diuretic hormone is suspected.
  • Preventing complications of immobility such as pressure ulcers and pneumonia.
  • Infection control precautions within 24 hours after the initiation of the antibiotics

NURSING DIAGNOSIS

Acute pain related to headache and muscle and joint aches as manifested by general discomfort of head,joints,and muscles,apathy,grimacing and movement.
  • Administer mild analgesics as prescribed, assist patient to position of comfort in the bed to relieve pain.
  • Encourage gentle motion and leg exercises to reduce joint stiffness and to reduce joint stiffness and to promote circulation.
  • Massage muscles as needed or requested to promote comfort and to show a caring attitude
  • Control environment to encourage rest because pain can be exhausting to the patient
 
Hyperthermia related to infection and abnormal temperature regulation by hypothalamus from increased ICP as manifested by increased temperature and chills.
  • Assess the temperature of the client
  • Carryout general measures to control fever
  • If prescribed a hypothermia blanket to reduce the fever because an elevated temperature increases brain metabolism and increases the risk of seizures or increased ICP
  • Reduce temperature to prevent shivering. Which can cause a rebound effect and arise rather than lower the effect.
Decreased sensory perception related to decreased LOC as manifested by inaccurate interpretation of environment,signs of fear and anxiety ,disorientation and restlessness.
  • Assess the LOC to determine extent of the problem
  • Administer sedative medications as ordered to reduce fear and anxiety
  • Keep room quiet and lights dim,use calm,reassuring approach to avoid stimulating or frightening the patient.
  • Assist and support patient during uncomfortable or frightening diagnostic procedures
 
Ineffective therapeutic regimen related to possible sequalae of condition as manifested by motor or sensory problems and activity limitation
  • Monitor for residual effects of the conditions such as vision,hearing activity and cognitive problems to determine appropriate referrals
  • Inform patient and others that residual problems often improve overtime to reduce anxiety.
  • Arrange for postoperative care if required so that patient needs are met.
Potential complications. Seizure activity related to cerebral irritation.
  • Monitor for seizure activity so that interventions can be started immediately
  • Keep the side rails up and padded up to protect if a seizure activity occurs
  • Administer sedatives and antiseizure drugs if ordered by the physician
  • Reduce fever to decrease brain s oxygen demand
  • Carry out interventions to treat underlying causes of inflammatory brain condition to prevent seizure activity

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