Nursing Considerations for Bacterial Meningitis Assess neurologic function often.

Observer level of consciousness (LOC) and signs of increased ICP (plucking at the bedcovers, vomiting, seizures, and a change in motor function and vital signs). Watch for signs for cranial nerve involvement (ptosis, strabismus, and diplopia). Be especially alert for a temperature increase up to 38. 9o Celsius (102 F), deteriorating LOC, onsent of seizures, and altered respirations, all of which may signal an impending crisis. Monitor fluid balance. Maintain adequate fluid intake to avoid dehydration, but avoid fluid overload because of the danger of cerebral edema. Measure central venous pressure and intake and output accurately. Watch for adverse effects of I.V. antibiotics and other drugs. To avoid infiltration and phlebitis, check I.V. site often and change the sites according to hospital policy. Position the patient carefully to prevent joint stiffness and neck pain. Turn him often, according to planned positioning schedule. Assist with range-of-motion exercises. Maintain adequate nutrition and elimination. It may be necessary to provide small, frequent meals or to supplement meals with nasogastric tube or parenteral feedings. To prevent constipation and minimize the risk of increased ICP resulting from straining at stool, give the patient a mild laxative or stool softener. Ensure the patients comfort. Provide mouth care regularly. Maintain a quiet environment. Darkening the room may de crease photophobia. Relieve headache with a nonopioid analgesic, such as aspirin or acetaminophen as ordered. Provide reassurance and support. The patient may be frightened by his illness and frequent lumbar punctures. If hes deliberious or confused, attempt to reori ent him often. Reassure his family that the delirium and behavior changes caused by meningitis usually disappear. However, fi a severe neurologic deficit appears permanent; refer the patient o a rehabilitation program as soon as the acute phase of this illness has passed. To help prevent development of meningitis, teach patients with chronic sinusitis or other chronic infections and the importance of proper medical treatment. Follow strict sterile technique when treating patients with head wounds or skull fractures. Prevention: Give haemophilus influenza type B and pneumococcal vaccins to children. Give meningocococcal vaccine to college students. Give prophylactic antibiotics to those who have been exposed to a patient with meningitis. Meningitis can also be caused by the direct spread of a nearby severe infection, such as an ear infection (otitis media) or a nasal sinus infection (sinusitis). An infection can also occur any time following direct trauma to the head or after any type of head surgery. Usually, the infections that cause the most problems are due to bacterial infections. Bacterial meningitis can be caused by many different types of bacteria. Certain age groups are predisposed to infections of specific types of bacteria. o Immediately after birth, bacteria called group B Streptococcus, Escherichia coli, and Listeria species are the most common. o After approximately 1 month of age, bacteria called Streptococcus pneumoniae, Haemophilus influenzae type B (Hib), and Neisseria meningitidis are more frequent. The widespread use of the Hib vaccine as a routine childhood immunization has dramatically decreased the frequency of meningitis caused by Hib. Meningitis in Children Symptoms and Signs In infants, the signs and symptoms of meningitis are not always obvious due to the infant's inability to communicate symptoms. Therefore, caregivers (parents, relatives, guardians) must pay very close attention to the infant's overall condition. The following is a list of possible symptoms seen in infants or children with bacterial meningitis (bacterial meningitis at any age is considered a medical emergency): Classic or common symptoms of meningitis in infants younger than 3 months of age may include some of the following: o Decreased liquid intake o Vomiting o Rash o Stiff neck o Increased irritability o Increased lethargy o Fever o Bulging fontanelle (soft spot on the top of the head) o Seizure activity Classic symptoms in children older than 1 year of age are as follows: o Nausea and vomiting o Headache o Increased sensitivity to light o Fever o Altered mental status (seems confused or odd) o Lethargy o Seizure activity o Neck stiffness or neck pain o Knees automatically brought up toward the body when the neck is bent forward or pain in the legs when bent (called Brudzinski sign) o Inability to straighten the lower legs after the hips have already been flexed 90 degrees (called Kernig sign) o Rash Symptoms of viral meningitis most commonly resemble those of the flu (fever, muscle aches, cough, headache but some may have one or more of the symptoms listed above for bacterial meningitis), but the symptoms are usually considerably milder. Exams and Tests Upon arrival at the emergency department, the child's temperature, blood pressure, respiratory rate, pulse, and oxygen in the blood may be checked. After quickly checking the child's airway, breathing, and circulation, the doctor completely examines the child to look for a focal source of infection, to assess any alteration in mental status, and to determine the presence of meningitis. If meningitis is suspected, several tests and procedures are needed to determine the diagnosis. In some children, the diagnosis of fifth disease (fever, cold symptoms, followed by a rash especially on the face) or other viral infection is deemed most likely and the child will usually not need the following tests: A spinal tap, or lumbar puncture, is an essential procedure in which cerebrospinal fluid is obtained from the child and then analyzed in a laboratory. Cerebrospinal fluid is the fluid surrounding the brain and spinal cord where the infection in meningitis occurs. Occasionally, a CT of the brain is done before the spinal tap if other problems are suspected by the doctor (see below); most clinicians will treat the child with antibiotics before the spinal tap if bacterial-caused meningitis is strongly suspected because of the possibility of a rapid decline in condition of the patient. o To perform this simple procedure, the doctor numbs the skin on the child's lower back with a local anesthetic. o A needle is then inserted into the lower back to obtain the necessary fluid from inside the spinal cord because the fluid bathing the spinal nerves is essentially the same that bathes the brain.

The fluid is sent to a laboratory and is checked for white and red blood cells, protein, glucose (sugar), and organisms (bacteria, fungus, parasites; viruses are not visualized). The fluid is also sent for culture (cultures may take about a week for viruses). o After the needle is removed, a small bandage is placed on the skin where the needle was inserted. o A spinal tap is not a dangerous procedure for a child. The needle is inserted at a location below the end of the main body of the spinal cord. A spinal tap is a simple procedure that is necessary to determine if a person has meningitis. Currently, no other procedure is available to aid in the diagnosis of meningitis. An IV may be started to obtain blood and to give fluids. This helps prevent dehydration and maintain a good blood pressure. Urine may be obtained to determine if any infection is present in the child's urinary tract system. A chest X-ray film may be taken to look for signs of infection in the child's lungs. A CT scan is sometimes necessary if any of the following is present or suspected: o Trauma o Increased brain pressure o Neurologic problem o Lack of fever o Brain abscess o Tumor Antibiotics may be given early in treatment of meningitis to help fight the infection as quickly as possible. The type of antibiotic depends on the child's age and any known allergies. Antibiotics are not helpful for viral meningitis. Steroids may be given to help minimize inflammation depending on which organism is suspected to be causing the infection Prevention of Meningitis in Children Specific vaccines are available to protect and reduce the chances of developing both the bacterial and viral types of meningitis. The antibacterial vaccines include Hib, meningococcal, and pneumococcal and the antiviral vaccines include influenza, varicella, polio, measles, and mumps. The following two tables show the CDC recommended vaccines for infants and children up to age 18 as of 2011 (most recent available) that include those that protect or reduce the chances for certain bacterial and viral meningitis infections and other infections: Nursing care plan primary nursing diagnosis: Infection related to pathogens in the Cerebrospinal fluid The most critical treatment is the rapid initiation of antibiotic therapy. In addition, assessment and maintenance of airway, breathing, and circulation (ABCs) are essential. Treatment with intubation, mechanical ventilation, and hyperventilation may occur if the patients airway and breathing are threatened. Serial neurological assessments and vital signs not only monitor critical changes in the patient but also monitor the patients response to therapy. Supportive measures such as bedrest and temperature control with antipyretics or hypothermia limit oxygen consumption. Gradual treatment of hyperthermia is required to prevent shivering. Other strategies to manage increased ICP include osmotic diuretics, such as mannitol, or intraventricular CSF drainage and ICP pressure monitoring. Fluids are often restricted if signs of cerebral edema or excessive secretion of antidiuretic hormone are present. If the patient experiences seizures, the physician prescribes anticonvulsant medications. Surgical interventions or CSF drainage may be required to prevent permanent neurological deficits as a result of complications such as hydrocephalus or abscesses. The patient is likely to have a severe headache from increased ICP. Because large doses of narcotic analgesia mask important neurological changes, most physicians prescribe a mild analgesic to decrease discomfort. In children, pain relief decreases crying and fretting, which if left untreated, have the potential to aggravate increased ICP. Rehabilitation begins with the acute phase of the illness but becomes increasingly important as the infection subsides. If residual neurological dysfunction is present as a result of irritation, pressure, or brain and nerve damage, an individualized rehabilitation program with a multidisciplinary team is required. Vision and auditory testing should be done at discharge and at intervals during long-term recovery because early interventions for these deficits are needed to prevent developmental delays. Make sure that the patient has adequate airway, breathing, and circulation. In the acute phase, the primary goals are to preserve neurological function and to provide comfort. The head of the bed should be elevated 30 degrees to relieve ICP. Keep the pati ents neck in good alignment with the rest of the body and avoid hip flexion. Control environmental stimuli such as light and noise, and institute seizure precautions. Soothing conversation and touch and encouraging the familys participation are important; they are particularly calming with children who need the familiar touch and voices of parents. Children are also reassured by the presence of a security object. Institute safety precautions to prevent injury, which may result from either the seizure activity or the confusion that is associated with increasing ICP. Take into account an increase in ICP if restraints are used and the patient fights them. Implement measures to limit the effects of immobility, such as skin care, range-of-motion exercises, and a turning and positioning schedule. Note the effect of position changes on ICP, and space activities as necessary. sleep pattern disturbance risk for ineffective airway clearance This care plan is designed for patients suffering from seizure disorder with a nursing diagnosis of risk for ineffective airway clearance related to neuromuscular impairment; tracheobronchial obstruction; and perceptual/cognitive impairment. Desired Outcome: Maintain effective respiratory pattern with airway patent/aspiration prevented. Nursing intervention with rationale: 1. Encourage patient to empty mouth of dentures/foreign objects if aura occurs and to avoid chewing gum/sucking lozenges if seizures occur without warning. Rationale: Reduces risk of aspiration/foreign bodies lodging in pharynx. 2. Place in lying position, flat surface; turn head to side during seizure activity. Rationale: Promotes drainage of secretions; prevents tongue from obstructing airway. 3. Loosen clothing from neck/chest and abdominal areas. Rationale: Facilitates breathing/chest expansion. 4. Insert plastic airway or soft roll as indicated and only if jaw is relaxed. Rationale: If inserted before jaw is tightened, these devices may prevent biting of tongue and facilitate suctioning/respiratory support if required. Airway adjunct may be indicated after cessation of seizure activity if patient is unconscious and unable to maintain safe position of tongue.

5. Suction as needed. Rationale: Reduces risk of aspiration/asphyxiation. Note: Risk of aspiration is low unless individual has eaten within the last 40 min. 6. Administer supplemental oxygen/bag ventilation as needed postictally. Rationale: May reduce cerebral hypoxia resulting from decreased circulation/oxygenation secondary to vascular spasm during seizure. Note: Artificial ventilation during general seizure activity is of limited or no benefit because it is not possible to move air in/out of lungs during sustained contraction of respiratory musculature. As seizure abates, respiratory function will return unless a secondary problem exists (e.g., foreign body/aspiration). 7. Prepare for/assist with intubation, if indicated. Rationale: Presence of prolonged apnea postictally may require ventilatory support. Nursing DIAGNOSES of Bacterial Meningitis Hyperthermia, related to infection and abnormal temperature regulation by hypothalamus Disturbed thought processes, related to intracranial infection Ineffective protection, related to progression of illness