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INFECTIOUS MENINGITIS:
1) Viral meningitis; - also called aseptic meningitis and the most type in children.
Most cases of viral are relatively mild with symptoms of headache, fever and
general ill feeling and those affected recovers 0without medical treatment and
unusually it can become life threatening. Viral meningitis is not usually associated
with septicemia; antibiotics are ineffective against viruses so treatment is
normally limited to easing the symptoms of the disease.
Many different viruses can cause viral meningitis; the most common causes are;
• Enteroviruses (viruses that can live in the cell lining our intestines, noses, and
throat) account for most cases of viral meningitis.
• Herpes viruses can cause meningitis or encephalitis, herpes meningitis is not
usually serious but it can recur (Belfast, 2011).
2) Bacterial meningitis-: Belfast 2011, explained that meningitis caused by
bacteria are usually more serious than other forms, there are at least- 50 kinds of
bacteria that can cause meningitis septicemia but the main types are;
MODE OF TRANSMISSION
■ Coughing
■ Sneezing
■ Kissing
■ Sharing water bottles, drinking glasses or eating utensils
■ Poor or improper hygiene.
■ It is transmitted through the air via droplets of respiratory secretions from an
infected person. Intimate or direct- close personal contact with an infected
individual within seven days can place an individual at risk of contacting bacterial
meningitis. Bacterial meningitis starts as an infection of the oropharynx and is
followed by meningococcal septicemia which extends to the meninges of the brain
and upper region of the spinal cord.
The meninges are protective coverings of the brain (cranial meninges) and spinal
cord (spinal meninges). They consist of three layers of membranous connective
tissue’
.
The Dura and Arachnoid maters are separated by a potential space, the subdural
space. The Arachnoid and Pia mater are separated by the subarachnoid space
containing cerebrospinal fluid.
THE DURA MATER
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In the spinal area the Dura mater form a loose sheath around the spinal
cord, extending from the foramen magnum to the second sacral vertebrae
thereafter it encloses the filum terminate and fuses j with the peritoneum of the
coccyx.
This is layer of fibrous tissue that lies between the Dura and Pia mater. It is
separated from the Dura mater by the subdural space, and from the Pia mater by
the subarachnoid space containing cerebrospinal fluid. The Arachnoid mater
accompanies the inner layer of the Dura in the formation of falx cerebri, tentorium
cerebella, and falx cerebelli. It continues downwards to end by merging
with Dura mater at the second sacral vertebrae.
THE PIA MATER
This is a delicate layer and the innermost layer of connective tissue containing
many minute blood vessels. It adheres to the brain, continues downward
surrounding the spinal cord. Beyond the cord continues the filum terminale, and
then goes on with the Dura mater to fuse with the periosteum of the coccyx.
• Primarily, they protect the delicate nerve tissue of the brain and spinal cord and
blood vessels to the brain.
• They serve as a shock absorber for the brain and spinal cord.
• They assist in the secretion and absorption of cerebrospinal fluid.
• They contain blood vessels that are responsible for nourishing the brain.
Within the brain, there are four irregular shaped cavities or ventricles
containing cerebrospinal fluid. They are;
Third ventricle,
Fourth ventricle.
The lateral ventricles; these cavities lie within the cerebral hemispheres one on
each side of the median plane just below the corpus callosum, they are lined by
ciliated epithelium. They communicate with the third ventricle by interventricular
foramina or foramen of monro.
Third ventricle; this cavity is situated below the lateral ventricles between the tw o
part of the thalamus; it communicates with the fourth ventricle by a canal, the
cerebral aqueduct or aqueduct of sylvus.
The cerebrospinal fluid is a clear, colourless, bodily fluid that occupies the
subarachnoid space and the ventricular system around and inside the brain and
spinal cord. It acts as a cushion for the cortex providing a protection to the inside
of the skull. It is produced by the choroid plexus.
The cerebrospinal fluid is produced at a rate of 500ml per day since the brain
can contain only 235-150ml; large amounts are drained primarily into the blood
through the Arachnoid villi (midha, 2003).
• Water
• Mineral salts
• Glucose
• Plasma protein
• Creatinine and urea in small amount
• A few electrolytes.
• It acts as a cushion and shock absorber between the brain and the cranial
bones.
• It keeps the brain and the spinal cord moist and permits the interchange of
substances between the cerebrospinal fluid and cells such as nutrients
PATHOPHYSIOLOGY OF MENINGITIS
infecting the brain and spinal cord. Whenever any of the infectious agents (i.e.
bacteria, virus, fungus, parasite) or secondary to other infection such as otitis
media, upper respiratory infection or pneumonia enters the central nervous
system from the nasopharynx and via respiratory tract either through the blood
stream or direct spread from adjoining structures results in inflammatory response
in the meninges leading to meningitis, once the infection spreads to the ventricles
of the brain it starts to secrete more
cerebrospinal fluid in an attempt to flush out the infectious agents and toxins, this
leads to increase cerebrospinal fluid production and circulation within the brain
and spinal cord.
The body tries to fight the infection; blood vessels become leaky and allow
fluid, white blood cells to enter the meninges and brain, this causes brain swelling
and eventually leads to decreased blood flow to part of the brain (Amanda 2011).
BACTERIA MENINGITIS
It is more serious form of the condition; the symptoms usually begin suddenly
and rapidly get worse.
Later symptoms:
• Drowsiness,
• Confusion,
• Seizure or fits,
• Photophobia,
• Neck stiffness,
• Rapid breathing rate,
• A blotchy red rash.
In babies and young children with bacterial meningitis possible symptoms include:
Nurses lab 2012 discussed the presentation of cerebrospinal fluid with bacterial
meningitis below;-
DIAGNOSTIC PROCEDURE.
Burnet (2007), explained different diagnostic technique for the detection of
meningitis;
> Instruct the patient to lie flat for several hours to reduce chances of
headache.
> Monitor the patient carefully following the procedure for adverse effect such
as vertigo, tinnitus, fever, respiratory distress.
> Administer to patient increased fluid for at least 24hours after the procedure.
> Ensure the comfort and safety of the patient.
> Record the procedure in the patient’s chart (haven 2006).
> Position patient carefully to prevent joint stiffness and neck pain, turn him
according to planned positioning scheduled and assist with range of motion
exercise.
> Give mild laxative or stool softeners to minimize straining at stool.
> Provide psychological support; reassure andreorient patientif confused about
the condition.
> Drug administration; ensure appropriate administration of drug and educate
patient concerning the adverse effect of intravenous antibiotics.
> Physical care; nurses should provide.
MEDICAL MANAGEMENT
CEFTRIAXONE (rocephine)
Group; it is an antibiotic
Mode of action; it inhibits the synthesis of bacterial cell wall mitosis and
growth of bacterial Indications; infectious fever, meningitis, urinary
tract infections e.t.c Route of administration: intramuscularly,
intravenously.
Dosage: 1-2g daily or 500mg-lg twice daily.
Side effects: diarrhea, abdominal pain, mouth soreness, body rashes, and
pruritis.
Contraindication: history of hypersensitivity to penicillin.
Nursing responsibilities:
• Find out if patient is hypersensitive
ACETAMINOPHEN (Paracetamol)
Nursing responsibilities:
Group; benzodiazepines
Mode of action; it sedates the central nervous system and also relaxes the
muscles thereby producing anticonvulsant, anti-anxiety and muscle relaxant
effect
There are a number of vaccines that can prevent many cases of viral and
bacterial meningitis, they include;
• The measles, mumps and rubella vaccination
• Give meningococcal vaccine to children
• Give haemophilus influenza type b, diphtheria, whooping cough, tetanus and
polio vaccine.
• Pneumococcal conjugated vaccine (PCV) for children should also be given.
The centre for disease control and prevention (2007), recommends the
meningococcal vaccine
for;
Viral meningitis usually resolves in 7-10 days and is fatal in less than 1%
cases
CHAPTER THREE
PATIENT’S IDENTIFICATION
Name; master E.J
Age; 6years old
Sex; male
File number; 0237433
Address; P. 212 Oromu street kayanfada Ilesha
Ethnicity: Yoruba
State of origin: Ondo state
Date of birth; 13/11/2007
Next of kin: Mrs. Joseph
Relationship: mother
Address of next of kin: P. 212 Oromu street kayanfada Ilesha
Nursing officer in charge: ADNS A.
Consultant: Dr A.
Diagnosis: bacterial meningitis
Religion – Christianity
■ Cerebrospinal fluid
glucose
■ Cerebrospinal fluid
protein
Cerebrospinal fluid shows hypoglycorrhachia with
elevated protein level
Cerebrospinal microscopic culture and sensitivity:
Gram positive diplococcic and numerous pus cells,
lymphocyte, polymorph Appearance- cerebrospinal fluid
appears turbid and cloudy.
Reflex examination:
* Kerning’s sign - positive
* Brudzinski’s sign - unequivocal
NURSING MANAGEMENT
Observation: vital signs were observed 6hourly, the temperature was done
frequently because of fever in order to take prompt interventions (tepid
sponging) to prevent convulsion of the child.
Position: the patient was placed on the bed lying supine with the bed
elevated by 30 degrees to promote venous return.
Maintaining fluid and metabolic status: he was placed on 4.3% dextrose
saline 1500mls over 24hours at 15drops/minute + 5ce vitamin B complex into
each pint, flow rate was maintained. High calorie and protein diet was
prescribed and patient was encouraged to eat.
Physical care: due to illness and age of patient, he was given an assisted
bathroom bath and oral care. He was made comfortable on bed and mother was
advice to leave patient body exposed during onset of fever as a result of
infection but light clothing was worm at night.
MEDICAL MANAGEMENT
The following drugs were prescribed:
IV ceftriaxone (rocephin) lOOOmg/lg daily,
IV ampicillin 900mg,
Tab acetaminophen
500mg IV mannitol
(45ml) of 20%
Dexamethasone (decadron).
CEFTRIAXONE (rocephin)
Group: antibiotic
Mode of action: it inhibits the synthesis of bacterial cell wall, mitosis and
growth of bacteria “streptococcus pneumonia”. It is used when there is
penicillin resistance.
Dosage: adult lg daily and in severe infection 2-4g daily. Infant and children
(under 50kg): 20- 50mg/kg and up to 80mg in severe infections.
Nursing responsibilities:
21st of January
22nd of January
Personal hygiene was taken care of and his bed was made, vital
signs; temperature 37.5°c, pulse 74b/m, respiratory rate 34c/m.
rd
23 of January
Had elevated temperature 38.8°c, he was exposed to fresh air
and tepid sponged. Pulse 112b/m, respiration 26c/m, had due
drugs.
24th of January
Oral and body care was done, oral drugs and food was served and
well tolerated, he slept well during the day and he is to continue the
present management, vital signs; temperature 38.2°c, pulse 98b/m,
respiration 28c/minutes.
25th of January
26th of January
27th of January
28th of January
29th of January
General condition is stable, meningitis is resolving, reflex is now
normal, he is active and alert. Vital signs: temperature 37.1°c, pulse
76b/min, respiration 20c/min.
30th of January
His condition is now stable, he is now active and alert, meal and
medications were tolerated well, vitamin C, 1 thrice daily and vitamin B
complex 1 twice daily was commenced. Vital signs: temperature
36.8°c, pulse 85b/min, respiration 22c/min.
31st of January
1st of January
ADVICE ON DISCHARGE
Master E.J was discharged on the 1st of August 2014, but prior
to discharge his mother was given various health information’s which
will contribute to their health.
ACTIVITY AND REST
DRUG COMPLIANCE
FOLLOW UP VISIT
REHABILITATION
The rehabilitation of patient which is an essential means of
planning programmed, in which it progresses towards maintaining
the maximum level of functioning of which he/she is capable, it
actually starts from the time the patient is admitted to the ward. A
major goal in the treatment of patient after discharged from the
hospital is to reintegrate the patient back to health.
There are five E’s of rehabilitation which include
Encourage: patient and parent need encouragement to adopt a
positive attitude towards the management of the patient.