Management of Patients with Neurologic Dysfunction Meningitis Chapter 64 1

Learning Objectives Describe the pathophysiology, clinical manifestations, and medical and nursing management of Meningitis. Use the nursing process as a framework for care of patients with Meningitis. 2

Meningitis Meningitis is an inflammation of the lining around the brain and spinal cord caused by bacteria or viruses (Iggulden, 2006). Meningitis can be the primary reason a patient is hospitalized or can develop during hospitalization and is classified as septic or aseptic. Septic meningitis is caused by bacteria. Septic meningitis is caused by bacteria. 3

Meningitis a In aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or human immunodeficiency virus (HIV). Factors that increase the risk of bacterial meningitis include tobacco use and viral upper respiratory infection, because they increase the amount of droplet production. Otitis media and mastoiditis increase the risk of bacterial meningitis, because the bacteria can cross the epithelial membrane and enter the subarachnoid space. People with immune system deficiencies are also at greater risk for development of bacterial meningitis. 4

Pathophysiology Meningeal infections generally originate in one of two ways: through the bloodstream as a consequence of other infections or by direct spread, such as might occur after a traumatic injury to the facial bones or secondary to invasive procedures. N. meningitidis concentrates in the nasopharynx and is transmitted by secretion or aerosol contamination. Bacterial or meningococcal meningitis also occurs as an opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS) and as a complication of Lyme disease (Chart 64-1). 5

Pathophysiology Once the causative organism enters the bloodstream, it crosses the blood–brain barrier and proliferates in the cerebrospinal fluid (CSF). The host immune response stimulates the release of cell wall fragments and lipopolysaccharides, facilitating inflammation of the subarachnoid and pia mater. Because the cranial vault contains little room for expansion, the inflammation may cause increased intracranial pressure (ICP). CSF circulates through the subarachnoid space, where inflammatory cellular materials from the affected meningeal tissue enter and accumulate. 6

Pathophysiology The prognosis for bacterial meningitis depends on the causative organism, the severity of the infection and illness, and the timeliness of treatment. Acute fulminant presentation may include adrenal damage, circulatory collapse, and widespread hemorrhages (Waterhouse-Friderichsen syndrome). This syndrome is the result of endothelial damage and vascular necrosis caused by the bacteria. Complications include visual impairment, deafness, seizures, paralysis, hydrocephalus, and septic shock. 7

Clinical Manifestations Headache and fever are frequently the initial symptoms. Neck mobility: A stiff and painful neck (nuchal rigidity) can be an early sign and any attempts at flexion of the head are difficult because of spasms in the muscles of the neck. Photophobia (extreme sensitivity to light): This finding is common, although the cause is unclear. 8

Clinical Manifestations Positive Kernig’s sign: When the patient is lying with the thigh flexed on the abdomen, the leg cannot be completely extended (Fig. 64-1). 9

Clinical Manifestations Positive Brudzinski’s sign: When the patient’s neck is flexed (after ruling out cervical trauma or injury), flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity (see Fig. 64-1). more sensitive Brudzinski’s sign is a more sensitive indicator of meningeal irritation than Kernig’s sign. 10

Clinical Manifestations A rash can be a striking feature of N. meningitidis infection. Skin lesions develop ranging from a petechial rash with purpuric lesions to large areas of ecchymosis. Disorientation and memory impairment are common early in the course of the illness. As the illness progresses, lethargy, unresponsiveness, and coma may develop. Seizures. ICP increases secondary to diffuse brain swelling or hydrocephalus, The initial signs of increased ICP include decreased level of consciousness and focal motor deficits. If ICP is not controlled, Brain stem herniation is a life- threatening event that causes cranial nerve dysfunction and depresses the centers of vital functions, such as the medulla. 11

Assessment and Diagnostic Findings A computed tomography (CT) scan or magnetic resonance imaging (MRI) scan is used to detect a shift in brain contents (which may lead to herniation) prior to a lumbar puncture. Bacterial culture and Gram staining of CSF and blood are key diagnostic tests. CSF studies demonstrate low glucose, high protein levels, and high white blood cell count (Mazzoni, et al., 2006). Gram staining allows for rapid identification of the causative bacteria and initiation of appropriate antibiotic therapy (van de Beek, et al., 2006). 12

Prevention the meningococcal conjugated vaccine be given to adolescents entering high school and to college freshmen living in dormitories. education addressing meningococcal meningitis and the availability of vaccination so that families can make informed decisions. People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis. Vaccination should also be considered as an adjunct to antibiotic chemoprophylaxis for anyone living with a person who develops meningococcal infection. Vaccination against H. influenzae and S. pneumoniae should be encouraged for children and at-risk adults. 13

Medical Management early administration of an antibiotic that crosses the blood– brain barrier into the subarachnoid space in sufficient concentration to halt the multiplication of bacteria. Vancomycin hydrochloride in combination with one of the cephalosporins (eg, ceftriaxone sodium, cefotaxime sodium) is administered intravenously (IV) (van de Beek, et al., 2006). Dexamethasone (Decadron) has been shown to be beneficial as adjunct therapy in the treatment of acute bacterial meningitis and in pneumococcal meningitis if it is administered 15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4 days. Dehydration and shock are treated with fluid volume expanders. Seizures, which may occur early in the course of the disease, are controlled with phenytoin (Dilantin). Increased ICP is treated as necessary. 14

Nursing Management The patient’s safety and well-being depend on sound nursing judgment. Neurologic status and vital signs are continually assessed. Pulse oximetry and arterial blood gas values are used to quickly identify the need for respiratory support if increasing ICP compromises the brain stem. Insertion of a cuffed endotracheal tube (or tracheotomy) and mechanical ventilation may be necessary to maintain adequate tissue oxygenation. Blood pressure (usually monitored using an arterial line) is assessed for incipient shock, which precedes cardiac or respiratory failure. Rapid IV fluid replacement may be prescribed, but care is taken to prevent fluid overload. measures are taken to reduce body temperature as quickly as possible. 15

Nursing Management Protecting the patient from injury secondary to seizure activity or altered LOC Monitoring daily body weight; serum electrolytes; and urine volume, specific gravity, and osmolality, especially if syndrome of inappropriate antidiuretic hormone (SIADH) is suspected Preventing complications associated with immobility, such as pressure ulcers and pneumonia Instituting infection control precautions until 24 hours after initiation of antibiotic therapy (oral and nasal discharge is considered infectious) 16

Nursing Management Because the patient’s condition is often critical and the prognosis guarded, the family needs to be informed about the patient’s condition. Because the patient’s condition is often critical and the prognosis guarded, the family needs to be informed about the patient’s condition. Periodic family visits are essential to facilitate coping of the patient and family. Periodic family visits are essential to facilitate coping of the patient and family. An important aspect of the nurse’s role is to support the family and assist them in identifying others who can be supportive to them during the crisis. An important aspect of the nurse’s role is to support the family and assist them in identifying others who can be supportive to them during the crisis. 17

CRITICAL THINKING EXERCISES A 19-year-old college student is admitted with suspected meningitis6. A 19-year-old college student is admitted with suspected meningitis6. Identify two assessment parameters that indicate meningitis? Identify two assessment parameters that indicate meningitis? What interventions would be included in your plan of care to protect the patient from injury? What interventions would be included in your plan of care to protect the patient from injury? The patient’s family has many questions about the disease and their risk of contracting meningitis. Develop a teaching plan that would describe meningitis and prophylactic therapy for the patient’s family and close contacts. The patient’s family has many questions about the disease and their risk of contracting meningitis. Develop a teaching plan that would describe meningitis and prophylactic therapy for the patient’s family and close contacts. 18