Angeles University Foundation

College of Nursing
AY 2009 – 2010
First Semester

A Case Study
TB MENINGITIS
(A Requirement for NCM 101
Pedia, Second Rotation)

PRESENTED BY:

Antonio, Alneil T.
Diyco, Kevin
Gutierrez, Richell
Manalac, Alexis

PRESENTED TO:

Mrs. Nona Gonzales, RN

INSTRUCTOR

I. INTRODUCTION
 If we were to look back through history, it would seem as if meningitis
has no definite origin. Some say that Hippocrates may have realized the
existence of the disease. Tuberculosis meningitis, which was called “dropsy in
the brain”, is often attributed to Edinburgh physician Sir Robert Whytt in a
posthumous report that appeared in 1768, although the link with tuberculosis
and its pathogen was not made until the next century. But no matter how
unclear the origins of meningitis are, we could definitely say that it is a
serious problem.

Although studies have shown that viral meningitis is more common

(10.9 per 100,000), bacterial meningitis still has a relatively high incidence
rate of about 3 per 100,000 annually in Western countries. And in Brazil, the
rate of bacterial meningitis is higher, at 45.8 per 100,000 annually. In sub-
Saharan Africa, large epidemics of meningococcal meningitis occur in the dry
season, leading to it being labeled the “meningitis belt”. In this area, there
are 500 cases encountered per 100,000 annually because it is poorly served
by medical care. The most recent epidemic, affecting Nigeria, Niger, Mali and
Burkina Faso, started in January 2009 and is ongoing. (Wikipedia, 2009)

As said by former Sec. Manuel Dayrit, there was an emerging trend of

meningitis, an ailment less fatal than meningococcemia, but is caused by the
same bacteria, Neisseria meningitidis. Whereas in the United States,
Pneumococcus is responsible for 3,000 cases of meningitis, 50,000 cases of
bacteremia, and 500,000 cases of pneumonia every year. Additionally,
Pneumococcus is the most common cause of bacterial meningitis and
bacterial pneumonia in children younger that 2 years old and has been the
featured topic of pediatric journals since then. (Philippine Daily Inquirer,
January 18, 2005)

Bacterial meningitis is a true emergency because it requires immediate

hospital-based treatment and can be life threatening if not treated promptly.
Of course, there are always risk factors involved which could increase the
chances of a person to acquire the disease. In addition, the absence of any
risk factor, or having a protective factor does not necessarily guard a person
from the disease. Risk factors would include contact with meningococcal
cases, and travel to Africa or parts of Asia where meningococcus is more
common. Institutions like schools and dormitories have been associated with
meningococcal outbreaks. Low humidity, dust storms, and cigarette smoke
also increases the risk of getting infected with the bacteria. And lastly, breaks
in the skin also would permit the entry of bacteria, as well as through droplet
and kissing. As for neonatal meningitis, persistence of cases results from
increasing numbers of infants surviving puncture delivery and limited access
to medical resources in developing countries. (Adele Pillitteri, 2003)

Almost any bacteria entering the body can cause meningitis. The most
common are meningococci (Neisseria meningitidis), pneumococci
(Streptococcus pneumoniae), and Haemophilus influenzae. These organisms
are often present in the nasopharynx, and they are fairly common and are
more often associated with other everyday illnesses. (Joyce M. Black, Jane
Hokanson Hawks, 2008)

The long-term outlook for children who develop meningitis varies

greatly and depends on the child’s age, the microorganisms causing the
infection, other complications, and the treatment the child receives. The
complications of bacterial meningitis can be severe and include neurological
problems such as hearing loss, visual impairment, seizures and learning
disabilities. Although some children develop long lasting neurological
problems from bacterial meningitis, most who receive prompt diagnosis and
treatment recover fully. (Joyce M. Black, et al, 2005)

A. CURRENT TRENDS

Many times meningeal infections can be prevented, especially when

the infecting pathogen is H. influenzae, S. pmeumoniae, or N. meningitidis.
The current immunization guidelines endorsed by the Advising Committee on
Immunization Practices and American Academy of Pediatrics are that all
children be immunized against H. Influenzae. The role of the government is
very crucial in times of outbreaks and life threatening diseases. The
government engages in research activities, continuous proper management
and initial treatment such as immunization, which is the concern of everyone.
While the treatment and prevention of bacterial meningitis have greatly
improved over the past decade. Significant therapeutic challenges still exist.
Controversies include the choice of empiric antimicrobial agents and the
administration of corticosteroids; the introduction of pneumococcal vaccines
and the new antibiotics have changed the epidemiology of meningitis.
Together, the availability of antibiotics has contributed to the emergence of
resistant organisms. One of the activities of the government is to respond to
this dilemma, according to Carlos, et al, through a study entitled
“Antimicrobial Resistance Surveillance Program in the Philippines” which was
held last 2000, and was about the resistance of H. influenzae to
cotrimoxazole, ampicillin and chloramphenicol whereas it is concluded the
three drugs are still recommended to use for H. influenzae. In addition to this,
scientists believe they may have found a way to protect people against every
strain of meningitis. The most current study that was published, “Vaccine
could beat meningitis”, talks about the new approach towards management
of meningitis. It shows that a vaccine against A and C strain of the disease
exists, however there is no job against the lethal B strain. Scientists use
genetic engineering technology to create a strain of meningitis B that is
incapable of causing for disease, after injecting the strains of the disease the
finding suggested that it may be possible to create a single vaccine to protect
against each strain. The unique thing about this research is that it provides
hope for a complete vaccine protecting people against all types of
meningococcal bacteria, the most common cause of meningitis worldwide.
(Carlos, 2004)

Successful eradication of CSF infection will rely on the continued

development of new antibiotics and vaccines as well as judicious use of those
antibiotics currently available. Routine immunization of young adolescent will
help prevent the rare but serious infection of the disease. In addition, the
absence of specific clinical findings makes diagnosis of meningitis more
difficult. As stated by Lincoln, whether its making sure that families have
access to quality health care and child care, in making sure that the children
receive the best educational opportunities we can give them, we must remain
committed to these needs because our children are our future. Embracing the
vital role of the government in creating barriers against the disease, the
initiative and braveness of the stat to fight for the children against the
disease is like struggling for a better economy. (Sarah Yuan, 2004)

B. REASONS FOR CHOOSING THIS CASE

The group’s main reasons for choosing this particular case would have
to be the patient’s mother and father. They both were nice people who have
let us student nurses handle their child without being hard to please or hard
to talk to. In other words, we were able to achieve a much more mutual
relationship with them, and this helped us a lot in understanding their child’s
overall condition. In doing so, we were able to raise our level of awareness in
terms of the forms of treatment and management that were needed.

Considering that the chosen case was meningitis, future encounters

with the disease as well as its complications would be much easier for us
because we have already established a background about it. In addition,
knowing the various risk factors involved in the occurrence of the disease
would allow us to give health teachings easily, especially when it comes to
prevention.
 II. Nursing Process

II. A. ASSESSMENT

1. Personal Data
I.A Demographic Data

Gian Dave Canlas, a 1y/o child, male. He is the son of Albert and
Vivian Canlas. He is presently residing at Block 4, Lot 31, Phase 1 Sapang
Bayabas Resettlement Dau Mabalacat. He was born on June 14, 2008 at
JBLMGH and a natural born Filipino and a Catholic. He was admitted at
JBLMGH on July 17, 2009 at 3:10pm with a diagnosis of t/c CNS infection
Probably TB Meningitis.
INFORMANT: Vivian Canlas
RELATION: Mother

2. Pertinent Family History

Gian Dave belongs to a nuclear type of family, which is consist of
five members. Mr. Albert Canlas, his father works as construction worker,
Mrs. Vivian Canlas on the otherhand serves as a fulltime housewife. The
eldest is Gladilyn Canlas supposetedly 13 years old but unfortunately she
died in the womb of her mother before she was born because of weak fetal
heart rate. The second eldest is Ma. Paulina, 11 years old she was born on
October 25, 1997. Next to her is Albert Ian Canlas a 5 year old boy that was
born on June 18, 2004. According to her mother Gian Dave and Ma. Paulina
didn’t had complications when they were born but Albert Ian was born
premature at 7 months old of gestation and he was confined at JBLMGH NICU
for almost a month because of respiratory problem.
The family lives in a small house which is made up of woods with poor
environmental condition. According to Mrs. Canlas, they only have one room
which is crowded and it has poor ventilation and poor lightning as evidenced
by a 2 small window which is blocked with black curtain and not exceeding
size of 10% of the total floor area.

Their source of their family income, comes only from the father who
works as a construction worker and earns P200.00 per day Mrs. Canlas stays
at home and take care of their children.. Some of their health habits are the
use of some medicinal plants and consultation to the Hilot and Herbolarios.
Despite of their practice of superstitious belief, they don’t hold them as their
basis in living their lives because they strongly believe in God and He is the
only one who serves as their mode of strength. Thus, they always see to it
that their whole family goes to church every Sunday morning. This is to show
their devotedness to God. Typically, they usually eat together as a sign of
their close family ties bound with familial love and trust. They teach their
children to respect their elders.

3. Personal History
When Mrs Canlas was pregnant her common habit is to taking a
bath every day, she always consulted the health center, and if there is
seminars related to pregnancy and family planning in the barangay, she's
always present. She eats lots of food, especially fruits and vegetables. She is
regularly taking vitamins. She undergo ultasounds or xrays to assure that her
baby will be deliver in normal. She believes in what others termed as “lihi”.
Her food intake is twice as what she usually eats before. According to her,
she loves eating mango, apples, sayote and potatoes which are cheaper but
nutritious one. She told us that her husband restricted her from doing
extreme activities. So to wash off her boredom, she spends her time
watching teleserye programs. Every morning, she sees to it that she had
accomplished walking along their street and sometimes she's doing light
household chores such us washing the plates.
Mrs. Canlas had also mentioned about her beliefs during her pregnancy
such as when you drink milk, the baby will be delivered with fair skin. She
also believes that if a pregnant woman is beautiful during the period of her
pregnancy, her child will be a girl. And if she is not that pretty her child will
be a guy.
According to Mrs. Canlas her obstetrical history is G4P4T3P1A0L3M0.
Mr and Mrs. Canlas have 4 children; Gian Dave weighs 6.5lbs at birth, with
AOG of 36 weeks . He is the fourth child and has one sister and one brother
and the eldest sibling who died at birth. During all of Mr. Canlas pregnancy
with Gian Dave he always visit their health center for prenatal check up.
When Mrs. Canlas was pregnant with Gian she always eats bread, rice, fruits
and vegetables. Despite of these all of her children were delivered through a
normal spontaneous delivery but her 1st child died in her womb because of
weak heart rate and her third child that was delivered premature at 7
months. Being a mother she practiced breastfeeding but she abstain from it
since Gian got sick.

GROWTH AND DEVELOPMENT

Erik Erickson (Psychosocial Theory)

Gian Dave is in the Trust vs. Mistrust stage of Erik Erickson’s Growth
and Development Stage. The infant depends on the parents, especially the
mother, for food, sustenance, and comfort. The child's relative understanding
of world and society come from the parents and their interaction with the
child. In this situation, the parents should expose their child to warmth,
regularity, and dependable affection, so that the baby will have trust to them.
The group instructed mother to give comfort, warmth of love, emotions and
feelings to provide a secure environment and to meet the child's basic needs,
and a sense of trust will result. Failed to provide this will be mistrust.

Jean Piaget (Cognitive Development)

 Gian Dave is in the Sensorimotor period of new means through
sensory combination of Piaget’s Cognitive Development. In this stage, infants
construct an understanding of the world by coordinating sensory experiences
(such as seeing and hearing) with physical, motoric actions.

Sigmund Freud (Psychosexual)

Gian Dave is in the stage of Oral receptive personality wherein it is

preoccupied with eating/drinking and reduces tension through oral activity such as
eating, drinking, biting nails. They are generally passive, needy and sensitive to
rejection. They will easily 'swallow' other people's ideas.. During this stage, the
focus of gratification is on the mouth and pleasure is the result. It is also an
exploration of the surroundings (as infants tend to put new objects in their
mouths). In this stage the id is dominant, since neither the ego nor the super ego
is yet fully formed. Thus the baby does not have a sense of self and all actions are
based on the pleasure principle.

MOTOR AND SOCIAL DEVELOPMENT IN INFANCY

AGE MOTOR DEVELOPMENT SOCIAL DEVELOPMENT

One month • Keeps hands • Can differentiate
fisted between faces and
• Able to follow objects.
object to midline
Two months • Holds head up • Makes cooing
when prone sounds
• Has social smile • Differentiate a cry
Three months • Holds head and • Laughs out loud
chest up when
prone
Four months • Grasp, stepping, • Very talkative,
tonic neck cooing babbling
reflexes are and gurgling when
 fading spoken to
• Recognize familiar
objects
Five months • Turns front and • Says some simple
back vowel sound (goo-
• No longer has goo and gah-gah)
head lag when
pulled upright
• Bears partial
weight
Six months • Can raise their • Starts to imitate
chest and the sounds
upper part of their • May say vowel
abdomen off the sounds
table. • Plays pick a boo
• Can sit with
support
• Turns both ways
• More reflex fading
• Uses palmar
reflex
Seven months • Can transfer toy • Show beginning
from one hand to fear of strangers
another
• First tooth erupts
(central incisor
below)
Eight months • Can sit without • Has peaked fear of
support strangers
Nine months • Creeps and crawls • Says first word (da-
• Sits so steady that da)
they can lean • Aware of changes
forward and in voice tone
 regain their
balance
Ten months • Brings the thumb • Master another
and first fingers word (bye-bye)
together in a • Recognize their
pincer-grasp names and listen
• Pull themselves in actively
standing position
Eleven months • Learns to cruise • Imitates speech
(walks with sounds
support) • Reacts with
• Can hold objects frustration when
restricted
Twelve months • Cannot perform • Depended to
activities parents and SO
according to age
due to sickness
fever and
seizures.
• Growth and
development slow
BCG DPT OPV HEPA B MEASLES
down.
Complete Complete Complete Complete Incomplete

IMMUNIZATION STATUS

4. HISTORY OF PRESENT ILLNESS

June 15, 2009 MDH

• Unknown Diagnosis
 • Incomplete Immunization

5. HISTORY OF PAST ILLNESS

3 wks PTA

• patient was diagnose with papillary complex By a PMD was given

Rifampicin, Isoniazid, Pyrazinamide, Zinc Sulfite, Vitamin B Complex

10 days PTa

• (+) LBM/Vomitting

• intermittent fever(-)

3 days PTA

• Persistence of above Seizure prompted consult Mabalacat district

Hospital

! day PTA

While at MDH, pt had seizure hence was transferred to JBLMRH for further
evaluation.

PAST MEDICAL HISTORY

June 15, 2009

MDH- Unknown Dx

Incomplete Immunization(no measles vaccine)

Family medical history

(-)seizure

(-)asthma

Personal environment and Social History

 (+) exposure to PTB patient(grandfather)

6. PHYSICAL EXAMINATION (IPPA –Cephalocaudal Approach)

July 17, 2009
Weight: 6.7 kgs
Vital Signs:
Temperature: 36.7O C
Pulse Rate: 140 bpm
Respiratory Rate:24 bpm
• GS: weak looking, conscious, coherent
• Skin: (-) jaundice, (-) pallor, (-) cyanosis, no active dermatoses,
poor skin turgor
• HEENT: (+) dry lips, NAD, sunken eyeballs, dry lips, PPC, AS
• C/L: SCE, (-) retractions, (-) crackles, no wheezes noted,
subcostal and intercostals refract
• AP: no murmur
• Heart: Normal Rate Regular Rhythm, (-) murmurs
• Abdomen: flat, no mass palpated, no tenderness
• GUT: Unremarkable
• IE: Unremarkable
• Extremities: no atrophy noted
• Neuro: drowsy
○ (+) neck rigidity
○ (+) brudzinki’s sign
○ (+) kernig’s sign
○ (-) babinski reflex
July 18, 2009
General Appearance: Patient is awake, lethargic.
Vital Signs: Temperature: 36.40O C
Pulse Rate: 133 bpm

SKIN: There is cyanosis, poor skin turgor, warm to touch and dry.

HAIR & The hair is black in color; no infestations.

SCALP
Nails are normal in size and shape, they are short and clean, with
NAILS
a normal capillary refill of 3 sec.
HEAD No tenderness of the scalp noted, presence of bulging fontanelle
FACE Symmetrical in shape, no tenderness upon palpation
Upward rolling of eyeballs, with pale palpebral conjunctiva, sclera
EYES
is white in color

Skin color is pale, auricle aligned with outer canthus of eye,

EARS
mobile, firm, and not tender
Nose is symmetrical, not tender and no lesions, without
NOSE
discharges, absence of bleeding and swelling
MOUTH &
Tongue is normal pale and dry, with dry mucous membrane,
THROAT

CHEST AND
Presence of subcostal retraction, symmetrical lungs
LUNGS

HEART
No murmurs, normal rate and regular rhythm.

ABDOMEN Borborygmi sounds heard upon auscultation. no mass and lesion,

Respiratory Rate: 35 bpm

 July 23, 2009

Vital Signs: Temperature: 36.9O C

Pulse Rate: 135 bpm

SKIN: There is cyanosis, poor skin turgor, warm to touch and dry.

HAIR & The hair is black in color; no infestations.

SCALP
NAILS Nails are pale,no clubbing capillary refill of 4sec
HEAD Presence of bulging fontanelles
FACE No tendernesss upon palpation
Symmetrical, with pale palpebral conjunctiva, sclera is white in
EYES
color, upward rolling of eyeballs

EARS No abnormal discharges or swelling

NOSE Nose is symmetrical, not tender and no lesions

MOUTH &
Tongue is pale, dry lips
THROAT

CHEST AND
Subcostal and intercostals refract
LUNGS

HEART
No murmurs, normal rate and regular rhythm.

ABDOMEN Borborygmi sounds heard upon auscultation. with masses

Respiratory Rate: 38 bpm

7. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic Date Indications/ Result Normal Analysis and

Ordered Purpose Values Interpretation
Procedures
Date
Result

Complete
Blood Count

Hemoglobin D.O.: It measures the 104 M: 125- Malnutrition is

7.17.09 total amount of 175g/L recognized to the
hemoglobin in the patient that may
D.R.: F: 115-
blood, to determine indicate the
7.17.09 155g/L
the O2 carrying cause of
capacity of the decrease In the
blood. level of
haemoglobin

Hematocrit D.O.: It measures the 0.31 M:0.40- There was a

7.17.09 percentage of RBCS 0.52 decrease in the
in the total blood result due to
D.R.:7.17.0 F:0.38-
volume hemodilution and
9 0.48
the recognized
malnutrition.

Leukocytes D.O.: It determines the 6.0 5- The result is

9
7.17.09 number of 10x10 /L within the normal
(WBC)
circulating WBCS of values
D.R.:7.17.0
the whole blood.
9
Neutrophils D.O.: Phagocytes present 0.37 (0.5-0.7) Neutrophils is
7.17.09 in the circulation or lower than
along the capillary normal which
D.R.:7.17.0
walls. indicatates risk
9
for infection.

Plate count D.O.: To evaluate 404 (150- The result is

7.17.09 platelet production, 450x10g within normal
to monitor and /l) values.
D.R.:7.17.0
diagnose severe
9
thrombocytosis or
thrombocytopenia

Blood D.O.: Specimen of Creatinine (M: 60- A decreased

Chemistry 7.17.09 venous blood are 120umol/ value for this test
52.3
taken for a CBC L) is rarely a
Creatinine D.R.:7.22.0
which includes concern. It can
9 (F: 58-
hemoglobin and occur with
100umol/
hematocrit decreased
L)
measurements, muscle mass.
erythrocyte RBC Conditions such
Count, Leukocyte as muscular
WBC count RBC dystrophy, which
indices and is an inherited
differential white defect in
cell count. muscles, can
cause a low
CBC is one of the
value for this
most frequently
test.
ordered blood test,
it shows the
increase, and
decrease of the
blood cell count
 that may be
associated with
different disorders,
and also
determines the
presence of
bacterial infection
or viral infections.
To asses for
electrolyte
imbalance.

Lympocytes D.O.: 0.63 0.20-.0.3 Lymphocytes is

7.17.09 5 higher than
normal range
D.R.:7.17.0
which may help
9
in fighting
against infection
Urinalysis D.O.7.17.0 To determine Color: yellow Pale yellow The result is within
9 urinary to Amber normal values.
Transparenc
complications Yellow
D.R.:7.18. y: clear
and possible
09
abnormal Albumin:
components negative Clear
(e.g.
Reaction:
CHON, glucose Acidic
blood, pus) or
Specific
infection.
Gravity :
1.010

Pus cell 0-
1/HPF

RBC 0-1.HPF

Stool Exam D.O.: Use to assess Color: Light Color: dark The result is within
7.17.09 gross brown brown normal values,
appearance of
D.R.:7.21. Result: No Consistency
ova or
09 ova or : formed
parasites in the
parasite
stool.
seen

Consistency:
Semi-formed
Chest X- Ray D.O.:7.17.09 Provides • Both lung Normal lung The result is
information fields are fields. normal with
D.R.:7.17.09
about location clear. no signs of
Normal heart
and extent of • Heart and pneumonia
size and
pneumonia and great or heart
configuration
cardiac vessels are problems.
abnormalities. normal in
size and
configuratio
n.
• Other chest
structures
are not
remarkable
IMPRESSION:
Normal Chest

NURSING RESPONSIBILITIES:

HEMATOLOGY (CBC)

Prior:

1. Explain the procedure to the S.O

2. Tell the S.O that no fasting is required
3. Assure S.O. that collecting blood sample take less than 3 minutes
4. Inform S.O that pt. will be experiencing pain on the site where the
needle was pricked.
During:

1. Collect 5-7 ml of venous blood in a lavender top tube

After:

1. Apply pressure or a pressure dressing to the venipuncture site

2. Check the venipuncture site for bleeding

3. Fill- up the laboratory form properly or label the specimen and send to
the laboratory technician
4. Record all procedure done
URINALYSIS (U/A)

Prior:

1. Explain the procedure to the S.O.

2. Obtain the materials needed for the procedure
3. Advise S.O. to wash the genital area of the pt. prior to collection of
specimen to prevent contamination
During:

1. Collect a fresh urine specimen using wee bag ( urine container)

After:

1. Label the specimen and transfer it to the laboratory immediately and

promptly.
STOOL ANALYSIS

Prior:

1. Explain procedure to S.O.

2. Determine the reason for collecting stool specimen and the correct
method of obtaining and handling
3. Obtain the necessary materials
During:
 1. Wear gloves
2. Use tongue blade to obtain specimen from the diaper using
scraping method
3. Take the sample from the center of a formed stool to ensure a
uniform sample.
After:

1. Ensure that the specimen label and laboratory requisition have the
correct information on them and are securely attached to the
specimen container.
2. Transfer the specimen to the laboratory immediately and promptly.
3. Document all relevant information.
CHEST X-RAY

Prior:

1. Verify doctor’s order

2. Explain to the S.O. the importance of the procedure
3. Ask the S.O. to remove any radiopaque objects (jewelry, metal
buttons)
During:

1. Client assumes various positions so that x-ray films can be obtained

from the most useful angles.
After:

1. Assist S.O. and patient to go back to his bed

Record all procedures done

NURSING RESPONSIBILITIES FOR BLOOD SPECIMEN COLLECTION:

• Place the tourniquet above the venepuncture site

• Palpate and locate the vein. it is difficult to disinfect the venepuncture
site meticulously with 10% isopropyl alcohol by swabbing the skin
concentrically from the center of the venepuncture site outwards. Let
 the disinfectant evaporate. Do not repalpate the vein again. Perform
venepuncture.
• If withdrawing with conventional disposable syringes, withdraw 510 ml
of whole blood from adults, 25 ml from children and .52ml for infants.
• IF withdrawing using vacuum systems, withdraw the desired amount of
blood directly into each. Transport tube and culture bottles.
• Remove the tourniquet. Apply pressure to site until bleeding has stop,
and apply sticking plaster (if desired)
• Using aseptic technique transfer the specimen to the relevant cap
transport tubes and culture bottles. Secure caps tightly Be sure to
follow manufacturer’s instructions on the correct amount and method
for inoculation of blood culture bottles.
• Label the tube including patient identification number using indelible
marker pen.
• Do not recap used sharps. Discard directly into the sharps disposable
container.
• Complete the case investigation and the laboratory request form using
the same identification
•
8. ANATOMY AND PHYSIOLOGY

Central Nervous System

The central nervous system (CNS) is the largest part of the nervous
system, and includes the brain and spinal cord. The spinal cavity holds and
protects the spinal cord, while the head contains and protects the brain. The
CNS is covered by the meninges, a three layered protective coat. The brain is
also protected by the skull, and the spinal cord is also protected by the
vertebrae.

The central nervous system (CNS) is the part of the nervous system
that functions to coordinate the activity of all parts of the bodies of
multicellular organisms. In vertebrates, the central nervous system is enclosed
in the meninges. The meninges (singular meninx) is the system of
membranes which envelops the central nervous system. The meninges consist
of three layers: the dura mater, the arachnoid mater, and the pia mater. The
primary function of the meninges and of the cerebrospinal fluid is to protect
the central nervous system. It contains the majority of the nervous system and
consists of the brain (in vertebrates which have them), and the spinal cord.

The meninges (singular meninx) is the system of membranes which

envelops the central nervous system. The meninges consist of three layers: the
dura mater, the arachnoid mater, and the pia mater. The primary function of
the meninges and of the cerebrospinal fluid is to protect the central nervous
system. The space between these membranes is bathed with a spinal fluid
much like lymph, which serves as a protective cushion for the delicate nerve
tissue, and allows some expansion space for the brain when its blood supply is
increased.
3 layers of meninges:

• Dura mater - (also rarely called meninx fibrosa, or pachymeninx) is a

thick, durable membrane, closest to the skull. It consists of two layers, the
periosteal layer, closest to the calvaria and the inner meningeal layer. It
contains larger blood vessels which split into the capilliaries in the pia
mater. It is composed of dense fibrous tissue, and its inner surface is
covered by flattened cells like those present on the surfaces of the pia
mater and arachnoid. The dura mater is a sac which envelops the
arachnoid and has been modified to serve several functions. The dura
mater surrounds and supports the large venous channels (dural sinuses)
carrying blood from the brain toward the heart.

The falx cerebri separates the hemispheres of the cerebrum. The falx
cerebelli separates the lobes of the cerebellum.

The tentorium cerebelli separates the cerebrum from the cerebellum.

The epidural space is a potential space between the dura mater and the
skull. If there is hemorrhaging in the brain, blood may collect here. Adults are
more likely than children to bleed here as a result of closed head injury.
The subdural space is another potential space. It is between the dura mater
and the middle layer of the meninges, the arachnoid mater. When bleeding
occurs in the cranium, blood may collect here and push down on the lower
layers of the meninges. If bleeding continues, brain damage will result from
this pressure. Children are especially likely to have bleeding in the subdural
space in cases of head injury.

• Arachnoid mater - The middle element of the meninges is the arachnoid

membrane, so named because of its spider web-like appearance. It
provides a cushioning effect for the central nervous system. The
arachnoid mater exists as a thin, transparent membrane. It is composed
of fibrous tissue and, like the pia mater, is covered by flat cells also
thought to be impermeable to fluid. The arachnoid does not follow the
convolutions of the surface of the brain and so looks like a loosely fitting
sac. In the region of the brain, particularly, a large number of fine
filaments called arachnoid trabeculae pass from the arachnoid through
the subarachnoid space to blend with the tissue of the pia mater.

The arachnoid and pia mater are sometimes together called the
leptomeninges.

The subarachanoid space lies between the arachnoid and pia mater. It is
filled with cerebrospinal fluid. All blood vessels entering the brain, as well as
cranial nerves pass through this space. The term arachnoid refers to the spider
web like appearance of the blood vessels within the space.

• Pia mater - The pia or pia mater is a very delicate membrane. It is the
meningeal envelope which firmly adheres to the surface of the brain and
spinal cord. As such it follows all the minor contours of the brain (gyri and
sulci). It is a very thin membrane composed of fibrous tissue covered on
its outer surface by a sheet of flat cells thought to be impermeable to
fluid. The pia mater is pierced by blood vessels which travel to the brain
and spinal cord, and its capillaries are responsible for nourishing the brain.
Cerebrospinal fluid - is a clear liquid produced within spaces in the brain
called ventricles. Like saliva it is a filtrate of blood. It is also found inside the
subarachnoid space of the meninges which surrounds both the brain and the
spinal chord. In addition, a space inside the spinal chord called the central
canal also contains cerebrospinal fluid. It acts as a cushion for the neuraxis,
also bringing nutrients to the brain and spinal cord and removing waste from
the system.

Choroid Plexus
All of the ventricles contain choroid plexuses which produce cerebrospinal fluid
by allowing certain components of blood to enter the ventricles. The choroid
plexuses are formed by the fusion of the pia mater, the most internal layer of
the meninges and the ependyma, the lining of the ventricles.

The Ventricles
These four spaces are filled with cerebrospinal fluid and protect the brain by
cushioning it and supporting its weight.

The two lateral ventricles extend across a large area of the brain. The
anterior horns of these structures are located in the frontal lobes. They extend
posteriorly into the parietal lobes and their inferior horns are found in the
temporal lobes.

The third ventricle lies between the two thalamic bodies. The massa
intermedia passes through it and the hypothalamus forms its floor and part of
its lateral walls.

The fourth ventricle is located between the cerebellum and the pons.
The four ventricles are connected to one another.

The two foramina of Munro, which are also know as the interventricular
foramina, link the lateral ventricles to the third ventricle.

The Aqueduct of Sylvius which is also called the cerebral aqueduct connects
the third and fourth ventricles.
The fourth ventricle is connected to the subarachnoid space via two lateral
foramina of Luschka and by one medial foramen of Magendie.

ANATOMY OF THE CNS

BRAIN

The center of the nervous system. The brain is located in the head,
protected by the skull and close to the primary sensory apparatus of vision,
hearing, balance, taste, and smell.

• The frontal lobe is concerned with higher intellectual functions, such as

abstract thought and reason, speech (Broca's area in the left hemisphere
only), olfaction, and emotion. Voluntary movement is controlled in the
precentral gyrus (the primary motor area).
• The parietal lobe is dedicated to sensory awareness, particularly in the
postcentral gyrus (the primary sensory area). It is also concernes with
abstract reasoning, language interpretation and formation of a mental
egocentric map of the surrounding area.
• The occipital lobe is responsible for interpretation and processing of visual
stimuli from the optic nerves, and association of these stimuli with other
nervous imputs and memories.
• The temporal lobe is concerned with emotional development and
formation, and also contains the auditory area responsible for processing
 and discrimination of sound. It is also the area thought to be responsible for
the formation and processing of memories.
The brain can be subdivided into several distinct regions:

1. Brainstem – consists of medulla oblongata, pons and midbrain.

• Medulla oblongata - is the lower portion of the brainstem. It deals with
autonomic functions, such as breathing and blood pressure. The cardiac
center is the part of the medulla oblongata responsible for controlling the
heart rate.
• Pons - relays sensory information between the cerebellum and cerebrum;
aids in relaying other messages in the brain; controls arousal, and
regulates respiration (see respiratory centres). In some theories, the pons
has a role in dreaming.
• Midbrain (mesencephalon) - The mesencephalon is considered part of
the brain stem. Its substantia nigra is closely associated with motor
system pathways of the basal ganglia.

The human mesencephalon is archipallian in origin, meaning its general

architecture is shared with the most ancient of vertebrates. Dopamine
produced in the substantia nigra plays a role in motivation and habituation of
species from humans to the most elementary animals such as insects.
1. Cerebellum - is a region of the brain that plays an important role in the
integration of sensory perception, coordination and motor control. In order
to coordinate motor control, there are many neural pathways linking the
cerebellum with the cerebral motor cortex (which sends information to the
muscles causing them to move) and the spinocerebellar tract (which
provides proprioceptive feedback on the position of the body in space). The
cerebellum integrates these pathways, like a train conductor, using the
constant feedback on body position to fine-tune motor movements.

2. Diencephalon - (or interbrain) is the region of the brain that includes the
thalamus, hypothalamus, epithalamus, prethalamus or subthalamus and
pretectum. The diencephalon is located at the midline of the brain, above
the mesencephalon of the brain stem. The diencephalon contains the zona
 limitans intrathalamica as morphological boundary and signalling center
between the prethalamus and the thalamus.
• Thalamus - plays an important role in regulating states of sleep and
wakefulness. Thalamic nuclei have strong reciprocal connections with
the cerebral cortex, forming thalamo-cortico-thalamic circuits that
are believed to be involved with consciousness. The thalamus plays a
major role in regulating arousal, the level of awareness, and activity.
Damage to the thalamus can lead to permanent coma.
• Epithalamus – is a dorsal posterior segment of the diencephalon (a
segment in the middle of the brain also containing the hypothalamus
and the thalamus) which includes the habenula, the stria medullaris
and the pineal body. Its function is the connection between the limbic
system to other parts of the brain.
• Hypothalamus - is a small part of the brain located just below the
thalamus on both sides of the third ventricle. Lesions of the
hypothalamus interfere with several vegetative functions and some
so called motivated behaviors like sexuality, combativeness, and
hunger. The hypothalamus also plays a role in emotion. Specifically,
the lateral parts seem to be involved with pleasure and rage, while
the medial part is linked to aversion, displeasure, and a tendency to
uncontrollable and loud laughing. However, in general the
hypothalamus has more to do with the expression of emotions

1. Cerebrum - or top portion of the brain, is divided by a deep crevice, called

the longitudinal sulcus. The longitudinal sulcus separates the cerebrum in to
the right and left hemispheres. In the hemispheres you will find the cerebral
cortex, basal ganglia and the limbic system. The two hemispheres are
connected by a bundle of nerve fibers called the corpus callosum. The right
hemisphere is responsible for the left side of the body while the opposite is
true of the left hemisphere.

PHYSIOLOGY OF THE CNS

Medulla
The medulla is the control center for respiratory, cardiovascular and digestive
functions.

Pons

The pons houses the control centers for respiration and inhibitory functions.
Here it will interact with the cerebellum.

Cerebrum

The cerebrum, or top portion of the brain, is divided by a deep crevice, called
the longitudinal sulcus. The longitudinal sulcus separates the cerebrum in to
the right and left hemispheres. In the hemispheres you will find the cerebral
cortex, basal ganglia and the limbic system. The two hemispheres are
connected by a bundle of nerve fibers called the corpus callosum. The right
hemisphere is responsible for the left side of the body while the opposite is
true of the left hemisphere. Each of the two hemispheres are divided into four
separated lobes: the frontal in control of specialized motor control, learning,
planning and speech; parietal in control of somatic sensory functions; occipital
in control of vision; and temporal lobes which consists of hearing centers and
some speech. Located deep to the temporal lobe of the cerebrum is the insula.

Cerebellum

The cerebellum is the part of the brain that is located posterior to the medulla
oblongata and pons. It coordinates skeletal muscles to produce smooth,
graceful motions. The cerebellum receives information from our eyes, ears,
muscles, and joints about what position our body is currently in
(proprioception). It also receives output from the cerebral cortex about where
these parts should be. After processing this
information, the cerebellum sends motor impulses
from the brainstem to the skeletal muscles. The
main function of the cerebellum is coordination. The
cerebellum is also responsible for balance and
posture. It also assists us when we are learning a
new motor skill, such as playing a sport or musical
instrument.
The Limbic System

The Limbic System is a complex set of structures found just beneath the
cerebrum and on both sides of the thalamus. It combines higher mental
functions, and primitive emotion, into one system. It is often referred to as the
emotional nervous system. It is not only responsible for our emotional lives, but
also our higher mental functions, such as learning and formation of memories.
The Limbic system explains why some things seem so pleasurable to us, such
as eating and why some medical conditions are caused by mental stress, such
as high blood pressure. There are two significant structures within the limbic
system and several smaller structures that are important as well. They are:

1. The Hippocampus
2. The Amygdala
3. The Thalamus
4. The Hypothalamus
5. The Fornix and Parahippocampus
6. The Cingulate Gyrus

Structures of the Limbic System

Hippocampus

The Hippocampus is found deep in the temporal lobe, shaped like a seahorse.
It consists of two horns that curve back from the amygdala. It is situated in the
brain so as to make the prefrontal area aware of our past experiences stored in
that area. The prefrontal area of the brain consults this structure to use
memories to modify our behavior. The hippocampus is responsible for memory.
Amygdala

The Amygdala is a little almond shaped structure, deep inside the

anteroinferior region of the temporal lobe, connects with the hippocampus, the
septi nuclei, the prefrontal area and the medial dorsal nucleus of the thalamus.
These connections make it possible for the amygdala to play its important role
on the mediation and control of such activities and feelings as love, friendship,
affection, and expression of mood. The amygdala is the center for identification
of danger and is fundamental for self preservation. The amygdala is the
nucleus responsible for fear.

Thalamus

Lesions or stimulation of the medial, dorsal, and anterior nuclei of the thalamus
are associated with changes in emotional reactivity. However, the importance
of these nuclei on the regulation of emotional behavior is not due to the
thalamus itself, but to the connections of these nuclei with other limbic system
structures. The medial dorsal nucleus makes connections with cortical zones of
the prefrontal area and with the hypothalamus. The anterior nuclei connect
with the mamillary bodies and through them, via fornix, with the hippocampus
and the cingulated gyrus, thus taking part in what is known as the Papez's
circuit.

Hypothalamus

The Hypothalamus is a small part of the brain located just below the thalamus
on both sides of the third ventricle. Lesions of the hypothalamus interfere with
several vegetative functions and some so called motivated behaviors like
sexuality, combativeness, and hunger. The hypothalamus also plays a role in
emotion. Specifically, the lateral parts seem to be involved with pleasure and
rage, while the medial part is linked to aversion, displeasure, and a tendency
to uncontrollable and loud laughing. However, in general the hypothalamus has
more to do with the expression of emotions. When the physical symptoms of
emotion appear, the threat they pose returns, via the hypothalamus, to the
limbic centers and then the prefrontal nuclei, increasing anxiety.

The Fornix and Parahippocampal

These small structures are important connecting pathways for the limbic
system.

The Cingulate Gyrus

The Cingulate Gyrus is located in the medial side of the brain between the
cingulated sulcus and the corpus callosum. There is still much to be learned
about this gyrus, but it is already known that its frontal part coordinates smells
and sights, with pleasant memories of previous emotions. The region
participates in the emotional reaction to pain and in the regulation of
aggressive behavior.

Memory and Learning

Memory is defined as: The mental faculty of retaining and recalling past
experiences, the act or instance of remembering recollection. Learning takes
place when we retain and utilize past memories.

Overall, the mechanisms of memory are not completely understood. Brain

areas such as the hippocampus, the amygdala, the striatum, or the
mammillary bodies are thought to be involved in specific types of memory. For
example, the hippocampus is believed to be involved in spatial learning and
declarative learning (learning information such as what you're reading now),
while the amygdala is thought to be involved in emotional memory. Damage to
certain areas in patients and animal models and subsequent memory deficits is
a primary source of information. However, rather than implicating a specific
area, it could be that damage to adjacent areas, or to a pathway traveling
through the area is actually responsible for the observed deficit. Further, it is
not sufficient to describe memory, and its counterpart, learning, as solely
dependent on specific brain regions. Learning and memory are attributed to
changes in neuronal synapses, thought to be mediated by long-term
potentiation and long-term depression.

There are three basic types of memory:

1. Sensory Memory
2. Short Term Memory
3. Long Term Memory

Sensory Memory

The sensory memories act as a buffer for stimuli through senses. A sensory
memory retains an exact copy of what is seen or heard: iconic memory for
visual, echoic memory for aural and haptic memory for touch. Information is
passed from sensory memory into short term memory. Some believe it lasts
only 300 milliseconds, it has unlimited capacity. Selective attention determines
what information moves from sensory memory to short term memory.

Short Term Memory

Short Term Memory acts as a scratch pad for temporary recall of the
information under process. For instance, in order to understand this sentence
you need to hold in your mind the beginning of the sentence as you read the
rest. Short term memory decays rapidly and also has a limited capacity.
Chunking of information can lead to an increase in the short term memory
capacity, this is the reason why a hyphenated phone number is easier to
remember than a single long number. The successful formation of a chunk is
known as closure. Interference often causes disturbance in short term memory
retention. This accounts for the desire to complete a task held in short term
memory as soon as possible.
Within short term memory there are three basic operations:

1. Iconic memory - the ability to hold visual images

2. Acoustic memory - the ability to hold sounds. Can be held longer than
iconic.
3. Working memory - an active process to keep it until it is put to use. Note
that the goal is not really to move the information from short term
memory to long term memory, but merely to put it to immediate use.

The process of transferring information from short term to long term memory
involves the encoding or consolidation of information. This is not a function of
time, that is, the longer the memory stays in the short term the more likely it is
to be placed in the long term memory. On organizing complex information in
short term before it can be encoded into the long term memory, in this process
the meaningfulness or emotional content of an item may play a greater role in
its retention in the long term memory. The limbic system sets up local
reverberating circuits such as the Papaz's Circuit.

Long Term Memory

Long Term Memory is used for storage of information over a long time.
Information from short to long term memory is transferred after a short period.
Unlike short term memory, long term memory has little decay. Long term
potential is an enhanced response at the synapse within the hippocampus. It is
essential to memory storage. The limbic system isn't directly involved in long
term memory necessarily but it selects them from short term memory,
consolidates these memories by playing them like a continuous tape, and
involves the hippocampus and amygdala.

There are two types of long term memory:

1. Episodic Memory
 2. Semantic Memory

Episodic memory represents our memory of events and experiences in a serial

form. It is from this memory that we can reconstruct the actual events that
took place at a given point in our lives. Semantic memory, on the other hand,
is a structured record of facts, concepts, and skills that we have acquired. The
information in the semantic memory is derived from our own episode memory,
such as that we can learn new facts or concepts from experiences.

There are three main activities that are related to long term memory:

1. Storage
2. Deletion
3. Retrieval

Information for short term memory is stored in long term memory by rehearsal.
The repeated exposure to a stimulus or the rehearsal of a piece of information
transfers it into long term memory. Experiments also suggest that learning is
most effective if it is distributed over time. Deletion is mainly caused by decay
and interference. Emotional factors also affect long term memory. However, it
is debatable whether we actually ever forget anything or whether it just
sometimes becomes increasingly difficult to retrieve it. Information may not be
recalled sometimes but may be recognized, or may be recalled only with
prompting. This leads us to the third operation of memory, information
retrieval.

There are two types of information retrieval:

1. Recall
2. Recognition
In recall, the information is reproduced from memory. In recognition the
presentation of the information provides the knowledge that the information
has been seen before. Recognition is of lesser complexity, as the information is
provided as a cue. However, the recall may be assisted by the provision of
retrieval cues which enable the subject to quickly access the information in
memory.

ANATOMY OF THE PNS

The peripheral nervous system includes 12 cranial nerves 31 pairs of spinal

nerves. It can be subdivided into the somatic and autonomic systems. It is a
way of communication from the central nervous system to the rest of the body
by nerve impulses that regulate the functions of the human body.

The twelve cranial nerves are

I Olfactory Nerve for smell

 II Optic Nerve for vision

III Oculomotor for looking around

IV Trochlear for moving eye

V Trigeminal for feeling touch on face

VI Abducens to move eye muscles

VII Facial to smile, wink, and help us taste

VIII Vestibulocochlear to help with balance, equilibrium, and hearing

IX Glossopharengeal for swallowing and gagging

X Vagus for swallowing, talking, and parasympathetic actions of digestion

XI Spinal accessory for shrugging shoulders

XII Hypoglossal for tongue more divided into different regions as muscles

The 10 out of the 12 cranial nerves originate from the brainstem, and mainly
control the functions of the anatomic structures of the head with some
exceptions. CN X receives visceral sensory information from the thorax and
abdomen, and CN XI is responsible for innervating the sternocleidomastoid and
trapezius muscles, neither of which is exclusively in the head.

Spinal nerves take their origins from the spinal cord. They control the functions
of the rest of the body. In humans, there are 31 pairs of spinal nerves: 8
cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal. The naming
convention for spinal nerves is to name it after the vertebra immediately above
it. Thus the fourth thoracic nerve originates just below the fourth thoracic
vertebra. This convention breaks down in the cervical spine. The first spinal
nerve originates above the first cervical vertebra and is called C1. This
continues down to the last cervical spinal nerve, C8. There are only 7 cervical
vertebrae and 8 cervical spinal nerves.
Peripheral nervous system

The PNS is a regional term for the collective nervous structures that do not lie
in the CNS. The bodies of the nerve cells lie in the CNS, either in the brain or
the spinal cord, and the longer of the cellular processes of these cells, known
as axons, extend through the limbs and the flesh of the torso. The large
majority of the axons which are commonly called nerves, are considered to be
PNS.

The peripheral nervous system (PNS) resides or extends outside the central
nervous system (CNS), which consists of the brain and spinal cord. The main
function of the PNS is to connect the CNS to the limbs and organs. Unlike the
central nervous system, the PNS is not protected by bone or by the blood-brain
barrier, leaving it exposed to toxins and mechanical injuries. The peripheral
nervous system is divided into the somatic nervous system and the autonomic
nervous system.

Physiological division

A less anatomical but much more functional way of dividing the human
nervous system is classification according to the role that the different neural
pathways play, regardless of whether or not they cross through the CNS/PNS:

• The somatic nervous system is responsible for coordinating voluntary

body movements (i.e. activities that are under conscious control).
• The autonomic nervous system is responsible for coordinating
involuntary functions, such as breathing and digestion.

In turn, these divisions of the nervous system can be further divided according
to the direction in which they conduct nerve impulses:
 • Afferent system by sensory neurons, which carries impulses from a
somatic receptor to the CNS
• Efferent system by motor neurons, which carries impulses from the CNS
to an effector
• Relay system by interneurons (also called "relay neurons"), which
transmit impulses between the sensory and motor neurons (both in the
CNS and PNS).
• The junction between two neurons is called a synapse. There is a very
narrow gap (about 20nm in width) between the neurons called the
synaptic cleft. This is where an action potential (the "message" being
carried by the neurons, also known as the nerve impulse) is transmitted
from one neuron to the next. This is achieved by relaying the message
across the synaptic cleft using neurotransmitters, which diffuse across
the gap. The neurotransmitters then bind to receptor sites on the
neighboring (postsynaptic) neuron, which in turn produces its own
electrical/nerve impulse. This impulse is sent to the next synapse, and
the cycle repeats itself.
• Nerve impulses are a change in ion balance between the inside and
outside of a neuron. Because the nervous system uses a combination of
electrical and chemical signals, it is incredibly fast. Although the
chemical aspect of signaling is much slower than the electrical aspect, a
nerve impulse is still fast enough for the reaction time to be negligible in
day to day situations. Speed is a necessary characteristic in order for an
organism to quickly identify the presence of danger, and thus avoid
injury/death. For example, a hand touching a hot stove. If the nervous
system was only comprised of chemical signals, the nervous system
would not be able to signal the arm to move fast enough to escape
dangerous burns. Thus, the speed of the nervous system is
evolutionarily valuable, and is in fact a necessity for life.

The Somatic System

The somatic nervous system is that part of the peripheral nervous system
associated with the voluntary control of body movements through the action of
skeletal muscles, and also reception of external stimuli. The somatic nervous
system consists of afferent fibers that receive information from external
sources, and efferent fibers that are responsible for muscle contraction. The
somatic system includes the pathways from the skin and skeletal muscles to
the Central Nervous System. It is also described as involved with activities that
involve consciousness.

The basic route of the efferent somatic nervous system includes a two neuron
sequence. The first is the upper motor neuron, whose cell body is located in the
precentral gyrus (Brodman Area 4) of the brain. It receives stimuli from this
area to control skeletal (voluntary) muscle. The upper motor neuron carries
this stimulus down the corticospinal tract and synapses in the ventral horn of
the spinal cord with the alpha motor neuron, a lower motor neuron. The upper
motor neuron releases acetylcholine from its axon terminal knobs and these
are received by nicotinic receptors on the alpha motor neuron. The alpha
motor neurons cell body sends the stimulus down its axon via the ventral root
of the spinal cord and proceeds to its neuromuscular junction of its skeletal
muscle. There, it releases acetylcholine from its axon terminal knobs to the
muscles nicotinic receptors, resulting in stimulus to contract the muscle.

The somatic system includes all the neurons connected with the muscles,
sense organs and skin. It deals with sensory information and controls the
movement of the body.

The Autonomic System

The Autonomic system deals with the visceral organs, like the heart, stomach,
gland, and the intestines. It regulates systems that are unconsciously carried
out to keep our body alive and well, such as breathing, digestion (peristalsis),
and regulation of the heartbeat. The Autonomic system consists of the
sympathetic and the parasympathetic divisions. Both divisions work without
conscious effort, and they have similar nerve pathways, but the sympathetic
and parasympathetic systems generally have opposite effects on target tissues
(they are antagonistic). By controlling the relative input from each division, the
autonomic system regulates many aspects of homeostasis. One of the main
nerves for the parasympathetic autonomic system is Cranial Nerve X, the
Vagus nerve.

Ten out of the twelve cranial nerves originate from the brainstem, and mainly
control the functions of the anatomic structures of the head with some
exceptions. The nuclei of cranial nerves I and II lie in the forebrain and
thalamus, respectively, and are thus not considered to be true cranial nerves.
CN X (10) receives visceral sensory information from the thorax and abdomen,
and CN XI (11) is responsible for innervating the sternocleidomastoid and
trapezius muscles, neither of which is exclusively in the head.

Spinal nerves take their origins from the spinal cord. They control the functions
of the rest of the body. In humans, there are 31 pairs of spinal nerves: 7
cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal. In the cervical region,
the spinal nerve roots come out above the corresponding vertebrae (i.e. nerve
root between the skull and 1st cervical vertebrae is called spinal nerve C1).
From the thoracic region to the coccygeal region, the spinal nerve roots come
out below the corresponding vertebrae. It is important to note that this method
creates a problem when naming the spinal nerve root between C7 and T1 (so it
is called spinal nerve root C8). In the lumbar and sacral region, the spinal nerve
roots travel within the dural sac and they travel below the level of L2 as the
cauda equina.

Cervical spinal nerves (C1-C4)

The first 4 cervical spinal nerves, C1 through C4, split and recombine to
produce a variety of nerves that subserve the neck and back of head.

Spinal nerve C1 is called the suboccipital nerve which provides motor

innervation to muscles at the base of the skull. C2 and C3 form many of the
nerves of the neck, providing both sensory and motor control. These include
the greater occipital nerve which provides sensation to the back of the head,
the lesser occipital nerve which provides sensation to the area behind the ears,
the greater auricular nerve and the lesser auricular nerve. See occipital
neuralgia. The phrenic nerve arises from nerve roots C3, C4 and C5. It
innervates the diaphragm, enabling breathing. If the spinal cord is transected
above C3, then spontaneous breathing is not possible.

Brachial plexus (C5-T1)

The last four cervical spinal nerves, C5 through C8, and the first thoracic spinal
nerve, T1,combine to form the brachial plexus, or plexus brachialis, a tangled
array of nerves, splitting, combining and recombining, to form the nerves that
subserve the arm and upper back. Although the brachial plexus may appear
tangled, it is highly organized and predictable, with little variation between
people.

Neurotransmitters

The main neurotransmitters of the peripheral nervous system are acetylcholine

and noradrenaline. However, there are several other neurotransmitters as well,
jointly labeled Non-noradrenergic, non-cholinergic (NANC) transmitters.
Examples of such transmitters include non-peptides: ATP, GABA, dopamine,
NO, and peptides: neuropeptide Y, VIP, GnRH, Substance P and CGRP.

The Sympathetic System

The Sympathetic Division

The sympathetic nervous system activates what is often termed the fight or
flight response, as it is most active under sudden stressful circumstances (such
as being attacked). This response is also known as sympathetico-adrenal
response of the body, as the pre-ganglionic sympathetic fibers that end in the
adrenal medulla (but also all other sympathetic fibers) secrete acetylcholine,
which activates the secretion of adrenaline (epinephrine) and to a lesser extent
noradrenaline (norepinephrine) from it. Therefore, this response that acts
primarily on the cardiovascular system is mediated directly via impulses
transmitted through the sympathetic nervous system and indirectly via
catecholamines secreted from the adrenal medulla.
Neurons

Neurons are electrically excitable cells in the nervous system that process and
transmit information. Neurons are the core components of the brain, the
vertebrate spinal cord, the invertebrate ventral nerve cord, and the peripheral
nerves. A number of different types of neurons exist: sensory neurons respond
to touch, sound, light and numerous other stimuli effecting sensory organs and
send signals to the spinal cord and brain, motor neurons receive signals from
the brain and spinal cord and cause muscle contractions and affect glands,
Interneurons connect neurons to other neurons within the brain and spinal
cord.

There are three types of directions of the neurons:

• Sensory system by sensory neurons, between the sensory and motor

neurons. However, there are relay neurons in the CNS as well.
• By function, the peripheral nervous system is divided into the somatic
nervous system, autonomic nervous system and the enteric nervous
system. The somatic nervous system is responsible for coordinating the
body movements, and also for receiving external stimuli. It is the system
that regulates activities that are under conscious control. The autonomic
nervous system is then split into the sympathetic division,
parasympathetic division, and enteric division. The sympathetic nervous
system responds to impending danger or stress, and is responsible for
the increase of one's heartbeat and blood pressure, among other
physiological changes, along with the sense of excitement one feels due
to the increase of adrenaline in the system. The parasympathetic
nervous system, on the other hand, is evident when a person is resting
and feels relaxed, and is responsible for such things as the constriction
of the pupil, the slowing of the heart, the dilation of the blood vessels,
and the stimulation of the digestive and genitourinary systems. The role
of the enteric nervous system is to manage every aspect of digestion,
from the esophagus to the stomach, small intestine and colon.

Glial cells
Glial cells are non-neuronal cells that provide support and nutrition, maintain
homeostasis, form myelin, and participate in signal transmission in the nervous
system. In the human brain, glia are estimated to outnumber neurons by about
10 to 1.

Glial cells provide support and protection for neurons. They are thus known as
the "glue" of the nervous system. The four main functions of glial cells are to
surround neurons and hold them in place, to supply nutrients and oxygen to
neurons, to insulate one neuron from another, and to destroy pathogens and
remove dead neurons.

Organization

Sympathetic nerves originate inside the vertebral column, toward the middle of
the spinal cord in the intermediolateral cell column (or lateral horn), beginning
at the first thoracic segment of the spinal cord and extending into the second
or third lumbar segments. Because its cells begin in the thoracic and lumbar
regions of the spinal cord, the SNS is said to have a thoracolumbar outflow.
Axons of these nerves leave the spinal cord in the ventral branches (rami) of
the spinal nerves, and then separate out as 'white rami' (so called from the
shiny white sheaths of myelin around each axon) which connect to two chain
ganglia extending alongside the vertebral column on the left and right. These
elongated ganglia are also known as paravertebral ganglia or sympathetic
trunks. In these hubs, connections (synapses) are made which then distribute
the nerves to major organs, glands, and other parts of the body.

In order to reach the target organs and glands, the axons must travel long
distances in the body, and, to accomplish this, many axons link up with the
axon of a second cell. The ends of the axons do not make direct contact, but
rather link across a space, the synapse.
In the SNS and other components of the peripheral nervous system, these
synapses are made at sites called ganglia. The cell that sends its fiber is called
a preganglionic cell, while the cell whose fiber leaves the ganglion is called a
postganglionic cell. As mentioned previously, the preganglionic cells of the SNS
are located between the first thoracic segment and the second or third lumbar
segments of the spinal cord. Postganglionic cells have their cell bodies in the
ganglia and send their axons to target organs or glands.

The ganglia include not just the sympathetic trunks but also the superior
cervical ganglion (which sends sympathetic nerve fibers to the head), and the
celiac and mesenteric ganglia (which send sympathetic fibers to the gut).

Relationship to sympathetic

While an oversimplification, it is said that the parasympathetic system acts in a

reciprocal manner to the effects of the sympathetic nervous system; in fact, in
some tissues innervated by both systems, the effects are synergistic.

The Parasympathetic Division

The parasympathetic nervous system is part of the autonomic nervous system.

Sometimes called the rest and digest system or feed and breed. The
parasympathetic system conserves energy as it slows the heart rate, increases
intestinal and gland activity, and relaxes sphincter muscles in the
gastrointestinal tract.

Receptors

The parasympathetic nervous system uses only acetylcholine (ACh) as its

neurotransmitter. The ACh acts on two types of receptors, the muscarinic and
nicotinic cholinergic receptors. Most transmissions occur in two stages: When
stimulated, the preganglionic nerve releases ACh at the ganglion, which acts
on nicotinic receptors of the postganglionic nerve. The postganglionic nerve
then releases ACh to stimulate the muscarinic receptors of the target organ.

The three main types of muscarinic receptors that are well characterised are:

• The M1 muscarinic receptors are located in the neural system.

• The M2 muscarinic receptors are located in the heart, and act to bring
the heart back to normal after the actions of the sympathetic nervous
system: slowing down the heart rate, reducing contractile forces of the
atrial cardiac muscle, and reducing conduction velocity of the
atrioventricular node (AV node). Note, they have no effect on the
contractile forces of the ventricular muscle.
• The M3 muscarinic receptors are located at many places in the body,
such as the smooth muscles of the blood vessels, as well as the lungs,
which means that they cause vasoconstriction and bronchoconstriction.
They are also in the smooth muscles of the gastrointestinal tract (GIT),
which help in increasing intestinal motility and dilating sphincters. The
M3 receptors are also located in many glands that help to stimulate
secretion in salivary glands and other glands of the body.

Nervous Tissue

The nervous system coordinates the activity of the muscles, monitors the
organs, constructs and also stops input from the senses, and initiates actions.
Prominent participants in a nervous system include neurons and nerves, which
play roles in such coordination.Our nervous tissue only consists of two types of
cells. These cells are neurons and neuroglia cells. The neurons are responsible
for transmitting nerve impulses. Neuroglia cells are responsible for supporting
and nourishing the neuron cells.

Types of neurons
There are three types of neurons in the body. We have sensory neurons,
interneurons, and motor neurons. Neurons are a major class of cells in the
nervous system. Neurons are sometimes called nerve cells, though this term is
technically imprecise, as many neurons do not form nerves. In vertebrates,
neurons are found in the brain, the spinal cord and in the nerves and ganglia of
the peripheral nervous system. Their main role is to process and transmit
information. Neurons have excitable membranes, which allow them to
generate and propagate electrical impulses. Sensory neuron takes nerve
impulses or messages right from the sensory receptor and delivers it to the
central nervous system. A sensory receptor is a structure that can find any kind
of change in it's surroundings or environment.

Structure of a neuron

Neurons have three different parts to them. They all have an axon, a cell body
and dendrites. The axon is the part of the neuron that conducts nerve
impulses. Axons can get to be quite long. When an axon is present in nerves, it
is called a nerve fiber. A cell body has a nucleous and it also has other
organelles. The dendrites are the short pieces that come off of the cell body
that receive the signals from sensory receptors and other neurons.

Myelin Sheath

Schwann cells contain a lipid substance called myelin in their plasma

membranes. When schwann cells wrap around axons, a myelin sheath forms.
There are gaps that have no myelin sheath around them; these gaps are called
nodes of Ranvier. Myelin sheathes make excellent insulators. Axons that are
longer have a myelin sheath, while shorter axons do not. The disease multiple
sclerosis is an autoimmune disease where the body attacks the myelin sheath
of the central nervous system.

Information transmission

Messages travel through the SNS in a bidirectional flow. Efferent messages can
trigger changes in different parts of the body simultaneously. For example, the
sympathetic nervous system can accelerate heart rate; widen bronchial
passages; decrease motility (movement) of the large intestine; constrict blood
vessels; increase peristalsis in the esophagus; cause pupil dilation, piloerection
(goose bumps) and perspiration (sweating); and raise blood pressure. Afferent
messages carry sensations such as heat, cold, or pain.

The first synapse (in the sympathetic chain) is mediated by nicotinic receptors
physiologically activated by acetylcholine, and the target synapse is mediated
by adrenergic receptors physiologically activated by either noradrenaline or
adrenaline. An exception is with sweat glands which receive sympathetic
innervation but have muscarinic acetylcholine receptors which are normally
characteristic of PNS. Another exception is with certain deep muscle blood
vessels, which have acetylcholine receptors and which dilate (rather than
constrict) with an increase in sympathetic tone. The sympathetic system cell
bodies are located on the spinal cord excluding the cranial and sacral regions.
 The preganglonic neurons exit from the vertebral column and synapse with the
postganglonic nerouns in the sympathetic trunk.

The parasympathetic nervous system is one of three divisions of the autonomic

nervous system. Sometimes called the rest and digest system, the
parasympathetic system conserves energy as it slows the heart rate, increases
intestinal and gland activity, and relaxes sphincter muscles in the
gastrointestinal tract.

Precipitataing factors
Predisposing Factors: Low economic Crowded
Malnutrition
Age (1 year old) Status environment
Male high Weight=6.7kg below (5members, 25sq
incidence normal
(P400/day) m)

Immature immune
system High risk for
contagious or
Decrease communicable disease
Low immune
quantity and
response
quality of food

Invasion of microorganisms to
nasopharyngeal area

(nisserea meningitides)

Colonization of microorganisms

Stiffening of the Neutrophils bind

neck to cerebral
fever Bulging Inflammatory
fontanelle responce endothelial cell Set the Release of
Meningeal
Vomiting
7.17.09-7.23.09 Increase
Congestion of of blood brain
Disrupts level of Increase body
hypothalamus histamine and
irritation Cerebralof
Obstruction
Formation of Increase
Release
IncreaseRelease Release
ofoftoxic of
permeability Increase
Release basal
of vascular
07.17-07.23.09
Infection
Invasion
Microorganism
Hematogenous
to
leads
the to
subarachnoid
systemic
enter
spread blood
systemic barrier
affection
space brainendotoxins
barrier temperature
center serotonin
surrounding
edema
Increase tissues
ICP
Inflammation
adhesion
CSF flow of meninges lymphocytes .63 metabolic rate permeability
7.14.09 of bloodcytokines
products
brain barrier interleukins
SYNTHESIS OF THE DISEASE

DEFINITION OF THE DISEASE

Tuberculous (TB) meningitis is correctly characterized as a

meningoencephalitis, as it affects not only meninges but also brain
parenchyma and vasculature. The primary pathologic event is formation of
thick TB exudate within subarachnoid space, most prominently at the base of
the brain. Accompanying this exudate is inflammation affecting adjacent blood
vessels. Ischemic cerebral infarction, resulting from vascular occlusion, is a
common sequela most often found in the distribution of the middle cerebral
artery (reflecting presence of TB exudate within sylvian fissure) and striate
arteries as they penetrate the base of the brain. Another characteristic feature
of TB meningitis is hydrocephalus secondary to CSF dynamic disturbance.

TB meningitis is divided into three clinical stages:

Stage Neurologic syndrome

Nonspecific (e.g., generalized

I (early)
malaise)

Lethargy
II Meningismus
(intermediate) Moderate focal neurologic deficits
(e.g., cranial nerve palsies)

Seizures
Severe neurologic deficits (e.g.,
III (advanced)
paresis)
Stupor or coma

Tuberculous meningitis is also known as TB meningitis or tubercular

meningitis. Tuberculous meningitis is Mycobacterium tuberculosis infection of
the meninges—the system of membranes which envelops the central nervous
system. It is the most common form of CNS tuberculosis. Fever and headache
are the cardinal features. Confusion is a late feature and coma bears a poor
prognosis. Meningism is absent in a fifth of patients with TB meningitis.
Patients may also have focal neurological deficits.

Causes are Tension headaches are due to contraction (tightness) of the

muscles in your shoulders, neck, scalp, and jaw. They are often related to
stress, depression, or anxiety. Overworking, not getting enough sleep, missing
meals, and using alcohol or street drugs can make you more susceptible to
headaches. Foods that can trigger a headache include chocolate, cheese, and
monosodium glutamate (MSG), a flavor enhancer. People who drink caffeine
can have headaches when they don't get their usual daily amount.
 Mycobacterium tuberculosis of the meninges is the cardinal feature and
the inflammation is concentrated towards the base of the brain. Infection
begins in the lungs and may spread to the meninges by a variety of routes.

Predisposing factors:

• Not completing the childhood vaccine schedule increases your risk of

meningitis

• Age. People that are too young or too old are prone to develop
meningitis due to immature or weakened state of immune system. Most
cases of meningitis occur in children below 5 years old(about 70%).

• Compromised Immune system. People with underdeveloped immune

systems are susceptible to any infection. Since the immune system is
immature, it cannot readily defend itself from invasion thus baby’s are
required to drink breast milk because the mother at that point transfers
her immunoglobulins to the baby thus strengthening the immune
system while babies who rely on bottle milk have lower immunity.

• Sex. Male (95% of cases) are more prone to meningitis than to female.

• Newborns and infants are at a higher risk of contracting certain types of

bacterial meningitis, not only because they are more commonly exposed
to some of the bacteria, but also because they may not yet have
received all the preventive immunizations. Infant meningitis is
frequently attributed to Group B streptococcus infections or exposure to
E.coli or listeria in milk or food products

Precipitating Factors

a. Low Economic Status (contractual salary of Php 200/day) –

usually those who can’t afford a healthy diet are in relation to
malnutrition are susceptible to develop meningitis
b. Crowded area (5 members living in one house of 25 sq.
meters) – close proximity in congested areas is a contributing
factor of meningitis due to easy transmission of disease
c. Malnutrition – people are susceptible to infection due to lack of
energy production and immune-builders
Signs and Symptoms

1. Fever and leukocytosis (an increase in the number of WBC’s) – are

the initial signs and symptoms of a systemic reactions caused by
inflammation. WBC increases as the body respond to the invasion
within the host.

2. Nuchal rigidity – due to the invasion of microbes in the meninges.

3. Elevated CSF protein – infection or inflammatory process that

interrupts the blood-brain barrier increases protein because there
is greater diffusion.

4. Increase intracranial pressure (vomiting) – may occur with an

increase in CSF volume, blood entering the CSF, cerebral edema,
space-occupying lesion such as trauma, hydrocephalus, infection,
Guillain-Barrie Syndrome (vomiting is triggered by the activation
of CTZ in the medulla this a forceful reflux of gastric content out
through the oral cavity)

5. Increase head circumference, bulging fontanels – due to increase

intracranial pressure secondary to the inflammation of the
meninges.
 1. NURSING MANAGEMENT (ACTUAL SOAPIERS)

July 17, 2009 SOAPIE

S: “Apat neng aldo e tatakla” verbalized by the SO.

O: Received patient cuddled by his mother with an ongoing IVF of D5 0.3 NaCl
500 cc regulated @ 41-42 ugtts/min @ 400 cc level infusing well on his right
hand; skin is warm to touch; with poor skin turgor; with upward rolling of the
eye balls; with hypoactive bowel sounds; VS taken and recorded as follow: T:
36.9°C; PR: 123 bpm; RR: 33cpm.

A: Constipation related to irregular defecation habits as evidenced by

hypoactive bowel sounds.

P: The significant others will be able to verbalize understanding of etiology and

appropriate intervention/solutions for individual situations.

I: > Established rapport.

‘> Assessed patient general conditions.

‘> Reviewed medical history often associated with constipation.

‘> Reviewed clients medications.

‘> Palpated abdomen for presence of distention, masses.

‘> Checked rectum for presence of fecal impaction.

‘> Discussed usual elimination habits and problems

‘> Auscultated abdomen for presence, location, and characteristics of bowel

sounds.

‘Change position q 2°

E: Goal met as evidenced by the significant others will be able to verbalized

understanding of etiology and appropriate intervention/solutions for individual
situations.

July 18, 2009 SOAPIE

S: “Medyo kumukulobot ang balat nya” verbalized by the mother.

O: Received patient awake, cuddled by his mother, with an IVF of D5IMB 500 cc
regulated at 16-17 ugtts/min at 400cc level infusing well on his left foot with
poor skin turgor, dry skin, no lesions, and with mild involuntary shaking. VS
taken and recorded as follows: T: 37.2; PR: 127 bpm: RR: 38 cpm.

A: Impaired skin integrity related to poor skin turgor secondary to dehydration.

P: After 4° of nursing interventions the SO will participate in prevention

measures and treatment program.

I: > Established rapport.

‘> Assessed patients general condition.

‘> Monitored skin color, texture and turgor

‘> Noted presence of compromised vision, hearing or speech.

‘> Repositioned patient every 2 hours.

‘> Reviewed importance of skin and measures to maintain proper skin
functioning.

‘> Assisted the SO in understanding and following medical regimen and

developing program of preventive care and daily maintenance.

‘> Stressed the importance of proper hygiene.

‘> Due meds given.

E: Goal met as evidenced by the SO able to participate in prevention measures

and treatment program.

July 23, 2009 SOAPIE

S: “Magumpisa nabengi melagnat ne” as verbalized by the mother.

O: Received patient on bed, awake with chills, with on-going IVF of D5IMB 500
cc regulated at 10-17 ugtts/min, 400cc level infusing well on his left foot; skin
is warm to touch, with flushed skin, with poor skin turgor; with muscle rigidity.
VS taken and recorded as follows: T: 38.6°C; RR: 124 bpm; RR: 39 cpm.

A: Hyperthermia

P: After 4° of nursing interventions the patient will maintain care temperature

within normal range.

I:> Established rapport.

‘> Assessed general condition.

‘> Identified underlying cause.

‘> Noted chronological and development age of the client.

‘> Monitored core temperature.

‘> Assessed neurological response.

‘> Monitored heart rate and rhythm.

‘> Monitored respirations.

‘> Auscultated breath sounds.

‘> Monitored/recorded all source of fluid loss such as urine.

‘> TSB done.

‘> Noted presence and absence of weaning.

‘> Promoted surface cooling by means of undressing.

‘> Administered medications as ordered.

‘> Promoted client safety.

‘> Maintained bed rest.

‘> Due medications given.

E: Goal met as evidenced by the patient will able to maintained core

temperature within normal range.

DOCTOR’S ORDER

July 17, 2009

Problem: Seizure

Wt= 6.7kg

July 18, 2009

Afebrile

(-) seizure

(+) bulging fontanelle

➢ -Please admit pedia ward under yellow service

➢ -TPR q shift
➢ -NPO except meds
Dx:

• Complete Blood Count with Platelet count

• Serum Na, K, Ca
• Urinalysis
• FCA
• CXR AP/L)
IVF: D5 0.3 NaCl 500cc @ 41-42mggts/min

t/c CNS infection probably meningitis with AGE with some Dehydration

➢ -Penicillin G 500,000U q 6 hours.

July 19, 2009

July 20, 2009

Afebrile

Bulging fontanelle

July 20, 2009 OPTHA NOTES

Dx seen Opthaklmic exam done findings EDNS glossy eyeball, equal, white
conjunctiva, clear cornea, clear lens, 3mm papillary round.

Fundoscopy

A. unremarkable fundoscopic examination at the time of exam

➢ Follow up for electrolyte test

➢ Follow up for chest x-ray
➢ Still for cranial ultrasound
➢ Refer to ophthalmologist
➢ Still for CT Scan
➢ IVF: D5IMB 500cc @ 16-17mgtts.min
➢ Insert NGT
July 21, 2009
July 22, 2009

July 23, 2009

SURGERY NOTES

Pt seen and examined and is being referred for neuroevaluation

Patient is awake

Afebrile

No seizure episode

Pink palpebral conjuctiva

Clear bowel sounds

No immediate surgical interventions needed at the time of exam

TB Meningitis with communicating hydrocephalus

➢ Insert NGT
➢ For Cranial Ct Scan
➢ For Ct Scan
➢ Reinsert NGT
➢ Vs q 1 hour
➢ Carry out giving of streptomycin as previously ordered
➢ Mainitain IVF
➢ Follow up for Ct Scan
➢ Refer for Neuroscan For issuance of clinical abstract
 Days 1 2 3
07.17.0 07.18.0 07.23.0
9 9 9
Nursing Problems

Hyperthermia •

Constipation •

Impaired skin integrity •

r/t poor skin turgor
secondary to
dehydration

Impaired skin integrity • • •

r/t poor skin turgor
secondary to
dehydration

Delayed growth & •

development r/t impaired
nutrition
Sleep pattern •
disturbances related to
increase body
temperature

Vital signs

Temperature 36.9˚C 37.2˚C 38.6˚C

Pulse Rate 123bp 127bp 124bp

m m m

Respiratory Rate 33cpm 38cpm 39cpm

Dx. Test

Hemoglobin 104 –
normal

Hematocrit 0.31 –
lower
than
normal
NOTE:

Nsg. Prob:

• = presence

Meds:

• = taken/done

VII. CONCLUSIONS

The central nervous system is of vital importance to sustain one’s life,

since it coordinates the activities of all parts of the body. It is covered and
protected by the meninges. So if these meninges would fail to function, a
person’s health would be at serious risk. Meningitis is such a condition, and it is
a fairly common illness that affects lots of children. The severity of the illness
will depend on the type of infection causing the disease, as well as the overall
health of the person who has it.

Outbreaks of meningitis can be a major health problem in the

community, especially when they occur in schools. A vaccine is available and is
recommended for those living in tight quarters, such as dormitories.
Considering that prevention is better than the cure, this could significantly
reduce morbidity and mortality.
And since it is common in the Philippines, the group decided to focus on
the interventions that could be rendered for the clients as well as to give
health teachings on how to prevent the occurrence of the said disease. The
group wanted to contribute in some ways in order to minimize the increasing
number of children who are infected through interventions and health
teachings.

RECOMMENDATIONS

Surgery is very much recommended, but considering the parents’

financial capabilities, it might not be performed unless it would be included in
their hospital bill. With that in mind, health teachings should be directed
towards maintaining the patient’s protocol for treatment, specifically the use of
antibiotics, since they have been known to reduce the death rate to less than
5% for all types of bacterial meningitis. It should also be stressed to the
patient’s parents that if untreated, their child’s condition could be fatal within
days. With regards to nutrition, adequate fluid and electrolyte balance must be
maintained while adhering to the indicated diet. There should be a focus on IVF
fluids while the patient is on NPO status until he is able to feed through NGT or
OGT. Neurologic status should also be frequently assessed as indicated to
detect early manifestations of increasing ICP and seizures. Anticonvulsants
may be prescribed for seizure prevention.
BIBLIOGRAPHY

• Seeley, Stephens & Tate. Essentials of Anatomy and Physiology. (Fifth

Edition). Mc. Graw Hill Co. Inc., 2005.
• Robert S. Feldman, Understanding Psychology. (Seventh Edition).
Mc.GrawHill Co. Inc., 2005
• Amy M. Karch. Nursing Drug Guide. 2009 Lippincotts William and Wilkins
• George R. Spratto. Adrienne L. Woods. Nurse’s Drug Handbook. (2008
edition)
 • Kozier. Fundamentals of Nursing: Concepts, Process and Practice.
(Eighth edition). Pearson education Inc., 2008.
• Adelle Pillitteri. Maternal and Child Health Nursing: Care of the
Childbearing and Childrearing Family. (Fifth edition). Lippincotts William
and Wilkins 2008
• Doenges, Marilynn E. Nursing Care Plans: Guidelines for Individualizing
Patient Care. (6th edition). F.A. Davis Co., 2002.
• Bacterial Meningitis two hours by Ria Rose Celis/2006
• Dengue Hemorrhagic fever grade 3 by Emmanuel yambao02007
• Acyte myecolytic leukemia by jenalyn Cao02005

Internet source:

http://www.scribd.com

http://pediatrics.about.com/cs/commoninfections/a/meningitis.htm

http://www.mims.com

SOCIOGRAM

July 17, 18 & 23, 2009

LEGEND ALNEIL ANTONIO

PATIENT
RICHELL GUTIERREZ MALE ALEXIS
STUDENT NURSE
MANALAC
CLINICAL INSTRUCTOR FEMALE STUDENT NURSE

OTHER STUDENT NURSES

GIAN DAVE
KEVINDIRECT
DIYCO CONTACT
CANLAS OTHER STUDENT NURSES
INDIRECT CONTACT
(patient)