Running head: BACTERIAL MENINGITIS

Meningitis Amy Durant ECC-City Campus

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Bacterial Meningitis Bacterial meningitis is a potentially fatal infection that can cause death or disability within hours. This paper will be a discussion of bacterial meningitis, including the pathophysiology, nursing care management, and diagnostic testing. Community resources will be identified and examined. Pathophysiology Bacterial meningitis is an inflammation of the lining around the brain and spinal cord caused by bacteria. (Brunner & Smeltzer, 2010). Meningeal infections can occur 2 ways, through the blood stream or by direct spread such as through a facial injury or an invasive procedure. (Brunner & Smeltzer, 2010). Once the infection is in the blood, it crosses the blood-brain barrier and enters the cerebrospinal fluid. When this occurs the bodys immune response causes inflammation of the subachnoid and pia mater. (Brunner & Smeltzer, 2010). The brain has little room for expansion and the result of the inflammation is increased intracranial pressure. (Brunner & Smeltzer, 2010). Nursing Care Management Assessment A nurse will assess for signs and symptoms of bacterial meningitis such as fever and headache. (Brunner & Smeltzer, 2010). The patient can also present with a stiff neck and muscle pain. (Donovan, 2009). The patient will also exhibit signs of mild lethargy, photophobia, and deterioration in level of consciousness. (Silverstri, 2008). With a meningococcal infection the patient will have a maculopapular rash that progresses to a petechial, the petichiae will then progress to a purpuric rash. (Donovan, 2009).

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Signs of meningeal irritation include nuchal rigidity, and a positive Kernigs sign and Brudzinskis sign. (Silverstri, 2008). Kernigs sign is performed with the patient supine with the hips and knees in flexion. (Saberi & Saeed, 2009). The patient is then asked to extend their knees and if they are not able to extend beyond 135 degrees without pain the test is considered positive. (Saberi & Saeed, 2009). Brudzinskis sign is done with the patient supine. (Saberi & Saeed, 2009). A hand is placed behind the patients head and on their chest and then the clients head is raised. (Saberi & Saeed, 2009). If this action creates flexion of the patients lower extremities (hip and knees) then this constitutes a positive sign. (Saberi & Saeed, 2009). A nurse will also take a thorough history, assess vital signs, perform a neurologic exam and a system assessment (especially lungs and skin), obtain daily weights, assess arterial blood gases, and note fluid intake and output. (Burnet, Huntley, & Kemp, 2007). Special attention must be paid to pulse oximetry in order to identify the need for respiratory support if the client experiences an increase in intracranial pressure. (Brunner & Smeltzer, 2010). Blood pressure must be monitored to assess for shock and rapid IV fluid replacement may be prescribed. (Brunner & Smeltzer, 2010). The patients temperature needs to be assessed because a fever can increase the workload of the heart and cerebral metabolism, the fever should be reduced as quickly as possible. (Brunner & Smeltzer, 2010). The neurologic exam consists of a cranial nerve assessment, motor strength, and a sensory exam. (Burnet, Huntley, & Kemp, 2007) Those most at risk for meningitis are infants and children under 5, those who have had close prolonged exposure with people who have meningitis, active smoking in adolescents, living in shared accommodations like college dormitories, a recent influenza infection, and those with a compromised immune system. (Donovan, 2009).

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Diagnoses Some nursing diagnoses for bacterial meningitis include: Risk for infection related to hematogenous dissemination of pathogen, stasis of body fluids, suppressed inflammatory response, and exposure of others to pathogens. (Doenges, Moorhouse, & Murr, 2011). Risk for ineffective cerebral tissue perfusion related to cerebral edema altering or interrupting cerebral arterial or venous blood flow, hypovolemia, and exchange problems at the cellular level. (Doenges, Moorhouse, & Murr, 2011). Acute confusion related to fluctuation in level of consciousness. (Doenges, Moorhouse, & Murr, 2011). Hyperthermia related to the infectious process and dehydration. (Doenges, Moorhouse, & Murr, 2011). Acute pain related to inflammation or irritation of the meninges and risk for injury related to altered level of consciousness. (Doenges, Moorhouse, & Murr, 2011). Planning After the nurse has identified nursing diagnoses they will then plan patient goals. (Ackley & Ladwig, 2010). The client will be free from infection and isolation procedures will be initiated. (Ackley & Ladwig, 2010). The client will demonstrate appropriate cognitive function and will be oriented to person, place and time. (Ackley & Ladwig, 2010). The client will be free from fever and report a pain rating on a scale from one to ten of less than three. (Berman & Kozier, 2008). Nursing Interventions The nurse will administer antibiotics as prescribed, monitor ABGs and vital signs, assist in mechanical ventilation, (perform suctioning), monitor fluids (both intake and output), monitor the patients IV site, and assist in fever reduction by administering antimetics. (Burnet, Huntley, & Kemp, 2007). The nurse will provide comfort measures like dimming the lights, promoting a

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quiet environment, and assisting the patient into a side lying position with no pillow. (Burnet, Huntley, & Kemp, 2007).The patient will be on isolation precautions until 24 hours after antibiotics are started. (Brunner & Smeltzer, 2010). The nurse will provide safety by instituting seizure precautions and reduce confusion by reorienting the patient. (Brunner and Smeltzer, 2010). Patients and families should be taught the importance of meningococcal vaccinations. (Brunner and Smeltzer, 2010). Evaluation The nurse will evaluate the effectiveness of the treatment by assessing for decreased neurological symptoms, a decrease in fever, normal vital signs, and adequate hydration. (Rocchiccioli & Strunk, 2010). Diagnostic Tests The diagnostic testing for bacterial meningitis includes a blood culture, computed tomography (CT) scan and a lumbar puncture. (Donovan, 2010). A blood culture is obtained through venous puncture and specimens are analyzed for the presence of bacteria. (Malarkey & McMorrow, 2006). If bacteria is found a susceptibility test may be done in order to determine the proper antibiotic or antimicrobial medication to be used. (Marlarkey & McMurrow, 2006). The procedure is explained to the client and the nurse provides reassurance to help limit anxiety, the patient is instructed to apply pressure to the puncture site for 2 to 5 minutes or until the bleeding stops. (Marlarkey & McMurrow, 2006). A CT scan or magnetic resonance imaging (MRI) is done before the lumbar puncture in order to detect a shift in brain contents. (Brunner and Smeltzer, 2010). It is used to rule out other causes of neurological changes, assess for hydrocephalus and show meningeal enhancement. (Burnet, Huntley, & Kemp, 2007). The nurse alleviates anxiety by explaining the procedure to

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the patient. The nurse assesses for allergies to iodine or shellfish and explains that the patient may feel a sensation of warmth with the injection of dye or contrast medium. (Marlarkey & McMurrow, 2006). If an intravenous contrast medium is being used the patient must discontinue all food and fluids 4 to 8 hours before the test. The patient is instructed to remove all clothes, jewelry, and other metal objects and is instructed to remain still during the scan. (Marlarkey & McMurrow, 2006). A lumbar puncture and cerebrospinal fluid (CSF) analysis is done to obtain a sample of the cerebrospinal fluid for microbiologic analysis. (Marlarkey & McMurrow, 2006). The sample needs to be examined for white blood cells, tested for total protein and glucose concentrations and sent for a Gram stain. (Donovan, 2010). In meningitis a CSF analysis will show low glucose, high proteins levels, and a high white blood cell count. (Brunner and Smeltzer, 2010). Gram staining of the CSF will determine the causative agent and initiation of the appropriate antibiotic therapy. (Donovan, 2010). Antibiotics should be started prior to CSF culture results especially is meningeal symptoms are present. (Burnet, Huntley, & Kemp, 2007). The physician is responsible for explaining the procedure to the patient and obtaining written consent. (Marlarkey & McMurrow, 2006). The nurse assists the patient into a lateral recumbent position with his or her back at the edge of the examination table and helps the client to remain still during the procedure. (Marlarkey & McMurrow, 2006). After the procedure the nurse assesses vital signs, the patients level of consciousness, and the puncture site for swelling, redness, bleeding, and leakage of cerebrospinal fluid. (Marlarkey & McMurrow, 2006). The client is also instructed that a spinal headache may occur, the client is allowed to rest and may be instructed to lie flat after the procedure; prescribed pain medication may also be administered. (Marlarkey & McMurrow, 2006).

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Community Resources Independent Nursing Care, LLC is a community resource outreach group located at 1038 Davis Rd. West Falls, NY 14170. Their mission and purpose is to complete your circle of care by promoting, maintaining, and restoring overall good health, and well being for the entire community- at home, at work, and away. They believe that an important part of healthcare is regular health screenings and immunizations. Independent Nursing Care, LLC is a provider of important vaccinations that contribute to the overall health and well being of individuals within our community. One of the many immunizations they provide includes meningococcal. This is beneficial to patients because vaccinations are either free of charge or reduced in fee. The organization travels around the community offering immunization clinics. If one cannot travel to the clinic sights the organization has a toll free number where one can set up an appointment for a screening and vaccination. Meningitis Angels is a nonprofit organization founded in memory of Ryan Wayne Milley, the only child of Bob and Frankie Milley. Ryans life was taken at age 18, as a result of meningococcal meningitis. The organization provides education to the public, health professionals, child care facilities, schools and universities on not only meningitis but other preventable diseases. They provide information though personal stories, educational brochures, posters and videos. Meningitis Angels is dedicated to support of victims of bacterial meningitis and their families. While helping the family cope with the loss or care of a family member they also offer some hands of support for those children affected with bacterial meningitis. The website offers a forum that acts as a support group. People share their stories, others offer support, some ask

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questions, and others mourn together the loss of their loved ones. The site gives facts about the disease, they offer educational material like brochures and posters, and also list other diseases that can be avoided thanks to vaccinations. Support groups play an important role in healing. When a patient has suffered from meningitis they often experience lasting effects of the disease. An online forum allows them to find support and comfort from others in the same situation. It also allows those who have lost loved ones to meningitis to come together and offer each other support. Meningitis.org is a website filled with thorough information about meningitis. The sight has a symptom checker, offers material about awareness and education, and provides a 24 hour helpline where a nurse will answer your questions. There are links for health professionals and information about vaccines. You can read about the research that is being done and even join a support group. This website would be a great way for a patient to learn more about their disease, ask questions and obtain information about vaccines that they may not have gotten. It also will link the patient up with healthcare providers and clinics in order to receive the vaccination. Conclusion Meningitis is a preventable disease that affects 1,500 people in the United States every year. Of those affected 11% will die from the disease. It is a devastating disease and can result in long term disability for a patient. The nurse is responsible for assessing a suspected case and recognizing signs of the disease. The nurse initiates treatment immediately and watches for complications from the disease like shock and respiratory failure. The nurse cares for the patient during diagnostic procedures and is an advocate for the patient and their family. Nurses in the community can promote preventive measures for this disease by encouraging their patients to be vaccinated. Prevention and early interventions can save a patients life.

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