MENINGITIS




Overview

                    Meningitis comes from Greek ward “meninx” which means membrane. So Meningitis means inflammation of the meninges which is the protective covering of the brain.

Incidence:-

  • Among new born 20-30% may die from bacterial meningitis.
  • Risk is lower in older children.
  • It raise again in adult hood.
  • Untreated bacterial meningitis has a mortality approaching 100%.
  • The main problem are deafness (14%) & cognitive impairment (10%)

Route of entry in CNS:-

  • Skull or back bone fracture.
  •  Medical procedure
  • Along peripheral nerve
  • Blood or lymphatic system.
Types of meningitis:-

  1. Bacterial Meningitis
  2. Viral Meningitis
  3. Fungal Meningitis

1.      Bacterial meningitis :-.

v  It also known as septic  meningitis.

v  The main causative organism are streptococcus pnemoniae, Neisseria meningitis, Hemophililus influenza, mycobacterium Tuberculai.

2.      Viral meningitis:-

v  It is also known as aseptic meningitis. It is more commonly found but less serious.

v  No specific treatment available , patient recover completely by their own.

v  It occur secondary to cancer or having weakened immune system.

v  Causative organism:- Entero virus, Adeno virus, Arbovirus, Measles virus, Herpes simplex virus.

3.      Fungal  Meningitis:-

v  It is much less common then the other two infections.

v  It is rare in healthy peoples but it is more likely in persons who have impaired immune system.

Risk Factors:-

v  Tobacco use

v  Viral RTIs.

v  Systemic infection

v  Otitis media & mastoiditis:- Here bacteria cross epithelial membrane & enter the sub arachnoid space.

v  Impair immune system.

v  Over crowding

v  Seasonal:- Winter. Spring.

Clinical Manifestation:-

  • Neck immobility( Nuchal rigidity):- A stiff & painful neck when attempting flexion of head due to spasm of muscle in the neck.
  • Positive kerning sign:- When patient is lying with the thigh flexed on the abdomen , the leg cannot be completely extended.
  •  Positive Brudzinski Sign:- When patient neck is flexed, there is flexion of the knee & hips.
  •  Photophobia:- Extreamly sensitive to light.
  • Patecheal rashes with perpuric lesion to large area of ecchymosis.
  • Disorientation & memory impairment.
  • Lethargy, unresponsiveness & coma.
  • Seizure
  •  Increase ICP & hydrocephalus
  • Brain stem herniation cause cranial nerve dysfunction.
  • Fever
  • Excessive purpuric lesion over face & extremities
  • Shock
  •  Death


Pathophysiology:-

Due to etiology

Micro organism enter the blood stream

Cross the blood brain barrier

Proliferation in CSF

Inflammation of the meninges

Increase ICP

Diagnostic evaluation:-

  • CT Scan & /MRI:- To detect herniation of brain content.
  • Bacterial culture & gram staining of blood & CSF for rapid diagnosis of bacteria.

v  Lumber Puncture:-

                                      Normal                             Bacterial                         viral                  fungal

·         Volume-                        5-20                                  >30                               Normal

·         Appearance:-               Normal                               Turbid                           Clear                Fibrin web   

·         Protein                        18-45                                       >/ 80                              <40

·         Glucose                     45-80                                5-40                               > 45                      <40

·         Neutrophil                    0                                 >/80                                    <40            

·         WBC:-                          0-5                          100-5000                          </250                  >200

Prevention:-

  • Wash hand thoroughly before eating
  • Maintain immune system by enough rest, diet & exercise.
  • Cover mouth when sneeze
  • Take vaccination Like :-
  • Haemophilus influenza type b(Hib) vaccine
  •  Pneumococcal conjugate vaccine:- 2 yr baby who  are at risk of pneumococcal disease, heart disease.
  • Meningial conjugate vaccine:- (11-12 yrs) single dose, booster in 16 yrs.

Management:-

1.      For bacterial Meningitis:-

·         Third generation cephalosporin such as cephalosporin or ceftriaxone.

·         Vancomycine is added in the regimen in case of resistance

·         Dehydration & shock can be treated with fluid therapy.

·         Phenytoin for seizure management

·         Anti tubercular therapy should be started – isoniazid, rifampicin, pyrazinamide & streptomycin.

·         In case of children BCG vaccine offer for protective effect.

2.      For viral meningitis:

·         Treatment is supportive only & no medication given for meningitis.

·         Seizure prophylaxis like lorazipam or phenytoin etc.

·         For Increase ICP provide manitol 1g/kg followed by 0.25, 0.5g/ kg & dexamethaxone.

·         Increase of hydrocephalus VP or LP shunt is required.

·         Adequate hydration to be maintained

·         Antipyretics

·         Antiemetic

Nursing Management:-

ASSESSMENT:- Assess the vital sign, neurologic evaluation, fluid I/O, evaluation of lungs & skin

NURSING DIAGNOSIS:-

  • Acute pain related to headache & muscle ache as evidenced by general discomfort of head, joint & muscle movement.
  • Hyperthermia related to infection & abnormal temperature regulation by hypothalamus from increase ICP as evidenced by Increase body temperature.
  • Disturbed sensory perception related to altered cognitive function as evidenced by in accurate interpretation of environment, sign of anxiety or fear.

1.      Acute pain related to headache & muscle ache as evidenced by general discomfort of head, joint & muscle movement.

INTERVENTIONS:-

  • Assess the patient pain level by using the face pain scale to know intensity of pain.
  • Provide optimal pain relieve with prescribed analgesic to relieve pain.
  • Use non pharmacological therapy like massage or divertional therapy.
  • Reduce or eliminate the factor which increase pain, ex-  fear.
  • Control environmental factor which increase pain like- room temp, lightening, noise.

2.      Hyperthermia related to infection & abnormal temperature regulation by hypothalamus from increase ICP as evidenced by Increase body temperature.

INTERVENTIONS:-

  • Monitor the body temperature frequently.
  • Monitor the vital sign to evaluate the effect of hyperthermia.
  • Monitor I/O chart because increase body temperature may cause fluid volume deficit.
  • Encourage fluid intake to maintain fluid balance.

3.      Disturbed sensory perception related to altered cognitive function as evidenced by in accurate interpretation of environment, sign of anxiety or fear.

INTERVENTIONS:-

·         Monitor neurological status on an ongoing basis to determine extent of problem.

·         Administer medication to reduce anxiety & fear.

·         Provide low stimulation environment to decrease over stimulation.

·         Approach patient slowly & from front to avoid stimulating & frightening patient.

·         Reorient the patient with each interaction to reduce anxiety.

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