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TYPES OF MENINGITIS

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Meningitis is either infectious (contagious) or non infectious. Infectious meningitis


is classified as viral, fungal or parasitic depending on the type of organism causing
the infection.

INFECTIOUS MENINGITIS:

1) Viral meningitis; - also called aseptic meningitis and the most type in children.
Most cases of viral are relatively mild with symptoms of headache, fever and
general ill feeling and those affected recovers 0without medical treatment and
unusually it can become life threatening. Viral meningitis is not usually associated
with septicemia; antibiotics are ineffective against viruses so treatment is
normally limited to easing the symptoms of the disease.

Many different viruses can cause viral meningitis; the most common causes are;

• Enteroviruses (viruses that can live in the cell lining our intestines, noses, and
throat) account for most cases of viral meningitis.
• Herpes viruses can cause meningitis or encephalitis, herpes meningitis is not
usually serious but it can recur (Belfast, 2011).
2) Bacterial meningitis-: Belfast 2011, explained that meningitis caused by
bacteria are usually more serious than other forms, there are at least- 50 kinds of
bacteria that can cause meningitis septicemia but the main types are;

Meningococcal bacteria (Neisseria meningitides) can cause meningitis the


disease can . affect anyone of any age but mainly affect babies, preschool children
and young people. Meningococcal meningitis is a life threatening disease but most
people recovers if properly treated. Meningitis research foundation (2011)
revealed that meningococcal infection has an important cause of illness globally
there was an estimated 1.2millon cases and 135,000 deaths worldwide each year.
In Africa alone epidemic can cause more than 100,000 cases of meningitis and
10,000 deaths in a single year (Bristol 2011).
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Pneumococcal bacteria (streptococcus pneumonia) are the second biggest cause of


bacterial meningitis. Pneumococcal meningitis occurs when the bacteria that have
invaded the blood stream move across to infect the meninges. The meninges are
filled with a liquid called cerebrospinal fluid and they release their poison causing
inflammation -and swelling in the meninges, brain and spinal cord.

3) Haemophilus influenza type b (HIB) meningitis: Not until the introduction of


HIB vaccine, it was the main form of meningitis in young children under four years
of age. Nowadays, HIB is rare in all age group.

Escherichia coli is caused by bacteria which grows in the bodies of healthy


people but some common strains can cause serious disease, it occurs mostly in
newborn babies, under three month babies or in older children who have a health
problem that suppresses their immune system or through head injuries through
which the bacteria enters.

4) Fungal meningitis: Fungal meningitis usually develops in patient with condition


that compromises the effectiveness of their system. Examples are HIV/AIDS,
lupus erythematos. Fungal meningitis occur in 10% of patient with AIDS (Stanley,
2012)
5) Parasitic meningitis: Parasitic meningitis is common in underdeveloped
countries and usually caused by parasites found in contaminated water, food, e.t.c
NON INFECTIOUS MENINGITIS

Non-infectious meningitis may develop as a complication of another illness such as


mumps, tuberculosis and

MODE OF TRANSMISSION

Meningitis is transferred by saliva, nasal mucous or sputum, common modes of


transmission includes contact through;
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■ Coughing
■ Sneezing
■ Kissing
■ Sharing water bottles, drinking glasses or eating utensils
■ Poor or improper hygiene.
■ It is transmitted through the air via droplets of respiratory secretions from an
infected person. Intimate or direct- close personal contact with an infected
individual within seven days can place an individual at risk of contacting bacterial
meningitis. Bacterial meningitis starts as an infection of the oropharynx and is
followed by meningococcal septicemia which extends to the meninges of the brain
and upper region of the spinal cord.

ANATOMY AND PHYSIOLOGY OF THE MENINGES

The meninges are protective coverings of the brain (cranial meninges) and spinal
cord (spinal meninges). They consist of three layers of membranous connective
tissue’

The Dura mater,

The Arachnoid mater


The Pia mater.

.
The Dura and Arachnoid maters are separated by a potential space, the subdural

space. The Arachnoid and Pia mater are separated by the subarachnoid space
containing cerebrospinal fluid.
THE DURA MATER
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It is the outermost, inelastic and consists of two layer of dense connective


fibrous tissue. The outer layer takes the place of periosteum on the inner surface
of the skull bones and the inner layer provides a protective covering for the brain.
There is a potential space between the two layers except where the inner sweep
inward between the cerebrum and cerebellum to form the tentorium cerebella.

In the spinal area the Dura mater form a loose sheath around the spinal
cord, extending from the foramen magnum to the second sacral vertebrae
thereafter it encloses the filum terminate and fuses j with the peritoneum of the
coccyx.

THE ARACHNOID MATER

This is layer of fibrous tissue that lies between the Dura and Pia mater. It is
separated from the Dura mater by the subdural space, and from the Pia mater by
the subarachnoid space containing cerebrospinal fluid. The Arachnoid mater
accompanies the inner layer of the Dura in the formation of falx cerebri, tentorium
cerebella, and falx cerebelli. It continues downwards to end by merging
with Dura mater at the second sacral vertebrae.
THE PIA MATER

This is a delicate layer and the innermost layer of connective tissue containing
many minute blood vessels. It adheres to the brain, continues downward
surrounding the spinal cord. Beyond the cord continues the filum terminale, and
then goes on with the Dura mater to fuse with the periosteum of the coccyx.

FUNCTIONS OF THE MENINGES

• Primarily, they protect the delicate nerve tissue of the brain and spinal cord and
blood vessels to the brain.
• They serve as a shock absorber for the brain and spinal cord.
• They assist in the secretion and absorption of cerebrospinal fluid.
• They contain blood vessels that are responsible for nourishing the brain.

VENTRICLES OF THE BRAIN

Within the brain, there are four irregular shaped cavities or ventricles
containing cerebrospinal fluid. They are;

Right and left ventricles (lateral),

Third ventricle,

Fourth ventricle.

The lateral ventricles; these cavities lie within the cerebral hemispheres one on
each side of the median plane just below the corpus callosum, they are lined by
ciliated epithelium. They communicate with the third ventricle by interventricular
foramina or foramen of monro.
Third ventricle; this cavity is situated below the lateral ventricles between the tw o
part of the thalamus; it communicates with the fourth ventricle by a canal, the
cerebral aqueduct or aqueduct of sylvus.

Fourth ventricle; it is a diamond-shaped cavity situated below and behind the


third ventricle between the cerebellum and Pons. It communicates with the
subarachnoid space through these opening foramen of magendie and foramen of
lushka.

THE CEREBROSPINAL FLUID

The cerebrospinal fluid is a clear, colourless, bodily fluid that occupies the
subarachnoid space and the ventricular system around and inside the brain and
spinal cord. It acts as a cushion for the cortex providing a protection to the inside
of the skull. It is produced by the choroid plexus.

Cerebrospinal fluid is produced in the brain by modified ependymal cells in the


choroid plexus, then secretes into the lateral ventricles then moves through the
foramen of monro to the third ventricle, after the third is filled it moves to the
fourth ventricles through the aqueduct of sylvus (cerebral aqueduct). The fourth
ventricle then secrete the cerebrospinal fluid into the subarachnoid space through
the foramen of magendie and foramen of lushka to supply the brain and spinal
cord, the cerebrospinal fluid is reabsorbed into venous circulation via the Arachnoid
villi.

The cerebrospinal fluid is produced at a rate of 500ml per day since the brain
can contain only 235-150ml; large amounts are drained primarily into the blood
through the Arachnoid villi (midha, 2003).

CONSTITUENTS OF THE CEREBROSPINAL FLUID

• Water
• Mineral salts
• Glucose
• Plasma protein
• Creatinine and urea in small amount
• A few electrolytes.

FUNCTIONS OF CEREBROSPINAL FLUID

• It supports and protects the brain and spinal cord.

• It maintains a uniform pressure around these delicate structures.

• It acts as a cushion and shock absorber between the brain and the cranial
bones.

• It keeps the brain and the spinal cord moist and permits the interchange of
substances between the cerebrospinal fluid and cells such as nutrients

PATHOPHYSIOLOGY OF MENINGITIS

The meninges act as a protective covering preventing the microorganisms from

infecting the brain and spinal cord. Whenever any of the infectious agents (i.e.
bacteria, virus, fungus, parasite) or secondary to other infection such as otitis
media, upper respiratory infection or pneumonia enters the central nervous
system from the nasopharynx and via respiratory tract either through the blood
stream or direct spread from adjoining structures results in inflammatory response
in the meninges leading to meningitis, once the infection spreads to the ventricles
of the brain it starts to secrete more

cerebrospinal fluid in an attempt to flush out the infectious agents and toxins, this
leads to increase cerebrospinal fluid production and circulation within the brain
and spinal cord.
The body tries to fight the infection; blood vessels become leaky and allow
fluid, white blood cells to enter the meninges and brain, this causes brain swelling
and eventually leads to decreased blood flow to part of the brain (Amanda 2011).

Presence of infection in the cerebrospinal fluid makes it appear purulent and


cloudy, the cloudiness and increased volume of cerebrospinal fluid invariably
increases intracranial pressure and increases blood pressure which could also
result to headache and patient being irritable, organism present in some centre in
the hypothalamus can also manifest some symptoms on the reflex leads to
vomiting, on the heat regulating centre leads to pyrexia resulting to fits in adults
and convulsion in children on the visual centre leads to photophobia.

SIGNS AND SYMPTOMS OF MENINGITIS

Fever is when the body temperature is higher than normal or usual. It is


common in both bacterial and viral meningitis.

It is only possible to distinguish between bacterial and viral meningitis by


carrying clinical test because it is not easy to tell from symptoms alone.

BACTERIA MENINGITIS

It is more serious form of the condition; the symptoms usually begin suddenly
and rapidly get worse.

Early warning signs;


• Pain in the muscles, joints or limbs such as in the leg or hand,
• Unusual cold hands and feet or shivering,

• Pale skin or blue lips.


Early symptoms: severe headache, fever, nausea, vomiting, feeling generally
unwell.

Later symptoms:
• Drowsiness,
• Confusion,
• Seizure or fits,
• Photophobia,
• Neck stiffness,
• Rapid breathing rate,
• A blotchy red rash.

In babies and young children with bacterial meningitis possible symptoms include:

• Becoming floppy and unresponsive or stiff with jerky movement,


• Unusual crying,
• Becoming irritable and not wanting to be held,
• Vomiting,
• Loss of appetite,
• Pale and blotchy skin,
• Very sleepy with a reluctance to wake up,
• Some babies develop swelling or bulging fontanels.
VIRAL MENINGITIS
Most people with viral meningitis will have mild flu-like symptoms as
described by Dublin

(2011) includes; headache, fever, generally not feeling unwell.


In severe cases neck stiffness, muscle or joint pain, diarrhea, photophobia,
nausea and vomiting.
Burke Karen (2011), explained two positive signs of meningeal irritation, these
are brudzinski’s sign and kerning’s sign.
In brudzinski’s sign when the client’s neck is flexed, the knees and hips also flex
while in kerning’s sign there is an inability to extend the leg when the hip is flexed
at 90 degree angle.

Nurses lab 2012 discussed the presentation of cerebrospinal fluid with bacterial
meningitis below;-

 Moderately elevated cerebrospinal pressures,


 Elevated cerebrospinal protein level (normal 15-45mg/dl),
 Decreased cerebrospinal glucose level (normal 60-80mg/dl),
 Elevated white blood cell count.

DIAGNOSTIC PROCEDURE.
Burnet (2007), explained different diagnostic technique for the detection of
meningitis;

• Imaging studies; - computed tomography scan and magnetic resonance


imagining (MRI) can be done to rule out other sources for neurological changes
while chest x-ray may be done to identify pneumonia or any secondary fungal
infection.
• Blood test; - to check for the presence of bacteria or viruses that can cause
meningitis.
• Complete blood cell count with differential which may show leukocytosis.

• Serum glucose which may be drawn as a baseline determination for normal


cerebrospinal fluid Glucose
• Liver function test to assess renal and hepatic function in order to identify
need to adjust antibiotic dosage.
• Cultures from the blood, urine, throat, nasal passage and drainage from
wounds for diagnosis of specific microorganism and the source of infection.
• Culture and sensitivity and gram stain of the cerebrospinal fluid can identify
the bacteria or virus causing meningitis.
• Lumbar puncture is done to collect samples of cerebrospinal fluid. The
followings indicates a positive diagnosis of bacterial meningitis; cerebrospinal
fluid appears cloudy, elevated protein level and white blood cell count,
decreased glucose level and elevated cerebrospinal fluid pressure (Burke
2011).

NURSING RESPONSIBILITIES FOR LUMBAR PUNCTURE

> Explain to the patient the purpose of the lumbar puncture,


> Obtain informed consent before the procedure, ,
> Assemble the necessary equipments; sterile tray containing sterile gloves,
local anesthetic and solution,
> Ask the patient to empty his/her bladder
> Position the patient, lateral recumbent at the edge of the bed, knee drawn
up to the abdomen and chin tucked to the chest.
> Help patient maintain the position, the nurse places her hand behind the
patient’s knees to help support the patient’s position throughout the procedure.
> Ensure an aseptic technique is maintained throughout the procedure.
> Ensure all specimen bottle are labeled correctly such as gram stain, cell
count, culture and sensitivity, protein and glucose.
> The entire procedure will last approximately for 15minutes then apply
pressure to the area briefly and apply a firm dressing.
> Monitor patient vital signs.

AFTER THE PROCEDURE

> Send the cerebrospinal fluid specimen to the laboratory immediately.

> Instruct the patient to lie flat for several hours to reduce chances of
headache.
> Monitor the patient carefully following the procedure for adverse effect such
as vertigo, tinnitus, fever, respiratory distress.
> Administer to patient increased fluid for at least 24hours after the procedure.
> Ensure the comfort and safety of the patient.
> Record the procedure in the patient’s chart (haven 2006).

MANAGEMENT OF ENINGITIS NURSING MANAGEMENT

> Collect comprehensive history then admit in an isolated room in order to


reduce noise stimulation and the room should be dimly lighted.
> Be alert for a temperature increase up to 38.9 degree Celsius to prevent
onset of seizure or convulsion.
> Assess neurological function often; observe level of consciousness and signs
of increased intracranial pressure.-
> Monitor fluid balance, maintain adequate fluid intake to avoid dehydration but
avoid fluid overload because of danger of cerebral edema.
> Monitor patient’s vital signs regularly.
> Maintain adequate nutrition and elimination, give small frequent meals or to
supplement meals with nasogastric tube to prevent constipation and minimize
the risk of increased intracranial pressure resulting from straining at stool, give
the patient a mild laxative or stool softener.
> Ensure the patient’s comfort, nurse patient in a quiet environment and
darkened room to decrease photophobia and relieve headache.

> Position patient carefully to prevent joint stiffness and neck pain, turn him
according to planned positioning scheduled and assist with range of motion
exercise.
> Give mild laxative or stool softeners to minimize straining at stool.
> Provide psychological support; reassure andreorient patientif confused about
the condition.
> Drug administration; ensure appropriate administration of drug and educate
patient concerning the adverse effect of intravenous antibiotics.
> Physical care; nurses should provide.

MEDICAL MANAGEMENT

In a study by nordquist, (2009), it was stated that meningitis treatment


usually depends on four main factors;

• The age of the patient,


• The severity of the infection,
• What organism is causing it?
• Are other medical conditions present?
Empirical therapy in bacterial meningitis include; cephalosporin’s, rifampin and
vancomycin. The empirical use of penicillin or ampicillin in the treatment of
central nervous system infection is avoided because of the beta-lactamase-
producing haemophilus influenza and neisseria meningitides. It is believed that
cephalosporin is more potent against the beta-lactamase organism (Horn
2009).

The treatment of severe‘meningitis (pharmacological) includes the following


group.
1. Antibiotics; the use of antibiotics has reduced the death rate to less than
5% for all types of bacterial meningitis usually administered intravenously by
injection such as the third generation cephalosporin( e.g. ceftriaxone).
2. Corticosteroids; if the patient’s meningitis is causing pressure in the brain,
corticosteroids such as dexamethasone may be administered.
3. Antipyretics; it is effective in regulating the heat centre in the
hypothalamus so as to bring the temperature down, example acetaminophen.
4. Anticonvulsant; if the patient has fits (seizures) he/she will be given an
anticonvulsant such as phenobarbitone in order to reduce the transmission of
impulses into nerve cell.
5. Oxygen therapy; if patient has breathing difficulties, oxygen therapy is
given.
6. Fluid control; dehydration is common for patients with meningitis therefore
dehydration needs to be prevented.
7. Sedatives are given to parents that are restless or irritable.

Common medications used in the treatment of meningitis are the following;

Cephalosporin is the third generation group of antibacterial drug.

CEFTRIAXONE (rocephine)
Group; it is an antibiotic
Mode of action; it inhibits the synthesis of bacterial cell wall mitosis and
growth of bacterial Indications; infectious fever, meningitis, urinary
tract infections e.t.c Route of administration: intramuscularly,
intravenously.
Dosage: 1-2g daily or 500mg-lg twice daily.
Side effects: diarrhea, abdominal pain, mouth soreness, body rashes, and
pruritis.
Contraindication: history of hypersensitivity to penicillin.
Nursing responsibilities:
• Find out if patient is hypersensitive

• Encourage copious fluid intake

ACETAMINOPHEN (Paracetamol)

Group; it is an analgesic and antipyretic drug

Mode of action; it alters the response of heat regulating centre in the


hypothalamus and raises pain threshold.

Indication; headache, joint pains, muscle aches.

Route of administration; orally


Dosage; adult 2 tablets three times daily, children( 7-12 years) ½ - 1 tablet
three times daily,( 1 year) ½ teaspoon syrup. *.

Side effects: skin rashes, liver damage, and leucopenia.

Contraindications: hypersensitivity to paracetamol, liver disease, renal


impairment and glucose -6- phosphate dehydrogenase deficiency.

Nursing responsibilities:

• Avoid overdose in patient


• It should not be given to patient hypersensitive to it.
DEXAMETHASONE (Decadron)
Group; it is a corticosteroid (glucocorticoid) and an anti-inflammatory drug.
• Mode of action: it suppresses inflammation by decreasing the release of
prostaglandin precursor from cells thereby reducing pain, swelling and stiffness
• It stimulates the heart rate.
• It serves as a replacement therapy in Addison’s disease.
Dosage; 0.5-15mg daily, for cerebral edema 2mg twice or thrice daily Route
of administration: orally
Indications: cerebral edema, bronchial asthma, shock.
Side effects: hypertension, tingling sensation, prolong bleeding, dyspepsia,
petechiae Contraindications: systemic fungi infection, avoid in those
receiving live virus vaccine.
Nursing responsibilities:

• Give with meal or milk to reduce gastrointestinal upset.


• Teach patient to report early signs of fatigue, muscular weakness or joint
pain.
• Ensure intramuscular injection is given deep into gluteal muscle rotate site.
• Educate patient on the action of the drug and expected side effects
PHENOBARBITONE
Group; it is long acting barbiturate and anticonvulsant drug
Mode of action; it reduces the transmission of impulses into nerve cells
Indications; epilepsy, febrile convulsion
Dosage; 30-120mg twice or thrice daily
Route of administration; orally, intramuscularly, and intravenously
Side effects: hypotension, insomnia, skin rashes, ataxia, respiratory distress,
irritability.
Contraindications; pregnancy, lactation, hepatic and renal diseases
Nursing responsibilities:
• It should not be given intravenously since it may cause respiratory arrest or
hypotension.
• It should be used with caution in old people, renal, hepatic impairment
patient
• It must not be taken with alcohol to avoid serious central nervous system
depression
• Monitor vital signs
DIAZEPAM (Valium)

Group; benzodiazepines

Mode of action; it sedates the central nervous system and also relaxes the
muscles thereby producing anticonvulsant, anti-anxiety and muscle relaxant
effect

Indications; insomnia, tetanus, convulsion, agitation

Dosage: usually 2-5mg thrice daily, children 2.5-5ml (l-2mg) orally.


Route of administration: orally, intramuscularly
Side effects: sleepiness, skin rashes, dizziness, hypotension, headache,
fatigue.
Contraindications: known allergy to benzodiazepine, pregnancy, respiratory
failure.
COMPLICATIONS OF MENINGITIS
It is estimated that quarter of people with meningitis will have complications
but can vary in severity (Angel 2011). Possible complications include;

 Hearing loss which may be partial or total.


 Problem with memory and concentration Coordination and balance problem
Hydrocephalus Learning difficulties
 Epilepsy; a condition that causes an individual to have repeated fit
 Cerebral palsy; a general term for a set of conditions that affects movement
and coordination Speech problem
 Vision loss which may be partial or total.
PREVENTION OF MENINGITIS

There are a number of vaccines that can prevent many cases of viral and
bacterial meningitis, they include;
• The measles, mumps and rubella vaccination
• Give meningococcal vaccine to children
• Give haemophilus influenza type b, diphtheria, whooping cough, tetanus and
polio vaccine.
• Pneumococcal conjugated vaccine (PCV) for children should also be given.

The centre for disease control and prevention (2007), recommends the
meningococcal vaccine

for;

• All children and adolescent age 11 through 18


• Scientist routinely exposed to meningococcal bacteria.
• Anyone with damaged spleen or who has had his/ her spleen removed.
• Anyone having or living in the part of the world where the disease is common
• Anyone who has immune system disorder
• But it should be noted to be contraindicated in any who has a severe allergy
function to any vaccine component.
PROGNOSIS OF MENINGITIS

Stanley (2012) stated that bacterial meningitis is fatal in as many as 25% of


cases.

Patient with meningitis that is caused by streptococcus pneumoniae and


patient younger than 2 years old or over 60 years of age have poor
prognosis. Prompt medical treatment reduces the risk of death to less than
15%.

Viral meningitis usually resolves in 7-10 days and is fatal in less than 1%
cases
CHAPTER THREE

PATIENT’S IDENTIFICATION
Name; master E.J
Age; 6years old
Sex; male
File number; 0237433
Address; P. 212 Oromu street kayanfada Ilesha
Ethnicity: Yoruba
State of origin: Ondo state
Date of birth; 13/11/2007
Next of kin: Mrs. Joseph
Relationship: mother
Address of next of kin: P. 212 Oromu street kayanfada Ilesha
Nursing officer in charge: ADNS A.
Consultant: Dr A.
Diagnosis: bacterial meningitis

Date of admission: 20/07/2014

Date of discharge: 1/08/2014.

Religion – Christianity

Ward, Children Isolation Ward


Informant - Mother
Cerebrospinal fluid analysis:

■ Cerebrospinal fluid
glucose
■ Cerebrospinal fluid
protein
Cerebrospinal fluid shows hypoglycorrhachia with
elevated protein level
Cerebrospinal microscopic culture and sensitivity:
Gram positive diplococcic and numerous pus cells,
lymphocyte, polymorph Appearance- cerebrospinal fluid
appears turbid and cloudy.
Reflex examination:
* Kerning’s sign - positive
* Brudzinski’s sign - unequivocal

* Pupil is 3mm bilaterally reactive to light.

NURSING MANAGEMENT

Admission: patient is admitted to a quiet and cool environment with a dim


light in place in order to reduce photophobia and headache, other appropriate
history were collected. He was made comfortable on bed.

Observation: vital signs were observed 6hourly, the temperature was done
frequently because of fever in order to take prompt interventions (tepid
sponging) to prevent convulsion of the child.

Position: the patient was placed on the bed lying supine with the bed
elevated by 30 degrees to promote venous return.
Maintaining fluid and metabolic status: he was placed on 4.3% dextrose
saline 1500mls over 24hours at 15drops/minute + 5ce vitamin B complex into
each pint, flow rate was maintained. High calorie and protein diet was
prescribed and patient was encouraged to eat.

Drugs: administration of the appropriate prescribed drugs was ensured, the


right drug, right patient, right dosage, right route and right documentation
during administration of drug was established.

Psychological care: patient’s mother was given psychological care and


reassured that the presentation of her child is the sign and symptoms of the
infection which will resolve with time as it was earlier discovered and brought to
the hospital for treatment and drug compliance “antibiotics” will help resolve the
infection.

Physical care: due to illness and age of patient, he was given an assisted
bathroom bath and oral care. He was made comfortable on bed and mother was
advice to leave patient body exposed during onset of fever as a result of
infection but light clothing was worm at night.
MEDICAL MANAGEMENT
The following drugs were prescribed:
IV ceftriaxone (rocephin) lOOOmg/lg daily,
IV ampicillin 900mg,
Tab acetaminophen
500mg IV mannitol
(45ml) of 20%
Dexamethasone (decadron).
CEFTRIAXONE (rocephin)

Group: antibiotic

Mode of action: it inhibits the synthesis of bacterial cell wall, mitosis and
growth of bacteria “streptococcus pneumonia”. It is used when there is
penicillin resistance.

Indication: serious infection due to sensitive bacteria including septicemia,


pneumonia, meningitis, osteomyelitis and gonorrhea.

Contraindication: cephalosporin hypersensitivity, neonate with jaundice,


hypoalbuminaemia.

Route of administration: intramuscularly and intravenously.

Dosage: adult lg daily and in severe infection 2-4g daily. Infant and children
(under 50kg): 20- 50mg/kg and up to 80mg in severe infections.

Side effects: diarrhea, nausea, and vomiting, abdominal discomfort,


headache, allergic reaction including rashes, pruritis, urticaria, confusion.

Nursing responsibilities:

❖ Give intravenously after diluting in normal saline, dextrose saline or sterile


water for injection as ordered.
❖ Confirm patient is not allergic to penicillin and cephalosporin during use.
❖ Urine production was observed because decrease in amount indicates
nephrotoxicity.
❖ Observation of signs and symptoms of anaphylaxis during first dose.
❖ Vital signs were monitored.
❖ Proper documentation of drug was done.
AMPICILLIN

Group: aminobenzylpenicillin, a penicillin antibiotic


Mode of action: ampicillin is active against certain gram positive and gram
negative organism; they are inactivated by penicillinase an enzyme that is
capable of antagonizing anti bacterial.
Indication: meningococcal infections, streptococcal infections, gonorrhea,
septicemia, mastoiditis.
Contraindication: hypersensitivity to penicillin
Route of administration: intramuscularly, intravenously and orally.
Dosage: adult 1-2g 6hourly, children 900mg 6hourly
Side effects: nausea and vomiting, rashes, diarrhea
Nursing responsibilities:
 Right dose was given through the right route.
 Ampicillin and gentamycin should not be mixed in the same intravenous tube
 Administer intravenous intermittently to prevent vein irritation,
 Mix with sterile water and give directly intravenously
 Advice mother to report immediately if rash, fever, or chills occur.

MANNITOL Group: osmotic diuretic


Mode of action: it elevates blood plasma osmolarity resulting in enhanced
flow of water from tissue including the brain and cerebrospinal fluid into
interstitial fluid plasma; as a result cerebrospinal fluid volume and pressure are
reduced.
Indication: cerebral edema, raised intraocular pressure, increased
cerebrospinal fluid Contraindication: pulmonary edema, intracranial
bleeding, severe dehydration, renal failure.
Route of administration: intravenously
Dosage: 20% solution over 30-60minutes, children 9g mannitol (45ml) of 20%
Side effects: chest pain, fever, chills, dizziness, fluid and
electrolyte imbalance
Nursing responsibilities:
 Give with meals to prevent nausea
 Weigh patient daily
 Monitor intake and output
 Monitor for signs of confusio
NURSING PROGRESS REPORT

Master E.J was admitted on 20lh of January 2014 with the


diagnosis of bacterial meningitis and he was properly managed and
treated till the condition was satisfactory. He had intravenous
infusion of 4.3% dextrose saline 1500ml in 24hours, mannitol 9g
(45ml) of 20% was given over 30minutes then 8hourly for two
doses. Intravenous ceftriaxone lOOOmg daily was administered. He
was placed on normal diet which was served tolerated. He was
allowed to sleep undisturbed during rest. His vital signs:
temperature 38.9°c, pulse 128b/m, respiration 38c/m. he was
exposed to fresh air and tepid sponged lateral position was
maintained.

21st of January

Last dose of mannitol given at 2pm, laboratory result of


microscopic culture and sensitivity shows gram positive cocci,
intravenous ampicillin 900mg 6hourly was prescribed same
.commenced. Result of cerebrospinal fluid shows hypoglycorrhachia
with elevated protein level. He was properly cared for, vital signs;
temperature 38.5°c, pulse 80b/m, respiratory rate 38c/min.

22nd of January

Personal hygiene was taken care of and his bed was made, vital
signs; temperature 37.5°c, pulse 74b/m, respiratory rate 34c/m.

rd
23 of January
Had elevated temperature 38.8°c, he was exposed to fresh air
and tepid sponged. Pulse 112b/m, respiration 26c/m, had due
drugs.
24th of January

Oral and body care was done, oral drugs and food was served and
well tolerated, he slept well during the day and he is to continue the
present management, vital signs; temperature 38.2°c, pulse 98b/m,
respiration 28c/minutes.

25th of January

Fever is subsiding, he has had 6 doses of rocephin, neck stiffness


is resolving, mother complained of the presence of squinted eye and
was reassured vital signs: temperature 37.5°c, pulse 90c/min,
respiration 20c/min.

26th of January

He is gradually improving and no longer irritable; he tolerated


feeding well vital signs temperature 37.4°c, pulse lOOb/min,
respiration 24c/min.

27th of January

His condition is improving; he had his intravenous rocephin 1


OOOmg daily and intravenous ampicillin 900mg 6hourly. Vital signs:
temperature 37.2°c, pulse 96b/min, respiration 24c/min.

28th of January

Intravenous ampicillin 900mg 6hourly was discontinued,


meningitis is resolving, vital signs: temperature 37°c, pulse
74b/min, respiration 22c/min.

29th of January
General condition is stable, meningitis is resolving, reflex is now
normal, he is active and alert. Vital signs: temperature 37.1°c, pulse
76b/min, respiration 20c/min.

30th of January

His condition is now stable, he is now active and alert, meal and
medications were tolerated well, vitamin C, 1 thrice daily and vitamin B
complex 1 twice daily was commenced. Vital signs: temperature
36.8°c, pulse 85b/min, respiration 22c/min.

31st of January

Drugs and meal were served, he was involved in playing with


others, physical and oral care was done, vital signs: temperature
36.5°c, pulse 74b/min, respiration 24c/min

1st of January

He was alert and conscious, reviewed by the managing team and


general condition is satisfactory. He was discharged home after 12
days of admission.

ADVICE ON DISCHARGE

Master E.J was discharged on the 1st of August 2014, but prior
to discharge his mother was given various health information’s which
will contribute to their health.
ACTIVITY AND REST

Mother was encouraged to allow him in little activities within his


tolerance and monitor him closely and also ensure he has enough
rest during the day for at least 1 - 2hours and at night 8-10hours.

DRUG COMPLIANCE

Mother was advised to ensure his drugs were given to him at


the right time and compliance to drug regimen and also to keep
hospital appointment. Tab vitamin C, 1 thrice daily and vitamin B
complex twice daily.

NUTRITION AND FLUID

Normal diet would be beneficial for client, so mother was


advised on the importance of balance or adequate diet with the right
preparation of meal and also fluid intake must be adequate. She was
also advised to give her child fruits and vegetables.

PERSONAL AND ENVIRONMENTAL HYGIENE

In a bid to prevent infection, mother was encouraged to


maintain good persona) and environmental hygiene.

FOLLOW UP VISIT

She was asked to report at the hospital if any complication


arises such as hearing loss, visual loss, cerebral palsy or any signs of
infection. The importance of keeping the appointment date was
stressed.

REHABILITATION
The rehabilitation of patient which is an essential means of
planning programmed, in which it progresses towards maintaining
the maximum level of functioning of which he/she is capable, it
actually starts from the time the patient is admitted to the ward. A
major goal in the treatment of patient after discharged from the
hospital is to reintegrate the patient back to health.
There are five E’s of rehabilitation which include
Encourage: patient and parent need encouragement to adopt a
positive attitude towards the management of the patient.

Education: patient and parent need to understand the illness and


need for gradual improvement and also were educated on drug
compliance and keeping to hospital appointments.

Exercise: moderate and good exercise promote good health as


standing or sitting in one position for hours could cause edema and
cyanosis of the extremities.

Employment: the primary goal is to help patient in keeping his/her


current job or go back to school wherever possible.

Evaluation: frequent evaluations are carried out to see if the set


objectives are met. Where they are not met then the activity
should be changed to meet client’s need.
PREVENTION
 Early identification and prompt treatment of cases in the health
facility and in the community.
 Education of people in the community on the symptoms of meningitis
and treatment of the disease.
 Avoid overcrowding and any close contact with any communicable
disease should be stressed.
 Immunization with meningococcal vaccine in order to prevent
meningitis.
CHAPTER FOUR SUMMARY
Meningitis is an inflammation of the meninges of the brain and
spinal cord. Bacterial meningitis may result from Neisseria meningitidis,
Streptococcus pneumoniae or haemophilus influenza. Organism usually
enters the brain through the blood stream, the respiratory tract or
penetrating wound of the skull or cranial surgery. Most often it could be
secondary to other infections such as otitis media or upper respiratory
tract infection, while viral meningitis also called aseptic meningitis is a
less severe disease than bacterial meningitis.

Master E J, a 6year old boy, conscious and alert, not in any


respiratory distress, febrile an d irritable was admitted on the 20th of
January, 2014 to the isolation children ward via children emergency on
account of fever, neck stiffness, throbbing headache with chills and
rigor, abdominal pain and squinted eye. A sample of cerebrospinal fluid
was sent for analysis which showed an organism “gram positive coccus”
and indicated hypoglycorrhachia with elevated protein, pupil reactive to
light, collective assessment of laboratory test, diagnostic, signs and
symptoms led to her diagnosis meningitis. From admission to day 12 of
hospitalization master EJ significantly improved and was discharged after
treatment with intravenous rocephin, ampicillin, mannitol, and
acetaminophen. On the lbt of February 2014 he was discharged after
rehabilitation, a 6days appointment was given and advice .given prior
discharge was reinforced with a satisfactory response in order to prevent
re-occurrence.
CONCLUSION
Meningitis is a universal phenomenon and can be devastating to any
patient specifically, meningococcal infection must be diagnosed and
treated promptly with antibiotics, a unique problem in treating central
nervous system infection is that an intact blood-brain-barrier, so for a
short time antibiotics penetrate the central nervous system. Antibiotics
are given intravenously, the blood-brain-barrier recovers as
inflammation subsides and high doses are required to reach the
cerebrospinal fluid to prevent complications and epidemic occurrence.
Adequate fluid and electrolyte balance must be maintained and frequent
assessment of neurologic status by trained caregivers was indicated to
detect early manifestations of increasing intracranial pressure and
seizures, also the patient must be watched carefully for change in
neurologic function or other signs of worsening condition.

The nurse must also have a thorough understanding of the anatomy


and physiology of the human brain and understanding of the
inflammatory process that occurs in meningitis and how it can properly
be treated.

Master E.J and his mother was educated on the importance of


keeping hospital appointment, the importance of balance diet and a tidy
environment were also stressed. This study cared for master E.J in its
totality as well as giving proper management while on admission and
even on discharge.
RECOMMENDATIONS

The following recommendations, would be beneficial to


individuals, families, community at large and the government
bodies in the prevention and effective management of meningitis.

 Health personnel should have adequate knowledge of the condition; it


is of optimal importance in order to be able to effectively manage the
condition.
 Prompt nursing and medical intervention is needed in order to prevent
damage to the brain which is a very vital organ.
 Proper education by health personnel to mothers on the importance of
personal and environmental hygiene, adequate diet and nutrition and
means of identifying signs and symptoms of infection.
 Mothers should report promptly any deviation from normal health in
their children under five and school age.
 Mothers should ensure complete immunization of their children less
than five years of age.
 Mothers should be aware of signs and symptoms of infection.
 Government should ensure the availability of vaccines that prevent
infectious meningococcal
 Government should also sponsor health campaign against the
prevention and control of meningitis.
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