Jamila Rojo N-211 11.16.

12 NCM Maam Collado

BACTERIAL MENINGITIS
an infection of the cerebral meninges often occurs in children younger than 24 months can occur in any month but peaks during winter US: frequently caused by Streptococcus pneumoniae ( group B Streptococcus) children younger than 2 months of age: group B Streptococcus and E. coli are common causes of meningitis children with myelomeningocele who develop meningitis: Pseudomonas are the common cause Children who have had a splenectomy: particularly susceptible to pneumococcal meningitis unless they have received a pneumococcal vaccine Haemophilus influenzae was once a major cause, but is now rarely seen because of routine immunization against this organism

Pathogenic organisms are usually spread to the meninges from : 1. upper respiratory tract tract infections 2. lymphatic drainage possibly through the mastoid sinuses 3. direct contact through a lumbar puncture or skull fracture

once organisms enter the meningeal space, they multiply

rapidly, and spread throughout the CSF -> organisms invade brain tissue through meningeal folds that extend down to the brain itself inflammatory response that occurs may lead to a thick fibrinous exudate that blocks CSF flow Brain abscess or invasion of the infection into cranial nerves can result in: 1. blindness 2. deafness 3. facial paralysis pus that accumulates in the narrow aqueduct of Sylvius can cause obstruct obstruction leading to hydrocephalous Brain tissue can put pressure on the pituitary gland causing increased production of antidiuretic hormone, resulting in the syndrome of inappropriate antiduretic hormone secretion (SIAHS) causes increased edema because the body cannot excrete adequate urine

ASSESSMENT
Symptoms can occur insidiously or suddenly 1. increasingly irritable because of headaches 2. seizures (in some children, seizure or shock is the first noticeable sign of this illness) Children usually have had 2 or 3 days of upper respiratory tract infection As disease progresses: signs of meningeal irritability occur evidenced by positive Brudzinskis and Kernigs sign

Childrens back may become arched and their necks hyperextended (opisthotonos) Cranial nerve paralysis (typically 3rd and 6th nerves) may occur child may not be able to follow a light through full visual fields If frontanelles are open = bulging and tense If frontanelles are closed = papilledema may develop meningitis is caused by H. influenzae = child may develop septic arthritis meningitis is caused by N. meningitidis = a papular or purple petechial skin rash New born symptoms are often vague poor cry weak sucking, lethargy, after this sudden cardiovascular shock, seizures, or apnea may occur

DIAGNOSIS
history and analysis of CSF obtained by lumber puncture A child with febrile seizure should be assumed to have meningitis until CSF findings prove otherwise CSF results indicative of meningitis: increased white blood cell and protein levels and a lowered glucose level (because bacteria have fed on the glucose) Healthy child = glucose level in the CSF in 60% of that of the serum glucose Because meningitis often spreads and causes septicemia, a blood culture is also done A fulminating (overwhelming) meningitis often leads to leucopenia If the child has had close association with someone with TB, a TB tuberculin skin test is also done to rule out tuberculosis meningitis

A CT scan, MRI, or ultrasound study may be ordered to examine for abscesses. Typically, ICP is severely elevated

THERAPEUTIC MANAGEMENT
Primary treatment measure : antibiotic therapy sensitivity studies Antibiotics given for rapid effect, intrathecal injections (directly into the CSF) may be necessary to reduce infection because the blood brain barrier may prevent an antibiotic from passing freely into the CSF If organism is identified as H. influenzae = ampicillin usually is the drug of choice In other instances: a 3rd generation cephalosporin, such as cefolaxime (Claforan) or ceftriaxone (rocephin), may be used for 8-10 days In some children it may take a month before the CSF cell count returns to normal A corticosteroid such as dexamethasone or omostic diuretic, mannitol, may be administered to reduce ICP and help prevent hearing loss Children with meningitis are placed on respiratory precautions for 24 hours after the start of antibiotic therapy to prevent transmission of the infection Antibiotics may also be given prophylactically for the immediate family of the ill child or for those who have been in close contact with the child

NURSING DIAGNOSIS AND RELATED INTERVENTIONS

Parents may feel responsible for the illness because they wonder if they couldve prevented it as soon as they knew that their child had a cold Reassure the parents that the symptoms of meningitis occur suddenly and that no one could predict meningitis from the first signs Encourage patients to care for their child during the illness to help make their child more comfortable and to help them manage their own anxiety Teach the parents effective infection control techniques so that they can perform tasks safely Nursing Diagnosis: Pain related to meningeal irritation Outcome Evaluation: Child states that pain is tolerable and shows no facial grimacing or other signs of discomfort A child with meningitis: May be difficult for them to deal with hospitalization Invasive treatments Different procedure Feels pain when head is flexed forward and is usually more comfortable without a pillow Be careful not to flex the childs neck when you are turning or positioning him/her

On admission extremely irritable, may be too uncomfortable to play (puppet play or drawing to help him express how he/she feels about the many invasive procedures)

Reassure parents that the childs behavior is caused by the disease and not something that they did wrong The child also needs a good explanation of what is happening The child need extra attention from the health care personnel not only during procedures As the child recovers, irritability lessens Promote rest for the child by keeping stimulation in the room to a minimum

Nursing Diagnosis: Risk for ineffective tissue perfusion (cerebral), related to increased ICP Outcome Evaluation: Childs vital signs return to normal: child is alert an oriented; motor, cognitive, and sensory function are within acceptable parameters for the childs age; specific gravity of the urine is 1.003 to 1.030

GROUP B B-Hemolytic Streptococcal Meningitis

Group B B-Hemolytic streptococci Major cause of meningitis in newborns Organism is either contracted in the utero or from secretions in the birth canal at birth

Can be spread to other newborns if proper hand washing technique is not used Colonization of this organism may result in early-onset or late-onset illness Early-onset = symptoms of pneumonia of apparent in the first few hours of life Late-onset = meningitis At apx. 2 weeks of age the infant may gradually become lethargic Fontanelles bulge from increased ICP Mortality = apx. 25% Surviving infants may develop neurological consequences such as hydrocephalous and seizures Antibiotic : ampicillin and cephalosporin are effective Parents need much support at this time