MENINGITIS

Is an inflammation of the meninges (membranes surrounding the brain and spinal cord).
Types of meningitis include aseptic, septic, and tuberculous. The aseptic form may be
viral or secondary to lymphoma, leukemia, or brain abscess. The septic form is caused
by bacteria such as Neisseria Meningitidis.

Pathophysiology

The causative organism enters the bloodstream, crosses the blood-brain barrier, and
triggers an inflammatory reaction in the meninges. Independent of the causative agent,
inflammation of the subarachnoid and pia mater occurs. Increased intracranial pressure
(ICP) results.meningeal infections generally originate in one of two ways: either through
the bloodstream from other infections (cellulitis) or by direct extension (after a traumatic
injury to the facial bones). In a few cases, the cause is iatrogenic or secondary to
invasive procedures (lumbar puncture) or devices (ICP monitoring devices) or to
opportunistic infections, such as acquired immunodeficiency sundrome (AIDS) or Lyme
disease.

Bacterial meningitis is the most significant form. The common bacterial pathogens are N.
meningitidis (meningococcal meningitis), Streptoccocus pneumonia (in adults), and
Haemophilus influenza (in children and young adults). These three organisms account
for about 75% of the cases. Mode of transmission is direct contact, including droplets
and discharges from the nose and throat of carriers or infected people. Bacterial
meningitis starts as an infection of the oropharynx and is followed by septicemia, which
extends to the meninges of the brain and upper region of the spinal cord.

Clinical Manifestations of Bacterial Meningitis

Severe headache and fever are frequently initial symptoms; these symptoms result from
infection and increased ICP. Additional manifestations include changes in level of
consciousness and disorientation and memory impairment early in the illness. Lethargy,
unresponsiveness, and coma may develop as the illness progresses. Signs of
meningeal irritation include the following:

• Nuchal rigidity (stiff neck) is an early sign

• Positive kernig’s sign: whenlying with thigh flexed on abdomen, patient cannot
completely extend leg

• Positive brudzinski’s sign: flexing patient’s neck produces flexion of the knees
and hips; passive flexion of lower extremity of one side produces similar
movement for opposite extremity.

• Photphobia (extreme sensitivity to light) is common

• Seizures (secondary to focal areas of cortical irritability) and increased ICP:

signs of increasing ICP include focal deficits, widened pulse pressure and
bradycardia, respiratory irregularity, headache, vomiting and depressed levels of
consciousness

• Rash (N. meningitidis):ranges from petechial rash with purpuric lesions to large
areas of ecchymosis
Clinical Manifestations of Meningococcal Meningitis

Ten percent of patients present with a fulminating infection, with signs of overwhelming
septicemia.

• Abrupt onset of high fever

• Extensive purpuric lesions (over face and extremities)

• Shock and signs of disseminated intravascular coagulopathy (DIC)

• Death is possible within a few hours of onset of infection

• In AIDS patients there are few if any symptoms because of the blunted
inflammatory response

Assessment and Diagnostic Findings

Infecting organisms are usually identified through culture and Gram staining of
cerebrospinal fluid and blood (polysaccharide antigens support a diagnosis of bacterial
meningitis).

Prevention

People who have close contact with patients should be considered candidates for
antimicrobial prophylaxis (rifampin). Close contacts of patients should be observed and
examined immediately if ever or other signs and symptoms of meningitis developed.

Meningococcal vaccination maybe beneficial, particularly for college students in some

visiting countries that are experiencing epidemic meningococcal diseases. Vaccination
should be considered as an adjunct to antibiotic chemoprophylaxis for anyone living
with a patient who has meningococcal disease. Polysaccharide vaccine (Haemophilus B
polysaccharide vaccine ) against invasive haemophilus influenza type B infection is used
routinely in children to prevent meningitis

Medical Management

Pharmacologic therapy

• Antimicrobial therapy: penicillin (or piperacillin or ampicillin), or one of the

cephalosphorins. The treatment for cryptococcal meningitis is intravenous
administration of amphotericin B; maybe used with or without 5-flucystosine.

• Vancomycin hydrochloride alone or in combination with rifampin, maybe used if

resistant strains of bacteria are identified.

• Dexamethasone maybe beneficial as adjunct therapy for acute bacterial

meningitis and pneumococcal meningitis

• Fluid volume expander are used to treat dehydration and shock

• Diazepam (valium) or phenytoin (dilantin) is used to control seizures

• An osmotic diuretic, such as mannitol, is used to treat cerebral edema

Nursing Management

Prognosis depends largely on the supportive care provided. Related nursing intervention
include the following:

• Monitor vital signs constantly. Determine oxygenation from atrial blood gas
values and oximetry.

• Insert cuffed endotracheal tube (or tracheostomy), and place patient on a

mechanical ventilation as prescribed

• Give oxygen to maintain atrial partial pressure of oxygen

• Monitor central venous pressure (CVP) for in patient shock, which proceeds
cardiac or respiratory failure

• Note generalized vasoconstriction, circumoral cyanosis, and cold extremities

• Reduce high fever to decreased load on heart and brain from oxygen demands

• Rapid intravenous fluid replacement maybe prescribed, but take care not to
overhydrate patient because of risk of cerebral edema

• If syndromes of inappropriate antidiuretic hormone (SIADH) secretion is

suspected, monitor closely for body weight, serum electrolytes, and urine
volume, specific gravity and osmolality

• Assess clinical status continuously; evaluate skin and oral hygiene; promote
comfort; and protect patient during seizures and while comatose

• Implement infection control precaution and respiratory isolation until 24 hours

after start of antibiotic therapy

• Inform family about patient’s condition and permit family to see patient at
appropriate intervals.
MENINGITIS

Tolosa, Ma. Angelica E.

BSN4J-J3
Clinical Instructor:

Ms. Gonzales