Management for Meningitis Reynel Dan L. Galicinao
Ideal Medical Management Diagnostic Evaluation Complete blood count (CBC) with differential - detect an elevated leukocyte count in bacterial and viral meningitis Lumbar puncture - (elevated CSF pressure, cloudy or milky white CSF, high protein level, positive Gram stain and culture that usually identifies the infecting organism unless it's a virus, and depressed CSF glucose concentration) CSF evaluation for pressure, leukocytes, protein, glucose
MRI/CT scan - with and without contrast rules out cerebral hematoma, hemorrhage, or tumor CT scan with contrast - to detect abscesses. Low CD4+ counts indicate immunosuppression in HIV-positive patients and other patients with immunosuppressive disorders. Latex agglutination may be positive for antigens in meningitis. Chest X-rays - may reveal pneumonitis or lung abscess, tubercular lesions, or granulomas secondary to fungal infection
Treatment team effort with nursing, infectious diseases specialists, neurology, internal medicine, and otolaryngology specialists, and laboratory and diagnostic staff Antibiotic therapy and vigorous supportive care Usually, I.V. antibiotics are given for at least 2 weeks, followed by oral antibiotics ampicillin, cefotaxime, ceftriaxone, and nafcillin Dexamethasone (Decadron) - as adjunctive therapy Mannitol - to decrease cerebral edema Anticonvulsant (usually given I.V.) or a sedative - to reduce restlessness Aspirin or acetaminophen - to relieve headache and fever
Supportive measures consist of bed rest, hypothermia, and fluid therapy to prevent dehydration Isolation - if nasal cultures are positive Therapy for any coexisting conditions, such as endocarditis or pneumonia Temozolomide (Temodar) - neoplastic meningitis Cochlear implantation rehabilitation - deafness caused by meningitis therapy for S. aureus and gram-negative bacilli - If meningitis is suspected after neurosurgical procedures, potential I.V. line bacteremia, CSF leak, or immunosuppression Antifungal agents - for cryptococcal meningitis Empiric antituberculosis drugs must be initiated if infection by Mycobacterium tuberculosis is suspected
Actual Medical Managemnet Diagnostic Evaluation Hematology Chest X-ray (APL) IVF D5 0.3 NaCl 500cc @ 30cc/hr D5 IMB 500cc @ 20cc/hr Nasogastric tube – for feeding O2 inhalation 2-3 L/min via cannula
Madications Ranitidine 6 mg IVTT q 8h Ceftriaxone (Medzef) 600 mg IVTT q 24h ANST (-) Dexamethasone 0.75 mg IVTT q 6h Phenobarbital 60mg IVTT now Pen G 300,000 IU IVTT q 6h ANST (-) Furosemide 6 mg IV now
Ideal Nursing Management Nursing Assessment Obtain a history of recent infections such as upper respiratory infection, and exposure to causative agents Assess neurologic status and vital signs Evaluate for signs of meningeal irritation Assess sensorineural hearing loss (vision and hearing), cranial nerve damage (eg, facial nerve palsy), and diminished cognitive function.
Ideal Nursing Diagnoses Acute pain related to meningeal irritation Anxiety Hyperthermia related to the infectious process and cerebral edema Impaired gas exchange Impaired Physical Mobility related to prolonged bed rest Ineffective Tissue Perfusion (cerebral) related to infectious process and cerebral edema Risk for deficient fluid volume related to fever and decreased intake Risk for impaired skin integrity
Key outcomes The patient will express feelings of comfort and relief of pain identify strategies to reduce anxiety exhibit temperature within normal range maintain adequate ventilation and oxygenation maintain fluid volume within normal range Have skin integrity remain intact
Ideal Nursing Interventions Reducing Fever Administer antimicrobial agents on time to maintain optimal blood levels. Monitor temperature frequently or continuously, and administer antipyretics as ordered. Institute other cooling measures, such as a hypothermia blanket, as indicated. Maintaining Fluid Balance Prevent I.V. fluid overload, which may worsen cerebral edema. Monitor intake and output closely. Monitor CVP frequently.
Enhancing Cerebral Perfusion Assess LOC, vital signs, and neurologic parameters frequently. Observe for signs and symptoms of ICP (eg, decreased LOC, dilated pupils, widening pulse pressure). Maintain a quiet, calm environment to prevent agitation, which may cause an increased ICP. Prepare patient for a lumbar puncture for CSF evaluation, and repeat spinal tap, if indicated. Lumbar puncture typically precedes neuroimaging Notify the health care provider of signs of deterioration: increasing temperature, decreasing LOC, seizure activity, or altered respirations. Reducing Pain Administer analgesics as ordered; monitor for response and adverse reactions. Avoid opioids, which may mask a decreasing LOC. Darken the room if photophobia is present. Assist with position of comfort for neck stiffness, and turn patient slowly and carefully with head and neck in alignment. Elevate the head of the bed to decrease ICP and reduce pain.
Promoting Return to Optimal Level of Functioning Implement rehabilitation interventions after admission (eg, turning, positioning). Progress from passive to active exercises based on the patient's neurologic status.
Community and Home Care Considerations Prevent bacterial meningitis by eliminating colonization and infection with the offending organism. Administer vaccines against H. influenzae type B for children; N. meningitidis serogroups A, C, Y, and W135 for patients at high risk (especially college students, those without spleens, immunodeficient); and S. pneumoniae for patients with chronic illnesses and the elderly. Administer vaccines for travelers to countries with a high incidence of meningococcal disease and household contacts of someone who has had meningitis. Chemoprophylaxis for meningococcal disease, most commonly with rifampin, may be necessary for health care workers, household contacts in the community, day care centers, and other highly susceptible populations. If maintenance antifungal prophylaxis is initiated for patients with low CD4+ counts, as seen in some patients with AIDS, the patient must understand the importance of long-term pharmacologic therapy.
Patient Education and Health Maintenance Advice close contacts of the patient with meningitis that prophylactic treatment may be indicated; they should check with their health care providers or the local public health department. To help prevent the development of meningitis, teach patients with chronic sinusitis or other chronic infections the importance of proper medical treatment. Encourage the patient to follow medication regimen as directed to fully eradicate the infectious agent. Encourage follow-up and prompt attention to infections in future. Inform patients who have children about the importance of vaccination with measles, mumps, rubella vaccine, H. influenzae type B vaccine, and pneumococcal vaccine as a preventive measure. Vaccination is recommended for children younger than school age.
Evaluation: Expected Outcomes Afebrile Adequate urine output; CVP in normal range Alert LOC; normal vital signs Pain controlled Optimal level of functioning after resolution
Nursing Interventions Monitored TPR q 4h Monitored I & O q shift Inserted IV line Regulated IVF to prescribed rate NGT feeding done Initiated seizure precautions Regulated O2 to prescribed rate TSB done for fever Encouraged rest periods Instructed SO on hand washing Given health teachings Medications given