MENINGITIS
o
Inflammation of the
meninges that surround the brain and the spinal cord.
o
Classified as Septic
and Aseptic
o
Neisseria meningitidis
(most common)
o
Haemophilus influenzae
and streptococcus pneumoniae ((causative agents)
o
Neisseria and
Streptococcus pneumoniae,most common cause ( Lippincott)
Pathophysiology
o
Infecting organism
gains entry through bloodstream (20 infection) or direct extension
o
Infecting organism
produce an inflammatory response
o
Meningeal vessels
becomes hyperemic and increasingly permeable
o
Blood cells
(neutrophils) migrate to SAS, producing exudate
o
Exudate formation
causes meningeal irritation and increased ICP
Clinical Manifestations
o Initial/ Classic: fever, headache
o Systemic infection
§
Fever, tachycardia,
chills and petechial rash
o
Meningeal Irritation
§
Nuchal rigidity - early sign
§
Positive Kernig’s sign
§
Positive Brudzinski’s
sign
§
Photophobia
o
Neurologic signs
§
Decrease in
consciousness
§
Cranial nerve palsies
(ptosis, diplopia, facial weakness, tinnitus, vertigo, and deafness)
§
Focal neurologic
deficits (ataxia and motor weakness)
§
Seizures
o
Petechial or purpuric
rash to large area of ecchymosis from coagulopathy, especially with N.
meningitidis.
o
Disorientation and
memory impairment
o
Behavioral
manifestation
o
Other signs f Increase
ICP
o
Fulminating infection
(10 % of Meningococcal meningitis)
Signs of septicemia
ü
Fever
ü
Extensive purpuric
lesion over face and extrinmities
ü
Shock
ü
DIC
Diagnostic Evaluation
o
LP: elevated CSF
pressure; cloudy, turbid, or clear in appearance; normal or increased protein;
glucose decreased or normal; culture and sensitivity test; presence of
polysaccharide antigen (supports bacterial meningitis)
o
Cultures: identify
source of infection in blood, urine, and nose and throat secretions
o
X-rays: assess for
fractures, abscesses, or signs of infection in chest, skull and sinuses
o
WBC count: elevated
Prevention
o
Vaccination:
meningococcal meningitis (MCV4)
- Antimicrobial prophylaxis for people in
close contact with meningococcal patients
v
Rifampicin (Rifadin),
Ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin)
- Vaccination as an adjunct to antibiotic
(H. influenzae and S. pneumoniae)
Medical Management
A.) Early antibiotic therapy
- Penicillin ( ampicillin
and piperacillin)
- Cephalosporin
(ceftriaxone sodium,
cefotaxime sodium)
- Vancomycin
hydrochloride – alone or
with rifampicin **
B.) Dexamethasone
- given 15 to 20 minutes
before 1st dose of
antibiotic (q 6 hrs
for 4 days)
C.) Fluid volume expanders – DHN and shock
D.) Phenytoin (dilantin)
E.) Meaures for increased ICP
F.) Diuretic, Isolation, and seizure precaution
Nursing Management
- Provide continuous or on-going
neurological assessment, monitor Vital signs
- Pulse oximetry and ABG is monitored
- Take measure to address Fever immediatey
- Monitor body weight, serum electrolytes,
and urine volume, specific gravity, and osmolality
- Protect the patient from injury (seizure
precaution)
- Prevent complication secondary to
immobility
- Institute droplet precautions until 24
hours after the initiation of antibiotic therapy (isolation technique)
- Report meningococcal
meningitis to local health authority
Brain Abscess
- Localized collection of pus within the
parenchyma of the brain and spinal cord
- Relatively rare, complication encountered by
immuno-compromised patients
Pathophysiology
- Direct invasion from intracranial trauma
or surgery
- Spread of infection from nearby sites
(sinuses, ears, and teeth)
- Spread of infection from other organs(lung
abscess, infective endocarditis)
Clinical Manifestation
- HEADACHE – worse in the morning
(prevailing symptom)
- Vomiting
- Focal neurologic signs (depends on the location of abscess)
- Change in mental status
- Fever may or may not be present
Diagnostics
ü
CT SCAN
ü
MRI
ü
Useful to obtain images
of the Brain Stem and posterior fossa
Medical Management
- Antimicrobial therapy & Surgical
incision or aspiration
v
Penicilin G (20 million
U) and Chloramphenicol (4-6 g/day given IV in divided doses)
v
Given preoperatively
and postoperatively
- Corticosteroids
- Antiseizure medications (phenytoid,
phenobarbital)
Nursing Management
- Focus is on Ongoing assessment
- Blood laboratory test result , blood
glucose and serum potassium levels
- Patient safety is a key nursing
responsibility
Encephalitis
- Acute inflammatory process of the brain tissue
- HERPES SIMPLEX VIRUS ENCEPHALITIS
- Herpes Simplex virus (HSV) is the most
common cause of acute encephalitis (HSV – 1)
PATHO:
- Infxn of buccal mucosa --- retrograde spread along trigeminal nerve
--- to brain
- Latent virus in brain tissue is reactivated
Clinical Manifestation
- Inflammation and necrosis in the T – F – L
(temporal, frontal and limbic system)
§
Initial : FEVER,
HEADACHE, CONFUSION, and BEHAVIORAL ABNORMALITIES
§
Focal neurologic
symptoms (within 7 days, last 14 – 21 days)
ü
Behavioral changes
ü
Focal seizures
ü
Dysphasia
ü
Hemiparesis
ü
Altered LOC
Diagnostics
- EEG
- CSF
§ High opening pressure
§ Low glucose and high protein levels
§ Viral cultures are almost always negative
§ PCR (polymerase chain reaction)
-
Identifies DNA bands of
the HSV (3rd and 10th day of Sx onset)
- NEUROIMAGING
v
MRI – is the
neuroimaging study of choice
Medical Management
v ACYCLOVIR (Zovirax) – medication of choice
ü Continued for 3 weeks (prevent relapse)
ü Slow administration (over 1 hour)
ü Usual dose is decrease in patient with Hx of renal
insufficiency
- FOSCARNET
SODIUM (Foscavir)
- in rare cases of acyclovir resistance
Nursing Management
- ON – Going Neurological Assessment
- Comfort measure for headache:
§
Dimming of lights
§
Limiting noise
§
Administering
analgesics
- Use opioid medication cautiously – mask
signs
- Initiate injury prevention and safety
- Monitor for renal complication (labs and I
& O)
Fungal Encephalitis
- Occur rarely in healthy people
- COMPROMISED IMMUNE SYSTEM
Common agents:
ü
Cryptococcus neoformans
ü
Histoplasma capsulatum
ü
Aspergillus
ü
Candida Albicans
PATHO:
o Fungal Spores enters the body via
inhalation
o Initially through the lungs and bloodstream
o CNS --- Meningitis – Encephalitis – brain abscess
o also causes abscess of the SC = SC compression
Clinical Manifestation
ü
Common: Fever, malaise,
headache, nuchal rigidity, lethargy and mental status changes
ü
Symptom of increase ICP
from hydrocephalus
Assessment and Diagnostics
o
Presence of a
compromised immune system and history of living or travel to certain areas
o
Elevated WBC and ANEMIA
o
Fungal antibodies in
serum
o
Neuroimaging – CT scan
and MRI
CSF :
o
Elevated WBC, and
protein
o
Culture of fungi
Medical Management
o
ANTIFUNGAL AGENTS
-
Specific period or
indefinite period (maintenance dose)
o
AMPOTHERICIN B
(Abelcet, AmBisome, Amphocin, Amphotec, Fungizone, and Fungizone IV)
- standard antifungal
treatment
- dose high enough without
causing renal toxicity
o
FLUCONAZOLE (diflucan)
or flucytosine (5-FC, 5- fluorocytosine, Ancobon)
- may be
administered in conjunction with ampothericin B
- causes transient increase in liver enzyme
- S/E: Nausea,
abdominal pain, headache, dizziness, rash, reversible alopecia
Nursing management
o
On – Going assessment
o
Provide patient
comfort:
§
Administering
non-opioid analgesics
§
Limiting environmental
stimuli
§
Positioning
o
Give diphenhydramine
(Benadryl) and acetaminophen (Tylenol) approx. 30 mins before amphothericin B
(fever, chills and body aches)
o
Monitor creatinine and
blood urea nitrogen
o
Provide support to
patient and family to cope up with work