July 2020

Evaluation

• Patient will
  • Demonstrate appropriate cognitive function
  • Be oriented to person, place, and time
  • Maintain body temperature within normal range
  • Report satisfaction with pain control

• As a nurse, since bacterial meningitis is very contagious and potentially a fatal infection, Universal precautions should ALWAYS be in place – you have the right to implement more conservative care (respiratory isolation) at any time as a professional nurse.

Viral Meningitis

• Most common causes are enterovirus, arbovirus, HIV, and HSV
  • Most often spread through direct contact with respiratory secretions
• Usually presents as headache, fever, photophobia, and stiff neck
  • Fever may be moderate or high
• Diagnostic testing of CSF
  • Rapid diagnosis with Xpert EV test
    • Sample of CSF is evaluated for enterovirus
    • Results available within hours
  • PCR to detect viral-specific DNA/RNA
• Treat with antibiotics after obtaining diagnostic sample but before receiving test results
  • Symptomatic management
  • Disease is self-limiting
  • Full recovery expected

Nursing implementation

• Health Promotion
  • Vaccinations for pneumonia and influenza
  • Meningococcal vaccines
    • MCV4 (Meningococcal conjugate vaccine), MPSV4 (Meningococcal polysaccharide vaccine), Serogroup B
  • Early, vigorous treatment of respiratory tract and ear infections
  • Prophylactic antibiotics for anyone exposed to bacterial meningitis
    • Bacterial meningitis is a medical emergency. Rapid diagnosis based on history and physical examination is crucial because the patient is usually in a critical state when health care is sought. When meningitis is suspected, antibiotic therapy is instituted after the collection of specimens for cultures, even before the diagnosis is confirmed. 
• Acute Care
  • Revolve around the nursing diagnoses of
    • Decreased intracranial adaptive capacity
    • Risk for ineffective cerebral perfusion
    • Increased fever
    • Acute pain
  • Close observation and assessment
  • Provide relief for head and neck pain
  • Position for comfort
  • Darkened room and cool cloth over eyes for photophobia
  • Minimize environmental stimuli
  • Provide safety
• Observe and record seizures
  • Prevent injury
  • Administer antiseizure medications
• Vigorously manage fever
  • Fever increases cerebral edema and the frequency of seizures
  • Neurologic damage may result from high, prolonged fever
• Assess for dehydration
  • Evaluate fluid intake and output
  • Compensate for diaphoresis in replacement fluids
• Maintain therapeutic blood levels of antibiotics
• Respiratory isolation until cultures are negative (Droplet precautions)
• Ambulatory Care
  • Provide for several weeks of convalescence
  • Increase activity as tolerated
    • Stress adequate nutrition
    • Encourage adequate rest and sleep
  • Progressive ROM exercises and warm baths for muscle rigidity
  • Ongoing assessment for recovery of vision, hearing, cognitive skills, motor and sensory abilities
  • Tend to signs of anxiety and stress of family and caregivers

Diagnostic studies

• Blood culture
• CT scan and  MRI
• Diagnosis verified
  • Lumbar puncture
  • Analysis of CSF (for protein, WBC, and glucose)
  • Specimens of secretions are cultured to identify causative organism
  • Gram-stain to detect bacteria
• Neutrophils are predominant WBC in CSF
• X-rays of skull

Interprofessional care

• Bacterial meningitis is a medical emergency
• Rapid diagnosis crucial
  • Patient  usually critical when health care is initiated
  • Antibiotic therapy instituted before diagnosis is confirmed

Nursing Assessment

• Initial assessment should include
  • Vital signs
  • Neurologic assessment
  • Fluid intake and output
  • Evaluation of lungs and skin

Nursing diagnosis

• Decreased intracranial adaptive capacity related to decreased cerebral perfusion or increased ICP
• Risk for ineffective cerebral tissue perfusion related to reduction of blood low and cerebral edema
• Hyperthermia related to infection
• Acute pain related to headache and muscle aches

Planning

• Overall Goals
  • Return to maximal neurologic functioning
  • Resolve the infection
  • Control pain and discomfort

Complications

• Increased ICP
  • Major cause of altered mental status
• Residual neurologic dysfunction
  • Cranial nerves III, IV, VI, VII, or VIII can become dysfunctional
  • Sequelae varies by cranial nerve
• Optic nerve (CN II) compressed by ↑ ICP
  • Papilledema with possible blindness
• Ocular movements affected with irritation to nerves III, IV, and VI
  • Ptosis
  • Unequal pupils
  • Diplopia
• CN V irritation
  • Sensory loss and loss of corneal reflex
• Inflammation of CN VII
  • Facial paresis
• Irritation of CN VIII
  • Tinnitus, vertigo, deafness
  • Hearing loss may be permanent
• Hemiparesis, dysphagia, hemianopsia
• Suspect the following if above do not resolve
  • Cerebral abscess, subdural empyema, subdural effusion, or persistent meningitis
• Acute cerebral edema may cause
  • Seizures
  • CN III palsy
  • Bradycardia
  • Hypertensive coma
  • Death

Clinical manifestation

• Key signs of meningitis
  • Fever
  • Severe headache
  • Nausea, vomiting
  • Nuchal rigidity
• Coma associated with poor prognosis
  • Occurs in 5% to 10% of cases
• Other symptoms that may be present
  • Photophobia
  • Decreased LOC
  • Signs of increased Intracranial pressure
    • Seizures occur in 1/3 of all cases
    • Headache worsens
    • Vomiting and irritability may occur

Inflammatory Brain Disorder

• Most common inflammatory conditions of the brain and spinal cord
  • Brain abscesses
  • Meningitis
  • Encephalitis
    • 10% to 30% mortality rate
    • Long-term neurologic deficits among survivors

Bacterial meningitis

• Acute inflammation of meningeal tissue surrounding brain and spinal cord
  • Usually occurs in fall, winter, or early spring
    • Often secondary to viral respiratory disease
• Mandatory reporting to CDC
• Mortality rate near 100% if untreated

Etiology and pathophysiology

• Leading causes of bacterial meningitis
  • Streptococcus pneumoniae
  • Neisseria meningitidis
    • Replaced Hemophilus as flu vaccine emerged
    • Organisms enter CNS through upper respiratory tract or bloodstream
    • May enter through skull wounds or fractured sinuses
• Inflammatory response
  • Increase CSF production
  • Purulent secretions spread to other areas of brain through CSF
  • Cerebral edema and increased ICP become problematic
    • If process extends into parenchyma
    • If concurrent encephalitis is present

Summary of cancer

• Initiation, the first stage, is a mutation in the cell’s DNA structure following exposure to a chemical, radiation, or viral agent. The mutation may also be inherited.
• Promotion, the second stage in the development of cancer, is characterized by the reversible proliferation of the altered cells.
• Progression, the final stage, is characterized by increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site (metastasis).

Factors that may influence ability to cope

• Ability to cope with stressful events in the past, availability of significant others, ability to express feelings and concerns, age at the time of diagnosis, extent of disease, disruption of body image, presence of symptoms, past experience with cancer, and attitude associated with cancer.

Cancer pain

• Patient report should always be believed and accepted as primary source for pain assessment data
• Drug therapy should be used to control pain
• Inadequate pain assessment is single greatest barrier to effective cancer pain management
  • Management of cancer pain
    • Fear of addiction is unwarranted
    • Numerous drug options for pain management
    • Nonpharmacologic interventions, including relaxation therapy and imagery, can be used effectively
  • Moderate to severe pain occurs in approximately 50% of patients who are receiving active treatment for their cancer and in 80% to 90% of patients with advanced cancer.
  • It is essential to perform a comprehensive pain assessment on an ongoing basis and to enact a pain management plan that addresses both components of pain if they are present.

Coping with cancer and treatment

• Nursing assessment and support are key
  • Pervasive anxiety and fear
    • Fears of dependency
    • Loss of control
    • Family relationship stress
    • Financial burden
    • Fear of death
      • Be available, especially during difficult times
      • Exhibit caring
      • Actively listen
      • Provide symptom relief
      • Provide accurate information
      • Build trust
      • Use touch
      • Assist setting realistic goals
      • Support usual lifestyle patterns
      • Maintain hope
      • Reassure of ongoing support
      • Offer support from survivors
        • Improvement in early detection and treatment
        • > 14.5 million in the United States