Meningitis - What Every Teen Needs to Know
Stacy A. Morehead, RN, BSN Whitney Benson, RN, BSN Good Samaritan Hospital Objective Upon completion of this lecture, participants will be able to : Describe the meningitis disease process Define causes, manifestations, and medical care Explain preventative measures. 4/26/2017 2 2 Meningitis Definition: an inflammation of the meninges, the protective membrane that surround the brain and spinal cord. 4/26/2017 3 Meninges Dura Arachnoid Pia
Dura Thick non-elastic structure
Lines the inside of the skull and the vertebral column Blood supply External carotid artery Middle meningeal artery Falx Cerebri Tentorium Cerebelli Falx- separates the 2 hemispheres longitudinally with increase ICP, you can see sub falcine herniation-herniation of the frontal lobe under the falx Tentorium- tent like structure of dura that separates the occipital lobe from the cerebellum, or the supratentorial from the infratentorial space herniation of the uncus of the temporal lobe through the tentorial notch occurs with increased ICP Arachnoid Arachnoid Villi Responsible for reabsorption of CSF
Transfer of CSF to venous system Arachnoid villi located in the superior sagittal sinus, responsible for reabsorption of CSF. Blood in the arachnoid space (SAH), scars the arachnoid villi and leads to decreased reabsorption, this can lead to hydrocephalus Pia Mater Thin, transparent membrane adherent to the surface of the brain Subtypes Aseptic: the cause is viral or due to lymphoma, leukemia, or brain abscess Septic: caused by bacteria Streptococcus pneumoniae= pneumococcal meningitis Neisseria meningitidis = meningococcal meningitis Haemophilus influenzae = Hib meningitis Viral meningitis is most common form of meningitis 90% caused by enteroviruses that are seasonal and peak in the summer and fall At least 1.2 million cases of bacterial meningitis are estimated to occur every year; 135,000 of them are fatal. Meningococcal meningitis is life threatening and highly contagious *Aseptic meningitis refers to cases of meningitis in which no bacterial infection can be demonstrated. Some cases of meningitis dont have a definitive diagnosis of bacterial or viral if a lumbar puncture could not be obtained for culture. Causes Through the bloodstream as a consequence of other infections:
Otitis Media & mastoiditis Infected shunt Recent dental surgery Traumatic injury to the facial bones Secondary to invasive procedures Contaminated lumbar puncture Once the causative organism enters the bloodstream, it crosses the blood-brain barrier and causes inflammatory reaction in the meninges Otitis Media & mastoiditis: bacteria can cross the epithelium membrane and enter the subarachnoid space 4/26/2017 9 9 Bacterial Meningitis Peak incidence is in winter and early spring
Who is at higher risk? Populations in dense community groups ie: college campuses and military Tobacco users Viral upper respiratory infections Immune system deficiencies AIDS Lyme Disease Organ transplantation Tobacco use & URI increase the amount of droplet production Since 1960, the incidence of meningococcal meningitis in the United States has been stable, at approximately cases per 100,000 people per year. The risk of cerebral herniation from acute meningitis is about 6-8%. 4/26/2017 10 10 Signs and Symptoms Classic Triad Nausea/ vomiting Photophobia Rash
Headache Fever Nuchal rigidity (stiff neck) Nausea/ vomiting Photophobia Rash Disorientation and memory impairment Behavioral changes Seizures and increased ICP Headache is a result of meningeal irritation Rash can range from a petechial rash with purpuric lesions to large areas of ecchymosis. Behavioral changes: as disease progresses lethargy, unresponsiveness, and coma may develop. Seizures occur secondary to focal areas of cortical irritability. ICP occurs secondary to accumulation of purulent exudate. Viral meningitis experiences same symptoms, but less severe 4/26/2017 11 11 Signs and Symptoms (continued)
Positive Kernigs sign: When the patient is supine and the hip is flexed at 90 degrees, straightening the leg produces pain in the hamstring Positive Brudzinskis sign: When the patient is supine, passively flexing the neck produces involuntary flexion of the knees and hips 4/26/2017 12 12 Diagnostic Testing Lumbar puncture
CSF studies: cell count, protein and glucose levels, culture, cytological analysis, and Grams staining Cultures: blood, sputum, nasopharyngeal specimen, rash aspirate Hematology: chemistry and coagulation panels Serology (antigen tests) CT of head Chest & sinus Xray EEG 4/26/2017 13 CT Scan Head CT demonstrates enlargement of the temporal horns indicating increased intracranial pressure. Small intracerebral hemorrhage foci on the right temporal lobe The effect of increased intracranial pressure on the cerebellum. CT scan findings are usually normal. However, imaging is an important cause of delay of therapy. Indications for performing CT scanning prior to lumbar puncture include altered level of consciousness, papilledema, focal neurological deficits, and/or focal or generalized seizure activity. Intracerebral hemorrhage foci and diffuse edema are seen below in a patient with meningitis. MRI with contrast is preferred to CT scanning, because MRI better demonstrates meningeal lesions, cerebral edema, and cerebral ischemia EEG An electroencephalogram (EEG) study is sometimes useful to document irritable electrical patterns that may predispose the patient to seizures. Person with bacterial meningitis would have diffuse slowing over both hemispheres of brain. Lumbar Puncture Therapeutic indications Diagnostic indications
Involves the introduction of a hollow needle with a stylet onto the lumbar subarachnoid space of the spinal canal using strict aseptic technique. Adult landmarks L3-L4 or L4-L5 Therapeutic indications Spinal anesthesia Intrathecal injection Removal of CSF to reduce pressure Diagnostic indications Measurement of CSF pressures Collection of sample for cytologic, chemical, and bacterial examination Evaluation of spinal dynamics for signs of blockage of CSF flow Injection of radiopaque media for visualization of parts of the nervous system 4/26/2017 16 The lumbar site is prepared, draped, and locally anesthetized.
Help the patient lay on their side along the edge of the bed, arching the back so that the knees are flexed on the chest with the chin touching the knees. The lumbar site is prepared, draped, and locally anesthetized. The needle is introduced into the appropriate subarachnoid space, the stylet is removed, and a manometer is affixed to measure and record opening pressures. The manometer is removed and samples of CSF are collected into sterile test tubes for visual and laboratory examination. When the procedure is completed, the needle is removed, and a Band-Aid is applied directly over the puncture site. Tubes are labeled according to draw order and promptly hand delivered to lab. The opening pressure is about the same as ICP in a patient who is reclining if no CSF obstruction is present. Nursing considerations: BE A PATIENT ADVOCATE! 4/26/2017 17 17 Post procedural care Have patient lay flat in bed for 6-8 hours
Monitor neurological and vital signs frequently Encourage fluids Administer pain medications as needed Monitor puncture site Notify physician of severe headache, voiding problems, nuchal rigidity, rise in temperature, or back spasms Autologous blood patch can be used to seal the site of CSF leakage with good results for severe headache. 4/26/2017 18 18 CSF Values Diagnostic for Meningitis
Parameter Normal CSF Bacterial Meningitis Viral Meningitis Culture Negative Positive negative Color Straw colored Cloudy, purulent Leukocyte count (wbc/mm3) 0-5 Increased Protein (mg/dL) 18-45 Elevated Normal or Elevated 45 normal Obtain blood sugar levels within 2 hours of LP 4/26/2017 19 19 Nursing Management Vital signs, Intake/Output
Advanced neurological assessment, GCS Monitoring of lab values Protect patient from injury secondary to seizure of altered level of consciousness Isolation precautions Droplet precautions Administration of antibiotics, IV fluids, corticosteroids, and antiepileptic medications Droplet for suspected or confirmed cases of meningitis Droplet precautions can be discontinued 24 hours after initiation of antibiotics For viral meningitis, droplet isolation precautions until bacterial meningitis is ruled out then standard precautions. droplet precautions require the use of a mask *GCS-Glasgow coma scale; 4/26/2017 20 Medical Treatment Bacterial Viral
Broad spectrum antibiotics until organism is identified Corticosteroids may be used for inflammation Consultation with infectious disease, neurosurgery Viral Antiviral drugs (Acylcovir) May resolve without specific treatment Supportive therapy Antibiotic therapy is recommended for people in close contact with an infected person. Rifampion Ceftriaxone Ciprofloxacin Outcomes Most patients with meningococcal meningitis recover completely if appropriate antibiotic therapy is instituted promptly. The prognosis for meningococcal meningitis is fair if the patient does not have focal neurologic deficits and is not stuporous or comatose. The prognosis for meningococcal disease is poor when the infection has a septicemic component. *Important to seek treatment early if symptoms are present Potential Complications
Hearing or vision loss Seizures Brain Abscess Hydrocephalus Respiratory complications Weight loss, nausea, fatigue Seizures would occur due to the cerebral iritation Brain abscess could cause increased intracranial pressure. Surgical decompression or intervention with burr hole may be necessary to alleviate pressure. Hydrocephalus can be defined broadly as a disturbance of formation, flow, or absorption of cerebrospinal fluid (CSF) that leads to an increase in volume occupied by this fluid in the Central nervous system. Respiratory complications can occur due to immobility, pain, aspiration secondary to seizures. Prevention Vaccination
Antimicrobial chemoprophylaxis should be given to anyone in close contact with patients diagnosed with meningococcal meningitis Since 2005, the Advisory Committee on Immunization Practices has recommended routine immunization with a quadrivalent meningococcal conjugate vaccine for all adolescents aged 11 to 18 years, as well as older high-risk groups, such as college freshmen living in dormitories. According to CDC estimates, approximately 16 million adolescents between the ages of 11 and 18 are at risk and remain unprotected against meningococcal disease Greene County Combined Health District offers vaccinations at affordable prices Meningococcal Conjugate vaccination (Child)$10.00 Meningococcal Conjugate, Pre Pay (Adult) $110.00 Advise any household contacts and close respiratory contacts that chemoprophylaxis agents are available to eliminate the carrier state and prevent the spread of infection Person-to-person transmission can be interrupted by chemoprophylaxis, which eradicates the asymptomatic nasopharyngeal carrier state. 4/26/2017 24 Case Study Drey Mingo Hometown: Atlanta, GA Co-Captain
Senior at Purdue Position: Forward Height: 62 Named third team All-Big Ten by coaches Set school season record for three-point field goal percentage Named to the Preseason WNIT All-Tournament Team AFTER SUFFERING FROM WHAT SHE THOUGHT WERE FLU-LIKE SYMPTOMS, MINGO SAW A RAPID CHANGE IN HER PHYSICAL CONDITION. SHE BEGAN TO EXPERIENCE HEADACHES AND A STIFF NECK BEFORE LOSING CONSCIOUSNESS. WHEN SHE WOKE UP, SHE WAS IN THE HOSPITAL, WITH NO RECOLLECTION AS TO HOW SHE GOT THERE. "I JUST REMEMBER KIND OF SLIDING TO MY FLOOR AND LOSING CONSCIOUSNESS AND WAKING UP IN A HOSPITAL ROOM," MINGO SAID. "I REMEMBER BEING IN A LOT OF PAIN BEFORE THAT. Mingo stated. Mingo was hospitalized for 5 days. IRONICALLY, MINGO, WHO IS STUDYING TO BE A DOCTOR, HAD JUST TAKEN AN ANATOMY EXAM COVERING MENINGITIS THE WEEK BEFORE SHE BECAME ILL. "THE FACT OF THE MATTER IS, I WAS CRINGING BECAUSE LITERALLY A WEEK BEFORE I GOT SICK WE HAD JUST HAD AN EXAM IN ANATOMY OVER MENINGITIS AND THE MENINGES AND SPINE AND THE INNER EAR," SHE SAID. Case Study Update I didnt know just how bad I was until afterwards. I dont think people wanted to freak me out because I was still kind of fragile in that moment in time Its crazy how bad things could have been and just where I am now, I am so thankful. Knowing that I cant hear as well as them, I think that will be a definite challenge. I actually recently went to the doctor and from my first hearing test I just had a recent hearing test- my hearing has improved more than they thought. They just didnt think that it would get any better at all. **** Read first point****** MINGO CREDITS HER CONDITIONING IN HELPING HER RECOVER SO QUICKLY. BECAUSE SHE WAS IN WHAT SHE CONSIDERS THE BEST SHAPE OF HER LIFE, SHE NOT ONLY LEFT THE HOSPITAL IN LESS THAN A WEEK, BUT HAS RETURNED TO THE FLOOR IN A LIMITED CAPACITY JUST 26 DAYS LATER. THOUGH MINGO MUST NOW REGAIN WHAT CARDIOVASCULAR FITNESS SHE LOST WHILE RECUPERATING, SHE SAID THE BIGGEST CHALLENGE WILL BE IN ADJUSTING TO THE HEARING LOSS SHE SUSTAINED ON HER LEFT SIDE THOUGH THERE IS CAUSE FOR HOPE. ***read last point***** References FDA Approves New Meningitis Vaccine
Yael Waknine February 23, Medscape Medical News2010Medscape, LLC Meningococcal MeningitisAuthor: Francisco de Assis Aquino Gondim, MD, MSc, PhD; Chief Editor: Karen L Roos, MD http://emedicine.medscape.com/article/ overview Copyright by WebMD LLC. Cuevas LE, Hart CA. Chemoprophylaxis of bacterial meningitis. J Antimicrob Chemother. Feb 1993;31 Suppl B:79-91. Bader, Mary Kay, & Littlejohns, L.R. (2004). AANN Core Curriculum for Neuroscience Nursing. Fourth edition. Glenview , IL : American Association of Neuroscience Nursing. Last slide Its been a pleasure to speak with you today! Questions? Thank you!