MENINGITIS – Etiological Factors, Pathophysiology, Clinical Manifestations, Diagnostic Evaluations and Management (Nursing)

MENINGITIS – Etiological Factors, Pathophysiology, Clinical Manifestations, Diagnostic Evaluations and Management (Nursing) 

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MENINGITIS – Etiological Factors, Pathophysiology, Clinical Manifestations, Diagnostic Evaluations and Management (Nursing)

Meningitis is inflammation of the protective membranes covering the brain and spinal cord, known collectively as the meninges. The inflammation may be caused by infection with viruses, bacteria, or other microorganisms, and less commonly by certain drugs. The swelling associated with meningitis often triggers the “hallmark” signs and symptoms of this condition, including headache, fever and a stiff neck in anyone over the age of 2.

ETIOLOGICAL FACTORS

Meningitis is mostly caused by microorganisms like bacteria, viruses, parasites and fungi. These microorganisms infect blood and the cerebrospinal fluid (CSF). Meningitis can also develop from non-infectious causes, including certain disease like AIDS, cancer, diabetes, physical injury, or certain drugs that weaken the body’s immune system.

  1. Bacterial Meningitis: Acute bacterial meningitis usually occurs when bacteria enter the blood stream and migrate to the brain and spinal cord. But it can also occur when bacteria directly invade the meninges, as the result of an ear or sinus infection or a skull fracture. A number of strains of bacteria can cause acute bacterial meningitis. The most common include: Myobacterium tuberculosis, streptococcus pneumonia, neisseria meningitides, haemophilus influenza and listeria monocytogenes.
  2. Viral Meningitis: Viral Meningitis is generally less severe and resolves without specific treatment. Other viral infections that can lead to meningitis include mumps, herpes virus, including Epstein Barr virus, herpes simplex viruses, varicella zoster virus, measles and influenza. In rare cases LCMV (lymphocytic choriomeningitis virus), which is spread by rodents, can cause viral meningitis.
  3. Fungal Meningitis: Fungal meningitis is rare, but can be life threatening. Although anyone can get fungal meningitis, people at higher risk include those who have AIDS, leukemia, or other forms of immunodeficiency and immune suppression. The most common cause of fungal meningitis for people with immune system deficiencies, like HIV, is Cryptococcus. This disease is one of the most common causes of meningitis. The fungus that causes thrush, Candida, can lead to meningitis in rare cases, especially in premature babies with very low birth weight.
  4. Non-Infectious Meningitis: This type of meningitis is not spread from person to person. Non-infectious meningitis can be caused by cancers, systemic lupus erythematosus (lupus), certain drugs, head injury and brain surgery.


 

PATHOPHYSIOLOGY

Due to etiological factors --------------- organisms enters into the blood stream and cross blood brain barrier ---------------- initiate inflammatory response ------------ reduced cerebral blood flow leads to altered cerebral tissue perfusion ---------- cell permeability increases and purulent exudates infiltrates cranial nerve sheaths and block choroid plexus and subarachnoid villi --------- increase intracranial pressure

 

CLINICAL MANIFESTATIONS

It’s easy to mistake the early signs and symptoms of meningitis for the flu (influenza). Meningitis signs and symptoms may develop over several hours or over one or two days and, in anyone over the age of 2, typically include:

  • Headache
  • Sudden high fever
  • Altered mental status
  • Confusion or altered consciousness
  • Vomiting
  • An inability to tolerate light (photophobia) or loud noises (phonophobia)
  • Irritability and drowsiness
  • Signs of meningeal irritation
  • Nuchal rigidity (Neck stiffness) associated with fever
  • Positive Brudzinski’s sign: when patient lying on supreme position forward neck flexion produces flexion of both thighs at hips and flexure movement of ankles and knees.
  • Positive Kernig’s sign: when client’s thigh flexed at 90 degree angles to abdomen with knees flexed at 90 degree to thigh, extending the knees upwards causes pain, spasms of hamstring muscles and existence to further leg extension at the knees.
  • Signs of increasing ICP – widened pulse pressure, bradycardia, respiratory irregularity, decreasing LOC, headache and vomiting, papilledema


DIAGNOSTIC EVALUATIONS


  • Blood cultures
  • Lumbar puncture
  • Chest x-ray
  • CSF examination for cell count, glucose and protein
  • CT scan of the head
  • Gram stain, other special stains and culture of CSF


 

MANAGEMENT

Intravenous administration of broad spectrum antibiotics includes cephalosporin antibiotics (rifampin, cefotexime or vancomycin). Anticonvulsant given such as dilantin. Analgesics and antipyretics may provide symptomatic treatment. Rifampin is recommended prophylactically to persons exposed to meningococcal meningitis.

  1. Bacterial Meningitis: Bacterial meningitis can be treated with a number of effective antibiotics. It is important that treatment be started early in the course of the disease. It bacterial meningitis is suspected, initial treatment with ceftriaxone and vancomycin is recommended. Appropriate antibiotic treatment of the common types of bacterial meningitis should reduce the risk of dying from meningitis to below 15 % although the risk is higher among the elderly.
  2. Viral Meningitis: There is no specific treatment for viral meningitis. Antibiotics do not help viral infections, so they are not useful in the treatment of viral meningitis. Most patients completely recover on their own within 7 to 10 days. A hospital stay may be necessary in more severe cases or for people with weak immune systems. Treatment of mild cases of viral meningitis usually includes: bed rest, plenty of fluids, good nutrition and over-the-counter pain medications to help reduce fever and relieve body aches aid in recovery from viral meningitis.
  3. Fungal meningitis: Fungal meningitis is treated with long courses of high dose antifungal medications. This is usually given using an IV line and is done in the hospital. The length of treatment depends on the status of the immune system and the type of fungus that caused the infection. For people with immune systems that do not function well because of other conditions, like AIDS, diabetes, or cancer there is often a need for longer treatment.


 

PREVENTION

The best way to protect from meningitis is to make sure he or she gets all the standard immunizations for children. These include shots for measles, chickenpox, haemophilus inflenzae type B (Hib) disease, and pneumococcal infection. The vaccines against Hib are very safe and highly effective. Talk to doctor about whether you or your child also needs the meningococcal vaccine, which is a shot to prevent bacterial meningitis.

NURSING MANAGEMENT

1. Administer intravenous fluids and medications, as ordered by the physician. 

a. Antibiotics should be started immediately
b. Corticosteroids may be used for the critically ill patient
c. Drug therapy may be continued after acute phase of the illness is over to prevent recurrence.
d. Record intake and output carefully and observe patient closely for signs of dehydration due to insensible fluid loss

 

2. Monitor patient’s vital signs and neurological status and record

a. Level of consciousness. Utilize GCS for accuracy and consistency
b. Monitor rectal temperature at least every 4 hours and if elevated, provide for cooling measures such as a cooling mattress, cooling sponge baths, and administration of ordered antipyretics.

 

3. If isolation measures are required, inform family members and ensure staff compliance of isolation procedures in accordance with (IAW) standard operating procedures (SOP).


4. Provide basic patient care needs.

a. The patient’s level of consciousness will dictate whether the patient requires only assistance with activities of daily living or total care. If patient is not fully conscious, follow the guidelines for care of the unsconscious patient


b. Maintain dim lighting in the patient’s room to reduce photophobic discomfort

 

5. Provide discharge planning information to the patient and family

a. Follow up appointments with the physician


b. Discharge medication instruction


c. Possible follow-up with the community health nurse