Case Pres Meningitis

KESTER GRANT COLLEGE, PHILIPPINES

BACTERIAL MENINGITIS

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A case presentationPresented to:

Mr. Homer Lee, RN, MAN

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In Partial FulfillmentOf the Requirements for

Information on Nursing Management

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Presented by:Aquino, Sheila Mae B.

Austria, Tiffany M.Cabigao, Marc Andrew G.

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January 28, 2010

Introduction

Background

Meningitis is a clinical syndrome characterized by inflammation of the meninges. Clinically, this medical condition manifests with meningeal symptoms (eg, headache, nuchal rigidity, and photophobia) and an increased number of white blood cells in the cerebrospinal fluid (CSF; pleocytosis). Depending on the duration of symptoms, meningitis may be classified as acute or chronic. Acute meningitis denotes the evolution of symptoms within hours to several days, while chronic meningitis has an onset and duration of weeks to months. The duration of symptoms of chronic meningitis is characteristically at least 4 weeks.

There are numerous infectious and noninfectious causes of meningitis. Examples of common noninfectious causes include medications (eg, nonsteroidal anti-inflammatory drugs, antibiotics) and carcinomatosis. The focus of this article is the infectious causes of meningitis. Infectious agents that cause primarily encephalitis are not discussed in this article.

Meningitis can also be classified according to its etiology. Acute bacterial meningitis denotes a bacterial cause of this syndrome. This is usually characterized by an acute onset of meningeal symptoms and neutrophilic pleocytosis. Depending on the specific bacterial cause, the syndrome may be called, for example, Streptococcus pneumoniae meningitis, meningococcal meningitis, or Haemophilus influenzae meningitis. Fungal and parasitic causes of meningitis are also termed according to their specific etiologic agent, such as cryptococcal meningitis,Histoplasma meningitis, and amebic meningoencephalitis.

Aseptic meningitis is a broad term that denotes a non-pyogenic cellular response, which may be caused by many different etiologic agents. In many cases, a cause is not apparent after initial evaluation. Patients characteristically have an acute onset of meningeal symptoms, fever, and cerebrospinal pleocytosis that is usually prominently lymphocytic. After an extensive workup, many of these cases are found to have a viral etiology and can then be reclassified as acute viral meningitis (eg, enterovirus meningitis, herpes simplex virus [HSV] meningitis). While viruses cause most cases of aseptic meningitis, it can also be caused by bacterial, fungal, mycobacterial, and parasitic agents.

Anatomy and Physiology

As the most complex system, the nervous system serves as the body control center and communications electrical-chemical wiring network. As a key homeostatic regulatory and coordinating system, it detects, interprets, and responds to changes in internal and external conditions. The nervous system integrates countless bits of information and generates appropriate reactions by sending electrochemical impulses through nerves to effector organs such as muscles and glands. The brain and spinal cord are the central nervous system (CNS); the connecting nerve processes to effectors and receptors serve as the peripheral nervous system (PNS). Special sense receptors provide for taste, smell, sight, hearing, and balance. Nerves carry all messages exchanged between the CNS and the rest of the body.

The neuron transmits electric signals like an electric wire. The perikaryon (cell body) is the neuron central part. Dendrites, short branches, extend from the neuron. These input channels receive information from other neurons or sensory cells (cells that receive information from the environment). A long branch, the axon, extends from the neuron as its output channel. The neuron sends messages along the axon to other neurons or directly to muscles or glands.

Neurons must be linked to each other in order to transmit signals. The connection between two neurons is a synapse. When a nerve impulse (electrical signal) travels across

a neuron to the synapse, it causes the release of neurotransmitters. These chemicals carry the nerve signal across the synapse to another neuron.

Nerve impulses are propagated (transmitted) along the entire length of an axon in a process called continuous conduction. To transmit nerve impulses faster, some axons are partially coated with myelin sheaths. These sheaths are composed of cell membranes from Schwann cells, a type of supporting cell outside the CNS. Nodes of Ranvier (short intervals of exposed axon) occur between myelin sheaths. Impulses moving along myelinated axons jump from node to node. This method of nerve impulse transmission is saltatory conduction.

The brain has billions of neurons that receive, analyze, and store information about internal and external conditions. It is also the source of conscious and unconscious thoughts, moods, and emotions. Four major brain divisions govern its main functions: the cerebrum, the diencephalon, the cerebellum, and the brain stem.

The cerebrum is the large rounded area that divides into left and right hemispheres (halves) at a fissure (deep groove). The hemispheres communicate with each other through the corpus callosum (bundle of fibers between the hemispheres). Surprisingly, each hemisphere controls muscles and glands on the opposite side of the body. Comprising 85 percent of total brain weight, the cerebrum controls language, conscious thought, hearing, somatosensory functions (sense of touch), memory, personality development, and vision.

Gray matter (unmyelinated nerve cell bodies) composes the cerebral cortex (outer portion of the cerebrum). Beneath the cortex lies the white matter (myelinated axons). During

embryonic development, the cortex folds upon itself to form gyri (folds) and sulci (shallow grooves) so that more gray matter can reside within the skull cavity.

The diencephalon forms the central part of the brain. It consists of three bilaterally symmetrical structures: the hypothalamus, thalamus, and epithalamus. The hypothalamus 'master switchboard' resides in the brain stem upper end. It controls many body activities that affect homeostasis (maintenance of a stable internal environment in the body).

The hypothalamus is the main neural control center (brain part that controls endocrine glands). The pituitary gland lies just below the hypothalamus. The pituitary gland is a small endocrine gland that secretes a variety of hormones (organic chemicals that regulate the body's physiological processes). When the hypothalamus detects certain body changes, it releases regulating factors (chemicals that stimulate or inhibit the pituitary gland). The pituitary gland then releases or blocks various hormones. Because of this close association between the nervous and endocrine systems, together they are called the neuroendocrine system.

The hypothalamus also regulates visceral (organ-related) activities, food and fluid intake, sleep and wake patterns, sex drive, emotional states, and production of antidiuretic hormone (ADH) and oxytocin. The pituitary gland produces both these hormones.

The thalamus is a relay and preprocessing station for the many nerve impulses that pass through it. Impulses carrying similar messages are grouped in the thalamus, then relayed to the appropriate brain areas.

The epithalamus is the most dorsal (posterior) portion of the diencephalon. It contains a vascular network involved in cerebrospinal fluid production. Extending from the epithalamus posteriorly is the pineal body, or pineal gland. Its function is not yet fully understood; it is thought to control body rhythms.

At the rear of the brain is the cerebellum. The cerebellum is similar to the cerebrum: each has hemispheres that control the opposite side of the body and are covered by gray matter and surface folds. In the cerebellum, the folds are called folia; in the cerebrum, sulci. The vermis (central constricted area) connects the hemispheres. The cerebellum controls balance, posture, and coordination.

The brain stem connects the cerebrum and cerebellum to the spinal cord. Its superior portion, the midbrain, is the center for visual and auditory reflexes; examples of these include blinking and adjusting the ear to sound volume. The middle section, the pons, bridges the cerebellum hemispheres and higher brain centers with the spinal cord. Below the pons lies the medulla oblongata; it contains the control centers for swallowing, breathing, digestion, and heartbeat.

The reticular formation extends throughout the midbrain. This network of nerves has widespread connections in the brain and is essential for consciousness, awareness, and sleep. It also filters sensory input, which allows a person to ignore repetitive noises such as traffic, yet awaken instantly to a baby's cry.

The spinal cord is a continuation of the brain stem. It is long, cylindrical, and passes through a tunnel in the vertebrae called the vertebral canal. The spinal cord has many spinal segments, which are spinal cord regions from which pairs (one per segment) of spinal nerves arise. Like the cerebrum and cerebellum, the spinal cord has gray and white matter, although here the white matter is on the outside. The spinal cord carries messages between the CNS and the rest of the body, and mediates numerous spinal reflexes such as the knee-jerk reflex.

Meninges, three connective tissue layers, protect the brain and spinal cord. The outermost dura layer forms partitions in the skull that prevents excessive brain movement. The arachnoid middle layer forms a loose covering beneath the dura. The innermost pia layer clings to the brain and spinal cord; it contains many tiny blood vessels that supply these organs.

Another protective substance, cerebrospinal fluid, surrounds the brain and spinal cord. The brain floats within the cerebrospinal fluid, which prevents against crushing under its own weight and cushions against shocks from walking, jumping, and running.

PNS: somatic (voluntary) nervous system, autonomic (involuntary) nervous system

The peripheral nervous system includes sensory receptors, sensory neurons, and motor neurons. Sensory receptors are activated by a stimulus (change in the internal or external environment). The stimulus is converted to an electronic signal and transmitted to a sensory neuron. Sensory neurons connect sensory receptors to the CNS. The CNS

processes the signal, and transmits a message back to an effector organ (an organ that responds to a nerve impulse from the CNS) through a motor neuron.

The PNS has two parts: the somatic nervous system and the autonomic nervous system. The somatic nervous system, or voluntary nervous system, enables humans to react consciously to environmental changes. It includes 31 pairs of spinal nerves and 12 pairs of cranial nerves. This system controls movements of skeletal (voluntary) muscles.

Thirty-one pairs of spinal nerves emerge from various segments of the spinal cord. Each spinal nerve has a dorsal root and a ventral root. The dorsal root contains afferent (sensory) fibers that transmit information to the spinal cord from the sensory receptors. The ventral root contains efferent (motor) fibers that carry messages from the spinal cord to the effectors. Cell bodies of the efferent fibers reside in the spinal cord gray matter. These roots become nerves that innervate (transmit nerve impulses to) muscles and organs throughout the body.

Twelve pairs of cranial nerves transmit from special sensory receptors information on the senses of balance, smell, sight, taste, and hearing. Cranial nerves also carry information from general sensory receptors in the body, mostly from the head region. This information is processed in the CNS; the resulting orders travel back through the cranial nerves to the skeletal muscles that control movements in the face and throat, such as for smiling and swallowing. In addition, some cranial nerves contain somatic and autonomic motor fibers.

The involuntary nervous system (autonomic nervous system) maintains homeostasis. As its name implies, this system works automatically and without voluntary input. Its parts include receptors within viscera (internal organs), the afferent nerves that relay the information to the CNS, and the efferent nerves that relay the action back to the effectors. The effectors in this system are smooth muscle, cardiac muscle and glands, all structures that function without conscious control. An example of autonomic control is movement of food through the digestive tract during sleep.

The efferent portion of the autonomic system is divided into sympathetic and parasympathetic systems. The sympathetic nerves mobilize energy for the 'Fight or Flight' reaction during stress, causing increased blood pressure, breathing rate, and bloodflow to muscles. Conversely, the parasympathetic nerves have a calming effect; they slow the heartbeat and breathing rate, and promote digestion and elimination. This

example of intimate interaction with the endocrine system is one of many that explain why the two systems are called the neuroendocrine system.

The relationship between sensory and motor neurons can be seen in a reflex (rapid motor response to a stimulus). Reflexes are quick because they involve few neurons. Reflexes are either somatic (resulting in contraction of skeletal muscle) or autonomic (activation of smooth and cardiac muscle). All reflex arcs have five basic elements: a receptor, sensory neuron, integration center (CNS), motor neuron, and effector.

Spinal reflexes are somatic reflexes mediated by the spinal cord. These can involve higher brain centers. In a spinal reflex, the message is simultaneously sent to the spinal cord and brain. The reflex triggers the response without waiting for brain analysis. If a finger touches something hot, the finger jerks away from the danger. The burning sensation becomes an impulse in the sensory neurons. These neurons synapse in the spinal cord with motor neurons that cause the burned finger to pull away. This spinal reflex is a flexor, or withdrawal reflex.

The stretch reflex occurs when a muscle or its tendon is struck. The jolt causes the muscle to contract and inhibits antagonist muscle contraction. A familiar example is the patellar reflex, or knee-jerk reflex, that occurs when the patellar tendon is struck. The impulse travels via afferent neurons to the spinal cord where the message is interpreted. Two messages are sent back, one causing the quadriceps muscles to contract and the other inhibiting the antagonist hamstring muscles from contracting. The contraction of the quadriceps and inhibition of hamstrings cause the lower leg to kick, or knee-jerk.

Sense organs

The sense organs are highly specialized structures that receive information from the environment. These organs contain special sense receptors ranging from complex structures, such as eyes and ears, to small localized clusters of receptors, such as taste buds and olfactory epithelium (receptors for smell).

Smell and taste are chemical senses, which contain chemoreceptors that respond to chemicals in solution. Food chemicals dissolved in saliva stimulate taste receptors in taste buds. The nasal membranes produce fluids that dissolve chemicals in air. These chemicals stimulate smell receptors in olfactory epithelium. The chemical senses complement each other and respond to many of the same stimuli.

Photoreceptors, which include rods and cones, in back of the eye respond to light energy. Rods provide dim-light, black-and-white vision, and are the source of peripheral vision. Cones operate in bright light and provide color vision. Cones are most concentrated at the back center of each eye. Rods are more numerous than cones, and surround the cones. Information from the rods and cones travels via the optic nerve into the brain for interpretation.

The ear has two specialized functions: sound wave detection and interpretation of the head position in space. Sound waves enter the outer ear through the external auditory canal (ear canal) and strike the tympanic membrane (eardrum). Vibration of the eardrum moves three ossicles (small bones) inside the middle ear, which in turn stimulate the organ of Corti (hearing receptor in the inner ear). Impulses travel from the organ of Corti through the vestibulocochlear nerve to be interpreted by the brain.

The ear also contains equilibrium (sense of balance) receptors. The vestibular apparatus, a group of equilibrium receptors in the inner ear, sense movement in space. Maculae receptors in the vestibule monitor static equilibrium (head position with respect to gravity when the body is still). Cristae receptors in the semicircular canals monitor dynamic equilibrium (movement). Impulses from the vestibular apparatus travel along the vestibulocochlear nerve to appropriate brain areas. These centers start responses that fix the eyes on objects and stimulate muscles to maintain balance.

Mechanoreceptors respond to mechanical energy forces: touch, pressure, stretching, and movement. Ranging in complexity from free nerve endings beneath the skin to more complex tactile receptors at the bases of hair, mechanoreceptors change shape when pushed or pulled.

Different types of skin receptors sense different environmental stimuli. Free nerve endings sense pain. Specialized receptors such as Merkel's discs and Meissner's corpuscles sense touch. Pacinian corpuscles sense deep pressure. Naked nerve endings are thought to be responsible for sensing temperature.

Other types of sensory receptors provide the brain information on the body. Interoreceptors in body organs inform the CNS about internal conditions such as hunger and pain. Proprioceptors in joints, tendons, and muscles detect changes in position of skeletal muscles and bones. This information allows humans to be aware the positions of their trunk and limbs without having to see them.

Definition

Meningitis (men-in-JIE-tis) is an inflammation of brain and spinal cord meninges by bacteria, virus, or fingi. Bacterial meningitis is also known as meningococcal meningitis. Aseptic meningtis is a form of meningitis in which there is no organism growth on culture, making the causative agent viral, protozoan, oor fungal. This is usually self-limiting and not contagious.

Etiology

Bacterial meningitis is caused by bacteria and is rare, but is usually serious and can be life-threatening if it's not treated right away. Common agents are:

Group B streptococcus Escherichia coli

Listeria monocytogenes Streptococcus pneumoniae (pneumococcus) Neisseria meningitidis (meningococcus) Haemophilus influenza type b (Hib)

Viral meningitis is caused by viruses.Common agents are:

Coxsackievirus Poliovirus Hepatitis A Herpesvirus

Epidemiology

Although meningitis is a notifiable disease in many countries, the exact incidence

rate is unknown. Bacterial meningitis occurs in about 3 people per 100,000 annually in

western world. Population-wide studies have shown that viral meningitis is more

common, at 10.9 per 100,000, and occurs more often in the summer. In Brazil, the rate of

bacterial meningitis is higher, at 45.8 per 100,000 annually. In Sub-saharan Africa, large

epidemics of meningococcal meningitis occur in the dry season, leading to it being

labeled the "meningitis belt"; annual rates of 500 cases per 100,000 are encountered in

this area, which is poorly served by Health Care. These cases are predominantly caused

by meningococci. The most recent epidemic, affecting Nigeria, Niger, Mali,Burkina-

Faso, West African meningitis outbreak.and is ongoing.

Meningococcal disease occurs in epidemics in areas where many people live

together for the first time, such as army barracks during mobilization, college campuse

and.

There are significant differences in the local distribution of causes for bacterial

meningitis. For instance, N. meningitides groups B and C cause most disease episodes in

Europe, while group A meningococci are more common in China and amongst Hajj

pilgrims. In the "meningitis belt" of Africa, group A and C meningococci cause most of

the outbreaks. Group W135 meningococci have caused several recent epidemics in Africa

and during the Hajj. These differences are expected to change further as vaccines against

common strains are introduced.

Transmission

Meningitis is spread by direct contact with a carrier’s secretions, especially by respiratory droplets. People may be carrier’s only, without having he actual disease.

High-risk groups

1. Anyone who lives in close contact with many people.2. Anyone who has frequent upper respiratory infections.3. Anyone who has had trauma or an invasive procedure involving the brain,

spinal cord, or sinuses.

Signs & Symptoms

1. Signs of infectiona. Feverb. Chills and malaise

2. Signs of increased intracranial pressurea. Headacheb. Vomiting

3. Signs of meningeal irritationa. Nuchal rigidity (stiff neck)b. Opisthotonos (backward arching of the body in muscle spasms)c. Photophobia (sensitivity to light)d. Diplopia (double vision)e. Delirium, stupor, coma: indicates a decreasing level of consciousness, an

agitated state followed by a progressive decrease in consciousness, and ultimately a lack of any response.

f. (+) Brudzinski’s sign (involuntary flexion of the knees caused by flexing the neck)

g. (+) Kernig’s sign (strong resistance to attempts to extend the knee from the flexed thigh position)

4. Children may exhibit any of the signs and symptoms listed above, as well as these signs:

a. Bulging fontanelleb. Twitching, seizures, and coma

Treatment

Bed rest I.V. fluid administration Oxygen therapy Medications for:

-Bacterial infection

-Muscle aches-Seizures-Fever-Pressure on the brain

Anticonvulsant (prevent seizures ): Phenytoin (Dilantin), Phenobarbital (Barbita, Luminal, Solfoton)

Analgesic or antipyretic (to treat fever and muscle aches ): acetaminophen (Tylenol or Panadol), nonsteroidal anti-inflammatory drugs (NSAIDs) Aspirin

ibuprofen, ketoprofen, and naproxen (reduce pressure within the brain ): Dexamethasone (corticosteroid medicine),

Mannitol (Osmitrol) Antibiotics - depend on the isolated microorganism

Prevention

(MMR) vaccine (measles, mumps, and rubella ) Haemophilus vaccine (HiB vaccine)) meningococcal vaccine (MCV4) pneumococcal conjugate vaccine Good personal hygiene Avoiding people who have meningitis.

Laboratory and Diagnostic Exam

Meningitis is diagnosed by analysis of the spinal fluid. Spinal fluid is obtained by a procedure called the lumbar puncture or spinal tap in which a needle is introduced into the space between vertebraeL-3 and L-4, because the spinal cord ends at L-2. Spinal fluis is withdrawn from the subarachnoid space.

Cerebrospinal Fluid Analysis

TEST NORMAL ABNORMAL FINDINGSPressure <200mm H20 IncreasedColor Clear Cloudy/Milky whiteCells RBC: None

WBC: Very few Positive neutrophilsProtein 15-75 mg/dL ElevatedGlucose 50-75mg/dL or >50% of

blood glucoseDecreased

* A CBC will indicate acute infection. Bacterial antigen testing may also be done.

*A Gram’s stain will determine the presence of bacteria. A full culture should be done with sensitivity.

* Radiography: skull and spine x-rays used to identify sinus infections, fracture, or osteomyellitis; chest x-rays may be used to identify respiratory infections, abscesses, lesions, or granulomas.

*CT scan: will usually be normal in uncomplicated cases of meningitis, but can show diffuse enhancement in some types or show hydrocephalus.

*Electroencephalogram: may be performed to show slow wave activity.

Pathophysiology

Enters the bloodstream & Crosses the blood-brain barrier

BACTERIA

Invasion of the nasopharynx

Proliferates the CSF

Inflammation of the subarachnoid & pia mater

Increased ICP

Theoretical Framework

Pure waterPure or Fresh water

Light

Efficient Drainage

Cleanliness

WellnessOr

Disease

Nightingale’s Environmental Theory

Florence Nightingale defined nursing as “the act of utilizing the environment of the patient to assist him in his recovery”. Based on her theory the five environmental factors: pure or fresh air, pure water, efficient drainage, cleanliness and light affect client’s illness or health. Any deficiencies in these five factors produced lack of health or illness.

CASE STUDY

Biographic Data

Patient: C.A.M (Second Child)

Sex: Male Age: 9 months (July)

Address: Sitio Taguisan Bagong Nayon, Antipolo City

Weight 8.6kg

Birth Day: October 24, 2008

Mother: Marites A. Magbanua

Age: 33years old

Occupation: Housewife

Birth Date: February 14 1976

Father: Henry V. Magbanua (Security Guard)

Age: 36 years old

Occupation: Security Guard

Birth Date: August 16 1973

Religion: Catholic

Socio-Economic History

Place and nature of dwelling: Own House, Slight crowded area, Good Ventilation.

Source of Water: Nawasa, Mineral

Type of lightning: Electricity, Florescent

Number of persons living in the house: 4

Member of the Family who work: 1 (Father)

Financial Status: 5,000.00/month

Admission

Confined Date: June 23, 2009 Time: 11:20am

Verbalized by the Mother: Fever, Convulsion

Behavior: Irritable

Medication Given By the Mother: Paracetamol

June 19 2009, Patient is febrile and lasted for four days; by June 23, 2009 @ 10pm patient was confined due to Convulsion at NCH.

Physical Examination

General Appearance and Condition: Asleep, not in Distress

Temperature: 38.30C

Pulse Rate: 128bpm

Weight: 8.6kgs

Height: 69cm

Head Circumference: 94cm

Chest Circumference: 46cm

Abdominal circumference: 45cm

Blood Pressure: 100/60 mmHg

Flushed and Warm Skin

HEENT: slightly pinkish, palpebral conjuctiva

Thorax and Spine: No deformity in Lungs

Nervous System

Cerebrum: awake

Cerebellum: No nystagmusNA

2-3mm ERTC when awake, pinpoint when asleep

III,IV,VI- (+) bicomeal reflex

VII- no facial assemtry

IX- (+) gag reflex

XI- midline tongue

Motor: cannot move all

Sensory: withdrawal and pain

Meningeal Signs:

Nuchal ridigity (+)

Kernig’s Sign (+)

Brudzinski’s sign (+)

Past and Present Illness

Otitis Media @ 6months

Fever for 4 days PTA

Cough & cold

Diarrhea

Immunization

Vaccine 1 2 3

BCG

DPT

OPV

MEASLES

HEPA B

MMR

Developmental Milestones

AGE DEVELOPMENTAL MILESTONE NORMAL

2 months Social smile 2months

5 months Moro reflex disappears 5-6months

6months Sits with support 6 months

8months Sits without support 8months

9months Creeps or crawl 9months

Nutritional-Metabolic Pattern

Soft Diet:

Bottle Feed: 4ounce

Rice Porridge

Biscuit

Water

Systems Review

A review of all health problems of body systems:

General: Fever

EENT: Eye redness, ear discharge

Skin: Warm and flushed

Respiratory: Cough & cold

GIT: diarrhea

GUT: dysuria

Laboratory and Diagnostic Exams

CT Scan

no lesion intact

Ventricles normal

Midline structure undisplaced

Sella/pineal gland/posterior fossa unremarkable

Anterior fontanelle infused

IMPRESSION:Meningitis with subdural empyema as described

Cerebrospinal Fluid Analysis

TEST NORMAL ABNORMAL FINDINGS

Pressure <200mm H20 220 mm H20Color Clear CloudyCells RBC: None

WBC: Very few Positive neutrophilsProtein 15-75 mg/dL 84mg/dLGlucose 50-75mg/dL or >50% of

blood glucose30mg/dL

Gram Staining

Showed that it is positive for the microorganism Streptococcus pnuemoniae, a gram-positive coccus that appear in pairs.

Pharmacologic Intervention

Drug Action Side effects Indication Contraindications

Chloramphenicol Antibiotic CNS: dizziness, drowsiness, lethargy, depression, light headedness, disorientation, anger, manic or hypomanic episodes, restlessness,

Serious infection when less potentially dangerous drugs are ineffective or contraindicatedChildren: 50 to 100 mg/kg/day I.V. in divided dose q 6 hrs.

Hypersensitivity to drug, Severe renal or hepatic impairment,

Prophylaxis for bacterial

Drug Action Side effects Indication Contraindications

Diazepam 2.5 mg IV Produces

anxiolytic effect and CNS depression Controls seizures by enhancing presynaptic inhibition.

CNS: confusion, delirium, depression, headache, peripheral neuropathy

anxiety; Children age 6 months & older- 1 to 2.5 mg P.O three to four times daily;

Hypersensitivity to drug, other benzodiazepines, alcohol or tartazine,Coma or CNS depression, Narrow-angle glaucoma

Drug Action Side effects Indication Contraindications

Metronidazole Anti-infectives, antiprotozoals, antiulcer agents

Seizures, dizziness, headache

Treatment of the following anaerobic infections:intra-abdominal infections,CNS infection, septicemia, Endocarditis

Hypersensitivity

Drug Action Side effects Indication Contraindications

Penicillin G Bactericidal action against susceptible bacteria

seizures Treatment of a wide variety of infections

Previous hypersensitivity to penicillins, procaine or benzathine

Nursing Diagnosis

Hyperthermia related to positive bacterial infection as manifested by flushed and warm to touch skin.

Acute pain related to meningeal irritation with spasm of extensor muscles (neck, shoulders and back) as manifested by positive kernig’s and brudzinski’s sign.

Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure

Risk for infection related to presence of infective organisms Risk for injury related to presence of infection Altered thermoregulation related to compression of hypothalamus Altered family processes related to having a child with a serious illness

Nursing Management

Monitor vital signs constantly. Determine oxygenation from arterial blood gas values and pulse oximetry

Give oxygen to maintain arterial partial pressure of oxygen

Reduce high fever to decrease load on heart and brain from oxygen demands Rapid intravenous fluid replacement may be prescribed, but take care not to

overhydrate patient because of risk of cerebral edema Assess clinical status continuously; evaluate skin and oral hygiene; promote

comfort; and protect patient during seizures Implement infection control precautions and respiratory isolation until 24 hours

after start of antibiotic therapy Inform family about patient’s condition

Nursing Care Plan

CUES NURSING DIAGNOSIS

GOAL NURSING INTERVENTION

EVALUATION

Subjective:

“Mataas pa din ang lagnat niya hanggang ngayon” as verbalized by the patient’s mother.

Objective: -flushed skin-warm to touch skin-T.38.2oC-PR 109-RR 34-BP 90/60

Hyperthermia related to positive bacterial infection as manifested by flushed and warm to touch skin.

Short term:

Within 1 hour of nursing intervention, the patient’s elevated temperature of 38.2oC will lessen to 37.4oC.

Long term:

Within 3 consecutive days of nursing intervention, the patient’s body temperature will return to its normal range.

Establish rapport to mother to gain trust and cooperation

Promote surface cooling by means of undressing ( heat loss by radiation and conduction)

Demonstrate on ways on how to do proper Tepid Sponge Bath using wet and dry cloth

Provide nutritious diet to meet increased metabolic demands

Administer antipyretics as ordered

After 1 hour of nursing intervention, the goal is partially achieved as manifested by temperature of 37.7oC.

CUES NURSING DIAGNOSIS

GOAL NURSING INTERVENTION

EVALUATION

Subjective:

“Umiiyak yan kapag nagagalaw yung batok niya tska nung may ginawa si doctor sa kanya”

Objective:- facial grimace- irritable- ( + ) Brudzinski’s sign- ( + ) Kernig’s sign

Acute pain related to meningeal irritation with spasm of extensor muscles (neck, shoulders and back) as manifested by positive kernig’s and brudzinski’s sign.

Short term:

Within 2 hours of nursing intervention, the patient’s pain from 8 will reduce to 4 using the facial pain rating scale.

Use pain rating scale appropriate to it’s age

Assess for neurologic status and vital signs

Position on the side with head gently supported in extension

Promote rest by keeping stimulation in the room to a minimum

Institute respiratory isolation

Monitor and record carefully intake and output

Administer mediation as ordered

After 2 hours of nursing intervention, there is no sign of facial grimace and irritability from the patient.

CUES NURSING DIAGNOSIS

GOAL NURSING INTERVENTION

EVALUATION

Objective:- lethargic- change in motor responses- changes in papillary reaction

Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure

Within an hour of nursing intervention, the nurse will be able to educate the patient’s mother about the causes and symptoms of ineffective cerebral tissue perfusion.

Educate patient’s mother about the causes of ineffective cerebral tissue perfusion.

Observe carefully for signs of increased intracranial pressure such as; lethargy, shrill cry, hyperactive reflexes, decreased pulse and respiratory rate, increased blood pressure and temperature

Carefully monitor the rate of all IV infusions to prevent overhydration

Check for the urine’s specific gravity to detect oversecretion or undersecretion of ADH due to pituitary pressure

After an hour of nursing intervention, the patient’s mother is educated about the causes and symptoms of ineffective cerebral tissue perfusion.

Measure head circumference and weight

Monitor vital signs

Discharge Planning

Medicines:-take your (antibiotics) medications as prescribed by physician.-do not quit taking your (antibiotics) meds until your physician say so

Wellness:-eat a variety of healthy foods such as fruits and vegetables-drink more liquid like water, juices and milk-avoid stress by providing calm and clean environment, stress causes slow healing.

Health teaching:-teach patient’s mother how to perform oral care and it’s benefits

Check-up:-teach patient’s mother to have a regular check-up in the health center or in the nearest hospital.