ISABELA STATE UNIVERSITY

CITY OF ILAGAN CAMPUS

College of Nursing

NUR 312
CHARLES Z. ARIOLA JR., MSN, LPT, RN.
Subject Professor
MENINGITIS
 Inflammation of the meninges (covering of the brain
and spinal cord)
Concepts!
 Meninges are composed of: Click HERE to load file
o Dura mater
o Arachnoid mater
o Pia mater
 Cerebrospinal Fluid or CSF is found in the
SUBARACHNOID SPACE
 CAUSATIVE AGENTS IN
•Viral
MENINGITIS
CMV – Cytomegalovirus
oOpportunistic infection for AIDS
•Fungal
Cryptococcal Meningitis
oSource is excreta of fowls and feathered animals
oAnother form of opportunistic infection for AIDS
•Bacterial
Tubercle Bacilli
oTB meningitis
•Staphylococcal meningitis
Secondary to skin infection
•Haemophilus influenzae bacilli
Common cause of meningitis in the United States
 CAUSATIVE AGENTS IN
MENINGITIS
 Meningococcemia
o Meningococcemial meningitis
o Spotted Fever Disease
o Most fatal
o The only type of meningitis where the VASCULAR SYSTEM is
affected
o Bleeding is triggered
o Disseminated Intravascular Coagulation occurs and leads to
vascular collapse
o Vascular collapse leads to death in ten percent (10%) of patients
o This ten percent (10%) has the FULMINANT TYPE or the
Waterhouse-Freiderichen Syndrome (characterized by vascular
collapse)
o Causative agent is Neisseria meningitides
 IMPORTANT
CONCEPT!!!
In children below four (4) years old,
Neisseria meningitidis is a normal flora in
the nasopharynx.
If resistance goes down, these children
become prone to infection
 MODE OF
TRANSMISSION
 Droplet transmission
 In cryptococcal meningitis:
o Inhalation of spores
 Respiratory system via the nasopharynx

PORTAL OF ENTRY
 Respiratory system via the nasopharynx
 PATHOPHYSIOLOGY TO
MENINGITIS
 From the nasopharynx, the microorganism goes to the bloodstream
 Once in the bloodstream, the microorganism causes petechiae formation
(pin point red spots on the skin)
 From the bloodstream, microorganism goes to the meninges and irritates
them
o There is inflammation of the meninges and accumulation of
substances in the meninges
 This results into increased Intracranial Pressure (ICP)
o Increased ICP leads to:
 Severe headache
 Projectile Vomiting
 Two (2) to three (3) feet away from patient
o Management involves turning patient to side
 Position kidney basin about two (2) to three (3) feet away
 PATHOPHYSIOLOGY TO
MENINGITIS
•Altered Vital Signs
Increased Temperature
Decreased Pulse Rate
Decreased Respiratory Rate
Increase in Systolic Blood Pressure and Normal Diastolic
Pressure
oThis results in the widening of the Pulse Pressure
•Convulsions (seizures)
•Diplopia
Due to choking of optic discs
Double vision but not crossed eyed
Determined by finger counting
•Altered level of consciousness
PATHOPHYSIOLOGY OF MENINGOCOCCEMIA
 Portal of entry of Neisseria meningitidis is also the
nasopharynx
 The bacteria then goes to the bloodstream
 Presence of bacteria in the bloodstream causes ecchymosis
o These ecchymoses are blotchy (pantal-pantal) purpuric
lesions
o They are purplish in color
o Usually found on the wrist and the ankles
 From the bloodstream, they go to the meninges and irritate
them.
 Same sequence of events follow as mentioned above
SIGNS AND SYMPTOMS
 Once the microorganism is at the nasopharynx:
o Fever
o Headache
o Sore throat
o Cough
o Colds
 Other signs and symptoms present as discussed in
the pathophysiology
PATHOGNOMONIC SIGNS

Stiffening of the neck

oNo flexing of the neck
oNo hyperextending of the neck
oNo turning from side to side
PATHOGNOMONIC SIGNS

Abnormal Reflexes
oPositive for Kernig’s Sign (Click HERE to load file)
 Place patient in supine position
 Flex both knees toward the abdomen
 Then ask the patient to extend the legs
 If pain is present, the patient is said to be
positive (+) for Kernig’s Sign or difficulty of
extending the leg
PATHOGNOMONIC SIGNS
Positive for Brudzinski’s Sign
oPlace the patient in supine position
oFlex the neck
oIf there is no reaction, the patient is said to be
negative (-) for Brudzinski’s Sign.
oIf there is INVOLUNTARY DRAWING UP of the
LEGS / HIP upon flexion of the neck, the
patient is said to be positive (+) for
Brudzinski’s Sign
DIAGNOSTIC TESTS
1. Lumbar Puncture
 Cerebrospinal Fluid (CSF) is the specimen used
o Assess for the color of the CSF
 Bacterial infection is present if:
o CSF is yellowish, turbid, cloudy
 Viral infection is present if:
o CSF is clear
 No infection is present if:
o CSF is clear
Send CSF for Laboratory Examination
 Laboratory findings would show:
o Increased protein levels
o Increased White Blood Cell levels
o Decreased Sugar content
IMPORTANT CONCEPTS!!!
 If caused by bacteria, do Culture and Sensitivity test
o This is done to know what bacteria caused the infection
o This is also done to determine what drug will be used to kill the
offending microorganism
 
 If CSF is clear, it is subjected to Counter Immuno-Electrophoresis (CIE)
 This is done to determine if causative agent or a protozoa
 IMPORTANT CONCEPT!!!
In patients with HIGHLY INCREASED INTRACRANIAL PRESSURE due to
CNS infection, lumbar puncture or aspiration of the CSF is
CONTRAINDICATED
o This will bring about HERNIATION OF THE BRAIN and would
eventually lead to death
 Therefore, it is important that the nurse performs Physical Assessment
before doing a lumbar tap.
DIAGNOSTIC TESTS

2. Blood Culture
Done because microorganism can travel to the
bloodstream
MEDICAL MANAGEMENT
 If bacterial
o Give anti-bacterial agent in the form of antibiotics
 If viral
o Symptomatic
 If fungal
o Give Amphotericin B
 If with inflammation
o Give corticosteroids in the form of DEXAMETHASONE
o Never give PREDNISONE
 Prednisone does not cross the Blood-Brain barrier
 Prednisone causes sodium retention
 Retains CSF
MEDICAL MANAGEMENT
 If with excess CSF
o Give osmotic diuretic in the form of MANNITOL
o Check blood pressure before administration as it causes hypotension
o Monitor the intake and output to evaluate the effectiveness of
Mannitol
o Expect that after two (2) to three (3) hours, the urine output must
increase by thirty (30) to fifty (50) ml.
o If no changes in urine output occurs, then Mannitol is not effective
o Refer this to the physician
 If there are convulsions due to CNS infection
o Give anti-convulsants
 Dilantin
 Phenytoin
MEDICAL MANAGEMENT
•Routes of Administration of Dilantin
Per Intravenous
oNursing Care for I.V. administration of Dilantin
Sandwich Dilantin with NSS
NSS – Dilantin – NSS
oRationale:
Dilantin would crystallize
Per Orem
oNursing Care for P.O. administration of Dilantin
Do frequent oral care
Do gum massage
Rationale:
oDilantin causes gingival hyperplasia or overgrowth of the gums
IMPORTANT CONCEPTS!!!

Dilantin is never given Intramuscularly

oThis is irritating to the tissues
oThis has an erratic effect
NURSING DIAGNOSIS
 
1. Alteration in body temperature related to
infection
Priority is to lower body temperature
oDo TSB
oProvide cold compress
oProvide loose clothing
NURSING DIAGNOSIS
2. Pain: Alteration in comfort related to increased
Intracranial Pressure
 Priority is to relieve headache within thirty (30)
minutes
o Provide diversion
o Provide proper positioning
 Low-Fowler’s position (30° incline)
o Provide comfort measures
o Massage the forehead
o Do petrissage with circular action
NURSING DIAGNOSIS
3. Potential for injury related to altered level of
consciousness
•Never leave the patient alone
•Place call switch and light within reach of patient
4. Potential for fluid and electrolyte imbalance
due to projectile vomiting
•Monitor intake and output
•Provide fluids per orem
IMPORTANT CONCEPTS!!!

An attack of meningitis does not provide

permanent immunity
PREVENTIVE MEASURES
1.Proper disposal of nasopharyngeal secretions
 Burning
 Burying
 Proper procedure for disposal of nasopharyngeal
secretions
o Use tissue paper
o Put it in a plastic bag after use
o Knot the plastic bag
o Dispose plastic bag in a trashcan
IMPORTANT CONCEPTS!!!
 The best and most economic way preventing spread of
infection is through swallowing of nasopharyngeal secretions
o This brings the secretions to the stomach and to the
intestines and would then be eliminated in the stool
 Children have less chance of spreading infection because they
swallow nasopharyngeal secretions.
 This is contraindicated, however, for tuberculosis patients
 Thus, for TB patients, they have to spit out nasopharygeal
secretions
 Swallowing is allowable for other respiratory infections
PREVENTIVE MEASURES
2. Cover nose and mouth when sneezing and
coughing
 
Important Concepts!
 When you transfer patient…
o Make the patient wear a mask so as not to infect
people in the hallway, elevator, etc.
 Wear mask when you enter the patient’s room
PREVENTIVE MEASURES

3. Vaccine
Hib vaccine for Haemophilus influenza