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COLLEGE OF NURSING
BERHAMPUR

SUBJECT- MEDICAL SURGICAL

NURSING
TOPIC-MENINGITIS
SUBMITTED TO- SUBMITTED
BY-
Mrs P Laxmi Bai Miss Anwesha
Assistant Professor MSc Nursing 1st yr.
MSc in Medical Surgical Nursing
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SL NO
CONTENT PAGE NO

1 INTRODUCTION 3
2 ETIOLOGICAL FACTORS OF MENINGITIS 4

3 PATHOPHYSIOLOGY 4

4 CLINICAL MANIFESTATION 5

5 DIAGNOSTIC EVALUATION 5

6 MANAGEMENT
 MEDICAL MANAGEMENT 6-8
 NURSING MANAGEMENT
7 AMBULATORY AND HOME CARE 9

8 PREVENTION 9

9 CONCLUSION 9

10 BIBLIOGRAPHY 9
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INTROPDUCTION-
Meningitis is an acute inflammation of the meningeal tissues surrounding the brain and spinal
cord caused by either viruses or bacteria and less commonly by certain drugs. Organisms may
reach the meninges through the blood, through head wounds, or from other cranial structures
such as the sinuses or inner ear. Meningitis usually occurs in fall, winter, or early spring and
is often secondary to viral respiratory disease. Older adults and persons who are debilitated
are affected more frequently than the general population. College students living in
dormitories and individuals living in institutions (e.g., prisoners) are also at a high risk for
contracting meningitis. Meningitis can also develop from non-infectious causes, including
certain diseases like AIDS, cancer, diabetes, physical injury or certain drugs that weaken the
body’s immune systems.

ETIOLOGICAL FACTORS OF MENINGITIS-

Meningitis is classified as aseptic or septic. In aseptic meningitis, bacteria are not the
cause of the inflammation; the cause is viral or secondary to lymphoma, leukaemia, or brain
abscess. Septic meningitis refers to meningitis caused by bacteria, most commonly Neisseria
meningitis, Haemophilus influenzae and Streptococcus pneumoniae. Bacterial meningitis is
considered a medical emergency. Untreated bacterial meningitis has a mortality rate near
100%.

1. Bacterial meningitis-Outbreaks of N. meningitis infection are most likely to occur in

dense community groups, such as college campuses and military installations. Peak
incidence is in the winter and early spring. Tobacco use and viral upper respiratory
infection increase the amount of droplet production hence increase the risk too.. Otitis
media and mastoiditis increase the risk of bacterial meningitis because the bacteria
can cross the epithelium membrane and enter the subarachnoid space. Persons with
immune system deficiencies are also at greater risk Streptococcus pneumoniae and
Neisseria meningitis are the leading causes of bacterial meningitis. Haemophilus
influenza was once the most common cause of bacterial meningitis. The organisms
usually gain entry to the CNS through the upper respiratory tract or the bloodstream.
However, they may enter by direct extension from penetrating wounds of the skull or
through fractured sinuses in basilar skull fractures.
2. Viral meningitis- It is generally less severe and resolves without specific treatment.
Other viral infections that lead to meningitis are mumps, herpes including Epstein-
Barr virus, herpes simplex virus, varicella zoster virus, measles and influenza. In rare
cases LCMV (Lymphocytic choriomeningitis virus), which is spread by rodents, can
cause it.
3. Fungal meningitis- rare, but can be life-threatening. Although anyone can get fungal
infection but people with AIDS, leukaemia or other forms of immunodeficiency and
immunosuppression are at greater risk. Most common cause is Cryptococcus. Candida
can lead to meningitis in rare cases in premature babies with very low birth weight.
4. Non-infectious meningitis- not spread from person to person. It is caused by cancers,
systemic lupus erythematous, certain drugs, head injury and brain surgery.
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PATHOPHYSIOLOGY-

Meningeal infections generally originate in one of two ways: through the bloodstream
as a consequence of other infections, or by direct extension, such as might occur after a
traumatic injury to the facial bones, or secondary to invasive procedures. N. meningitidis
concentrates in the nasopharynx and is transmitted by secretion or aerosol contamination.
Bacterial or meningococcal meningitis also occurs as an opportunistic infection in patients
with acquired immunodeficiency syndrome (AIDS) S. pneumoniae is the most frequent
causative agent of bacterial meningitis associated with AIDS Once the causative organism
enters the bloodstream, it crosses the blood–brain barrier and causes an inflammatory
reaction in the meninges. Independent of the causative agent, inflammation of the
subarachnoid space and pia mater occurs. Since there is little room for expansion within the
cranial vault, the inflammation may cause increased intracranial pressure. Cerebrospinal fluid
(CSF) flows in the subarachnoid space, where inflammatory cellular material from the
affected meningeal tissue enters and accumulates in the subarachnoid space, thereby
increasing the CSFcell count. The prognosis for bacterial meningitis depends on the causative
organism, the severity of the infection and illness, and the timeliness of treatment. In acute
fulminant presentations there may be adrenal damage, circulatory collapse, and widespread
hemorrhages (Waterhouse-Friderichsen syndrome). This syndrome is the result of endothelial
damage and vascular necrosis caused by the bacteria.

The inflammatory response to the infection tends to increase CSF production with a
moderate increase in ICP. In bacterial meningitis the purulent secretions produced quickly
spread to other areas of the brain through the CSF and cover the cranial nerves and other
intracranial structures. If this process extends into the brain parenchyma or if concurrent
encephalitis is present, cerebral edema and increased ICP become more of a problem. Closely
observe all patients with meningitis for manifestations of increased ICP, which is thought to
be a result of swelling around the dura and increased CSF volume.

Due to etiological factors

Pathogens attach themselves to mucus epithelium and enter into blood stream

Bacteria that are able to survive in circulation enter CSF

Pathogen multiply rapidly in subarachnoid space

Multiplication and lysis of bacteria by formation of

Inflammatory cytokinase, interleukin-1, tumour necrosis factor by
Monocytes, macrophages, brain astrocytes and microglial cells

Reduced blood flow lead to altered cerebral tissue perfusion

Formation of purulent exudate in SAS

Large no of leukocytes in the SAS add to exudate and obstruct the flow of CSF

Cerebral edema and Increase intracranial pressure

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CLINICAL MANIFESTATION-

Tends to remain high throughout the course of the illness. The headache is usually severe as a
result of meningeal irritation. Meningeal irritation results in a number of other well-
recognized signs common to all types of meningitis:

 Headache- The headache becomes progressively worse and may be accompanied by

vomiting and irritability
 Sudden high fever
 Altered mental status
 Confusion or altered consciousness- changes depend on the severity of the infection
as well as the individual response to the physiologic processes
 Vomiting
 Photophobia, phonophobia
 Irritability, drowsiness
 Sign of meningeal irritation
 Nuchal rigidity with fever- an early sign. Any attempts at flexion of the head are
difficult because of spasms in the muscles of the neck. Forceful flexion causes severe
pain.
 Sign of increasing ICP- widened pulse pressure, bradycardia, and respiratory
irregularity, decreasing LOC, papilledema, headache and vomiting.
 Positive Kernig’s sign: When the patient is lying with the thigh flexed on the
abdomen, the leg cannot be completely extended
 Positive Brudzinski’s sign: When the patient’s neck is flexed, flexion of the knees and
hips is produced; when passive flexion of the lower extremity of one side is made, a
similar movement is seen in the opposite extremity (see Fig. 64-1).
 A rash can be a striking feature of N. meningitis infection, occurring in 50%. Skin
lesions develop, ranging from a petechial rash with purpuric lesions to large areas of
ecchymosis.
 Behavioural manifestations -lethargy, unresponsiveness, and coma may
 Seizures and increased intracranial pressure (ICP) are also associated with meningitis.
Seizures occur secondary to focal areas of cortical irritability. Intracranial pressure
increases secondary to accumulation of purulent exudate.
 in about 10% of patients with meningococcal meningitis signs of overwhelming
septicaemia: an abrupt onset of high fever, extensive purpuric lesions (over the face
and extremities), shock, and signs of disseminated intravascular coagulopathy (DIC)

DIAGNOSTIC EVALUATION-
When the clinical presentation points to meningitis, diagnostic testing to identify the
causative organism is conducted.

History taking
Physical examination
Gram staining of CSF and blood are key diagnostic tests. The presence of
polysaccharide antigen in CSF further supports the diagnosis of bacterial meningitis
Lumbar puncture is done to obtain a CSF sample for laboratory analysis. The sample
is examined to detect the presence of microorganisms in the CSF and to identify the
infecting organism. A lumbar puncture should be completed only after the CT scan
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has ruled out an obstruction in the foramen magnum in order to prevent a fluid shift
resulting in herniation. With bacterial meningitis, the CSF appears milky and purulent
because of white blood cells suspended in the fluid. CT or MRI scans are used to
assess for complications.
A blood culture and CT scan should be done..
Specimens of the CSF, sputum, and nasopharyngeal secretions are taken for culture
before the start of antibiotic therapy to identify the causative organism.
CSF analysis- Protein levels in the CSF are usually elevated and are higher in
bacterial than in viral meningitis. The CSF glucose concentration is commonly
decreased in bacterial meningitis but may be normal in viral meningitis. The CSF is
purulent and turbid in bacterial meningitis. It may be the same or clear in viral
meningitis. The predominant white blood cell type in the CSF during bacterial
meningitis is neutrophils
X-rays of the skull may demonstrate infected sinuses. CT scans and MRI may be
normal in uncomplicated meningitis. In other cases, CT scans may reveal evidence of
increased ICP or hydrocephalus.

MANAGEMENT OF MENINGITIS-

 MEDICAL MANAGMENT-

 Successful outcomes depend on the early administration of an antibiotic that

crosses the blood–brain barrier into the subarachnoid space in sufficient
concentration to halt the multiplication of bacteria. Penicillin antibiotics (e.g.,
ampicillin, piperacillin) or one of the cephalosporin (e.g., ceftriaxone sodium,
cefuroxime, and cefotaxime sodium, and ceftazidime (Ceptaz), rifampin) may be
used.
 Vancomycin hydrochloride alone or in combination with rifampin may be used if
resistant strains of bacteria are identified. Rifampin is recommended
prophylactically to persons exposed to meningococcal meningitis. High doses of
the appropriate antibiotic are administered intravenously.
 Dexamethasone has been shown to be beneficial as adjunct therapy in the
treatment of acute bacterial meningitis and in pneumococcal meningitis if given
15 to 20 minutes before the first dose of antibiotic and every 6 hours for the next 4
days. Studies indicate that dexamethasone improves the outcome in adults and
does not increase the risk of gastrointestinal bleeding
 Dehydration and shock are treated with fluid volume expanders.
 Seizures, which may occur in the early course of the disease, are controlled with
phenytoin (Dilantin).
 Increased ICP is treated as necessary.
 Collaborate with the health care provider to manage the headache, fever, and
nuchal rigidity often associated with meningitis. Analgesic and antipyretic may
provide symptomatic treatment

Management of meningitis requires prompt recognition and treatment with antimicrobial

agents. In severe infections, broad-spectrum antimicrobials are used after a CSF specimen is
obtained. Changes in therapy may be made when the results of culture and sensitivity tests
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are reported. Bacterial infections usually respond to antimicrobial therapy but no specific
drugs are effective against most viral infections of the CNS.
If needed, Isolation Precautions should be initiated. Organisms responsible for
meningococcal meningitis are spread by the respiratory route and appropriate safeguards
must be used to protect other patients, family, and staff until the organism is no longer in the
air.

1. Bacterial meningitis- with antibiotics. Initial treatment with Ceftriaxone and

vancomycin. Appropriate antibiotic treatment of most common types of bacterial
meningitis reduce the risk of dying to below 15%, although risk is higher among
elderly.
2. Viral meningitis- No specific treatment. Mostly patient recover on their own within 7-
10days. Hospital stay is necessary for people with weak immune system. Treatment of
mild cases include- best rest, plenty of fluids, good nutrition, OTC pain medications
to reduce fever and body ache.
3. Fungal meningitis- Treated with long courses of high dose antifungal medications.
Length depends on immune system and type of fungus. Patients with AIDS, diabetes,
cancer need longer treatment.

 NURSING MANAGEMENT-
Subjective data-
 Past health history collection
 Functional health pattern-ask for duration, intensity, frequency of pain, headache
 The nurse must assess the family’s ability to express their distress at the patient’s
condition, cope with the patient’s illness and deficits, and obtain support.
Objective data-
 Initial assessment should include vital signs, neurologic evaluation, fluid intake and
output, and evaluation of the lungs and skin.
 Nursing care focuses on ongoing assessment of the neurologic status, administering
medications, assessing the response to treatment, and providing supportive care.
 Ongoing neurologic assessment alerts the nurse to changes in ICP, which may
indicate a need for more aggressive intervention. The nurse also assesses and
documents the responses to medications.
 Asses for risk for injury, fall and neurologic deficits like hemiparesis, seizures, visual
deficits, and cranial nerve palsies.
 Blood laboratory test results, specifically blood glucose and serum potassium levels,
need to be closely monitored and other diagnostic findings.

Nursing diagnosis-1- Ineffective Cerebral Tissue Perfusion related to increased intracranial

pressure (ICP) as evidence by confusion state of patient
Goal- maintaining adequate cerebral tissue perfusion by decreasing ICP
Intervention-establish neurologic baseline assessment and vital signs on admission.
- Observe for signs of increased ICP and cerebral edema.( fever, seizure, pupillary
size,hypercapnia).Asses for nuchal rigidity, restlessness, irritability
- Monitor ABGs, head circumference and maintain intake output chart if it is below
1ml/kg/hr.
- Maintain head and neck in midline, provide small pillow for support. During
reposition avoid bending of knee and pushing heels against mattress.
- Provide comfort measures and decrease external stimuli.
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- Elevate head of bead to 30 degree and avoid neck and hip flexion
- Administer oxygen as needed.
- Administer osmotic diuretic, anticonvulsant as prescribed.
Evaluation- patient will show vital signs return to normal and patient is alert and orient.

Nursing diagnosis-2- Acute Pain related to irritation of meninges as evidence by nuchal

rigidity and headache
Goal-
Intervention-asses for headache, photophobia, kernig sign and brudzinski sign.
- Maintain keep and quiet environment, prevent stimulation and restrict visitors.
- Turn the client often and position the client carefully. Assist in ROM.
- Administer analgesic as prescribed.
Evaluation-client will express feelings of comfort and relief of pain.

Nursing diagnosis-3-hyperthermia related to infection as evidence by hot flushed skin and

body temperature above normal range.
Goal- reducing fever.
Intervention- asses the vital signs closely.
- Asses for sign of dehydration like dry mouth, sunken eyes, concentrated urine.
- Perform tepid sponge.
- Institute other cooling measures like hypothermia blanket.
- Maintain adequate fluid intake as tolerated
- Administer antibiotic and antipyretic as prescribed.
- Protect the skin from excessive drying and injury and prevent breaks in the skin.
Evaluation-client will regain and maintain body temperature within a normal range.

Nursing diagnosis-4- Disturbed sensory perception related to decreased LOC as evidence by

confusion
Goal- improving sensory perception
Intervention-Asses level of consciousness, monitor change in orientation, speak, natural
feelings, sensory and thought processes.
- Signs of cerebral edema like dizziness, headache, neck pain, vomiting.
- Asses ability to follow simple and complex command and presence of reflexes.
- Reorient client to environment as needed. Validate patient’s perception and give
feedback.
- Observe and document pattern and frequency of seizure
- A quiet dark environment lessens the stimulation to headache or photophobia and who
may be agitated, disoriented or at risk of seizure.
- Administer anticonvulsant as per prescribed dosage.
Evaluation-client will maintain normal LOC.

Nursing diagnosis-5- Risk for Injury related to confusion, seizures, and restlessness
Goal- Reduce risk of injury
Intervention-asses neurologic status, change in behaviour pattern
- Note seizure activity including onset, frequency, duration, type of movement.
- Stay with client, sit near and speak in low voice.
- Remove sharp instrument from patient’s access and keep needed items near the
patient.
- Keep the bed in a low position, with the side rails padded and raised.
- Reorient the patient to the setting as needed and keep he call bell within easy reach.
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- Remind patients who are dizzy not to get up without assistance.

Evaluation- Absence of injury: no falls or other trauma

AMBULATORY AND HOME CARE-

After the acute period has passed, the patient requires several weeks of convalescence
before resuming normal activities. In this period, stress the importance of adequate nutrition,
with an emphasis on a high protein, high-calorie diet in small, frequent feedings. Muscle
rigidity may persist in the neck and the backs of the legs. Progressive range-of-motion
exercises and warm baths are useful. Have the patient gradually increase activity as tolerated,
but encourage adequate rest and sleep. Residual effects can result in sequelae such as
dementia, seizures, deafness, hemiplegia, and hydrocephalus. Assess vision, hearing,
cognitive skills, and motor and sensory abilities after recovery, with appropriate referrals as
indicated. Throughout the acute and convalescent periods, be aware of the anxiety and stress
experienced by the caregiver and other family members.

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, chicken pox, hemophilus
influenza type-B (Hib) disease and pneumococcal infection. The vaccine against Hib are very
safe and highly effective. Talk to doctor about whether your child also needs the
meningococcal vaccine, which is a shot to prevent bacterial meningitis.

CONCLUSION-
Meningitis is a fatal disease that calls for immediate intervention in other to secure
the live of the individual.Moratlity is often high but can be prevented with appropriate
medical therapy. Early recognition and treatment are mandatory to prevent complications.

BIBLIOGRAPHY-

 Basavanthappa B T, Essentials of Medical Surgical Nursing, 1st edition, Jaypee

publishers, page no-835-839.
 Cheever K.H., Hinkle J.L. (2018), Brunner and Suddarth’s textbook of Medical
Surgical Nursing, Wolter Kluwer publishers, India, page no-1939-1945, volume-II.
 Lewis L.S., Linda B (2014), Lewis’s Medical Surgical Nursing, 9th edition, Elsevier
publishers, page no- 1379-1385, volume-II.
 Linton A D, Introduction to medical surgical nursing, 6th edition, ELSEVIER
publications, page no- 461-465.
 Smeltzer. S C, Textbook of medical surgical nursing, 12th edition, Jaypee publishers,
page no- 1950- 1955, volume-II.
 William S.L.,Hopper P.D.,Understanding Medical Surgical Nursing, 3rd edition, F A
Davis company, page no-1204-1209.
 Workman, Ignatavicius, Medical Surgical Nursing, 8th edition,Elsevier publication,
page no- 697-710.