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Pediatric Nursing Care Planning for Bacterial Meningitis Tran Thi Hong Van-MD,MS... • Identify nursing diagnosis for child with meningitis and care planning.. • Perform some skills in nu

Pediatric Nursing Care Planning

for Bacterial Meningitis

Tran Thi Hong Van-MD,MS

Learning objectives:

2 Practice:

• Assess some signs, symptoms and complications in

child with meningitis.

• Identify nursing diagnosis for child with meningitis and care planning.

• Perform some skills in nursing care for children with

meningitis:

 assistant doctors to do lumbar puncture

 keeping patients in the right position

 administer oxygen by face mask

 suction the child, suction by equipment as needed

 monitoring respiratory and cardiovascular status

Learning objectives:

3 Attitude

Having knowledge that:

• Bacterial meningitis is very serious

disease; it can lead the patient to the dead

or sequalae for life

• The mistake in treatment and nursing

care cause the increase incidence of

mortality and sequalae.

1 Definition

• Meningitis is inflammation of the meninges

of the brain, spinal cord, or both.

• Causes: Bacteria, virus, fungi, parasites

2 Etiology

1 Post-neonatal meningitis (after age 1 month)

• Bacteria:

- Most cases are caused by:

Neisseria meningitidis (Meningococcus)

Hemophilus influenzae type b

Streptococcus pneumoniae (Pneumococcus)

+ Vaccination reduce these diseases

+ All 3 pathogens can be isolated from the throat or nasopharynx of healthy individuals.

- Others : Streptococcus group B, Gr (-) enteric bacilli, Listeria monocytogenes, Staphylococcus aureus, Pseudomonas aeruginosa …

(Streptococcus agalactiae & Escherichia coli account for

50–66% of cases of neonatal meningitis).

• Listeria monocytogenes ( approximately 1–5%).

• Klebsiella…

− 300–400 cases per 100,000 live births

− 141cases per 100,000 during the second

month of life

− < 50 cases per 100,000 in the second year of life

Image 049_23 Haemophilus influenzae Infections

Incidence of H influenzae type b (Hib) and non-type b invasive disease, per 100,000

population, United States, 1989 to 1996 The marked decrease in incidence of type b

disease is the result of routin Hib vaccin administration

• Rick factors:

- Age: < 3 yrs , specially in newborn

- Gender: male > female

- Immunodeficiency: premature newborn, malnutrition, chronic diseases, AIDS…

- Acute or chronic infectious diseases in

respiratory and ENT

- Malformation or trauma in brain, spinal cord :

meningocele, ventricular drainage, craniocerebral

trauma, lumbar puncture

- Crowded population and poor hygiene

4.Pathology and Pathophysiology

• Meningeal purulent exudate : distributed around the cerebral

veins, venous sinuses, convexity of the brain, and cerebellum and in the sulci, sylvian fissures, basal cisterns, and spinal cord

• Ventriculitis with bacteria and inflammatory cells in ventricular fluid (more often in neonates), may subdural effusions and, rarely, empyema

• Perivascular inflammatory infiltrates

small arteries and veins, vasculitis, thrombosis of small cortical veins, occlusion of major venous sinuses, necrotizing arteritis

producing subarachnoid hemorrhage, cerebral cortical necrosis

• Cerebral infarction , resulting from vascular occlusion due to

inflammation, vasospasm, and thrombosis

• Increased ICP due to inflammation, brain parenchymal edema, CSF

obstrution.

• The syndrome of inappropriate antidiuretic hormone secretion (SIADH)

• Hydrocephalus due to adhesive thickening of the arachnoid villi around

the cisterns at the base of the brain, interference with the normal

Perivascular inflammatory

infiltrates

1.3 Cơ chế bệnh sinh:

5 Signs and Symptoms

5 Signs and Symptoms

• Flex the neck of the patient in the supine position.

• When positive, the patient will involuntarily flex hips and knee.

5 Signs and Symptoms

• In a young infant, signs of meningeal

inflammation can be minimal or absent

– In patients < 12 mos, absence of nuchal rigidity.– lethargy, poor feeding, restlessness

– Bulging fontanelle

• Seizures

• Petechiae and purpura, shock: meningococcal disease

• Neonates

− apnea

− feed poorly – Hyperthermia or hypothermia – Irritability or lethargy

– Respiratory distress or diarrhea (or both) – Nuchal rigidity (rarely)

– Bulging fontanelle

6 Laboratory Findings

• The initial laboratory examination should include:

– CSF examination and culture

– Blood culture

– Measurement of serum electrolyte and glucose

concentrations

– Complete blood count and platelet count

– Measurement of urine specific gravity

• If the patient has petechiae or purpura or is in shock, then the laboratory tests should include:

– Partial thromboplastin time

7.Treatment Approach

• Acute bacterial meningitis is always a medical emergency;

should be observed closely

• Therapies that are crucial for all patients with bacterial

meningitis

– Fluid management

– Possible antiinflammatory adjunctive treatments

– Antimicrobial therapy

• As soon as bacterial meningitis is diagnosed, intravenous

administration of appropriate antimicrobial agents and possibly antiinflammatory agents should begin.

• Management of the child who is awake and has stable

cardiorespiratory vital signs consists primarily of:

– Administering antimicrobial agents and fluids and careful monitoring for:

• Changes in level of consciousness

• Development of seizures

• Changes in vital signs

• If increased intracranial pressure is a major clinical

concern and treatment has been initiated or is

anticipated, a neurosurgeon should be consulted and an intracranial pressure monitoring device placed.

– If an intraventricular catheter can be placed, then

increased intracranial pressure can often be treated by removing CSF.

• Placement of a pressure transducer affords continuous intracranial monitoring, so that mannitol and hyperventilation can be used as

8 Prognosis

– Despite the appropriate use of bactericidal antibiotics, the mortality rate for bacterial

meningitis remains 5–10%.

– Case-fatality rate for neonates generally ranges from 20–25%.

– In general, mortality is lower for full-term infants than for low–birth-weight infants (< 2500 g).

– Approximately 15–30% have mild to moderate neurologic sequelae.

– 5–10% have major sequelae.

• Approximately 50% of group B β-hemolytic streptococcal meningitis survivors are normal.

– 20% have mild to moderate sequelae.

– 15–30% have major sequelae, such as:

• As many as 80% of neonates who have gram-negative enteric meningitis caused by

either Citrobacter or certain Enterobacter species will develop single or multiple brain abscesses.

by Citrobacter species or Enterobacter sakazakii.

attainment of developmental milestones.

• Outcome of aseptic meningitis relates to both the causative agent and the child’s age.

meningitis in very young infants.

chance of sequelae increases.

• Predicting long-term sequelae for an individual child is difficult at the time of hospital discharge.

seizure disorder.

examinations make remarkable gains.

• Hearing should be tested formally before discharge from the

hospital.

– Most sensorineural hearing loss can be detected at this time.

– The rate of persistent bilateral or unilateral sensorineural hearing loss is:

• 31% after pneumococcal meningitis

• 10.5% after meningococcal meningitis

• 6% after Hib meningitis

– In young infants, auditory brainstem response or otoacoustic emissions testing is necessary for screening.

– In older toddlers and children, conditioned response, play, or

conventional audiometry may be performed.

– Current thinking asserts that much of the hearing loss in meningitis

occurs soon after infection.

• This may explain why not all studies have shown reduction of hearing loss

by dexamethasone therapy.

• Timing of other neurologic sequelae is less certain.

9 Nursing Diagnosis

2.1 Coma and convulsion related to increased

intracranial pressure (ICP):

- increased intracranial pressure due to inflammation &

edema in brain, CSF obstruction

- Coma and convulsion with different levels, may be no coma and convulsion

2.2 Respiratory and CVS failure related to increased

intracranial pressure and/or infection

2.3 Hyperthermia related to infection and/or temperature regulation centre

2.4 Electrolyse disorder related to SIADH, poor intake or diarrhoea

10 Nursing care planning

intracranial pressure:

• Goal: The child will develop no signs of increased ICP

as soon as possible

• Interventions:

- Assess the child’s neurologic status every 2-4 hs

(child’s crying, lethargy, bulging fontanels, pupillary

changes, seizures)

- Monitor the child’s fluid input and output everyshif

- Monitor the child’s vital signs every 2-4 hours

10 Nursing care planning

- Keep the child in the right position: elevated head

30o & turn to right/left side

- RS assistant if necessary: aspiration, oxygen

therapy

- seizures: assist the child to avoid trauma,

administer anticonvulsant medications, as ordered

- Fluid infusion, mannitol, dexamethasol,

anticonvulsant medications as ordered & in the

right way

- Assistance the doctor to make PL

10 Nursing care planning

3.2 Fever:

• Interventions:

- Monitor the child’ temperature every 2-4 giờ

- Maintain a cool environment

- Administer tepid sponge baths (37oC), as needed, to relieve fever

- Administer antipyretics if To > 38,5o C, as ordered

- Administer antimicrobials, as ordered

10 Nursing care planning

3.3 Nursing care & nutrition:

• Goal: having a good intake, hygiene to prevent

malnutrition & nosocomia

• Interventions:

- Set the diet ( thin, easy to digest, vitamin)

- Use nasogastric sonde if necessary

- Take care eyes, ENT, skin…

10 Nursing care planning

3.4 Take care the psychology, education for parent about care & prevention

- Hib: 3 times with 1 month interval (2,3,4 mos)

- Meningococcal vaccin A & C ( 18 mos)

- Pneumococcal vaccin (2 yrs )

Image 049_33 Haemophilus influenzae Infections An infant girl with

periorbital cellulitis and meningitis due to H influenzae type b This is

the same patient as in image 049_32.

Image 049_23 Haemophilus influenzae Infections Incidence of H

influenzae type b (Hib) and non-type b invasive disease, per 100,000

population, United States, 1989 to 1996 The marked decrease in incidence of type b disease is the result of routine Hib vaccine

administration.