MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES

SCHOOL OF NURSING

DEPARTMENT OF CLINICAL NURSING

PEDIATRIC NURSING

TOPIC:MANAGEMENT OF CHILD WITH MENINGITIS

PRESENTER:SONGOMA JOHN

INTRODUCTION

Meningitis is an inflammation of the meninges , the protective membranes that surround the brain and spinal cord.

Common causes of meningitis may include:

Bacteria, Virus, Fungi and Parasites. Most episodes of meningitis result from

hematogenous seeding of infection from other sites to the meninges.

1. Bacterial causes

Varies with age: 1. Newborn to 3 months of age:

E. coli and other coliforms, group B Streptococci,Listeria monocytogenes, Strep pneumoniae, H. influenza type b, Neisseria meningitidis

2. Age 3 months to adolescence: N. meningitidis, S pneumoniae, H influenza type b (in young children)

Mycobacterium tuberculosis is most common in young children, but can affect children of any age.

. Fungal Causes

Common in immunocompromised patients. May include:Histoplasma , Coccidioides ,Paracoccidiodes ,Candida , Aspergilus Cryptococcus neoformans

Viral Causes (aseptic meningitis) include:-

Mumps Enterovirus (coxackie, polio) Adenovirus and Herpes simplex

Classification of meningitis

1. Based on duration, meningitis is classified as: Acute: symptoms present within a period of 0 –

24 hrs Sub acute: symptoms lasting from 1-7 days. Chronic: symptoms lasting over 7 days

2. Based on aetiology: Bacterial meningitis Viral (aseptic) meningitis Fungal meningitis

Clinical Presentation: Symptoms and signs

1. Young infants < 3 months: The signs and symptoms are non specific and may include: Fever or hypothermia Bulging fontanelle or acute increase in head

circumference Convulsions / seizures High-pitched cry, irritability Lethargy, altered mental state Apnoea Poor feeding, vomiting.

2. Children > 3 months to adolescents: Fever is present in about ~ 50% of

patients. Headache, photophobia, stiff neck, irritability or

lethargy, vomiting and altered level of consciousness.

Kerning’s sign in older children (inability to completely extend the leg).

Brudzinski’s sign in older children (flexion at the knee in response to forward flexion of the neck).

Convulsions in 20 – 30% of cases. Focal neurological deficits due to vasculitis

or thrombosis of blood vessels. Papilledema (Swelling of the optic disc

(where the optic nerve enters the eyeball); usually associated with an increase in intraocular pressure) is uncommon unless in advanced cases. This suggests increased intracranial pressure.

Laboratory Investigations1. CSF

Lumbar puncture or a shunt tap is performed as soon as the diagnosis of meningitis is suspected.

CSF should be examined for:

Microbiology and Biochemistry

Laboratory Investigations cont.

2. C-Reactive protein (CRP).3. Blood culture and other cultures (urine,

abscess, and middle ear).4. Full Blood Picture (CBC) and ESR.5. Serum electrolytes, BUN, Creatinine.

Investigations cont

6.Other examinations Electro encephalogram (EEG) if seizures are

prominent. Head imaging (CT). Indications for CT are:

Focal neurological examination findings, Seizures, Increasing head circumference, Lack of improvement despite appropriate

treatment and Suspected brain abscess.

CT should only be done when the patient is stable.

Medical Treatment of Meningitis pediatric

1. Triage and ensure the ABCDs.2. IV line for IV medication and rehydration 3. Drug therapy.

Treatment of Bacterial meningitis 1

Give antibiotic treatment as soon as possible:1. Infants < 3 month old:

Ampicillin 200 mg/kg/day IV div q6hr, PLUS

Cefotaxime 200 mg/kg/day IV div q6hr for 10 to 14 days

Treatment of bacterial meningitis 2

2. Age 3 months to < 18 years; choose on of the following regimens:

1)Chloramphenicol 25 mg/kg IV (or IM) 6 hourly, plus Ampicillin 50 mg/kg IV (or IM) 6 hourly

2)Chloramphenicol 25 mg/kg IV (or IM) 6 hourly, plus Benzyl penicillin 6o mg/kg (100,000 IU /kg) IV or IM 6 hourly.

Treatment of bacterial meningitis 2

2. Age 3 months to < 18 years; choose on of the following regimens:

1)Chloramphenicol 25 mg/kg IV (or IM) 6 hourly, plus Ampicillin 50 mg/kg IV (or IM) 6 hourly

2)Chloramphenicol 25 mg/kg IV (or IM) 6 hourly, plus Benzyl penicillin 6o mg/kg (100,000 IU /kg) IV or IM 6 hourly.

Treatment of bacterial meningitis 3

Alternative treatment: If Haemophilus influenza or

Pneumococcus is common;1) Ceftriaxone 50 mg/kg IV or IM 12 hourly or

100 mg/kg IV od for up to 10 – 14 days, or 2) Cefotaxime 50 mg/kg every 6 hrs for 3

weeks.

Supportive Treatment

Give paracetamol 15 mg/kg 6 – 8 hrly for fever (>38.50 C)

IV fluids: isotonic fluids at maintenance rate (250 ml/24hrs).

Feeding according to age requirement (75 – 100 kcal/kg/day).

Give anticonvulsant if convulsing Correct hypoglycemia if present NGT for feeding Physiotherapy

Nursing management

Monitor vital signs 2-4 hrly (Temperature, Pulse rate, Oxygen saturation, BP, and Respiratory Rate)

Monitor Input/output Give treatment as prescribed. Maintain a clear airway• Turn the patient every 2 hours.• Do not allow the child to lie in a wet bed.• Pay attention to pressure points Monitor IV fluids very carefully and examine

frequently for signs of fluid overload

Nurses should monitor the child’s state of consciousness, respiratory rate and pupil size every 3 hours during the first 24 hours (thereafter, every 6 hours).

On discharge, assess all children for neurological problems, especially hearing loss.

Measure and record the head circumference of infants.

If there is neurological damage, refer the child for physiotherapy, if possible, and give simple suggestions to the mother for passive exercises

Nursing management at emergency Step one Triage according to clinical indicators. Step two Prioritise care. The nurse’s role is to

prioritise Airway, Breathing and Circulation,

accompanied by a rapid assessment of conscious level using the AVPU# scale.

Step three

Follow with specific nursing assessments. These should include the following:

■ Assess for decreased cerebral tissue perfusion related to increased ICP:

– neurological observations, including blood pressure should be performed at intervals determined by the child’s clinical state

– assess for increased ICP

– monitor fluid and electrolyte status.

■ Assess for ineffective breathing pattern related to increased ICP:

– monitor respiratory rate, work of breathing and pulse oximetry

Assess for potential for injury related to seizures:– document characteristics of seizure activity-duration,

characteristics of motor behaviour and post-ictal phase– assess the patient’s environment for potential hazards.■ Assess for alteration in fluid and electrolytes related to

SIADH, DI, diuretics, fluid restrictions:– monitor haemodynamic parameters– monitor urine output– monitor SG, urine electrolytes and osmolality.■ Assess for alterations in comfort related to meningeal

irritation, headache, photophobia, fever– monitor temperature and assess effectiveness of comfort

measures.

Reference

NSW HEALTH( 2010) Management of acute bacterial meningitis in infants and children Clinical Practice Guidelines

WHO (2005) POCKET BOOKOF Hospital care for children GUIDELINES FOR THE MANAGEMENT OF COMMON ILLNESSES WITH LIMITED RESOURCES