Which type of precautions should the nurse implement for the infant diagnosed with meningitis?

Meningitis is a disease condition that typically affects pediatrics and young adults, so it is usually taught as part of a pediatrics course. The highest disease rates are children younger than 12 months, with the second highest occurrence being in teens and young adults age 16-23. This can further be stratified into those living in crowded conditions or tight quarters such as a college dormitory.  However, it is important to note that it can occur at any age. 

Meningitis is inflammation of the meninges, which are the outer layers surrounding the brain and spinal cord. The meninges are composed of three distinct layers – the pia mater, the arachnoid and the dura mater. The inflamed meninges can be quite painful and can lead to other neurological symptoms, which will be discussed further on.

What causes meningitis?

Meningitis is usually a result of bacterial or viral infection, but can also be due to fungal or protozoan infection as well. Of these, bacterial meningitis is the most severe. In most cases, meningitis occurs secondary to another infection such as pneumonia or sinusitis. It can also occur due to infections secondary to lumbar puncture, skull fractures or ventricular shunts. The pathogen essentially enters the system and is carried throughout the brain and spinal cord tissues by the CSF. 

What are the different types of meningitis?

Viral meningitis – This is the most common form of meningitis and is usually less severe than the bacterial form. It is most often caused by enteroviruses, but can also be related to chicken pox, measles, mumps, rubella, and bites from insects such as mosquitos. It can be spread person-to-person through fecal contamination, so it’s important to teach patients to thoroughly wash hands after using the bathroom or changing a baby’s diaper. Vaccination against measles, mumps, chicken pox and rubella can also help prevent disease. Viral meningitis often resolves on its own.

Bacterial meningitis – This is the most severe form of meningitis. If not treated promptly, bacterial meningitis can lead to hearing loss, brain damage and death. The most likely pathogens are Haemophilus influenzae Type B, Neisseria meningitidis, and Streptococcus pneumoniae. It can be spread through direct contact such as coughing, sneezing or kissing an infected individual. Some forms of bacterial meningitis can even be spread through contaminated food that contains the Listeria bacterium. Examples of these are hot dogs, sandwich meats and soft cheeses. In addition to vaccination, a key prevention intervention you will hear repeated over and over again is to teach college students who live in dorms to avoid sharing utensils with others. 

Fungal Meningitis – This is a rare form of meningitis that occurs when a fungus enters the blood stream and finds its way to the meninges. Individuals with a weakened immune system are most at risk and is most often caused by inhaling fungal spores from bird and bat droppings or contaminated soil. Fungal meningitis requires extensive courses of antifungal medication, usually administered in the inpatient setting via IV infusion.

Parasitic Meningitis – This is another rare form of meningitis and is usually fatal. It is caused by the parasite Naegleria fowleri, which enters the body through the nose, and the condition progresses rapidly over one to 12 days. The parasite lives worldwide in warm freshwater sources such as rivers, hot springs and lakes. It also lives in water heaters, inadequately treated swimming pools, industrial water runoff and soil. This form of meningitis is not transmissible person-to-person.

Non-infectious Meningitis – This is another form of non-transmissible meningitis. It usually occurs in correlation with conditions related to inflammation such as rheumatoid arthritis and lupus. It can also occur in cases of brain surgery, cancer, head injury and with the use of NSAIDS and certain antibiotics. Treatment is focused on the underlying cause and symptom management.

The LATTE Method for Meningitis

Let’s go through bacterial and viral meningitis using the Straight A Nursing LATTE method. This is a streamlined way to look at disease conditions so you focus on the “must-know” information you need to thrive in nursing school (and beyond!). To utilize the LATTE method with this and other conditions, download the template here. 

L: How does the patient LOOK?

The “L” component of the LATTE method looks at the patient’s signs/symptoms and what you notice about them. Rapid diagnosis of meningitis is essential as it can be fatal if left untreated. And while it is outside the scope of the RN to diagnose medical conditions, you do want to know what to watch for so you can alert the MD, DO, PA or NP that the patient needs prompt attention.

The classic signs of meningitis are nuchal rigidity, severe headache, photophobia and nausea/vomiting. Other common signs include:

• Chills and fever that can be as high as 104-degrees F
• Altered mental status – difficulty waking, confusion, difficulty concentrating, irritability, and/or delirium
• Seizures – occur in about one third of cases
• Coma – in severe cases
• Skin rash – a component of meningococcal meningitis
• Decreased appetite and/or decreased thirst
• In infants you may notice signs of increased ICP – a shrill and high-pitched cry, vomiting, and a full or bulging fontanel.

A: How do you ASSESS the patient with meningitis?

• Get a full set of vital signs, the key one for meningitis is temperature (which can be quite high…up to 104-degrees F is not uncommon).
• Conduct a thorough pain assessment – The patient is likely to complain of a headache that is unlike any other they have ever had, and it may progressively worsen. Additionally, exposure to light may make their pain worse (photophobia).
• Conduct a thorough neuro assessment. The patient may be confused, have decreased level of consciousness with or without elevated ICP. In severe cases, the patient may be comatose or have seizures. Signs of elevated ICP include pupillary changes, extraocular movements and decreased LOC. In infants, common signs are a shrill and high-pitched cry, vomiting, and a full or bulging fontanel.
• Monitor I/O – The patient may be dehydrated due to fever, decreased thirst and altered mental status. Conversely, the patient may be at risk for fluid volume overload in cases of bacterial meningitis, which can cause increased amounts of ADH to be released (SIADH).
• Conduct a skin assessment. A sign of meningococcal meningitis is a petechial or purpuric rash. The most common location for this rash is the feet and hands, but it can extend to cover the entire arm or leg as the disease progresses.
• Ask about recent infections, procedures, or trauma – particularly those that would involve the head or spine.
• Assess for a positive “Brudzinski’s sign.”  Instruct the patient to lie flat. Place your hands behind their neck and bend it forward. If the patient also flexes their hips and knees this is a positive sign and may be indicative of meningitis.*
• Assess for a positive “Kernig’s sign.” While the patient is supine, flex the leg at the hip and knee then straighten it. If there is pain or resistance with this movement, this is also indicative of meningitis.*
• *These two signs are still found in some textbooks and may show up on exams. However, they are not very reliable as standalone diagnostic tools. Studies have found both of these assessments to have a low sensitivity and high specificity. This means that a positive sign is a good indicator of disease, but a negative sign does not mean they are without disease.

T: What TESTS will be conducted?

• Lumbar puncture (LP) – This is the KEY diagnostic test for meningitis. This test yields two important diagnostic criteria. One is the CSF pressure measurement, which will be elevated in  meningitis. The other is evaluation of the fluid and identification of specific pathogens. 
  • Viral meningitis: CSF will be clear with elevated WBC and elevated protein.
  • Bacterial meningitis: CSF will be cloudy with elevated WBC, elevated protein, and decreased glucose. A normal range of CSF glucose is 50 to 80 mg/100 mL (though this can vary slightly based on laboratory).
• CT scan may be ordered to rule out other causes for neurological symptoms and identify complications such as hemorrhage, abscesses, or swelling.
• Sputum, nasopharyngeal swabs, and/or blood may also be collected to assist in identifying the source of infection and aid in prescribing the correct medications. 

T: What TREATMENTS will be provided?

• Analgesics for headache include acetaminophen and ibuprofen. While opioids can be used, it is advised they be avoided if possible to prevent masking neurological deterioration. 
• Antipyretics (acetaminophen, ibuprofen are most commonly used). We tend to avoid aspirin use in children due to the risk of Reye’s syndrome.
• Corticosteroid to reduce inflammation (ex: dexamethasone). These medications will cause an increase in serum glucose, so insulin may be needed in some cases.
• Anti-seizure medication, especially if the patient has had a seizure or is at high risk such as with increased ICP (ex: phenytoin)
• Osmotic diuretic (ex: mannitol) may be given to decrease cerebral edema and reduce ICP. Note that mannitol can cause fluid losses and electrolyte imbalances.
• Maintain fluid balance with IV fluids, diuretics, fluid restriction, or hypertonic saline as needed. Replace electrolytes as needed. Levels can be depleted due to vomiting and diuretic use.
• Antibiotics for bacterial meningitis. Antibiotic therapy is crucial and will begin with a broad-spectrum antibiotic before culture results are available. It is important to remember to always collect specimens BEFORE you begin administering antibiotics. The initial IV antibiotics utilized in bacterial meningitis are typically vancomycin in combination with either ceftriaxone or cefotaxime. Once the pathogen is identified, antibiotic therapy becomes very focused and specific.
• Nursing interventions for a patient with meningitis include: 
  • Standard precautions for all patients with meningitis
  • Bacterial meningitis (includes meningococcal meningitis): droplet precautions for 24 hours after an effective therapy has been initiated.
  • Promote a neuro-friendly environment – lights dimmed or off, quiet room, minimize stimulation, close door, speak in whispers or quiet voices.
  • Avoid increased ICP – Maintain bedrest with HOB at 30-degrees, avoid tight or constricting clothing, avoid severe flexion at the hips, keep head midline with neutral neck position, instruct the patient to avoid coughing/sneezing if at all possible, instruct the patient to avoid straining with bowel movements.
  • Provide cooling measures as ordered (such as a cooling blanket) or provide cool cloths and ice packs for patient comfort.

E: How do you EDUCATE the patient/family?

• Health promotion – Prevention is always best and educating patients/families on meningococcal vaccines for those appropriate is important. You also want to teach young adults living in close quarters (such as a college dorm) to avoid sharing personal items such as utensils and toothbrushes.
• Teach the patient/family how to maintain a calm environment (low lights, low noise, low stimulation). 
• In cases of bacterial meningitis: Teach the patient/family to let those who have been in close contact know about the diagnosis so they can begin prophylactic antibiotics. 
• Teach the importance of finishing all antibiotics that may be prescribed to avoid antibiotic resistance. 
• After the acute phase has passed, teach the patient they will need several weeks of rest and good nutrition before resuming their regular activities. Emphasize an abundance of fresh fruits and vegetables, whole grains and lean proteins.
• Teach the patient that muscle rigidity may linger. Passive ROM and warm baths are often very helpful in relieving the tension. 

I hope you’ve enjoyed learning about meningitis. For more topics related to neuro nursing, click here.

References:

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