35 Bacterial meningitis
Physical assessment
Diagnostic tests
LP, csf analysis, and gram stain and culture:
To identify causative organism. Glucose is generally decreased, and protein increased. Increased total lactate dehydrogenase (LDH) in CSF is a consistent finding. Presence or absence of C-reactive protein (CRP) in the CSF can differentiate between bacterial (positive for CRP) and nonbacterial (negative for CRP) meningitis. Typically, CSF will be cloudy or milky because of increased white blood cells (WBCs); CSF pressure will be increased because of the inflammation and exudate, causing an obstruction in outflow of CSF from the arachnoid villi. This test, in the presence of IICP, can cause brain herniation. If CSF pressure is elevated, check neurologic status and VS at frequent intervals for signs of brain herniation (decreased LOC; pupillary changes such as dilation, inequality, or decreased reaction; irregular respirations; hemiparesis).
Culture and sensitivity testing of blood, sputum, urine, and other body secretions:
To identify infective organism and/or its source and determine appropriate antibiotic.
Polymerase chain reaction:
To analyze DNA in peripheral blood or CSF to identify causative infectious agents.
Radioimmunoassay, latex particle agglutination, or enzyme-linked immunosorbent assay:
To detect microbial antigens in the CSF to identify causative organism.
Sinus, skull, and chest x-ray examinations:
Taken after treatment is started to rule out sinusitis, pneumonia, and cranial osteomyelitis.
Computed tomography (CT) scan with contrast:
To rule out hydrocephalus or mass lesions such as brain abscess and detect exudate in CSF spaces.
Magnetic resonance imaging (MRI):
To rule out hydrocephalus or mass lesion and detect exudate in CSF spaces.
Nursing diagnosis:
Deficient knowledge
related to unfamiliarity with rationale and procedure for Transmission-Based Precautions: Droplet
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| For patients with meningitis caused by H. influenzae or N. meningitidis, assess their knowledge base and explain, as indicated, the method of disease transmission via respiratory droplets generated by patient when coughing, sneezing, or talking or during performance of cough-inducing procedures (e.g., suctioning) and by contact with oral secretions and rationale for private room and droplet precautions. | Patients with N. meningitidis, with H. influenzae, or in whom the causative organism is in doubt require observation with Transmission-Based Precautions: Droplet, for 24 hr after initiation of appropriate antibiotic therapy. Patient should be placed in a private room if possible. If private room is not available, infected patient may be placed in a room with another patient who is at low risk for adverse outcome if transmission occurs, ensuring that patients are physically separated (i.e., more than 3 ft) from each other. |
| Provide instructions for covering mouth before coughing or sneezing and properly disposing of tissue (Respiratory Hygiene/Cough Etiquette). | Infection may be spread by contact with respiratory droplets or oral secretions. Masks should be worn for close patient contact (e.g., within 3 ft), along with adherence to Standard Precautions (see p. 721). |
| Instruct patients with Transmission-Based Precautions: Droplet, to stay in their room. If they must leave the room for a procedure or test, explain that a mask must be worn to protect others from contact with respiratory droplets. | As above. |
| For individuals in contact with patient, explain importance of wearing a surgical mask and practicing good hand hygiene. Gloves should be worn when handling any body fluid, especially oral secretions. For more information, see Appendix A, “Infection Prevention and Control,” p. 721. | As above. |
| Reassure patient that Transmission-Based Precautions: Droplet are temporary. | These precautions will be discontinued once patient has been taking the appropriate antibiotic for at least 24 hr. |
| Instruct individuals in contact with patient that if symptoms of meningitis develop (e.g., headache, fever, neck stiffness, photophobia, change in mental status), they should report immediately to their health care provider. | This measure helps ensure prompt treatment. Mortality rate is high (70%-100%) in persons in whom meningitis is left untreated. However, in individuals in whom diagnosis and antibiotic treatment are established early, prognosis is good, and complete neurologic recovery is possible. |
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