Primary Nursing Diagnosis

Infection related to pathogens in the CSF

OUTCOMES. Immune status; Knowledge: Infection control; Risk control; Risk detection; Nutrition status; Treatment behavior: Illness or injury; Hydration; Knowledge: Infection control

INTERVENTIONS. Infection control; Infection protection; Surveillance; Fluid/electrolyte management; Medication management; Temperature regulation

H PLANNING AND IMPLEMENTATION Collaborative

The most critical treatment is the rapid initiation of antibiotic therapy. In addition, assessment and maintenance of airway, breathing, and circulation (ABCs) are essential. Treatment with intubation, mechanical ventilation, and hyperventilation may occur if the patient's airway and breathing are threatened. Serial neurological assessments and vital signs not only monitor critical changes in the patient but also monitor the patient's response to therapy. Supportive measures such as bedrest and temperature control with antipyretics or hypothermia limit oxygen consumption. Gradual treatment of hyperthermia is required to prevent shivering.

Other strategies to manage increased ICP include osmotic diuretics, such as mannitol, or intraventricular CSF drainage and ICP pressure monitoring. Fluids are often restricted if signs of cerebral edema or excessive secretion of antidiuretic hormone are present. If the patient experiences seizures, the physician prescribes anticonvulsant medications. Surgical interventions or CSF drainage may be required to prevent permanent neurological deficits as a result of complications such as hydrocephalus or abscesses. The patient is likely to have a severe headache from increased ICP. Because large doses of narcotic analgesia mask important neurological changes, most physicians prescribe a mild analgesic to decrease discomfort. In children, pain relief decreases crying and fretting, which if left untreated, have the potential to aggravate increased ICP.

608 Meningitis

Rehabilitation begins with the acute phase of the illness but becomes increasingly important as the infection subsides. If residual neurological dysfunction is present as a result of irritation, pressure, or brain and nerve damage, an individualized rehabilitation program with a multidisci-plinary team is required. Vision and auditory testing should be done at discharge and at intervals during long-term recovery because early interventions for these deficits are needed to prevent developmental delays.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Antibiotics

High-dose parenteral therapy IV for 2 wk

Choice of antibiotic depends on gram stain and culture and sensitivities; if no organisms are seen on gram stain, a third-generation cephalosporin is often used while culture results are pending. Broad-spectrum coverage such as vancomycin and ceftazidime may be chosen

Cause bacterial lysis and prevent continuation of infection; initial dosages are based on weight or body surface area and then are adjusted according to peak and trough results to maintain therapeutic levels.

Other Drugs: Adjunct corticosteroid therapy has been reported to decrease the inflammatory process and decrease incidence of hearing loss but is controversial. Vaccinations exist for meningococcal, pneumococcal, and hemophilic meningitis, and the prophylaxis for persons exposed to meningococcal meningitis is rifampin.

Independent

Make sure that the patient has adequate airway, breathing, and circulation. In the acute phase, the primary goals are to preserve neurological function and to provide comfort. The head of the bed should be elevated 30 degrees to relieve ICP. Keep the patient's neck in good alignment with the rest of the body and avoid hip flexion. Control environmental stimuli such as light and noise, and institute seizure precautions. Soothing conversation and touch and encouraging the family's participation are important; they are particularly calming with children who need the familiar touch and voices of parents. Children are also reassured by the presence of a security object.

Institute safety precautions to prevent injury, which may result from either the seizure activity or the confusion that is associated with increasing ICP. Take into account an increase in ICP if restraints are used and the patient fights them. Implement measures to limit the effects of immobility, such as skin care, range-of-motion exercises, and a turning and positioning schedule. Note the effect of position changes on ICP, and space activities as necessary.

Explain the disease process and treatments. Alterations can occur in thought processes when ICP begins to increase and the level of consciousness begins to decrease. Reorient the patient to time, place, and person as needed. Keep familiar objects or pictures around. Allow visitation of significant others. Establish alternate means of communication if the patient is unable to maintain verbal contact (e.g., the patient who needs intubation). As the patient moves into the rehabilitative phase, developmentally appropriate stimuli are needed to support normal growth and development. Determine the child's progress on developmental tasks. Make appropriate referrals if the child is not progressing or if the child or family evidence signs of inability to cope.

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