Meningitis and Encephalitis

1. Meningitis and Encephalitis Submitted by: Rimando , Maria Clarita Tondy A. BSN3-d2 Submitted to: Ms. Shalimaar Dimaandal Clinical Instructor

2. Meningitis

3. Meningitis: Definition Meningitis is the infection and inflammation of the meninges (covering of the brain and spinal cord: duramater , arachnoid and piamater ) and the cerebrospinal fluid.

4. Meningitis: Signs and Symptoms

5. Meningitis: Causative Agents Causative agents Neisseria meningitides Incubation period: 2-10 days Haemophilus influenzae Incubation period: 1-4 days Enteroviruses Incubation period: 3 to 7 days

6. Meningitis: Pathognomonic Sign Nuchal rigidity: It is the inability to flex the head forward due to rigidity of the neck muscles; if flexion of the neck is painful but full range of motion is present, nuchal rigidity is absent.

7. Meningitis: Pathognomonic Sign Kernig's sign: It is positive when the leg is bent at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful (leading to resistance).

8. Meningitis: Pathognomonic Sign Brudzinski's signs It is the appearance of involuntary lifting of the legs in meningeal irritation when lifting a patient's head off the examining couch, with the patient lying supine.

9. Meningitis: Drug of Choice Antibiotics: Ampicillin , Third-generation Cephalosporin such as Ceftriaxone or Ampicillin and an Aminoglycoside . Other drugs include Digitalis glycoside such as Digoxin (to control arrythmias ), Mannitol (to decrease cerebral edema ) or a Sedative (to reduce restlessness) and Aspirin or Acetaminophen (to relieve headache and fever).

10. Meningitis: Drug of Choice Rifampacin and Ciprobay Anti-fungal, Antibiotic, Mannitol Corticosteroid ( Dexamethasone / Solucortef ) Anti- convulsant ( Phenytoin ) (to reduce restlessness)

11. Meningitis: Period of Communicability A person can pass the infection to others for as long as the bacteria are present in discharges from the nose and mouth. A person is no longer infectious within 24 to 48 hours after starting antibiotic treatment.

12. Meningitis: Methods of Control Encourage personal hygiene especially the practice of hand washing. Keep hands clean and wash hands properly. Wash hands when they are dirtied by respiratory secretions e.g. after sneezing. Cover nose and mouth while sneezing or coughing and dispose of nasal and mouth discharge properly. Do not share eating and drinking utensils and wash them before use by others. Avoid going to overcrowded places. For Neisseria meningitidis meningitis, household contacts and others who have had close personal contact with infected persons are recommended to receive a preventive antibiotic which kills bacteria living in nose and throat secretions. For contacts of Haemophilus influenzae meningitis, antibiotics may also be recommended Effective vaccines against Haemophilus influenzae type b, and some types of Neisseria meningitidis are available.

13. Meningitis: Immunization Haemophilus Influenzae type B Haemophilus influenzae  type b ( Hib ) is a bacterium that can infect the outer lining of the brain causing meningitis. Hib disease occurs most often at three months to three years of age, peaking at six to seven months of age. The disease is uncommon after age five years. Children should get Hib vaccine at: 2 months of age 6 months of age 4 months of age 12-15 months of age

14. Meningitis: Immunization Vaccines against four strains of N. meningitidis Meningococcal Conjugated vaccine are given to adolescents entering high school and to college freshmen living in dormitories.

15. Meningitis: Nursing Management Assess neurologic status. Monitor vital signs especially temperature frequently or continuously. Pulse oximeter and arterial blood gas (ABG) are use to quickly identify the respiratory support for increasing ICP Institute other cooling measures such as TSB. Monitor I & O closely. Encourage adequate fluid intake. Darken the room if photophobia is present. Assist with position to comfort neck stiffness and turn patient slowly and carefully with head and neck in alignment. Elevate the head of the bed to decrease intracranial pressure and reduce pain. Administer vaccines against H. influenza type B for children; N. meningitides for patients at high risk; and S. pneumonia for patients with chronic illnesses and the elderly. Inform patients about the importance of vaccination.

16. Meningitis: Medical Management Vancomycin Hydrochloride in combination with one of the Cephalosporins is administered IV. Dexamethasone ( Decadron ) Dehydration and shock are treated with fluid volume expanders. Phenytoin ( Dilantin )- treatment for seizures if occurs.

17. Meningitis: Diagnostic Procedure Lumbar Puncture (Increase Protein and WBC, Low Sugar level) A lumbar puncture takes samples of the fluid around the spine and brain, known as cerebral spinal fluid (CSF). A culture of the spinal fluid is done to check for organisms known to cause illness. Blood Culture A blood culture is a test on a sample of blood to check for bacteria in the bloodstream; it may be done if a doctor suspects a blood infection. A blood culture may be helpful in determining the specific bacteria causing an infection and selecting the appropriate antibiotic to treat it.

18. Meningitis: Diagnostic Procedure Imaging (X-rays and CT scans) X-rays and computerized tomography (CT) scans of the head, chest or sinuses may reveal swelling or inflammation. These tests can also help your doctor look for infection in other areas of the body that may be associated with meningitis.

19. Meningitis: Mode of Transmission Both viral meningitis and bacterial meningitis can be transmitted through direct contact with nose and throat secretions of infected person (Droplet) . Healthy persons, who have no signs of illness, can carry these bacteria in their nose or throat (Upper respiratory tract infection). Viral meningitis can also be transmitted through fecal -oral route.

20. Meningitis: Pathophysiology Nasopharyngeal Colonization ↓ Local Invasion ↓ Bacteremia ↓ Endothelial Cell Injury ↓ Meningeal Invasion ↓ Sub arachnoid Space Inflammation ↓ Increased CSF outflow resistance ↓ Interstitial Edema ↓ Increased Intracranial Pressure ↓ Decreased Cerebral Blood Flow

21. Encephalitis

22. Encephalitis: Definition Encephalitis is irritation and swelling (inflammation) of the brain parenchyma, most often due to infections. Encephalitis with meningitis is known as  meningoencephalitis .

23. Encephalitis: Causative Agents Causative agents Specifically to rural areas are Arboviruses or Arthropod-borne Viruses (viruses carried by arthropods, such as mosquitoes and tick), while in urban areas it is most frequently caused by Enteroviruses ( Coxsackievirus , Poliovirus and Echovirus) Enteroviruses Incubation Period is most oftenly 3-5 days

24. Encephalitis: Signs and Symptoms Severe headache Fever Altered consciousness Confusion or agitation Personality changes Seizures Loss of sensation or paralysis in certain areas of the body Muscle weakness Hallucinations Double vision Perception of foul smells Problems with speech or hearing Loss of consciousness

25. Encephalitis: Drug of Choice Antiviral medications, such as Acyclovir ( Zovirax ) and Foscarnet ( Foscavir ) -- to treat herpes encephalitis or other severe viral infections (however, no specific antiviral drugs are available to fight encephalitis) Antibiotics -- if the infection is caused by certain bacteria Anti-seizure medications (such as Phenytoin ) -- to prevent seizures Steroids (such as Dexamethasone ) -- to reduce brain swelling (in rare cases) Sedatives -- to treat irritability or restlessness Acetaminophen -- for fever and headache

26. Encephalitis: Period of Communicability The period of communicability varies by etiologic agent, and some of them are not transmitted from person to person (e.g., histoplasmosis and toxoplasmosis). Enteroviruses may be shed in feces for several days to many weeks after symptoms have resolved. Enteroviruses may also be shed in respiratory secretions, usually for no longer than one week following symptoms.

27. Encephalitis: Methods of Control Dress to protect yourself.  Wear long-sleeved shirts and long pants if you're outside when mosquitoes are most active and when you're in a wooded area with tall grasses and shrubs where ticks are more common. Apply mosquito repellent.  To repel mosquitoes. Keep mosquitoes out of your home.  Repair holes in screens on doors and windows.

28. Encephalitis: Nursing Management Monitoring pupils and vital signs frequently for increased intracranial pressure(ICP; irregular pupils, widening pulse pressure, tachycardia, irregular breathing hyperthermia). Monitor neurologic status closely. Watch for subtle changes, such as behavior or personality changes, weakness, or cranial nerve involvement Maintain adequate fluid intake to prevent dehydration, but avoid fluid overload, which may increase cerebral edema . Maintain adequate nutrition. Give small, frequent meals, or supplement meals with nasogastric tube or parenteral feedings. To prevent constipation and minimize the risk of increased ICP resulting from straining at stool, provide a mild laxative or stool softener.

29. Encephalitis: Nursing Management Carefully positioned the patient to prevent joint stiffness and neck pain, and turn the patient often. Provide thorough mouth care. Maintain a quiet environment. Darkening the room may decrease headache. If the patient has seizures, take precautions to protect him from injury. Measure and record intake and output. If the patient becomes delirious or confused, try to reorient him often. Teach the patient and his family about the disease and its effects. Teach eradication of the source of infection: Use insecticide or insect repellent and placement of screens to doors and windows.

30. Encephalitis: Medical Management Antiviral agent Acyclovir given I.V. for 10 days to 3 weeks for herpes simplex virus. Blood cultures and foscarnet I.V. for CMV encephalitis. Anticonvulsants to treat seizures, corticosteroids to reduce cerebral edema , and sedatives and analgesics as supportive therapy.

31. Encephalitis: Diagnostic Procedure Spinal fluid analysis By doing a lumbar puncture (also called a spinal tap), your doctor can check the spinal fluid for an increase in white blood cells and protein.

32. Encephalitis: Diagnostic Procedure Electroencephalography (EEG) This can identify abnormal brain waves by monitoring electrical activity in the brain through the skull. Among its many functions, EEG is used to help diagnose certain seizure disorders, brain damage from head injuries, specific viral infections such as herpes virus, and inflammation of the brain and/or spinal cord. Blood tests. These tests can show what type of virus is causing encephalitis.

33. Encephalitis: Diagnostic Procedure Computer-assisted imaging  (Computed tomography: CT SCAN and Magnetic resonance imaging: MRI) This can reveal signs of brain inflammation, internal bleeding or hemorrhage , or other brain abnormalities.

34. Encephalitis: Mode of Transmission Breathing in respiratory droplets from an infected person Skin contact Mosquito, tick, and other insect bites Tick of Horses Migratory Birds Contaminated food or drink

35. Encephalitis: Mode of Transmission

36. Encephalitis: Pathophysiology ARTHROPOD-BORNE VIRUS Mosquito bite ↓ Inadequate Host Immune Response ↓ Viremia ↓ Cerebral Capillaries ↓ Central Nervous System ↓ Cortical Gray Matter, The Brain Stem and Thalamus ↓ Meningual Exudates ↓ Irritating The Meninges ↓ Increasing Intracranial Pressure

37. Encephalitis: Pathophysiology FUNGAL ENCEPHALITIS Fungal Spores (enter body through inhalation) ↓ Infect the Lungs ↓ Vague Respiratory Symptoms or Pneumonitis ↓ Bloodstream ↓ Fungemia ↓ Central Nervous System ↓ Encephalitis ↓ Fever, Malaise, Headache, Meningeal signs and change in Cranial Nerve Dysfunction