Case Study

CNS Infection
(Meningitis)
OBJECTIVES
General
This case presentation aims to identify and determine the general health
problems and needs of the patient with an admitting diagnosis of Stroke in
the Young. This presentation also intends to help patient promote health and
medical understanding of such condition through the application of the
nursing skills.
Specifc
To raise the level of awareness of patient on health problems that he
may encounter.
To facilitate patient in taking necessary actions to solve and prevent
the identifed problems on his own.
To help patient in motivating him to continue the health care provided
by the health workers.
To render nursing care and information to patient through the
application of the nursing skills.
INTRODUCTION
A stroke occurs when the blood supply to the part of the brain is suddenly
interrupted (ischemic) or when a blood vessel in the brain bursts spilling blood into
the spaces surrounding the brain cells (hemorrhagic).
The symptoms of stroke can be! sudden numbness or weakness especially on one
side of the body" sudden confusion or trouble speaking or understanding speech"
sudden trouble seeing in one or both eyes" sudden trouble walking" di##iness" or
loss of balance or coordination. $rain cells die when they no longer receive o%ygen
and nutrients from the blood or when they are damaged by sudden bleeding into or
around the brain. These damaged cells can linger in a compromised state for
several hours. &ith timely treatment these cells can be saved.
'any children who have strokes e%perience them from unknown causes. There are
some known causes of (hildhood Stroke" they include the following things.
Brain Infections ) like Encepalitis is an in*ammation of the brain and
!enin"itis #ic is an infection of the membranes that surround the brain
and spinal cord.
$rterio%enous &alfor&ation '$V!( ) An arteriovenous malformation
(A+') is a congenital disorder characteri#ed by a comple% tangled web of
arteries and veins.
Birt In)ury ) ,vents during the time of birth that can damage the
developing brain.
Con"enital *eart Disease 'C*D(
Disse&inated intra%ascular coa"ulation ) when the blood clotting
mechanisms are activated throughout the body instead of being locali#ed to
an area of in-ury.
Dru" Use ) All of the disorders producing stroke in toddlers and school)aged
children may still produce stroke in adolescents. .owever an increasing
percentage of strokes of both ischemic and hemorrhagic types occur in
relation to drug use. The most common drug causing stroke is cocaine in its
smoked form (crack). Smoked amphetamines (meth ice etc.). Any type of
illicit drug in-ected into the bloodstream can produce stroke.
E&+olus )A blood clot that has formed at the site of blockage or that has
formed somewhere /upstream/ in the arterial tree has broken o0 and been
carried /downstream/ in the blood *ow through progressively smaller
branches in the arterial tree until it enters a vessel too small to ft through
plugging it closed. An ,mbolus often forms within the heart or one of the
larger arteries leading away from it then breaks o0 and travels to the brain
or another organ.
Infection ) (hicken 1o% in e%treme cases can be one cause of pediatric
stroke.
,olycyte&ia ) An overproduction of blood cells which can cause
/thickening/ of blood increasing its viscosity and its clotting tendency.
,re&aturity ) 1reterm or /premature/ birth is when your baby is born three
weeks or more before it2s due date.
$ut among the causes given above the most signifcant cause which we will
focus is on 'eningitis which our patient has manifested and was attested
through our 1t3s '45 result.
'eningitis is a serious in*ammation of the meninges the membranes (lining) that
surround the brain and spinal cord. 5t can be of bacterial viral or fungal origin.
+iral meningitis also called aseptic meningitis is generally less severe and usually
self)limited to 67 days or less while bacterial meningitis can be 8uite serious and
may result in brain damage hearing loss or learning disabilities in children. The
infection may even cause death.
The bacteria which cause bacterial meningitis live in the back of the nose and throat
region and are carried by 67 to 9: percent of the population. They cause meningitis
when they get into the bloodstream and travel to the meninges. At least :7 kinds of
bacteria can cause bacterial meningitis. According to the (enters for ;isease
(ontrol ((;() before the 6<<7s Haemophilus infuenzae type b (.ib) was the
leading cause of bacterial meningitis but subse8uent vaccines given to all children
as part of their routine immuni#ations have reduced the occurrence of the disease
due to H. infuenzae. As of 977= Streptococcus pneumoniae and Neisseria
meningitidis were the leading causes of bacterial meningitis.
5n newborns the most common agents of meningitis are those that are contracted
from the newborn2s mother including >roup $ streptococci (becoming an
increasingly common infecting organism in the newborn period) Escherichia coli
and Listeria monocytogenes. The highest incidence of meningitis occurs in babies
less than a month old with an increased risk of meningitis continuing through about
two years of age. ?lder children are more fre8uently infected by the bacteria
Haemophilus infuenzae Neisseria meningitidis and Streptococci pneumoniae.
'ost cases of viral meningitis are caused by enteroviruses (viruses that typically
cause stomach *u). .owever many other types of viruses such as the herpes
simple% virus the mumps and measles viruses (against which most children are
protected due to mass immuni#ation programs) the virus that causes chickenpo%
the rabies virus and a number of viruses that are ac8uired through the bites of
infected mos8uitoes.
'eningitis symptoms include high fever headache and sti0 neck in children over
the age of two years. These symptoms can develop over several hours or they may
take one to two days. ?ther symptoms may include nausea vomiting discomfort
looking into bright lights confusion and sleepiness. 5n some cases a rash may be
present. 5n newborns and small infants these symptoms may be absent or di@cult
to detect and the infant may only appear slow or inactive or be irritable have
vomiting or be feeding poorly. As the disease progresses patients of any age may
also have sei#ures.
NURSING $SSESS!ENT
,resent *ealt *istory
The present health history started 9 weeks ago prior to admission. The patient had
a sudden onset of severe headache" no medication and consultation to the doctor
was done. The following day she had fever with ma%imum of AB.:C( and by
afternoon she felt numbness and weakness in his left upper e%tremity that led the
parents of the patient bring him to the hospital. She was admitted at ,ast Avenue
'edical (enter.
,ast *ealt *istory
1rior to her hospitali#ation at ,ast Avenue 'edical (enter her parents denied in
having any record or medical history of being admitted due to trauma accident and
disease. They also confrmed that our patient has no allergies to food and drugs.
-a&ily *ealt *istory
Do hereditary disease can be attributed from her mother side but her father had a
family health history of hypertension. ?ther than the latter no other hereditary
disease from both of her parents are within the patient3s parents knowledge.
DE!OGR$,*IC D$T$
Dame
Address
EAF; '.A
$aler Gue#on (ity
Age
Se%
Dationality
4eligion
(ivil Status
,ducational Attainment
Hather
?ccupation
'other
?ccupation
A:years old
female
Hilipino
4oman (atholic
'arried
A'A (ollege
)
)
.ousewife
,ysical $ssess&ent . General $ppearance
',ASI4,',DTS H5D;5D>S
&eight
.eight
Jevel of (onsciousness
$ody $uild
1osture K >ait
?verall hygiene K >rooming
=7 kg
:3=L
unconscoius
'edium
slightly erect posture
&eak looking
Satisfactory
*E$D TO TOE $SSESS!ENT
BOD/ ,$RT TEC*NI0UE USED -INDINGS INTER,RET$TION
M .,A;
Skull
ScalpN .air
Hace
,yesN +ision
M palpation
M inspection
M palpation
M inspection
M inspection
M palpation
M proportional to
the si#e of the body
round with
prominences in the
frontal area
anteriorly K the
occipital area
posteriorly
symmetrical in all
planes gently
curved
M scalp is white
clean free from
masses lumps nits
dandru0 K lesions
with no areas of
tenderness upon
palpation" hair is
black evenly
distributed K covers
the whole scalp K
thick.
M oblong shaped
symmetrical smooth
K no involuntary
muscle movements
M eyes are parallel
K evenly placed
symmetrical non)
protruding with
scant amount of
secretions both eyes
black K clear"
sclera is white K
clear"
M eyebrows are black
symmetrical thick
can raise both
symmetrically K with
di@culty
M eyelashes are
evenly
M Dormal
M Dormal
M Dormal
M Dormal
M Abnormal
M Dormal
distributed K turned
outward" upper
eyelids cover a small
portion of the iris
cornea K the sclera
when the eyes are
open when the eyes
BOD/ ,$RT TEC*NI0UE USED -INDINGS INTER,RET$TION
are closed the lids
meet
completely
symmetrical K the
color is the same as
the surrounding
skin" lid margins are
clear without scaling
or secretions" lower
palpebral con-unctiva
are shiny moist
transparent K pink in
color" iris are
proportional to the
si#e of the eye round
K
symmetrical" pupils
are from pinpoint to
almost the si#e of
the iris round
symmetrical
constricts with
increasing light K
accommodation"
able to move eyes in
full range of direction
,arsN .earing
Dose
M inspection
M palpation
M inspection
M ears are parallel
symmetrical
proportional to the
si#e of the head
bean)shaped heli%
is in line with the
outer canthus of the
eye skin is the
same color as the
surrounding area K
clean" ear canal is
pinkish clean with
scant amount of
cerumen K a few
cilia" able to hear
whisper spoken 6
feet away
M nose is in midline
M Dormal
M Dormal
'outhN Jips
M palpation
M inspection
M palpation
symmetrical patent"
internal nares are
clean dark pink with
few cilia
M lips are pale and
dry
symmetrical lip
margin is well
defned "u&s are
slight pinkish
M Abnormal
BOD/ ,$RT TEC*NI0UE USED -INDINGS INTER,RET$TION
M D,(O
M T.?4AP K
JID>S
M inspection
M palpation
M inspection
M palpation
M percussion
M auscultation
moist no swelling
no retraction no
discharge
M tongue is pale
slightly rough on top
K with di@culty in
moving
Mcheeks are pale
moist K smooth"

M proportional to
the si#e of the body
K head symmetrical
K straight no
palpable lumps
masses or areas of
tenderness
M chest contour is
symmetrical spine is
straight no lumps
no masses no tender
areas with clear
breath sounds
M Abnormal
M Abnormal
M Dormal
M Dormal
M .,A4T
M A$;?',D
M I11,4
M inspection
M palpation
M percussion
M auscultation
M inspection
M auscultation
M percussion
M palpation
M inspection
M no abnormal
pulsations K visible
in
apical area
M abdominal skin is
unblemished no
scars color is
uniform with the
body color
abdomen is
rounded with
symmetric
movements caused
M Dormal
M Dormal

M Dormal
,PT4,'5T5,S M palpation by respiration"
umbilicus is concave.
M symmetrical with
visible veins fne
hair evenly
distributed warm
dry K elastic upon
palpation with area
of tenderness on the
left arm" nails are
transparent smooth
K conve% with light
1ale nail beds K
white translucent
tips"
BOD/ ,$RT TEC*NI0UE USED -INDINGS INTER,RET$TION
M J?&,4
,PT4,'5T5,S

M inspection
M palpation
M right shoulders
arms
elbows hands K
wrists can be moved
with di@culty

M skin is smooth
fne hair is evenly
distributed absence
of varicose veins
muscles
symmetrical length
symmetrical : toes
in each foot K sole
Mdorsal surface is
pale nail beds with
pale tips
both legs knees
ankles
M left toes can be
be moved in di0erent
range of motion with
relative ease while
the right toes have
di@culty in
movement
M Abnormal
M Dormal

M Abnormal
M Abnormal
REVIE1 O- S/STE!S
,sycosocial
1atient used to be very active and sports minded prior to hospitali#ation. .e is a
member of their school basketball varsity player and is fond of interacting with
other people. .is parents consider him very friendly to everybody as he is liked by
everyone. .e does not have any vices like smoking and drinking as to the
knowledge of his parents.
Rest . $cti%ity
A typical day to her would be waking up at around :!A7 am get ready for her work
eat breakfast and leave the house. She comes home in the afternoon take a bath
then goes to the barangay to -oin her friends. then -oin her family for dinner or
watch television with her siblings. She normally sleeps 66)69midnight.
Safety
She usually stays home during weekends e%cept when she is invited by friends to
go out.
O2y"enation
According to her parents before the onset of her sickness she had no di@culty in
breathing and ventilation.
Nutrition
According to her parents she eats moderately. s.e eats everything from fsh meat
products and vegetables. The patient drinks only soda and water as refreshment.
$N$TO!/
'eningitis and encephalitis are usually caused by viruses or bacteria. 'ost often
the body3s immune system is able to contain and defeat an infection. $ut if the
infection passes into the blood stream and then into the cerebrospinal *uid that
surrounds the brain and spinal cord it can a0ect the nerves and travel to the brain
andNor surrounding membranes causing in*ammation. This swelling can harm or
destroy nerve cells and cause bleeding in the brain.
The meninges comprise
three membranes that
together with the
cerebrospinal *uid
enclose and protect the
brain and spinal cord (the
central nervous system).
The pia mater is a very
delicate impermeable
membrane that frmly
adheres to the surface of
the brain following all the
minor contours. The
arachnoid mater (so
named because of its
spider)web)like
appearance) is a loosely
ftting sac on top of the pia
mater. The subarachnoid
space separates the
arachnoid and pia mater
membranes and is flled with cerebrospinal *uid. The outermost membrane the
dura mater is a thick durable membrane which is attached to both the arachnoid
membrane and the skull.
5n bacterial meningitis bacteria reach the meninges by one of two main routes!
through the bloodstream or through direct contact between the meninges and
either the nasal cavity or the skin. 5n most cases meningitis follows invasion of the
bloodstream by organisms that live upon mucous surfaces such as the nasal cavity.
This is often in turn preceded by viral infections which break down the normal
barrier provided by the mucous surfaces. ?nce bacteria have entered the
bloodstream they enter the subarachnoid space in places where the blood)brain
barrier is vulnerableQsuch as the choroid ple%us. 'eningitis occurs in 9:R of
newborns with bloodstream infections due to group $ streptococci" this
phenomenon is less common in adults.

;irect contamination of the cerebrospinal
*uid may arise from indwelling devices skull fractures or infections of the
nasopharyn% or the nasal sinuses that have formed a tract with the subarachnoid
space (see above)" occasionally congenital defects of the dura mater can be
identifed.
The large)scale in*ammation that occurs in the subarachnoid space during
meningitis is not a direct result of bacterial infection but can rather largely be
attributed to the response of the immune system to the entrance of bacteria into
the central nervous system. &hen components of the bacterial cell membrane are
identifed by the immune cells of the brain (astrocytes and microglia) they respond
by releasing large amounts of cytokines hormone)like mediators that recruit other
immune cells and stimulate other tissues to participate in an immune response. The
blood)brain barrier becomes more permeable leading to /vasogenic/ cerebral
edema (swelling of the brain due to *uid leakage from blood vessels). Jarge
numbers of white blood cells enter the (SH causing in*ammation of the meninges
and leading to /interstitial/ edema (swelling due to *uid between the cells). 5n
addition the walls of the blood vessels themselves become in*amed (cerebral
vasculitis) which leads to a decreased blood *ow and a third type of edema
/cytoto%ic/ edema. The three forms of cerebral edema all lead to an increased
intracranial pressure" together with the lowered blood pressure often encountered in
acute infection this means that it is harder for blood to enter the brain and brain
cells are deprived of o%ygen and undergo apoptosis (automated cell death).
5t is recogni#ed that administration of
antibiotics may initially worsen the
process outlined above by increasing
the amount of bacterial cell membrane
products released through the
destruction of bacteria. 1articular
treatments such as the use of
corticosteroids are aimed at dampening
the immune system2s response to this
phenomenon.
,$T*O,*/SIO3OG/
Nasopharyngeal Colonization
Bacterial Components
Endothelial Cells CNS-macropage
IL-1 Endothelium-leucocycle
TNF and IL-1
PE! P"F

Increased BBB Throm#osis
Permea#ility
$asogenic Edema Increased ICP %ecreased Cere#ral
Blood Flo&
Increased CSF phogocytosis '(ygen %epletion
CSF protein

Cytoto(ic
Edema
%ecreased Increased
CSF lucose CSF Lactose
CSF out)lo& Interstitial
*esistant Edema
LABORATORY DIAGNOSIS
5n someone suspected of having meningitis!
$J??; T,STS are performed for markers of in*ammation (e.g. ()reactive
protein complete blood count) as well as blood cultures.

JI'$A4 1ID(TI4, is the most important test in identifying or ruling out
meningitis. The analysis of the cerebrospinal *uid through lumbar puncture
(J1 spinal tap).
(T or '45 scans are performed at a later stage to assess for complications of
meningitis.

'?D5T?45D> ?H $J??; ,J,(T4?JYT,S . 5n severe forms of meningitis
monitoring of blood electrolytes may be important" for e%ample
hyponatremia is common in bacterial meningitis due to a combination of
factors including dehydration the inappropriate e%cretion of the antidiuretic
hormone (S5A;.) or overly aggressive intravenous *uid administration.

>ram stain of meningococci from a culture showing >ram negative (pink) bacteria
often in pairs
'eningitis can be diagnosed after death has occurred. The fndings from a post
mortem are usually a widespread in*ammation of the pia mater and arachnoid
layers of the meninges covering the brain and spinal cord. Deutrophil granulocytes
tend to have migrated to the cerebrospinal *uid and the base of the brain along
with cranial nerves and the spinal cord may be surrounded with pusQas may the
meningeal vessels.
!EDIC$3 !$N$GE!ENT
Specifc treatment for meningitis will be determined by your physician based on!
your age overall health and medical history
e%tent of the disease
the organism that is causing the infection
your tolerance for specifc medications procedures or therapies
e%pectations for the course of the disease
Treatment may include!
$acterial 'eningitis
Treatment for bacterial meningitis usually involves intravenous (5+)
antibiotics. The earlier the treatment is initiated the better the outcome.
&hile steroid administration has been shown to be helpful in treating
bacterial meningitis in infants and children this treatment is used less
fre8uently in adults. ;e%amethasone a type of steroid may be given in more
acute cases of bacterial meningitis to decrease the in*ammatory response
caused by the bacteria.
+iral 'eningitis
Treatment for viral meningitis is usually supportive (aimed at relieving
symptoms). &ith the e%ception of the herpes simple% virus there are no
specifc medications to treat the organisms that cause viral meningitis.
Supporti%e Terapy for &enin"itis
&hile a person is recovering from meningitis other therapies may be initiated to
improve healing and comfort and provide relief from symptoms. These may include
the following!
bed rest
medications (to reduce fever and headache)
5n addition supplemental o%ygen or mechanical ventilation (respirator) may be
re8uired if you become very ill and have di@culty breathing.
,re%ention of &enin"itis4
Several vaccines are currently available to prevent some of the bacterial organisms
that can cause meningitis. .owever routine vaccination with these vaccines is
recommended primarily for infants and children.
5n certain conditions your physician may recommend one of the meningitis
vaccines. These conditions may include but are not limited to the following!
chronic lung conditions such as emphysema or (?1;
heart disease
diabetes
chronic renal (kidney) failure
travel to countries where meningitis is prevalent
decreased immunity status
certain blood disorders
DISC*$RGE ,3$N
M edication
Always take your medicine as directed by your physician. ;o not use any
medicines over)the)counter drugs vitamins herbs or food supplements without
frst talking to your physician. ;o not also 8uit taking your medicines unless
ordered.
E conomic
The use of non) pharmacotherapy such as drinking plenty of water and proper
hygiene to promote cleanliness thus eliminating infection.
T eatment
The patient has to undergo therapy both physical and occupational to mobili#e
a0ected parts and be able to do his activities of daily living and start his life back
again.
! "giene
Advise to follow proper body hygiene and to maintain cleanliness on surroundings.
O #t $atient% &o''o()#*
Any odd signs such as fever headache or sti0 neck confused or hard to wake up
sei#ure (convulsion) or if your symptoms are getting worse or returning must be
immediately reported to the physician.
D iet
5nstruct to eat foods that are low fat low fber non)irritating and non)carbonated.
EV$3U$TION
CONC3USION
The patient in this study had undergone supportive and symptomatic
management. .e was admitted last Suly 67 and was transferred from 15(I
then ?$S &ard to the Deuro 1edia &ard last Suly 6F onwards.
>ood nursing care is fundamental in maintaining skin care feeding
hydration positioning and monitoring vital signs such as temperature pulse
and blood pressure were done to promote comfort and repression of
symptoms. .ygiene was also strictly implemented to avoid risk for further
infection. Dursing assistance was also given to help him in his activities of
daily living.
1hysical therapy (1T) and occupational therapy (?T) are the cornerstones of
the rehabilitation process. 1T involves re)learning functions as transferring
walking and other gross motor functions. ?T focusses on e%ercises and
training to help relearn everyday activities known as the Activities of daily
living (A;Js) such as eating drinking dressing bathing cooking reading
and writing and toileting. Speech and language therapy is appropriate for
patients with problems understanding speech or written words problems
forming speech and problems with eating (swallowing).
Health teaching is a very important role on the part of the nurses. This is of great significance to
the knowledge deficit of patients regarding health and illness.
RECO!!END$TION
Strict compliance to the medical treatment health teachings and medical
check)up is advised. &ith proper nutrition and conformity to the medications
K therapy recovery would be easier and faster. 4ehabilitation should begin
immediately.