Meningitis, Encephalitis, Epilepsi

Linlin Lindayani, PhD

Anatomy and physiology
n The nervous system
consists of two
divisions:
¨ Thecentral nervous
system (CNS)
n The Brain and spinal
cord
¨ Theperipheral
nervous system
Anatomy and physiology
n Brain divided into
three major areas
¨ The cerebrum
¨ The brain stem
¨ The cerebellum
Anatomy and physiology
The cerebrum
n Composed of two hemispheres,
thalamus, hypothalamus, and the basal
ganglia.
n Has connections for the olfactory and
optic nerves.
n The cerebral hemispheres are divided
into pairs of frontal, parietal, temporal,
and occipital lobes.
Anatomy and physiology
¨ The brain stem
n Midbrain, pons, medulla, and
connections for cranial nerves II and IV
through XII.

¨ The cerebellum
n Located under the cerebrum and behind
the brain stem.
Anatomy and physiology
n Structures protecting the brain are
¨ Rigid skull
¨ The meninges (fibrous connective tissues
that cover the brain and spinal cord)
n Dura mater- the outermost layer.
n Arachnoid – the middle membrane.
n Pia mater- the innermost membrane.
Anatomy and physiology
n CSF
¨ Clear and colorless fluid
¨ Produced in the ventricles
¨ Circulated around the brain and the spinal
cord through the ventricular system.
¨ The composition is similar to other
extracellurla fluids, but the concentrations
of the various constituents are different
Anatomy and physiology
n Blood-brain barrier
¨ Formed by endothelial cells of the brain’s
capillaries, which forms continuous tight
junctions, creating a barrier to
macromolecules and many compounds.
¨ Has protective function but can be altered
by trauma, cerebral edema, and cerebral
hypoxemia.
Meningitis
n An inflammation of the pia mater, the
arachnoid, and the cerebrospinal fluid
(CSF)-filled subarachnoid space.
INTRODUCTION

¨ Meningitis is an inflammation of the meninges

, the protective membranes that surround the brain
and spinal cord.
Common causes of meningitis may include:
¨ Bacteria, Virus, Fungi and Parasites.
¨ Most episodes of meningitis result from
hematogenous seeding of infection from
other sites to the meninges.

Mycobacterium tuberculosis is most common in young

children, but can affect children of any age.
Classifications
n Septic:
¨ Caused by bacteria.
¨ most common pathogens are streptococcus
pneumonia and Neisseria meningitidis

n Aseptic: caused by viral or secondary to

lymphoma, leukemia, or HIV
Pathophysiology
n infections generally originate in one of two
ways:
¨ through the bloodstream as a consequence of
other infections
¨ or by direct spread, such as might occur after
a traumatic injury to the facial bones or
secondary to invasive procedure
Pathophysiology
n Once the causative organism enters the blood
stream, it crosses the blood-brain barrier and
proliferates in the CSF.
n The host immune response stimulates the
release of cell wall fragments and
lipopolysaccharides, facilitating inflammation of
the subarachnoid and pia mater.
Pathophysiology
n Because the cranial vault contains little room for
expansion, the inflammation may cause
increased intracranial pressure (ICP).
n CSF circulates through the subarachnoid space,
where inflammatory cellular materials from the
affected meningeal tissue enter and accumulate
Pathophysiology
n CSF studies demonstrate decreased glucose,
increased protein levels, and increased WBCs
count.
n The prognosis pf bacterial meningitis depends
on the causative organism, the severity of the
infection and illness, and the timeliness of
treatment.
Clinical Manifestations
n Initial symptoms:
¨ Headache
n either steady or throbbing
and very severe as a
result of meningeal
irritation.
¨ Fever
n tends to remain high
throughout the course of
illness.
Clinical Manifestations
n Meningeal irritation signs:
¨ Nuchal rigidity:
n Early sign
n Any attempts at flexion of
the head are difficult
because of spasm in the
muscles of the neck.
n Forceful flexion causes
severe pain
Clinical Manifestations
n Meningeal irritation signs:
¨ Positive kernig’s sign:
• n When the patient is lying with the thigh flexed on
the abdomen, the leg can’t be completely extended.
Clinical Manifestations
n Meningeal irritation signs:
¨ Positive Brudziniski’s sign
n When the patient’s neck is flexed, flexion of the
knees and hips is produced
n When the lower extremity of one side is passively
flexed, a similar movement is seen in the opposite
extremity
n More sensitive indicator of meningeal irritation than
Kernig’s sign.
Clinical Manifestations
n Meningeal irritation signs:
¨ Positive Brudziniski’s sign
Clinical Manifestations
n Meningeal irritation signs:
¨ Photophobia (extreme sensitivity to light)
Clinical Manifestations
n Rash
n disorientation and memory impairment
n seizures
¨ occur in 30% of adults with S. pneumonea
meningitis
¨ the result of areas of irritability in the brain
Clinical Manifestations
n Signs of increased ICP
¨ Decrease level of consciousness
¨ Focal motor deficit
¨ Brain stem herniation

n Signs of overwhelming septicemia

Diagnostic findings

n Bacterial culture and gram staining of CSF

and blood are key diagnostic tests
n The presence of polysaccharide antigen in
CSF further supports the diagnosis of
bacterial meningitis
Prevention

n Vaccination against meningococcal

meningitis
n Antimicrobial chemoprophylaxis for the
people who is in direct contact with
patients with meningococcal meningitis
n Prophylactic therapy should be started
with 24 hours of exposure
Medical Management

n Antibiotics that cross the blood-brain

barrier into subarachnoid space
¨ Penicillin antibiotics or one of the
cephalosporins
¨ If resistant strains of bacteria identified,
vancomycin hydrochloride alone or in
combination with rifampin may be used
Medical Management

n Dexamethasone as adjunct therapy

¨5 -20 minutes before the first dose of
antibiotic, and every 6 hours for the next 6
days
n Fluid volume expanders to treat hock an
dehydration
n Phenytoin to treat the seizure
Encephalitis

n an acute inflammatory process to the

brain tissue
n Herpes simplex virus (HSV) is the most
common cause
Pathophysiology
Herpes Simplex Virus 1

Retrograde intraneuronal path from

olfactory and trigeminal nerves to the brain

Viruses reactivate in the brain tissue

Encephalitis
Clinical Manifestations

n Fever, headache, and confusion are the

initial symptoms
n Focal neurologic symptoms reflect the
areas of cerebral inflammation and
necrosis and include behavioral changes,
focal seizures , dysphasia, hemiparesis,
and altered level of consciousness
Diagnostic Tests

n Neuroimaging studies (MRI shows the

edema in the temporal lobe)
n EEG (demonstrates periodic high-voltage
spikes originating in the temporal lobe)
n CSF examination
¨ lumber puncture reveals a high opening
pressure and low glucose and high protein
level in CSF samples
n Polymerase chain reaction (PCR)
Diagnostic Tests

n Neuroimaging studies (MRI shows the

edema in the temporal lobe)
n EEG (demonstrates periodic high-voltage
spikes originating in the temporal lobe)
n CSF examination
¨ lumber puncture reveals a high opening
pressure and low glucose and high protein
level in CSF samples
¨ Polymerase chain reaction (PCR)
Medical Management

n Acyclovir (antiviral agent)

Nursing management
Assessment Nursing Objective Intervention evaluation
diagnosis
Headache, 8 Acute pain Headache will -Dimming Headache is
on scale related to be reduced the lights reduced
meningeal within 2 hours -Limiting from 8 to 2
irritation noise on scale
-
Administerin
g analgesic
agents and
prescribed
Nursing management

¨ Monitor vital signs 2-4 hrly (Temperature, Pulse

rate, Oxygen saturation, BP, and Respiratory
Rate)
¨ Monitor Input/output

¨ Give treatment as prescribed.

¨ Maintain a clear airway

• Turn the patient every 2 hours.

• Do not allow the child to lie in a wet bed.
• Pay attention to pressure points
¨ Monitor IV fluids very carefully and examine
frequently for signs of fluid overload
¨ Nurses should monitor the child’s state of
consciousness, respiratory rate and pupil size
every 3 hours during the first 24 hours (thereafter,
every 6 hours).
¨ On discharge, assess all children for neurological
problems, especially hearing loss.
¨ Measure and record the head circumference of
infants.
¨ If there is neurological damage, refer the child for
physiotherapy, if possible, and give simple
suggestions to the mother for passive exercises
Nursing management at emergency
¨ Step one
¨ Triage according to clinical indicators.
¨ Step two
¨ Prioritise care. The nurse’s role is to prioritise
¨ Airway, Breathing and Circulation,
accompanied by a rapid assessment of
conscious level using the AVPU# scale.
¨ Step three
Follow with specific nursing assessments. These should
include the following:
■ Assess for decreased cerebral tissue perfusion related to
increased ICP:
– neurological observations, including blood pressure
should be performed at intervals determined by the
child’s clinical state
– assess for increased ICP
– monitor fluid and electrolyte status.
■ Assess for ineffective breathing pattern related to
increased ICP:
– monitor respiratory rate, work of breathing and pulse
Assess for potential for injury related to seizures:
– document characteristics of seizure activity-duration,
characteristics of motor behaviour and post-ictal phase
– assess the patient’s environment for potential hazards.
■ Assess for alteration in fluid and electrolytes related to SIADH,
DI, diuretics, fluid restrictions:
– monitor haemodynamic parameters
– monitor urine output
– monitor SG, urine electrolytes and osmolality.
■ Assess for alterations in comfort related to meningeal
irritation, headache, photophobia, fever
– monitor temperature and assess effectiveness of comfort
measures.
Nursing management
Assessment Nursing Objective Intervention evaluation
diagnosis
Headache, 8 Acute pain Headache will -Dimming Headache is
on scale related to be reduced the lights reduced
meningeal within 2 hours -Limiting from 8 to 2
irritation noise on scale
-
Administerin
g analgesic
agents and
prescribed
Nursing management
Assessment Nursing Objective Intervention evaluation
diagnosis
- Headache Risk for The patient -Bed rest with -Headache
ineffective returned to supine sleeping is reduced
-Body position without
weakness cerebral the state of a pillow -Vital signs
-Decreased tissue the -Monitor the are within
level of perfusion neurological signs of normal
consciousnes related to status neurologic limits.
status with
s increased before the GCS. -Increased
ICP illness. awareness.
-Monitor vital
Increased signs
-No signs
patient -Provide
of increased
awareness treatment in
accordance intracranial
and sensory with physician pressure.
function. advice.
Nursing management
Assessment Nursing Objective Intervention evaluation
diagnosis
General Risk for To prevent -Monitor the -No signs
weakness Injury R/T the patient twitching of the of seizure
hands, feet and
general from having mouth or other -No any
weakness seizures or facial muscles. injuries
and risk of other -Provide
-Improved
seizure injuries security for
patients by patient’s
attacks. within 8 providing clinical
hours assistance on status
the bed and
use the side
rails.
-Give
medication as
indicated
Nursing management
Assessment Nursing Objective Intervention evaluation
diagnosis
Inappropriate Interrupted Enhance Inform -Family
and poor Family family family about express
family Process R/T coping and patient’s understandi
communicatio critical functioning condition ng of mutual
n nature of and permit problems
situation family to -Family
and see patient provide
uncertain at information
prognosis appropriate regarding
intervals. stressful
situations
Summary
n Meningitis is an inflammation to meninges while
encephalitis is an inflammation to the brain tissue
itself.
n Meningeal irritation signs are Meningeal Nuchal,
Positive kernig’s sign, Positive Brudziniski’s sign,
and Photophobia
n CSF and blood culture is the main diagnostic test.
n Antimicrobials and antivirals are medical
management.
n Nurses play a significant role in providing care for
patients with meningitis.
 Introduction

¨ Epilepsy is a group of syndromes

characterized by recurring seizures.
Epilepsy syndromes are classified by
specific pattern of clinical features, family
history & seizures type. Epilepsy is a
syndrome of another underlying condition
such as brain tumor.
 Definition

¨ “Epilepsy is a recurrent seizure disorder

characterized by abnormal electrical
discharge from brain, often in the cerebral
cortex.”
Or
¨ “Epilepsy is a chronic seizures disorder
with recurrent & unprovoked seizures.”
 Or
¨ “Epilepsy is a recurrent episodic
disturbance of the brain function due to
abnormal electrical activity of the neuron. It
is manifested as abnormal motor, sensory
phenomenon often with impaired or loss of
consciousness.”
 Incidence

¨ Epilepsy is the most common neurological

problem. An estimated 2-4 million people
are affected in the US with epilepsy.
Approximately 50 million people are
affected of all age groups globally by
epilepsy. According to Venkataswamy
(1998), the prevalence of epilepsy in India
is 4.4/1000 population.
 Epidemiology

¨ Agent factor:
¨ Exposure to toxins, e.g. lead, infection &
neurologic injury.
¨ Fever
Cont…
¨ Host factor:
¨ Age: Most common onset of epilepsy is before the
age of 20 years. It is higher during the first year of
life & at the onset of puberty.
¨ Genetic factor (inheritance)
¨ CVA
¨ Birth hypoxia
¨ Brain tumor & abscess
¨ Congenital abnormalities
¨ Trauma
Cont…

¨ Environmental Factors:
¨ Air pollution, i.e. carbon-mono-oxide & lead
poisoning.
¨ Some factors or events may precipitate the
seizures.
¨ Unskilled handling at the time of birth causing
brain injury & birth asphyxia.
¨ Intrauterine infections.
¨ Emotional disturbances & environmental
stressors.
¨ Drugs & alcohol intoxication.
 Patho-physiology

¨ Disturbance of the brain functions due to

any cause, e.g. genetic factors or head
injury may cause brain cells to become
overactive & to discharge in sudden,
violent disorderly manner, the burst of
electrical energy which spreads to adjust
areas of the brain & may jump to distant
areas of CNS, resulting in seizures.
 Clinical Manifestations

¨ Clinical manifestation in epilepsy range from

starting episodes to prolonged convulsions
with loss of consciousness. The clinical
manifestations vary according to the part of the
brain involved.
¨ Classification of seizures & related clinical
manifestation:
1. Partial seizures
2. Generalized seizures
 Cont…
¨ Partial seizures: When seizures appears to
result from abnormal activity in just one part of
the brain.
Ø Simple partial seizures: They have
elementary or simple symptoms & there is no
loss of consciousness in this. The patient may
experience only a finger or hand shake, mouth
may jerk uncontrollably he/she may talk
unintelligibly, may feel dizziness or may
experience unusual or unpleasant sight,
sound, odors or tastes.
 Cont…

Ø Complex partial seizures: The patient’s

consciousness is altered during the event. The
seizures may begin with an aura. Patient may
have no movement or moves automatically but
inappropriately for time & place; may
experience excessive emotions of fear, anger,
elation or irritability & does not remember the
episodes when it is over.
 Generalized seizures

¨ Generalized seizures (Grand Mal Seizures):

Generalized seizures involve both the
hemispheres of the brain. There is intense
rigidity of the entire body, followed by alternate
of muscles relaxation & contraction
(generalized tonic-clonic contraction).
¨ There are following manifestation:
 Cont…
Ø Tonic phase:
• Simultaneous contraction of the diaphragm &
chest muscles which produce characteristic
epileptic cry.
• Face may become pale, head turned to one side,
eye fixed in one position & hands are clenched.
• Loss of consciousness. Tongue is bitten.
• Frothy discharge from the mouth.
• Ineffective breathing.
• Pulse becomes weak & irregular.
• This state may last for 30 seconds.
 Cont…

Ø Clonic phase:
• Jerky movement last for 1-2 minutes.
• Incontinence of urine & stool.
• The patient relaxes after jerky movements &
goes into the deep sleep (coma) breathing is
noisy.
• This state lasts for 1-2 minutes.
 Postictal State

¨ After the seizures, the patients are often

confused & hard to arouse & may sleep for
hours. Many complain of headache,
muscle-ache, fatigue & depression.
 Assessment & diagnostic
methods
¨ History of events during pregnancy & child
birth for example, difficult labor, trauma &
birth asphyxia.
¨ Neurological examination.
¨ MRI to detect lesions in the brain, e.g.
abscess or tumor, etc.
¨ EEG to classify the type of seizure.
¨ CT-scan to identify the epilepto-genic zone.
¨ Blood tests.
 Prevention

¨ Primary Prevention:
¨ Use of safety precautions to prevent injury during
birth.
¨ Early detection of high-risk mothers to prevent
complications during pregnancy & labor.
¨ Essential obstetrical care, i.e.:
1. Institutional delivery to provide basic emergency
obstetrical care & basic newborn resuscitation
services.
2. Skilled attendance at birth with appropriate referral
services for complicated cases.
Cont…
¨ Avoidance of drugs in pregnancy except where
they are essential.
¨ Genetic counseling:
I. Prospective genetic counseling helps to identify
heterozygous individuals for any particular defect by
screening procedures & explaining to them the risk
of having affected children if they marry another
heterozygote for the same gene.
II. Retrospective genetic counseling can be offered to
those individuals or couples where hereditary
disorders, for example, the nature of seizures has
already occurred, in-order to suggest them to adopt
methods to prevent conception, pregnancy
termination & sterilization depending upon their
Cont…

¨ Secondary Prevention:
¨ It includes early detection & treatment of
cases:
¨ Medical management: Includes need for
long-term need & immediate treatment of
epileptics using medications. The usual
treatment is a single-drug therapy.
¨ Air-way & oxygen administration & I/V line is
established for giving medications.
Cont…
¨ I/V diazepam, lorezepam or fosphenytoin are
administered slowly in an attempt to halt the
seizures. General anesthesia with a short-
acting barbiturate may be used if initial
treatment is unsuccessful.
¨ To prevent further seizures, other medications
(Phenytoin, Phenobarbital) are prescribed
after the initial seizure is treated.
Cont…
¨ Surgical management: It is indicated in the
following conditions:
¨ Anatomical lesion, e.g. brain tumor, hematoma
& abscess or cysts, etc.
¨ Surgical removal of the epileoptogenic focus is
done for seizure that originates in a well
defined area of the brain that can be excised
without producing significant neurologic
defects.
Cont…

¨ Tertiary Prevention:
¨ It aims at rehabilitation& preventing
complication & disabilities. Vocational
rehabilitation should be done of the patient
through proper training & education in some
suitable vocation. This enhances the patient’s
self-esteem, self-confidence & reduces fears &
in-security. Psychological support to the
patient & his/her family must be provided to
relieve their anxiety & fears.
 Nurses role

q Protect from injury by removal of sharp

objects.
q Prevent patient from fall by providing side
rails which should be padded. Remove pillow
or ease the patient to the floor, if possible.
q Remove secretions by suctioning to prevent
asphyxia & to keep the airway clear. Turn the
patient to side-lying position to help in
draining pharyngeal secretions.
q Never leave the patient alone. The patient
should not be restrained during the seizure
attack.
Cont…
q Do not insert anything in patient’s mouth.
q Close observation should be kept on the
conscious level & note fluctuation in
mood & attitude.
q Administer oxygen as advised by
physician.
q Loosen the patient’s clothing from around
his/ her neck.
q After the seizure, put the patient on one
side to prevent aspiration.
Cont…
¨ Health teaching should be given to the patient
& his/her family for long term care & follow-up
regarding the following:
ü To continue medication as per physician’s
advice, teach patient & family regarding side-
effects of medicines.
ü Care during convulsions to prevent injury,
tongue bite & not restraining forcefully during
the convulsive phase.
ü Proper nutrition to prevent malnutrition, should
avoid stimulants.
Cont…

ü Remove stigma attached to the condition.

ü Should carry an emergency medical
identification card or wear an identification
bracelet.
ü Counseling of the family & patient should be
done regarding the type & nature of epilepsy,
need to follow the treatment regimen for life or
as the physician advices. Teach the family & the
patient to avoid fear, participate in social &
recreational activities.
Cont…

ü Instruct the patient to avoid excessive stimulants such as bright

light by wearing dark glasses or covering the eyes from glare
with hand if nothing is available.
ü Emphasize regular follow-up.
heyyaa fellas….!!! prepare a health talk
on epilepsy. Gotcha..???
-Love, Mr. Pool