MENINGITI

B Y: M O L LY R E E H L
MONIQUE THOMPSON
SARAH ZERBST
 J.H. is a 5-week-old infant
brought to the emergency
department (ED) by his
mother, who speaks little
English. Her husband is at
Scenario work. She is young and
appears frightened and
anxious. Through a
translator, Mrs. H. reports
that J.H. has not been eating,
sleeps all the time, and is
“not normal.”
Communication Obstacles 
• What are some of the obstacles you need to consider, recognizing that
Mrs. H. does not speak or understand English well? 
• Some obstacles to consider are the obvious language barrier which can delay
the care of the infant because she cannot effectively convey information, and
this can present issues on discharge as to the ongoing care of the patient.   
• Other obstacles that this presents are increased anxiety and frustration because
she can't understand what is going on pertaining to the care of her child and
lastly misinterpretation due to the lack of understanding. 
Primary Assessment Finding
• Anterior fontanel palpable and
tense
• Pupils equal and +3
• Temperature 96.8 ° F (36 ° C)
rectally
• Heart rate: 85 beats/min
• Positive Babinski reflex
• High-pitched cry
• Refusal of PO intake per mother
• Findings reported to provider:
• Anterior fontanel palpable and
tense- d/t increased ICP
(intracranial pressure)
• Temperature of 96.8 ° F (36 ° C)
rectally- indication of hypothermia
• Heart rate: 85 bpm- bradycardia
and normal HR for infants are
between 90-160 bpm
• Refusal of PO intake- dehydration
and indication of infection 
 Babinski Reflex
• The Babinski reflex is elicited by
stroking the outer edge of the
sole of an infant's foot up toward
the toes 

• The infant's toes fan upward and

out
 • Order of Priority
• 1. Place patient in contact/droplet
isolation
• 2. Assist w/ Lumbar puncture
• 3. Place IV
Interventions  • 4. Obtain blood culture, CMP
• 5. Straight catherization for urine
specimen
• 6. Administer Certriaxone
(Rocephin)
• 7. Administer Tylenol 
Rocephin IM
Injection
• You have a difficult time placing the IV
line and the provider writes an order to
give the Rocephin IM while you wait for
the vascular access team to place the IV. 
• Select a 22-25 gauge, ½-1-inch needle. 
• Vastus Lateralis is the recommended site in
infants and small children. 
• Position the infant in a supine, or side-
lying. 
• Inject up to 0.5 mL for infants. 
Image Retrieved from https://mvec.mcri.edu.au/immunisation-
references/administration-of-injected-vaccines-correct-technique/
Ceftriaxone (Rocephin) Loading Dose Order
• Ceftriaxone (Rocephin) 260 mg • 3.5kg x 100= 350mg Loading dose
IV now (loading dose) • The loading dose is safe as it does
• The therapeutic range is 100 not exceed the max of 350mg. 
mg/kg loading dose and then 80 • The loading dose for a therapeutic
mg/kg daily. J.H. weighs 3.5 kg.  range= 350mg
• Is the loading dose ordered safe? 
• Is it therapeutic? The loading dose is ordered at
260mg which can be increased to
reach the therapeutic amount. 
 Urinalysis 
• pH 7.2
• Color Clear 
• Leukocytes Negative 
Complete Blood Count 
Chart View : • Hct 32% 
Laboratory Test • HgB 10.5 g/dL 
• WBC 22,000/mm3- High counts
Results  of white blood cells indicates an
infection. 
Interpret the CSF findings: Would you
suspect bacterial or viral meningitis?  Why?
• Chart Review:  Typically, bacterial meningitis is referred
• CSF Analysis to as purlelent (pus forming), because it
has the ability to create thick exudate that
• CSF Clear surrounds the meninges and adjacent
• Gram stain Pending structure.  However, in the early stages of
• Protein 300 mg/dL (Elevated) the illness, the cerebral spinal fluid may be
• Leukocytes 1030 cells/mcL clear, which according to this case study
(elevated) may be the case.  The CSF, will also show
• Glucose 40 mg/dL (decreased) an increase in intercranial pressure, while
the laboratory results may show a high
white cell count, an increase in protein,
and a decrease in glucose.  With the
exception of an increased ICP, all the other
laboratory values are consistent with CSF
review in this case study. 
 • Typically CSF microscopic
analysis yields a glucose
Interpret the CSF concentration <40mg/dL, a CSF
serum glucose ration of ≤ 0.4, a
findings: Would protein concentration of >200
you suspect mg/dL and a WBC count above
bacterial or viral 1000/microL, with at a
presentative of neutrophils
meningitis?  Why? usually greater than 80%.  All of
(continued) which gives further proof that J.
H. has bacterial meningitis.  
What are the most common pathogens in this
group? 
• Should J. H. have not received • Group B Streptococcus
the H. influenzae type b vaccine, • Escherichia coli
that is the most common bacteria • Listeria momocytogenes
to cause bacterial meningitis in
infants greater than one month of
age.  
• S. pneumoniae (Antibiotic
resistances remain a concern)
• N. meningitidis
 J . H . I S D I A G N O S E D
W I T H E . C O L I
M E N I N G I T I S .   H I S
M E D I C A L C A R E P L A N
W I L L I N C L U D E 1 4
T O 2 1 D A Y S O F
A N T I B I O T I C
T H E R A P Y .   Y O U A R E
D E V E L O P I N G H I S
N U R S I N G P L A N O F
C A R E

10.) OUTLINE A PLAN OF CARE FOR

J . H . ,   D E S C R I B I N G N U R S I N G I N T E RV E N T I O N S   T H AT
W O U L D B E A P P R O P R I AT E F O R M A N A G I N G PA I N
A N D I N F E C T I O N ,   M A I N TA I N I N G H Y D R AT I O N ,
ASSISTING WITH INCREASED INTRACRANIAL
PRESSURE (ICP), AND TEACHING TO  REVIEW WITH
HI S PARENT S.
Pain
• Related to inflammation of the • Cluster cares
meninges, therefore, any sources of
stimulus will illicit pain.
• Avoid jarring the crib—
• The nurse will want to decrease all lower/raise the side rails quietly
environmental stimuli • Use soft voice and a genital
• Dim the lights
• Decrease noise 
touch 
• Isolation for 24 hours after initiation of
antibiotics 
• Provide pain medication, should the nurse
determine the patient is in pain 
• Provide an anticonvulsant to decrease the
risk of seizures, therefore decreasing pain
due to over stimuli 
 • Placement of an IV to administer
often extremely caustic
antibiotics.  
• Decrease fever associated with
infection
• Antipyretics, sponge baths, or a
hypothermia (cooling) mattress
may also control fever 

Infection  
Hydration 
• Placement of an IV for
both hydration and electrolyte
replacement therapy
• Strict intake and Output
measurements must be
completed to ensure J. H. is
remaining hydrated
• Preform good oral hygiene, as
the child will be NPO  day to detect constipation and prevent
• Diet is advanced clear liquids to an
age-appropriate diet
• Specialty formulary may be given when
NG feedings are necessary
• During the convalescent period, oral
fluids are encouraged unless
contraindicated
• A decrease in output of urine (oliguria),
which could signal urinary retention
• Bowel movements are recorded each
fecal impaction 
 Increased Intercranial Pressure 
Preform frequent Assess vital signs
neurological frequently
assessments  status and records and
Slowed pulse rate, irregular
respirations, and increased
blood pressure may indicate an
increased ICP
Assess for sublte sings
of ICP
Changes in alertness or twiching
muslce
Joints observed for swelling,
pain, and imobility
Oxygen may be given The nurse will monitor
the child's neurological
report any abnomral
findings:
Weakness of the limbs
Speech difficulties
Mental confusion
Behavioral problems
Developmental deficiences 
Patient Education 
• The nurse would want to be supportive of the parents as they go
through this by offering a therapeutic relationship
• The nurse would want to educate on: 
• The disease process
• The necessity of treatment along with complications should treatment be with
held
• The necessity of any devices:
• IVs, EKGs, tests, alarms, etc.
• The need for antibiotics for 14-21 days, etc.
• The side effects vs. the adverse effects of antibiotics
• The need for decreased stimuli and pain
QUESTIONS
?
 • Hasbun, R. (2020). Clinical features and
diagnosis of acute bacterial meningitis in
adults. In J. Mitty. (ed.) UpToDate.
Retrieved July 27th, 2020 from
https://www.uptodate.com/contents/clinical
-features-and-diagnosis-of-acute-bacterial-
meningitis-in-adults?search=bacterial%20
References meningitis%20csf&source=search_result&
selectedTitle=1~150&usage_type=default
&display_rank=1
• Holman, H. Williams, D. Sommer, S.
Johnson, J. Wheless, L. Wilford, K.
Mcmichael, M. (2019). RN nursing care of
children (11.0 ed.). Assessment
technologies institute, LLC. 
• Kaplan, S. (2020). Bacterial meningitis in
children older than one month: clinical
features and diagnosis. In C. Armsby (Ed.)