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meningitis and reye syndrome chapter 12 Unit 2 nursing care of children with system disorders Section Neurosensory Disorders Chapter 12 Meningitis and Reye Syndrome Overview ●● ●● ●● Meningitis is an inflammation of the meninges, which are the membranes that protect the brain and spinal cord. Reye syndrome is a life-threatening disease that leads to multisystem failure. Meningitis and Reye syndrome have similar symptoms and are both often preceded by viral infections. Therefore, testing may be necessary to differentiate between the two. Meningitis Overview ●● ●● Viral or aseptic, meningitis usually requires only supportive care for recovery. Bacterial, or septic, meningitis is a contagious infection. The prognosis depends on how quickly care is initiated. Assessment ●● Risk Factors ◯◯ Viral Meningitis ■■ ◯◯ Viral illnesses (mumps, measles, herpes) Bacterial Meningitis ■■ ■■ ■■ ■■ Upper respiratory infections (otitis media, tonsillitis) caused by bacterial agents (Neisseria meningitides [meningococcal], Streptococcus pneumonia [pneumococcal], Haemophilus influenzae, Escherichia coli) Immunosuppression Injuries that provide direct access to cerebrospinal fluid (skull fracture, penetrating head wound) Overcrowded living conditions rn nursing care of children 101 meningitis and reye syndrome ●● ●● Subjective Data ◯◯ The child may report photophobia or headache. ◯◯ Parents may report that the child is irritable, has vomited, and is drowsy. Objective Data ◯◯ Physical Assessment Findings ■■ ■■ ■■ Newborns ☐☐ No illness is present at birth, but it progresses within a few days. ☐☐ Clinical signs may be vague and difficult to diagnose. XX Poor muscle tone, weak cry, and poor feeding XX Fever or hypothermia ☐☐ Nuchal rigidity is not usually present. ☐☐ Bulging fontanels are a late sign. 2 months to 2 years ☐☐ Seizures with a high-pitched cry ☐☐ Fever and irritability ☐☐ Bulging fontanels ☐☐ Possible nuchal rigidity ☐☐ Poor feeding ☐☐ Vomiting ☐☐ Brudzinski’s and Kernig’s signs do not assist with the diagnosis. 2 years through adolescence ☐☐ Seizures (often initial sign) ☐☐ Nuchal rigidity ☐☐ ☐☐ Positive Brudzinski’s sign (flexion of extremities occurring with deliberate flexion of the child’s neck) Positive Kernig’s sign (resistance to extension of the child’s leg from a flexed position) View Media Supplement: ⦁ 102 Brudzinski’s Sign (Image) ☐☐ Fever and chills ☐☐ Headache ☐☐ Vomiting ☐☐ Photophobia ⦁ Kernig’s Sign (Image) rn nursing care of children meningitis and reye syndrome ☐☐ ◯◯ ☐☐ Petechia or purpuric type rash (seen with meningococcal infection) ☐☐ Involvement of joints (seen with meningococcal and Haemophilus influenza) ☐☐ Chronic draining ear (seen with pneumococcal infection) Laboratory Tests ■■ Perform a blood culture and sensitivity to identify an appropriate broad-spectrum antibiotic. ■■ Complete blood counts should be taken. ■■ Cerebrospinal fluid (CSF) should be collected. ☐☐ ◯◯ Irritability and restlessness that may progress to drowsiness, delirium, stupor, and coma Results indicative of meningitis XX CSF that appears cloudy (bacterial) or clear (viral) XX Elevated WBC XX Elevated protein levels XX Decreased glucose (bacterial) XX Elevated CSF pressure Diagnostic Procedures ■■ Cerebrospinal fluid (CSF) analysis ☐☐ ☐☐ ☐☐ This is the best diagnostic test for meningitis. The collection of CSF with a lumbar puncture (performed by a health care provider). Nursing Actions XX XX XX XX XX XX ☐☐ Have the child empty his bladder if appropriate. Place the child in the fetal position and assist in maintaining the position. Older children may be placed in the sitting position. Administer sedatives as prescribed. Apply a eutectic mixture of local anesthetics (EMLA), which contains equal quantities of lidocaine and prilocaine, over the area between L3 and L5 60 min prior to the procedure. Appropriately label the three test tubes of CSF and deliver them to the laboratory. Monitor the site for hematoma and/or infection. Client Education XX The child should be encouraged to remain in bed for 4 to 8 hr in a flat position to prevent leakage and a resulting spinal headache. This may not be possible for infants, toddlers, or preschoolers. rn nursing care of children 103 meningitis and reye syndrome ■■ CT scan or MRI ☐☐ These may be performed to identify increased ICP and/or an abscess. ☐☐ Nursing Actions XX Assist with positioning. XX Administer sedatives as prescribed. Collaborative Care ●● Nursing Care ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ The presence of petechia or a purpuric-type rash requires immediate medical attention. Isolate the child as soon as meningitis is suspected. Initiate and maintain isolation precautions (droplet precautions) per facility protocol. This requires a private room or a room with cohorts, the wearing of a surgical mask when within 3 feet of the child, appropriate hand hygiene, and the use of designated equipment, such as blood pressure cuff and thermometer. Continue for 24 hr after the first antibiotic has been administered. Continue frequent monitoring of vital signs, urine output, fluid status, pain level, neurologic status, and head circumference (for infants). Initiate IV fluids to maintain hydration. Continue fluid and electrolyte replacement as indicated by laboratory values. Maintain NPO status if the child has a decreased level of consciousness. As the child’s condition improves, advance to clear liquids and then to a diet that the child can tolerate. Decrease environmental stimuli. ■■ Provide for a quiet environment. ■■ Minimize the child’s exposure to bright light (natural and electric). Provide for comfort. ■■ ■■ 104 Keep the child’s room cool. Position the child without a pillow and slightly elevate the head of the bed. The child may prefer a side-lying position to take pressure off his neck. ◯◯ Maintain safety (keep the bed in a low position, take seizure precautions). ◯◯ Keep the family informed of the child’s condition. rn nursing care of children meningitis and reye syndrome ●● Medications ◯◯ Antibiotics ■■ ■■ Administer for bacterial infections via an IV route. Length of therapy is determined by the child’s condition and CSF results (normal blood glucose levels, negative culture). Therapy may last as long as 10 days. Nursing Considerations ☐☐ ■■ ☐☐ ☐☐ ◯◯ Educate the family about the need to complete the entire course of medication. ■■ Administer to prevent neurologic complications. ■■ Nursing Considerations ■■ Assess for effectiveness of medication. Client Education ☐☐ ☐☐ Provide support for the child and family. Educate on the administration of the medication and side effects that may occur. Anticonvulsants – Phenytoin (Dilantin) ■■ Prophylaxis for seizures ■■ Nursing Considerations ■■ ☐☐ Assess for effectiveness of the medication. ☐☐ Monitor therapeutic medication levels. Client Education ☐☐ ◯◯ Provide support for the child and family. Corticosteroids – Dexamethasone (Decadron) ☐☐ ◯◯ Assess for allergies. Client Education Educate about the need to administer the medication on schedule. Analgesics ■■ ■■ ■■ Nonopioids should be used to avoid masking changes in the level of consciousness. Nursing Considerations ☐☐ Monitor respiratory status. ☐☐ Monitor level of consciousness. Client Education ☐☐ Provide support for the child and family. rn nursing care of children 105 meningitis and reye syndrome ●● Care After Discharge ◯◯ Client Education ■■ ■■ ●● Early and complete treatment should be provided for upper respiratory infections. Encourage parents to maintain appropriate immunizations for the child. Children should receive the Haemophilus influenza Type B vaccine (Hib) and the pneumococcal conjugate vaccine (PCV) at 2, 4, and 6 months of age, then again between 12 and 15 months of age. Client Outcomes ◯◯ The child will experience minimal neurologic deficits. Complications ●● Increased ICP ◯◯ ◯◯ Could lead to brain damage Nursing Actions ■■ Monitor for signs of increased intracranial pressure. ☐☐ ☐☐ ■■ Infants – Bulging or tense fontanels, increased head circumference, highpitched cry, distended scalp veins, irritability, bradycardia, and respiratory changes Children – Increased irritability, headache, nausea, vomiting, diplopia, seizures, bradycardia, and respiratory changes Provide interventions to reduce ICP (positioning, avoidance of coughing, straining, and bright lights, environmental stimuli). Reye Syndrome Overview ●● Reye syndrome primarily affects the liver and brain, causing: ◯◯ Liver dysfunction ■■ ◯◯ 106 Bleeding and poor blood clotting Cerebral edema (with increased intracranial pressure). ■■ Lethargy progressing to coma ■■ Potential for cerebral herniation ◯◯ Hypoglycemia ◯◯ Shock rn nursing care of children meningitis and reye syndrome ●● ●● Reye syndrome has been mistaken for a variety of other disorders, including encephalitis, meningitis, poisoning, sudden infant death syndrome (SIDS), diabetes mellitus, and psychiatric illness. The prognosis for Reye syndrome is best with early recognition and treatment. Assessment ●● Risk Factors ◯◯ ◯◯ ●● Peak incidence occurs in January, February, and March. The symptoms most often appear at the end of a viral illness (viral upper respiratory infection, varicella) but may occur earlier in the illness. Subjective Data ◯◯ ●● The cause of Reye syndrome is unknown. However, research has revealed an association between using aspirin (salicylate) products for treating viral infections and the development of Reye syndrome. History of recent viral illness or recent use of aspirin. Objective Data ◯◯ Physical Assessment Findings ■■ Reye syndrome presents in five clinical stages. Each stage contains intensified signs and symptoms of the previous stage. Stage Manifestations I • • • • • • Lethargy Vomiting Anorexia Early liver dysfunction Brisk pupillary reaction Ability to follow commands II • • • • • • Confusion/disorientation/delirium Combativeness Hyperventilation Hyperactive reflexes Sluggish pupillary response Response to painful stimuli III • Coma • Seizures • Decorticate (extension) rn nursing care of children 107 meningitis and reye syndrome Stage ◯◯ IV • • • • • Deeper coma Decerebrate (flexion) Fixed, large pupils, and loss of corneal reflexes Brainstem dysfunction Minimal liver dysfunction V • • • • Hypotonia Seizures Respiratory arrest Absence of liver dysfunction Laboratory Tests ■■ ■■ ■■ ◯◯ Liver enzymes (alanine aminotransferase [ALT], aspartate aminotransferase [AST]) – Elevated Serum ammonia level – Elevated Serum electrolytes – Metabolic alkalosis, hypocalcemia, hyponatremia, and hypernatremia ■■ Serum blood glucose – Hypoglycemia ■■ CBC may indicate low Hgb, Hct, and platelets. ■■ Coagulation times may be extended. Diagnostic Procedures ■■ Liver biopsy ☐☐ ☐☐ ☐☐ A liver biopsy consists of taking a piece of liver tissue, via a large-bore needle, and sending this tissue to the pathology department. Care should be taken to ensure that the child’s clotting studies are within normal limits prior to the procedure. Nursing Actions XX Maintain NPO status prior to the procedure. XX Monitor for hemorrhage postprocedure. XX Assess vital signs frequently postprocedure. Client Education XX ■■ Encourage the parents to limit the child’s postprocedure activities to decrease the risk of hemorrhage. Cerebrospinal fluid (CSF) analysis ☐☐ 108 Manifestations A lumbar puncture should be performed to collect CSF and rule out meningitis as a cause of symptoms (performed by a provider, usually a physician) rn nursing care of children meningitis and reye syndrome Collaborative Care ●● Nursing Care ◯◯ ◯◯ ◯◯ ◯◯ ●● Maintain hydration. ■■ Administer IV fluids as prescribed. ■■ Maintain accurate I&O. ■■ Insert indwelling urinary catheter as ordered. Position the child. ■■ Avoid extreme flexion, extension, or rotation. ■■ Maintain the head in a midline neutral position. ■■ Keep the head of the bed elevated 30°. Monitor appropriateness of coagulation. ■■ Note unexplained or prolonged bleeding. ■■ Apply pressure after procedures. ■■ Prepare to administer vitamin K. Monitor pain status and response to painful stimuli. Administer pain medications when appropriate. ◯◯ Insert a nasogastric tube as ordered. ◯◯ Assist with intubation and maintain a ventilator if required. ◯◯ Take seizure precautions. ◯◯ Keep the family informed of the child’s status. ◯◯ Provide private time for the family to be with the child if death is imminent. ◯◯ Contact support for the family. Medications ◯◯ Osmotic diuretic – Mannitol (Osmitrol) ■■ To decrease cerebral swelling, administer as prescribed. ■■ Nursing Considerations ☐☐ ◯◯ Monitor the child for increased intracranial pressure. Insulin ■■ Administer to increase glucose metabolism. ■■ Nursing Considerations ☐☐ Monitor blood glucose levels prior to insulin administration and periodically. rn nursing care of children 109 meningitis and reye syndrome ■■ Client Education ☐☐ ●● ◯◯ ●● The child who has neurologic deficits post-Reye syndrome will require interventions from other members of the health care team. Occupational therapy and physical therapy may be needed to help the child adapt to neurologic deficits. A dietician may also be needed to assist in maintaining adequate nutrition. Care After Discharge ◯◯ Client Education ■■ ■■ ●● Provide support for the child. Interdisciplinary Care Teach parents to avoid giving salicylates for pain or fever in children. Teach parents to read labels of over-the-counter medications to check for the presence of salicylates. Client Outcomes ◯◯ The child will experience minimal neurologic deficits. Complications ●● Neurologic Sequelae ◯◯ ◯◯ Neurologic complications may include speech and/or hearing impairment, cerebral palsy, paralysis, and/or developmental delays based on the length and severity of illness. Nursing Actions ■■ ◯◯ Client Education ■■ ●● Help the family identify support services for home care. Death ◯◯ 110 Explain the child’s condition and needs to the family. Nursing Actions ■■ Support the family in grief. ■■ Contact spiritual support as appropriate. rn nursing care of children meningitis and reye syndrome Chapter 12: Meningitis and Reye Syndrome Application Exercises Scenario: A mother brings her 3-year-old child to the emergency department. Four days ago, the child was diagnosed with otitis media. Now the mother says her child is lethargic and cries constantly when held. The child vomited 3 hr ago. 1. What interventions should the nurse anticipate after assessing the child? 2. When performing the initial assessment, the nurse found that when the child’s head was flexed, his knees and hips also flexed. The nurse should document this finding as A. Kernig’s sign. B. Nuchal rigidity. C. Brudzinski’s sign. D. Cushing’s reflex. 3. The child grimaces when the light is on in the room. Which of the following interventions should the nurse implement to minimize photophobia? A. Avoid using the television. B. Keep the volume down on the radio. C. Bandage both eyes temporarily. D. Elevate the head of the bed. 4. Which of the following vaccines should a nurse administer to protect an infant from bacterial meningitis? (Select all that apply.) Inactivated polio vaccine (IPV) Pneumococcal conjugate vaccine (PVC) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) Haemophilus influenzae type B vaccine (Hib) Trivalent inactivated influenza vaccine (TIV) 5. A child is admitted with possible Reye syndrome. The nurse should recognize that which of the following factors in the child’s health history supports this diagnosis? A. Recent history of urinary tract infection B. Recent history of bacterial otitis media C. Recent episode of gastroenteritis D. Recent episode of Haemophilus influenzae meningitis rn nursing care of children 111 meningitis and reye syndrome 6. Which of the following manifestations are indicative of stage II of Reye syndrome? (Select all that apply.) 112 Coma Fixed pupils Hyperventilation Combativeness Hyperactive deep-tendon reflexes rn nursing care of children meningitis and reye syndrome Chapter 12: Meningitis and Reye Syndrome Application Exercises Answer Key Scenario: A mother brings her 3-year-old child to the emergency department. Four days ago, the child was diagnosed with otitis media. Now the mother says her child is lethargic and cries constantly when held. The child vomited 3 hr ago. 1. What interventions should the nurse anticipate after assessing the child? After the assessment, the nurse should suspect meningitis; therefore, droplet isolation precautions should be initiated by placing the child in a private room, wearing a mask when within 3 feet of the child, performing frequent hand hygiene, and designating personal equipment for the child. The nurse should also be prepared to initiate IV access and to assist with performance of a lumbar puncture. NCLEX® Connection: Safety and Infection Control, Standard/Transmission-Based/Other Precautions 2. When performing the initial assessment, the nurse found that when the child’s head was flexed, his knees and hips also flexed. The nurse should document this finding as A. Kernig’s sign. B. Nuchal rigidity. C. Brudzinski’s sign. D. Cushing’s reflex. Brudzinski’s sign is the flexion of the hips and knees when the child’s head is purposefully flexed. Kernig’s sign is the pain associated with extending the knee when the hip is flexed. Nuchal rigidity is resistance of the neck to passive range of motion. Cushing’s reflex is a late neurologic sign of increased intracranial pressure in which there is increased blood pressure with widened pulse pressure and bradycardia. NCLEX® Connection: Reduction of Risk Potential, System Specific Assessment rn nursing care of children 113 meningitis and reye syndrome 3. The child grimaces when the light is on in the room. Which of the following interventions should the nurse implement to minimize photophobia? A. Avoid using the television. B. Keep the volume down on the radio. C. Bandage both eyes temporarily. D. Elevate the head of the bed. Photophobia is an abnormal sensitivity to light. Keeping the television off will minimize light exposure. Regulating the volume of sounds will not affect light sensitivity. Bandaging both eyes is not an appropriate intervention for a 3-year-old child. Elevating the head of the bed is an effective comfort measure for the child with meningitis, but it has no effect on photophobia. NCLEX® Connection: Physiological Adaptation, Infectious Disease 4. Which of the following vaccines should a nurse administer to protect an infant from bacterial meningitis? (Select all that apply.) Inactivated polio vaccine (IPV) X Pneumococcal conjugate vaccine (PVC) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) X Haemophilus influenzae type B vaccine (Hib) Trivalent inactivated influenza vaccine (TIV) Immunizing infants beginning at 2 months of age with Hib and PCV protects them from common types of bacterial meningitis. IPV, DTaP, and TIV vaccines will not prevent bacterial meningitis. NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention 5. A child is admitted with possible Reye syndrome. The nurse should recognize that which of the following factors in the child’s health history supports this diagnosis? A. Recent history of urinary tract infection B. Recent history of bacterial otitis media C. Recent episode of gastroenteritis D. Recent episode of Haemophilus influenzae meningitis Gastroenteritis is the only recent illness mentioned that is related to a viral episode. The other choices are caused by bacterial infections. NCLEX® Connection: Physiological Adaptation, Infectious Disease 114 rn nursing care of children meningitis and reye syndrome 6. Which of the following manifestations are indicative of stage II of Reye syndrome? (Select all that apply.) Coma Fixed pupils X Hyperventilation X Combativeness X Hyperactive deep-tendon reflexes Stage II symptoms include confusion/disorientation/delirium, combativeness, hyperventilation, hyperactive reflexes, sluggish pupillary response, and an ability to respond to painful stimuli. Coma and fixed pupils are symptoms in later stages of Reye syndrome. NCLEX® Connection: Physiological Adaptation, Infectious Disease rn nursing care of children 115
