Prevention and Treatment of Bacterial Meningitis in Children - Case Study Example

Bacterial Meningitis in Children Name Institution Date Bacterial Meningitis in Children Introduction Prevention of diseases is very essential to public health (National Health and Medical Research Council (Australia), 2012). Generally, preventing a disease is better than treating it. Vaccines prevent illnesses in the individuals who get them and provide protection to the people who interact with unvaccinated people (Australia, 2012). Besides saving lives, vaccines prevent infectious illnesses. Additionally, vaccines control a lot of infectious illnesses like diphtheria, mumps, Haemophilus influenza type b (Hib), pertusis, measles, tetanus, and polio, all of which were once frequent in many countries like Australia (Australia, 2012). In case children are not vaccinated and come in contact with a disease, the children’s body might not be powerful enough to attack the disease. Prior to introduction of vaccines, a lot of children lost their lives from illnesses that are now prevented by vaccines. Even though childhood immunization is highly recommended, there are numerous reasons why a number of parents do not vaccinate their children, even though several of them settled on misinformation from anti-vaccine activists (Australia, 2012). With reference to Robert’s case study whose diagnosis is bacterial meningitis, this paper will discuss bacterial meningitis in terms of causes, signs and symptoms, assessment, diagnosis and management. Further, the paper offers a relation of immunization and bacterial meningitis. Overview of Bacterial Meningitis Meningitis refers to membranes’ inflammation that surrounds the spinal cord and the brain (Engdahl, 2010). Microbiologic causes involve fungi, parasites, viruses, and bacteria. Among children who are more than 5 years old as well as adolescents, N. meningitidis and S. pneumoniae are the leading bacterial meningitis causes (Goldschmidt, 2010). A lot of bacteria that cause invasive disease, not excluding meningitis, among children contain a polysaccharide capsule (Agrawal & Nadel, 2011). Meningitis normally comes from an infection that is viral; however, bacterial infection can also be a cause. Less commonly, meningitis can be caused by fungal infection. Bacterial meningitis normally occurs once the bacteria invade the bloodstream and move to the spinal cord or the brain (National Institute for Health and Clinical Excellence, 2010). Additionally, it can occur once the bacteria directly attacks the meninges, due to sinus or ear infection, or fracture of the skull, or rarely, following some surgeries (Goldschmidt, 2010). Since bacterial infections are considered very serious and may be life-threatening, identification of the infection source is a significant element in development of a treatment plan (McMillan & Oski, 2006). The major risk factor associated with meningitis is skipping vaccinations (Agrawal & Nadel, 2011) Research indicates that once a child has not completed the required childhood vaccination schedule, he or she is at higher risk of getting meningitis (Goldschmidt, 2010). Meningitis complications can be serious. The permanent neurological complications or damage include and not limited to seizures, shock, kidney failure, gait problems, brain damage, learning disabilities, memory difficulty, hearing loss, or even death (Agrawal & Nadel, 2011). Assessment Robert is a 6yr old who has been sent to emergency by his local GP with suspected bacterial meningitis. He is accompanied by his mother. Dad is at home with five other children. Robert’s family is conscientious objectors to childhood immunisation and therefore Robert has not received any of the standard childhood inoculations. Onset of illness was sudden. Robert’s mother was able to take him straight to the family GP who immediately referred him up to the emergency hospital with a high grade fever, meningeal signs and absence of other explanation for fever.  On arrival Robert is irritable and has just vomited.  Observations include GCS 14, HR 138, BP 128/ 70, RR 32, SaO2 98%, temp 40.1, ICP > 3 secs, BGL normal. Bacterial meningitis manifestations depend on the patient’s age (Bergelson et al, 2008). It is quite easy to mistake early symptoms and signs of meningitis for influenza. Signs and symptoms of meningitis may develop within several hours or for some days (Agrawal & Nadel, 2011). The common meningitis signs and symptoms that may present in any individual older than 2 years of age include: abrupt high fever as seen in Robert whose fever is categorized as high grade; severe headache not simply confused with other kinds of headache; stiff neck; seizures; nausea and vomiting with headache; difficulty concentrating or confusion; loss of appetite; and skin rash in some cases like in meningococcal meningitis (Agrawal & Nadel, 2011). The initial step at the emergency department is to triage according to the patient’s clinical indicators (Long, 2012). Care is then prioritized because the role of the nurse is to prioritize and this involves establishment of airway, breathing and circulation going hand in hand with quick assessment of the level of conscious with the use of Glasgow Coma Scale (GCS) (Long, 2012). This scale offers a score within the range of 3 to 15; patients who have scores of 3 to 8 are normally considered as being in coma (Long, 2012). With this respect, Robert’s GCS result which is 14 indicates that he is not in coma. The next step is to follow specific assessments in nursing. These should entail: assessment of reduced perfusion of cerebral tissue related to raised intracerebral pressure (ICP). Neurological observations like blood pressure need to be carried out at intervals established by the clinical state of the child. It is important to assess for raised ICP. Monitoring electrolyte and fluid status is also important. Robert’s ICP rises in 3 seconds and his blood pressure is BP 128/ 70. The normal blood pressure in children between 3 to 6 years of age ranges from 95-110 mmHg for the normal systolic pressure, with regards to gender and height, and 60-75 mmHg for diastolic pressure (Goldschmidt, 2010). With this reference, Robert’s blood pressure is considered high. Ineffective pattern of breathing should be assessed in relation to increased ICP. Assessing for possibility of injury in relation to seizures is important and documentation of characteristics of activity-duration of the seizure is encouraged (Agrawal & Nadel, 2011). Due to vomiting, assessing for electrolytes and fluid alteration is encouraged. The nurses should also assess for comfort’s alterations related to meningeal headache, fever, photophobia, and irritation. Temperature should be assessed. Robert’s temperature which is 40.1 degrees Celsius is regarded as high grade fever since it is above the normal parameters 36.5 to 37.5 degrees Celsius (Goldschmidt, 2010). Other assessments should be done on the patient include heart rate, respiratory rate, and SaO2. In children, the normal parameter of heart rate is 65 to 110 beats per minute for children between the ages of 3 to 6 years old (Goldschmidt, 2010). Robert’s HR of 138 bpm is elevated. The normal parameter of respiratory rate in children aged 3 to 6 years is 20 to 25 breaths per minute (Goldschmidt, 2010). There is elevation in Robert’s RR evidenced by 32 bpm. A normal saturation level of oxygen for children should be between 98% and 100%, with 97% saturation level regarded borderline normal (Goldschmidt, 2010). Anything which is 96% or less is regarded as abnormal. Robert’s SaO2 of 98% is considered normal. Blood glucose level can decrease in bacterial meningitis but Robert’s BGL is normal. It is essential that healthcare providers understand clinical symptoms and signs that may be used to facilitate identification of children presenting with suspected bacterial meningitis (Goldschmidt, 2010). In emergency department nursing staff have a major role in working together with other medical staff to make sure that these symptoms and signs are correctly identified (Price & Gwin, 2012). Diagnosis One of the diagnoses for bacterial meningitis is lumbar puncture which involves cerebrospinal fluid (CFS) analysis, collected in a spinal tap procedure (Price & Gwin, 2012). CSF analysis should involve Gram stain as well as cultures, WBC count and differential, as well as protein and glucose concentrations (Agrawal & Nadel, 2011). CFS analysis helps in identification of the exact bacterium that is bringing about the illness, thus determine suitable treatment as well as prognosis (Agrawal & Nadel, 2011). CSF’s cytocentrifugation enhances the capacity of bacteria detection and carries out determination of the differential of WBC in a more accurate manner. In bacterial meningitis, characteristic findings within the CSF include pleocytosis, normally with the count of WBC being more than 1000 cells/mm3 and polymorphonuclear leukocytes’ predominance (Agrawal & Nadel, 2011). In a number of cases, particularly when carried out early during the disease, the count of WBC may be normal, and there might be predominance of lymphocyte (Agrawal & Nadel, 2011). An increase of polymorphonuclear leukocyte is expected following 48 hours of diagnosis which thereafter reduces. A lumbar puncture that is traumatic causes introduction of blood in the spinal fluid in the course of the procedure, making CSF cell count interpretation difficult. Hence caution is required during traumatic lumbar punctures’ interpretation (Agrawal & Nadel, 2011). CSF’s Gram-stained has a lower edge of detection of nearly105 colony-forming units/mL. There is 80-90% of positive CSF Gram stain in patients who have bacterial meningitis that is untreated (Agrawal & Nadel, 2011). Imaging is another diagnostic measure for bacterial meningitis (Agrawal & Nadel, 2011). This involves computerized tomography (CT) scans and X-rays of the chest, sinuses or head which may reveal inflammation or swelling (Agrawal & Nadel, 2011). CT is indicated for focal neurological assessment findings, seizures, suspected abscess of the brain. However, CT should be carried out only when the child is stable (Agrawal & Nadel, 2011). These tests facilitate identification of infection within other regions of the child’s body that might be linked to meningitis. Management Management of bacterial meningitis depends on the kind of meningitis that the child has (James et al, 2013). The first management indicated for Robert is triage and ensuring the ABCDs which denote airway, breathing, circulation, and disability. Establishing an IV line indicated for rehydration as well as IV medication is paramount as well. This is then followed by drug therapy. Antibiotic treatment should be commenced as soon as possible. For instance, giving antibiotics like chloramphenicol 25 mg/kg IV (or IM) hourly, with Ampicillin 50 mg/kg IV (or IM) 6 hourly is recommended for children aged 3 months to less than 18 years. Acute bacterial meningitis needs rapid treatment with IV antibiotics and, more presently, cortisone medications, to guarantee recovery and decrease the possibility of complications, like seizures and brain swelling (Harding et al, 2013). The antibiotic or antibiotics’ combination chosen is dependent on the kind of bacteria that causes the infection. It is recommended to give antibiotic of broad-spectrum until there is establishment of the precise meningitis cause. Infected mastoids or sinuses might require to be drained. Supportive treatment include giving paracetamal 15 mg/kg 6 to 8 hourly for fever which is more than 38.5 degrees Celsius; IV fluids like isotonic fluids are also encouraged; feeding with respect to age requirement; providing anticonvulsants in case the child convulse; NGT for feeding in case the child’s tolerance to feeding is problematic. Reassuring the parent is very important and this will mean that she is involved in the care plan of his son. Monitoring the child’s vital signs 2-4 hourly (temperature, oxygen saturation, BP, respiratory rate, and heart rate) are important. The nurse should also monitor the patient’s consciousness state, pupil size and respiratory rate every 3 hrs in the initial 24 hours (then, every 6 hours). Assessing and monitoring for improvement or deterioration in physiological parameters of a child is an important role for nurses within any acute hospital environment (James et al, 2013). The need for monitoring deterioration signs closely after a child with meningitis presents to the hospital is very important. This involves proper understanding of the child’s condition and that his or her condition can deteriorate quickly, in spite of the outcome of severity of the initial assessment. Hence, healthcare providers involved in management of children who are critically ill should be trained with respect to meningococcal disease recognition and management (Wong et al, 2011). On discharge, assess the child for neurological issues particularly hearing loss. In case of any neurological damage, the child should be referred for physiotherapy and the mother should be shown some passive exercises for the child (Betz & Sowden, 2008). Education on the importance of immunization is imperative. Robert’s family should be empowered about the importance of immunization in relation to illnesses in children. With respect to significant factors like culture let the family appreciate that some illnesses like bacterial meningitis can be avoided when vaccination is administered. Also address the issue of fear in the parents about declining childhood immunization. Encouraging both parents to be there during education on the importance of childhood immunization is important. Use of therapeutic communication will be required because from this, the perspectives of the parents regarding immunization will be tabled. Additionally, therapeutic communication is important in nursing (James et al, 2013). While stressing his or her legal responsibilities as a nurse, the nurse will act as the child’s advocate and try to illustrate the importance of childhood immunization to the parents. However, it is important to be culture sensitive hence professional competency is highly required. Immunizations Required for Prevention of Bacterial Meningitis With regards to Robert’s case, lack of immunization has to some extent contributed to his condition. Some bacterial meningitis forms are preventable when the following vaccinations are provided: Haemophilus influenza type b (Hib) vaccine (Engdahl, 2010). It is recommended to give this vaccine beginning at around 2 months of age. The second vaccine is pneumococcal conjugate vaccine (PCV7) (Engdahl, 2010). This vaccine is recommended for children who are between 2 and 5 years and are at risk of acquiring pneumococcal disease like those with lung or chronic heart disease (Engdahl, 2010). Haemophilus influenza type b and Neisseria meningitidis is recommended during childhood. Children are vaccinated in 4 doses; at 2 months, 4, 6, and between 12 and 15 months (Engdahl, 2010). Hence, skipping this vaccine would mean that a child is predisposed to diseases like meningitis. Pneumococcal polysaccharide vaccine (PPSV) is another vaccine that is recommended for children whose immune system is weak or those who have chronic diseases like sickle cell anemia or heart disease (Engdahl, 2010). The last vaccine is meningococcal conjugate vaccine (MCV4). Aside from being given to older children, this vaccine is recommended to younger children at great risk of bacterial meningitis. Its use is approved in children from 9 months old (Agrawal & Nadel, 2011). Conclusion In conclusion, this paper has discussed various issues with regards to Robert’s case study. For starters, immunization is very important during childhood. This prevents a child from various infections and illnesses like influenza and meningitis. Even though immunization is highly recommended, there are some parents who do not appreciate this factor and hence do not take their children for vaccination. With reference to Robert’s case, he suffered bacterial meningitis which to some extent could have been prevented through early immunization. Bacterial meningitis is serious illness and can cause severe complications like hearing loss among others. This is why accurate diagnosis should be established so that a suitable plan of care can be instituted. The complexity involved in the management of young children can be quite challenging for nursing as well as inexperienced medical staff, but with proper training, this can be a smooth practice. Reference Engdahl, S. (2010). 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Agrawal, S., & Nadel, S. (2011). Acute bacterial meningitis in infants and children: epidemiology and management. Paediatric Drugs, 13(6), 385-400. Read More