Meningitis is a life-threatening disorder most often caused by bacteria or viruses. The condition carries a mortality rate of close to 25% despite great innovations in healthcare. There were 8.7 million reported cases of meningitis worldwide, with 379,000 subsequent deaths. In the United States, the annual incidence of bacterial meningitis is approximately 1.38 cases/per 100,000 population, with a case fatality rate of 14.3%. The highest incidence of meningitis worldwide is in sub-Saharan Africa, dubbed “the meningitis belt,” stretching from Ethiopia to Senegal.
Meningitis is the inflammation of leptomeninges including subarachnoid space to a constellation of signs and symptoms and the presence of inflammatory cells in the cerebrospinal fluid (CSF). Acute meningitis is defined as the onset of symptoms of meningeal inflammation over the course of hours to several days. Chronic meningitis is defined as at least 4 weeks of symptoms of inflammation of the meninges.
It is crucial to identify the specific cause of meningitis because the treatment differs depending on the cause. There are several types of meningitis:
- Bacterial meningitis. Bacterial meningitis consists of pyogenic inflammation of the meninges and the underlying subarachnoid CSF, with a bacterial cause of this syndrome. If not treated, it may lead to lifelong disability or death.
- Viral meningitis. Viral meningitis is the most common type of meningitis. Most clients get better on their own without treatment. Non-polio viruses are the most common cause of viral meningitis in the United States. Close contacts of someone with viral meningitis can become infected with the virus, however, these close contacts are not likely to develop meningitis.
- Fungal meningitis. Fungal meningitis can develop after a fungal infection spreads from somewhere else in the body to the brain or spinal cord. Some causes of fungal meningitis include Cryptococcus, Histoplasma, Blastomyces, Coccidioides, and Candida. These fungi are microscopic in size, therefore, people can become infected if they breathe in fungal spores.
- Parasitic meningitis. Parasitic meningitis is less common than viral and bacterial meningitis. Various parasites can cause meningitis or can affect the brain or nervous system in other ways. These parasites normally infect animals and not people. People get infected primarily by eating infected animals or contaminated foods. Generally, people do not spread parasitic meningitis or the parasites that cause it.
- Amebic meningitis. Primary amebic meningoencephalitis (PAM) is a rare brain infection that is usually fatal and caused by Naegleria fowleri. Naegleria fowleri is a free-living ameba, a single-celled living organism that is microscopic in size. It infects people by entering the body through the nose, usually while swimming in warm, fresh water. It travels up the nose to the brain, where it destroys the brain tissue.
- Non-infectious meningitis. Congenital malformations of the stapedial footplate have been implicated in the development of meningitis. Head and neck surgery, penetrating head injury, comminuted skull fracture, and osteomyeliteic erosion may infrequently result in direct implantation of bacteria into the meninges. Skull fractures can tear the dura and cause a CSF fistula, especially in the region of the frontal ethmoid sinuses.
Risk Factors for Meningitis include
- Chronic medical disorders. Hypertension and cancer are the most common underlying conditions in clients diagnosed with diabetes who develop spontaneous bacterial meningitis. Previous studies have shown an increased frequency of bacterial meningitis in patients diagnosed with diabetes. The reason could be immunosuppression, but also the fact that the study group is older and has underlying diseases.
- Extremes of age. Mortality for bacterial meningitis is highest in the first year of life, decreases in midlife, and increases again in old age. The prognosis is worse for clients below 2 years of age or above 60 years of age.
- Undervaccination. Some causes of meningitis are vaccine-preventable, such as Pneumococcus, Haemophilus influenzae type B, Meningococcus, measles, and varicella virus.
- Immunosuppression. Clients diagnosed with acute HIV infection may present with aseptic meningitis syndrome, usually as part of the mononucleosis like the acute seroconversion phenomenon.
- Living in crowded conditions. Infection is common in crowded living conditions, as is observed in college dormitories (college freshmen living in dormitories are at the highest risk) and military facilities, which have been reported in clusters of cases.
- Travel to endemic areas. The incidence of meningitis is presumed to be higher in developing countries because of less access to preventive services, such as vaccination. In these countries, the incidence has been reported to be 10 times higher than that in developed countries. Clients with a travel history should be evaluated for any meningotropic viruses endemic in the local geographic area.
- Vectors. Clients diagnosed with rabies could present atypically with aseptic meningitis. Exposure to rodents suggests infection with lymphocytic choriomeningitis virus (LCM) and Leptospira infection.
- Alcohol use disorder. Alcoholism and cirrhosis are risk factors for meningitis. Unfortunately, the multiple etiologies of fever and seizures in clients with alcoholism or cirrhosis make meningitis challenging to diagnose.
- Presence of ventriculoperitoneal (VP) shunt. The presence of a VP shunt or a history of recent cranial surgery should be elicited. Clients diagnosed with low-grade ventriculitis associated with a VP shunt may have a less dramatic presentation than those with acute bacterial meningitis.
- Sickle cell anemia and splenectomy. Both increase the risk of meningitis secondary to encapsulated organisms.
Most cases of meningitis are caused by an infectious agent that has colonized or established a localized agent that has colonized or established a localized infection elsewhere in the host. The organism invades the submucosa at these sites by circumventing host defenses. An infectious agent can gain access to the CNS and cause meningeal disease via any of the three following major pathways: invasion of the bloodstream and subsequent hematogenous seeding of the CNS, a retrograde neuronal pathway, and direct contiguous spread. In meningitis, the blood-brain barrier can become disrupted; once bacteria or other organisms have found their way to the brain, they are somewhat isolated from the immune system and can spread.
Meningitis is a serious disorder with high morbidity and mortality. the majority of the clients first present to the emergency department, therefore, the nurse must be fully aware of the signs and symptoms of the illness and refer the client immediately to the healthcare provider. The following are nursing diagnoses associated with meningitis.
- Acute Pain
- Ineffective Cerebral Tissue Perfusion
- Disturbed Sensory Perception
Meningitis Nursing Care Plan
Below are sample nursing care plans for the problems identified above.
The meninges cover the brain and spinal cord, which runs through the neck and torso region but stops in the lower back. Of these areas where the meninges run, only the neck is highly mobile. The thoracic spine is mostly stabilized by the ribs to protect internal organs. If the meninges become inflamed and painful with movement, the reduction in movement will be most noticeable in the neck.
- Acute pain
- Inflammation or irritation of the meninges
- Spasm of extensor muscles (neck, shoulders, back)
- Verbal reports of pain or stiffness of the neck
- Guarding or distraction behaviors
- Narrowed focus
- Changes in the vital signs
After implementation of nursing interventions, the client is expected to:
- Report pain is relieved or controlled.
- Follow the prescribed pharmacological regimen.
- Verbalize methods that provide relief.
- Demonstrate use of relaxation skills and diversional activities.
|Perform a comprehensive assessment of pain including location, characteristics, onset, duration, frequency, quality, and severity.||When the neck cannot flex forward all the way, nuchal rigidity or neck stiffness is present. This could possibly be due to neck muscles stiffening to avoid painful movements of the meninges within the cervical spine.|
|Assess for the Brudzinski sign.||To assess for the Brudzinski sign, place the client in a supine position, then gently lift the head upward. If the hips and knees flex, as a result, the Brudzinski sign is positive. Moving the neck upward causes the inflamed meninges surrounding the spinal cord to stretch, and the hips and knees reflexively move upward to reduce the tension.|
|Assess for the Kernig sign.||With the client in a supine position, the knee is lifted, and then the leg is gradually extended. If the pain results and the movement to straighten the leg is resisted, the Kernig sign is considered positive.|
|Assess for headache through jolt accentuation.||A client with a headache turns the head side to side two or three times per second. If the headache worsens, the test is considered positive. Jolt accentuation is typically done for someone reporting headache but no neck stiffness.|
|Provide a calm, darkened, and quiet environment.||Photophobia is shared by many neurological and ophthalmological conditions, including meningitis. Meningeal irritation might modulate the pathophysiological mechanism of photophobia, thereby decreasing the threshold for painful light sensitivity. The nurse must create an environment that would ease the client’s hypersensitivity to sensory input such as light or sound, thus creating a structured environment to eliminate behavioral outbursts.|
|Schedule the client’s rest and activities.||The client’s activity limitations are individualized based on each client’s clinical picture. Bed rest is recommended for the acute phase of the infection.|
|Assist the client in range-of-motion (ROM) exercises and proper positioning.||Proper positioning and ROM exercise should be initiated as soon as safely possible in the acute phase. Proper positioning with pillows and towels will protect the skin integrity and prevention of contractures. Maintaining mobility of the trunk and neck is important to sustain functional mobility.|
|Elevate the head of the bed to 30°.||To reduce the headache caused by increased intracranial pressure, elevate the client’s head of the bed to 30° with the neck aligned to facilitate venous drainage from the brain).|
|Provide neck supports and pads as appropriate. Apply heat or cold compresses if not contraindicated.||Neck pain can be reduced by pillows or soft neck support aids which help maintain a comfortable position. Most people experience relief with ice packs or cold compresses placed on or near the head, neck, or shoulders. The client may also experience relief from the heat, especially if there are muscle spasms in the neck and shoulders.|
|Administer mannitol, as prescribed.||Mannitol may be used for the reduction of intracranial pressure. The mannitol causes the cells in the brain to dehydrate mildly. the water inside the brain cells leaves the cells and enters the bloodstream as the mannitol draws it out of the cells and into the bloodstream. Once in the bloodstream, the excess water is whisked out of the skull.|
|Administer pain medications as indicated.||Several medications, including ibuprofen and naproxen, can help relieve pain. These medications also have anti-inflammatory effects, which can help with some of the neck pain. Acetaminophen can also provide relief for neck pain and headache, especially if the pain is mild to moderate in severity.|
Ineffective Cerebral Tissue Perfusion
The brain is naturally protected from the body’s immune system by the barrier that the meninges create between the bloodstream and the brain. In meningitis, the blood-brain barrier is disrupted; once bacteria or other organisms have found their way into the brain, they are somewhat isolated from the immune system and can spread. When the body tries to fight the infection, the problem can worsen; blood vessels become leaky and allow fluid, WBCs, and other infection-fighting particles to enter the meninges and brain. This process causes brain swelling and can eventually result in decreased blood flow to parts of the brain, worsening the symptoms of infection.
- Ineffective cerebral tissue perfusion
- Interruption of blood flow by cerebral edema
- Increased intracranial pressure
- Altered mental status
- Changes in vital signs
After implementation of nursing interventions, the client is expected to:
- Maintain or improve the level of consciousness, cognition, and motor or sensory function.
- Demonstrate stable vital signs and the absence of increased ICP.
|Assess and monitor the neurological status frequently and compare it with the baseline.||Glasgow Coma Scale (GCS) assesses trends and potential for increased ICP and is useful in determining the location, extent, and progression of damage.|
|Assess verbal responses; note whether the client is alert, oriented, or confused.||this measures the appropriateness of speech and content of consciousness. If minimal damage has occurred, the client may be aroused by verbal stimuli but may appear drowsy or uncooperative.|
|Assess motor responses to simple commands.||This measures overall awareness and the ability to respond to external stimuli and best indicates the state of consciousness in the client.|
|Monitor vital signs.||Increasing systolic BP accompanied by decreasing diastolic BP is an ominous sign of increased ICP when accompanied by decreased LOC. Changes in heart rate and dysrhythmias may develop without impacting hemodynamic stability. Irregular respirations may suggest increasing ICP and the need for further intervention, including possible respiratory support.|
|Monitor intake and output.||Intake and output are useful indicators of total body water, which is an integral part of tissue perfusion. Cerebral ischemia can result in diabetes insipidus or syndrome of inappropriate antidiuretic hormone.|
|Monitor ABGs or pulse oximetry.||ABGs determine respiratory sufficiency (presence of hypoxia and acidosis) and indicates therapy needs.|
|Maintain the head and neck in a neutral position.||Support the client’s head and neck with small towel rolls and pillows. Turning the head from side to side compresses the jugular veins and inhibits cerebral venous drainage, thereby increasing ICP .|
|Educate the client to avoid or limit coughing, vomiting, straining at stool, or bearing down, when possible.||These activities increase intrathoracic and intra-abdominal pressures, which can increase ICP.|
|Elevate the head of the bed gradually to 20 to 30 degrees, as tolerated. Instruct to avoid hip flexion more than 90 degrees.||This promotes venous drainage from the head, thereby reducing cerebral congestion and edema, and the risk of increased ICP.|
|Limit the number and duration of suctioning.||Decreasing the frequency of suctioning prevents hypoxia and associated vasoconstriction that can impair cerebral perfusion.|
|Administer IV fluids as prescribed.||If the client is in shock or hypotensive, crystalloid should be infused until euvolemia is achieved.|
|Administer supplemental oxygen via a mechanical ventilator and mask.||Oxygen supplementation reduces hypoxemia, which is known to increase cerebral vasodilation and blood volume, elevating ICP.|
|Administer osmotic diuretics as prescribed.||Mannitol may reduce subarachnoid space pressure by creating an osmotic gradient between CSF in the arachnoid space and plasma.|
|Administer corticosteroids as indicated.||The use of steroids has been shown to improve the overall outcome for clients diagnosed with certain types of bacterial meningitis and pneumococcal meningitis. They should be administered before or during the administration of antimicrobial therapy to counteract the initial inflammatory burst consequent from antibiotic-mediated bacterial killing.|
|Administer anticonvulsants as prescribed.||Anticonvulsants are used to help aggressively control seizures if present in acute meningitis because seizure activity increases ICP. Phenobarbital elevates the seizure threshold, limits the spread of seizure activity, and is a sedative.|
Disturbed Sensory Perception
Sensory perception represents a complex physiological process that allows humans to interact efficiently with the environment. Impairments of sensory perception that occur during a period of critical care can seriously impact health and nutritional status, activities of daily living, independence, quality of life, and the possibility of recovery. In meningitis, the physical exam is centered on identifying focal neurologic deficits and meningeal irritation. Cranial nerve abnormalities are seen in 10%–20% of clients diagnosed with meningitis.
- Disturbed sensory perception
- Decreased loss of consciousness
- Altered sensory reception, transmission, or integration
- Disorientation to time, place, person
- Change in usual response to stimuli
- Motor incoordination
- Altered communication patterns
- Visual and auditory distortions
- Altered thought processes
- Changes in behavior pattern.
After the implementation of nursing interventions, the client is expected to:
- Regain or maintain usual LOC and perceptual functioning.
- Acknowledge changes in ability and presence of residual involvement.
- Demonstrate behaviors and lifestyle changes to compensate for, or overcome, deficit.
|Evaluate changes in orientation and sensorium continuously.||Upper cerebral functions are often the first to be affected by altered circulation and oxygenation. Damage may develop later because of the swelling.|
|Assess the client’s sensory awareness. Note problems with vision and other senses.||All sensory systems may be affected, with changes involving increased or decreased sensitivity or loss of sensation and the ability to perceive and respond appropriately to stimuli.|
|Evaluate sense of hearing||One of the risk factors for congenital hearing loss is a history of meningitis. Congenital hearing loss is commonly the result of congenital malformations in the structure or functional components of the auditory system.|
|Eliminate extraneous noise and stimuli, as necessary.||This reduces anxiety, exaggerated emotional responses, and confusion associated with sensory overload.|
|Speak in a calm, quiet voice and use short, simple sentences.||The client may have limited attention span or understanding during acute and recovery stages, and these measures can help the client attend to communication.|
|Reorient the client frequently to the environment, staff, and procedures.||This assists the client to differentiate reality in the presence of layered perceptions. cognitive dysfunction and auditory deficits potentiate disorientation and anxiety.|
|Schedule adequate rest and uninterrupted sleep periods.||This measure reduces the client’s fatigue, prevents exhaustion, and improves sleep. Note: absence of rapid eye movement (REM) sleep is known to aggravate sensory perception deficits.|
|Allow adequate time for communication and performance of activities.||Providing the client with adequate time reduces frustration associated with altered abilities and delayed response patters .|
|Provide for client’s safety, such as padded side rails, assistance with ambulation, and protection from hot or sharp objects.||Agitation, impaired judgment, poor balance, and sensory deficits increase the risk of client injury.|
|Document specific changes in abilities or sensorium.||Accurate documentation helps localize the areas of cerebral dysfunction and identifies signs of progress toward improved neurological function.|
|Refer the client to physical, occupational, and cognitive therapies.||An interdisciplinary approach can create an integrated treatment plan based on the individual’s unique combination of abilities and disabilities with a focus on evaluation and functional improvement in physical, cognitive, and perceptual skills.|
- Centers for Disease Control and Prevention. (2019, August 6). Parasitic Meningitis. CDC. Retrieved May 11, 2022, from https://www.cdc.gov/meningitis/parasitic.html
- Centers for Disease Control and Prevention. (2021, May 25). Amebic Meningitis. CDC. Retrieved May 11, 2022, from https://www.cdc.gov/meningitis/amebic.html
- Centers for Disease Control and Prevention. (2021, May 25). Fungal Meningitis. CDC. Retrieved May 11, 2022, from https://www.cdc.gov/meningitis/fungal.html
- Centers for Disease Control and Prevention (CDC). (2021, May 25). Viral Meningitis. CDC. Retrieved May 11, 2022, from https://www.cdc.gov/meningitis/viral.html
- Fellner, A., Goldstein, L., Lotan, I., Keret, O., & Steiner, I. (2020, March 15). Meningitis without meningeal irritation signs: What are the alerting clinical markers? Journal of Neurological Sciences, 410. https://doi.org/10.1016/j.jns.2019.116663
- Giddens, J. F. (2020). Concepts for Nursing Practice (with Access on VitalSource) (J. F. Giddens, Ed.). Elsevier – Health Sciences Division.
- Goel, A. (2021, August 18). How Meningitis Is Treated. Verywell Health. Retrieved May 12, 2022, from https://www.verywellhealth.com/how-meningitis-is-treated-4163542
- Hersi, K., Gonzalez, F. J., & Kondamudi, N. P. (2021, November 7). Meningitis – StatPearls. NCBI. Retrieved May 11, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK459360/
- Moorhouse, M. F., Murr, A. C., & Doenges, M. E. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company.
- Physiopedia. (2022). Meningitis. Physiopedia. Retrieved May 11, 2022, from https://www.physio-pedia.com/Meningitis
- Pomar, V., de Benito, N., Mauri, A., Coll, P., Gurgui, M., & Domingo, P. (2020). Characteristics and outcome of spontaneous bacterial meningitis in patients with diabetes mellitus. BMC Infectious Diseases, 20(292). https://doi.org/10.1186/s12879-020-05023-5
- Schiffman, S. S. (2007, July 16). Critical illness and changes in sensory perception. Proceedings of the Nutrition Society, 66(3), 331-345. 10.1017/S0029665107005599
- Sinicropi, S. (2017, November 28). How Meningitis Causes Neck Pain and Stiffness. Spine-health. Retrieved May 11, 2022, from https://www.spine-health.com/conditions/neck-pain/how-meningitis-causes-neck-pain-and-stiffness
- Tenny, S., Patel, R., & Thorell, W. (2022, February 21). Mannitol – StatPearls. NCBI. Retrieved May 12, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK470392/
- Vasudeva, S. S., & Stuart, M. (2021, November 16). Meningitis: Practice Essentials, Background, Pathophysiology. Medscape Reference. Retrieved May 11, 2022, from https://emedicine.medscape.com/article/232915-overview
- Wan, C., & Singh, N. N. (2018, July 17). Viral Meningitis Treatment & Management: Approach Considerations, Pharmacologic Treatment and Medical Procedures, Patient Activity. Medscape Reference. Retrieved May 11, 2022, from https://emedicine.medscape.com/article/1168529-treatment#d10