Pediatric Meningitis: Diagnosis and Treatment (Nursing)

by Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN

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    00:00 Alright, let's talk about the diagnosis and treatment of meningitis in children. The lumbar puncture is the gold standard diagnostic test for identifying meningitis.

    00:12 It can be done sidelying or sitting. The typical place of puncture is the L4-L5 landmark. The needle for the puncture is usually put into the subarachnoid space in between those 2 vertebrae. You may note that the iliac crests are almost directly assigned from it so basically they form kind of a straight line across the back.

    00:39 Nurses often use that landmark to know where to put numbing cream before an infant or a child's lumbar puncture so that to help relieve some of the pain associated with it. Think about these positions and think about the young infant's airway. One thing that often goes unnoticed by some people not as familiar with children and with infants especially is that the infant airway especially when they're a neonate is very floppy and very sensitive to occlusion. If you curl them up, either way they have to be curled up for this particular test. It actually can cause airway compromise. It can even cause them to stop breathing. So for this reason, it's super super important that when you have an infant having a lumbar puncture, there is somebody monitoring their airway at all times. Usually, a nurse is required to be in the room. A respiratory therapist is required to be in the room and the physician or provider performing the procedure. This is just a closer look at a lumbar puncture procedure with the needle going into that subarachnoid space between L4 and L5. So, lumbar puncture findings are usually diagnostic, meaning between L4 and L5. So, lumbar puncture findings are usually diagnostic, meaning you can diagnose the disease of meningitis based on them. The culture and sensitivity is needed to diagnose the organism causing them. If increased intracranial pressure is suspected, sometimes a CT scan of the head may occur before the LP. The blood culture, while it is probably going to be done, is not always reliable. It may be inconsistent in identifying meningitis and the source of it. Alright, let's review treatment and prevention of meningitis. So, basically the prognosis for meningitis depends on the time it was identified, how quickly it was identified, and also the antibiotic initiation if it was bacterial or able to be treated by antibiotics or antifungals. Sometimes fungal meningitis can also be treated by medication. The main treatment is antibiotics and if a child has bacterial meningitis especially or fungal meningitis, they're going to receive IV antibiotics in the hospital. Antibiotics are going to be adjusted based on what pathogen is specifically identified in the cerebrospinal fluid from the lumbar puncture. And this is based on the culture and sensitivity results. The goal of course of treatment is to get rid of any bacteria or whatever organism it is from the CSF because CSF is supposed to be a sterile fluid. Other treatments you may see are intravenous fluids to help keep the infant or child hydrated, antiepileptic medications if they have had signs and symptoms of seizure activity or have had seizures, intracranial pressure monitoring if there has been any concern for increased intracranial pressure basically, and then of course isolation precautions which would have been initiated hopefully the moment they slept in the hospital. Vaccines, nurses, and antibiotics all play important roles into prevention of meningitis. Fortunately, we have vaccines now from many of the serious forms of meningitis to help prevent them.

    04:10 The meningococcal vaccine is given the first time in early adolescence and then the second dose should be given around age 16. The pneumococcal vaccine, that series begins around 4 months of age. And the Haemophilus influenza or HIB vaccine series begins around 2 months of age. Nurses play a major role in helping educate the public and their patients and families about the importance of vaccines. And antibiotics are sometimes used prophylactically so preventatively in patients with a high risk of meningococcal disease or group B strep. This is the NCSBN Clinical Judgment Measurement Model. It's a framework being used now for many NCLEX exam questions and case studies. You may also see it on nursing school or see questions framed using it on your nursing school exams. So now, we're going to connect some of the content you just heard to the first 2 important steps of this model, recognize cues and analyze cues. To be able to recognize and analyze cues in an infant or child who may have meningitis, you have to be really aware of how they may present and how they may present differently if they're a neonate versus an older infant or a child or adolescent. Remember, the neonates may be very very subtle in how they present the meningitis. They may have only feeding differences.

    05:40 They may be refusing feeds. They may or may not have a fever. They may even be hypothermic so never rely on a temperature as a sign of illness because it may not be present. They may be very irritable or lethargic. And, you may see some fontanelle abnormalities. You may also see some seizure activity or they may have seizure activity that has not been identified such as lip smacking or eye deviation or nystagmus, some of the more subtle signs of infant seizures that can be very focal and very limited in how they present. In older children, the signs and symptoms of meningitis will be more pronounced usually, but may not be classic like the ones you may see in older child or adult. So they may complain of neck stiffness or pain. They may complain of pain in general not being able to localize it. They're more likely to have vomiting and pretty forceful vomiting. They're more likely to have nuchal rigidity or stiffness of their neck. The Brudzinski and the Kernig signs are not extremely useful in the pediatric population and not super consistent but you may still see them use as a way to add assessment findings or to elevate suspicion of meningitis. And lastly, being aware of the various ways meningitis can be given to a child to different organisms that do result in meningitis and the risk factors for how to transmit these organisms and how children may get these organisms is very important as well. Being able to be aware of not just the first 2 types of bacterial and viral but all the types of meningitis helps you know what questions to ask as part of the history taking so you can identify the infants and children that are at the high risk for meningitis or more likely to have symptoms related to meningitis.

    About the Lecture

    The lecture Pediatric Meningitis: Diagnosis and Treatment (Nursing) by Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN is from the course Neurologic Disorders – Pediatric Nursing.

    Included Quiz Questions

    1. Lumbar puncture
    2. CT scan
    3. Two blood cultures, four hours apart
    4. Blood culture and sensitivity test
    1. There is a high risk of a compromised airway.
    2. It can only be performed in a side-lying position.
    3. The needle is inserted between L1-L2 in children under five.
    4. The anatomical landmark is the greater trochanter.
    1. Antibiotics
    2. Intravenous fluids
    3. Antiepileptic medications
    4. ICP monitoring
    1. Meningococcal vaccine
    2. Pneumococcal vaccine
    3. H. influenzae vaccine
    4. Rotavirus vaccine
    5. Diptheria vaccine

    Author of lecture Pediatric Meningitis: Diagnosis and Treatment (Nursing)

     Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN

    Elizabeth Stone, PHD, RN, CPEN, CHSE, FAEN

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