16.13 Meningococcal Meningitis

Meningitis refers to inflammation and/or infection of the meninges that cover the brain and spinal cord. Meningococcal meningitis is a specific type of meningitis caused by the bacteria Neisseria meningitidis. Meningococcal meningitis has a high mortality rate and is considered a medical emergency. Without treatment, up to 50% of clients will die. Children are at increased risk for developing this disease due to higher rates of colonization with these bacteria in the nose and throat. Other risk factors that increase the risk of developing meningococcal meningitis include being HIV positive, male gender, and living in close quarters.^[1],[2]

Potential early complications of meningococcal meningitis include septic shock, organ failure, increased intracranial pressure, and death. Late complications are also possible. These include chronic pain, neurological damage, seizures, and issues with seeing or hearing.^[3]

Pathophysiology

Although many people may be carriers of this potentially deadly Neisseria meningitidis bacteria, only a few will ultimately develop meningococcal meningitis when the bacteria invade the submucosa of the upper respiratory tract and spread to the blood. If the client’s immune system is unable to eliminate the bacteria from the blood, the bacteria can rapidly spread to the central nervous system and cause meningitis.^[4]

Assessment (Recognizing Cues)

Physical Exam

Meningococcal meningitis develops rapidly and has three classic symptoms of a stiff neck, an elevated temperature, and an altered mental status. Other symptoms that may be present are headache, light sensitivity, vomiting, and muscle aches. A petechial rash on the lower limbs often follows these symptoms. Increased respiratory rate, increased heart rate, decreased blood pressure, and other signs of sepsis are also likely. Infants suffering from meningococcal meningitis may have nonspecific symptoms such as fatigue, irritability, and distended fontanelles. When a provider completes a physical exam on a client suspected of having meningococcal meningitis, irritation of the meninges can be confirmed by testing for the Kernig and Brudzinski signs. Kernig's sign is tested by placing the client in the supine position with their hips flexed to 90°, and the examiner extends their knee. If the client experiences pain or resists extending their knee, the test is positive. Brudzinski's sign is tested by placing the client in the supine position, and the examiner places one hand behind their head and the other on their chest to prevent them from rising. The examiner then passively flexes the client’s neck. If the client’s hips and knees automatically flex, the test is considered positive.^[5] The examination techniques for Kernig and Brudzinski signs are portrayed in the video in the following box.

Common Laboratory and Diagnostic Tests

Diagnosis of meningococcal meningitis is made by analysis of cerebrospinal fluid obtained from a lumbar puncture. In some clients, a CT scan may be recommended before a lumbar puncture to rule out an increased risk for brain herniation. Other lab tests that may be performed are a complete blood count and blood cultures.^[7],[8]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with meningococcal meningitis include managing symptoms, preventing infection spread, and avoiding the development of complications. Nursing diagnoses for clients with meningococcal meningitis are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment. Possible nursing diagnoses for clients with meningococcal meningitis are as follows^[9]:

• Ineffective cerebral tissue perfusion r/t disease process
• Hyperthermia r/t disease process
• Acute pain r/t disease process

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, achievable, relevant, and timebound (SMART) within a set time frame based on the application of appropriate nursing interventions. Sample expected outcomes for clients with meningococcal meningitis include the following^[10]:

• The client will remain alert and oriented to person, place, time, and situation as appropriate for age.
• The client will exhibit a temperature that is within normal limits for age within 24 hours of treatment.
• The client will exhibit a reduction in pain using a numeric scale, FACES, or FLACC within one hour of medication administration.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Due to the severity of this disorder, antibiotics should be administered immediately upon diagnosis of suspected meningococcal meningitis and not delayed while waiting for lab results confirmation. Steroids may also be prescribed, but their use is controversial. Clients with meningococcal meningitis may also require respiratory and cardiac support such as intubation and mechanical ventilation, intravenous fluids, and vasopressor administration.^[11]

Clients who have been in close contact with someone with a confirmed case of meningococcal meningitis should receive antibiotic prophylaxis.^[12]

Nursing Interventions

Registered nurses develop interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client. When caring for a client with meningococcal meningitis, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching as described in the following subsections.^{[13],[14],[15]}

Nursing Assessments

• Closely monitor the client’s vital signs for hemodynamic stability and potential complications such as septic shock or increasing intracranial pressure.
• Monitor the client’s neurological status, including level of consciousness, level of orientation, pupil response, and motor and sensory responses to quickly identify and report potential complications.
• Assess the client’s intake and output 24-hour trends because fever and decreased intake due to meningitis can cause dehydration.

Nursing Actions

• Ensure the client with confirmed or suspected meningococcal meningitis is placed in droplet transmission-based precautions.
• Administer antibiotics, antipyretics, intravenous fluids, and other medications as prescribed.
• Promote a comfortable environment for the client by dimming lights, minimizing noise levels, and assisting with position changes.
• In clients with increased intracranial pressure, keep the head in the midline position and elevated to 30-45 degrees to allow for venous drainage.

Client Teaching

• Educate the client and their parents/caregivers about effective hand hygiene to prevent the spread of infection.
• Encourage parents/caregivers to be involved in the care of the hospitalized pediatric client to reduce anxiety.
• Teach the client and their caregivers that a hearing screen is recommended four weeks after discharge from the hospital to assess for hearing loss due to meningitis.
• Educate clients and/or parents/caregivers about the importance of vaccination with the quadrivalent meningococcal conjugate vaccine to prevent meningococcal meningitis.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.