National University Baguio

College of Nursing
AY 2012 2013
Second Semester

A Case Study
TB MENINGITIS
(A Requirement for NCM 105
Pedia Ward,)

PRESENTED BY:
Mercado, Sean Derick C.

PRESENTED TO:
Mrs. Rhoda Delim
INSTRUCTOR

I. INTRODUCTION
If we were to look back through history, it would seem as if meningitis
has no definite origin. Some say that Hippocrates may have realized the
existence of the disease. Tuberculosis meningitis, which was called dropsy in
the brain, is often attributed to Edinburgh physician Sir Robert Whytt in a
posthumous report that appeared in 1768, although the link with tuberculosis
and its pathogen was not made until the next century. But no matter how
unclear the origins of meningitis are, we could definitely say that it is a
serious problem.
Although studies have shown that viral meningitis is more common
(10.9 per 100,000), bacterial meningitis still has a relatively high incidence
rate of about 3 per 100,000 annually in Western countries. And in Brazil, the
rate of bacterial meningitis is higher, at 45.8 per 100,000 annually. In subSaharan Africa, large epidemics of meningococcal meningitis occur in the dry
season, leading to it being labeled the meningitis belt. In this area, there
are 500 cases encountered per 100,000 annually because it is poorly served
by medical care. The most recent epidemic, affecting Nigeria, Niger, Mali and
Burkina Faso, started in January 2009 and is ongoing. (Wikipedia, 2009)
Bacterial meningitis is a true emergency because it requires immediate
hospital-based treatment and can be life threatening if not treated promptly.
Of course, there are always risk factors involved which could increase the
chances of a person to acquire the disease. In addition, the absence of any
risk factor, or having a protective factor does not necessarily guard a person
from the disease. Risk factors would include contact with meningococcal
cases, and travel to Africa or parts of Asia where meningococcus is more
common. Institutions like schools and dormitories have been associated with
meningococcal outbreaks. Low humidity, dust storms, and cigarette smoke
also increases the risk of getting infected with the bacteria. And lastly, breaks
in the skin also would permit the entry of bacteria, as well as through droplet
and kissing.

As for neonatal meningitis, persistence of cases results from

increasing numbers of infants surviving puncture delivery and limited access

to medical resources in developing countries. (Adele Pillitteri, 2003)

Almost any bacteria entering the body can cause meningitis. The most
common

are

meningococci

(Neisseria

meningitidis),

pneumococci

(Streptococcus pneumoniae), and Haemophilus influenzae. These organisms

are often present in the nasopharynx, and they are fairly common and are
more often associated with other everyday illnesses. (Joyce M. Black, Jane
Hokanson Hawks, 2008)
The long-term outlook for children who develop meningitis varies
greatly and depends on the childs age, the microorganisms causing the
infection, other complications, and the treatment the child receives. The
complications of bacterial meningitis can be severe and include neurological
problems such as hearing loss, visual impairment, seizures and learning
disabilities. Although some children develop long lasting neurological
problems from bacterial meningitis, most who receive prompt diagnosis and
treatment recover fully. (Joyce M. Black, et al, 2005)
A. CURRENT TRENDS
Many times meningeal infections can be prevented, especially when
the infecting pathogen is H. influenzae, S. pmeumoniae, or N. meningitidis.
The current immunization guidelines endorsed by the Advising Committee on
Immunization Practices and American Academy of Pediatrics are that all
children be immunized against H. Influenzae. The role of the government is
very crucial in times of outbreaks and life threatening diseases. The
government engages in research activities, continuous proper management
and initial treatment such as immunization, which is the concern of everyone.
While the treatment and prevention of bacterial meningitis have greatly
improved over the past decade. Significant therapeutic challenges still exist.
Controversies include the choice of empiric antimicrobial agents and the
administration of corticosteroids; the introduction of pneumococcal vaccines
and the new antibiotics have changed the epidemiology of meningitis.
Together, the availability of antibiotics has contributed to the emergence of
resistant organisms. One of the activities of the government is to respond to
this dilemma,

according

to Carlos,

et al,

through

a study

entitled

Antimicrobial Resistance Surveillance Program in the Philippines which was

held last 2000, and was about the resistance of H. influenzae to

cotrimoxazole, ampicillin and chloramphenicol whereas it is concluded the
three drugs are still recommended to use for H. influenzae. In addition to this,
scientists believe they may have found a way to protect people against every
strain of meningitis. The most current study that was published, Vaccine
could beat meningitis, talks about the new approach towards management
of meningitis. It shows that a vaccine against A and C strain of the disease
exists, however there is no job against the lethal B strain. Scientists use
genetic engineering technology to create a strain of meningitis B that is
incapable of causing for disease, after injecting the strains of the disease the
finding suggested that it may be possible to create a single vaccine to protect
against each strain. The unique thing about this research is that it provides
hope for a complete vaccine protecting people against all types of
meningococcal bacteria, the most common cause of meningitis worldwide.
(Carlos, 2004)
Successful eradication of CSF infection will rely on the continued
development of new antibiotics and vaccines as well as judicious use of those
antibiotics currently available. Routine immunization of young adolescent will
help prevent the rare but serious infection of the disease. In addition, the
absence of specific clinical findings makes diagnosis of meningitis more
difficult. As stated by Lincoln, whether its making sure that families have
access to quality health care and child care, in making sure that the children
receive the best educational opportunities we can give them, we must remain
committed to these needs because our children are our future. Embracing the
vital role of the government in creating barriers against the disease, the
initiative and braveness of the stat to fight for the children against the
disease is like struggling for a better economy. (Sarah Yuan, 2004)
B. REASONS FOR CHOOSING THIS CASE
The main reasons for choosing this particular case would have to be
the patients mother and father. They both were nice people who have let us
student nurses handle their child without being hard to please or hard to talk
to. In other words, we were able to achieve a much more mutual relationship

with them, and this helped us a lot in understanding their childs overall
condition. In doing so, we were able to raise our level of awareness in terms
of the forms of treatment and management that were needed.
Considering that the chosen case was meningitis, future encounters
with the disease as well as its complications would be much easier for us
because we have already established a background about it. In addition,
knowing the various risk factors involved in the occurrence of the disease
would allow us to give health teachings easily, especially when it comes to
prevention.
II. Nursing Process
II. A. ASSESSMENT
1.
Personal Data
I.A Demographic Data
Lyka G, a 1y/o child, female. She is presently residing at Dulli,
Ambaguio, Nueva Viscaya. She was born on November 11, 2011

and a

natural born Filipino and a Catholic. She was admitted at BGHMC on February
7, 2013 at 1:25 AM with a diagnosis of TB Meningitis Hydrocephalus
Communicating.

GROWTH AND DEVELOPMENT

Erik Erickson (Psychosocial Theory)
Lyka is in the Trust vs. Mistrust stage of Erik Ericksons Growth and
Development Stage. The infant depends on the parents, especially the
mother, for food, sustenance, and comfort. The child's relative understanding
of world and society come from the parents and their interaction with the
child. In this situation, the parents should expose their child to warmth,
regularity, and dependable affection, so that the baby will have trust to them.
The group instructed mother to give comfort, warmth of love, emotions and

feelings to provide a secure environment and to meet the child's basic needs,
and a sense of trust will result. Failed to provide this will be mistrust.
Jean Piaget (Cognitive Development)
Lyka is in the Sensorimotor period of new means through sensory
combination of Piagets Cognitive Development. In this stage, infants
construct an understanding of the world by coordinating sensory experiences
(such as seeing and hearing) with physical, motoric actions.
Sigmund Freud (Psychosexual)
Lyka is in the stage of Oral receptive personality wherein it is preoccupied
with eating/drinking and reduces tension through oral activity such as eating,
drinking, biting nails. They are generally passive, needy and sensitive to rejection.
They will easily 'swallow' other people's ideas.. During this stage, the focus of
gratification is on the mouth and pleasure is the result. It is also an exploration of
the surroundings (as infants tend to put new objects in their mouths). In this stage
the id is dominant, since neither the ego nor the super ego is yet fully formed.
Thus the baby does not have a sense of self and all actions are based on the
pleasure principle.
MOTOR AND SOCIAL DEVELOPMENT IN INFANCY
AGE
One month

MOTOR DEVELOPMENT
Keeps hands

SOCIAL DEVELOPMENT
Can differentiate

fisted
Able to follow

Two months

object to midline
Holds head up

Makes cooing

Three months

when prone
Has social smile
Holds head and

sounds
Differentiate a cry
Laughs out loud

chest up when
prone

between faces and

objects.

Four months

Five months

Grasp, stepping,

Very talkative,

tonic neck

cooing babbling

reflexes are fading

and gurgling when

Turns front and

back
No longer has

spoken to
Recognize familiar

objects
Says some simple
vowel sound (googoo and gah-gah)

head lag when

Six months

pulled upright
Bears partial

weight
Can raise their

Starts to imitate

sounds
May say vowel

sounds
Plays pick a boo

Show beginning

chest and the

upper part of their
abdomen off the

Seven months

table.
Can sit with

support
Turns both ways
More reflex fading
Uses palmar

reflex
Can transfer toy
from one hand to

fear of strangers

another
First tooth erupts
(central incisor

Eight months
Nine months

below)
Can sit without

Has peaked fear of

support
Creeps and crawls
Sits so steady that

strangers
Says first word (da-

they can lean

da)
Aware of changes

forward and
regain their

in voice tone

Ten months

balance
Brings the thumb

Master another

word (bye-bye)
Recognize their

and first fingers

together in a

Eleven months

pincer-grasp
Pull themselves in

standing position
Learns to cruise

names and listen

actively

Imitates speech

sounds
Reacts with

(walks with

Twelve months

support)
Can hold objects

frustration when

Cannot perform
activities

restricted
Depended to
parents and SO

according to age
due to sickness
fever and

seizures.
Growth and
development slow
down.

BCG

DPT

OPV

HEPA B

MEASLES

Complete

Complete

Complete

Complete

Incomplete

IMMUNIZATION STATUS

4. HISTORY OF PRESENT ILLNESS

February 7, 2013 BGHMC
-TB Meningitis Hydrocphalus Communucating

5. HISTORY OF PAST ILLNESS

Patient was apparently well until 2 months after PTA. Patients had signs
of on and off fever. Consulted RHU and was given Paracetamol. Due to
persistence of fever consult at PMP and was admitted and was
managed
As a case of Dengue and UTI, after 6 days, patient was discharged but
still with on and off fever.
Patient was brought to Veterans Hospital, Diagnosis case of Meningitis
given Ceftriaxone

Mannitol CT scan revealed Communicating High

Pressure Hydrocephalus. Lumbar Tap was given. Inu, RZA, was started.
Still febrile, Metpan was given but shifted to Ciprofloxacin. VP shunting
was advised. BT, CBC revealed decreased HGB. Thus PRBC was given,
still patient had fever.
After 16 hospital days patient was transferred at our institution.
6. PHYSICAL EXAMINATION (IPPA Cephalocaudal Approach)
Awake
Warm Skin
(+) Strabismus, Lateral Gaze
(+) Babinski, Nuchal Rigidity
SKIN:

There is poor skin turgor, warm to touch and dry.

HAIR &

The hair is black in color; no infestations.

SCALP
NAILS
HEAD
FACE
EYES

EARS
NOSE

Nails are normal in size and shape, they are short and clean, with
a normal capillary refill of 3 sec.
tenderness of the scalp noted, presence of bulging fontanelle
Asymmetrical in shape, no tenderness upon palpation
Sunset eyes, with pale palpebral conjunctiva, sclera is white in
color
Skin color is pale, auricle aligned with outer canthus of eye,
mobile, firm, and not tender
Nose is symmetrical, not tender and no lesions, without
discharges, absence of bleeding and swelling

MOUTH &

Tongue is normal pale and dry, with dry mucous membrane,

THROAT
CHEST AND

Presence of subcostal retraction, symmetrical lungs

LUNGS
HEART

No murmurs, irregular rate and regular rhythm.

ABDOMEN

Borborygmi sounds heard upon auscultation. no mass and lesion,

7. DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic
Procedures

Indications/

Result

Purpose

Normal

Analysis and

Values

Interpretation

Complete
Blood Count
Hemoglobin

It measures the
total amount of
hemoglobin in the
blood, to determine
the O2 carrying

103

M: 125-

Malnutrition is

175g/L

recognized to the

F: 115155g/L

patient that may

indicate the
cause of

capacity of the

decrease In the

blood.

level of
haemoglobin

Hematocrit

It measures the

0.30

percentage of RBCS
in the total blood

M:0.40-

There was a

0.52

decrease in the

F:0.38-

volume

0.48

result due to
hemodilution and
the recognized
malnutrition.

Leukocytes
(WBC)

Neutrophils

It determines the

14.81

number of

5-

The result is

10x109/L

above the normal

circulating WBCS of

values which

the whole blood.

indicats infection

Phagocytes present

0.84

(0.5-0.7)

Neutrophils is

in the circulation or

lhigher than

along the capillary

normal which

walls.

indicatates risk
for infection.

Plate count

To evaluate platelet

404

(150-

The result is

production, to

450x10g/ within normal

monitor and

l)

values.

(M: 60-

A decreased

diagnose severe
thrombocytosis or
thrombocytopenia
Blood

Specimen of

Chemistry

venous blood are

Creatinine

taken for a CBC

which includes
hemoglobin and
hematocrit
measurements,

Creatinine
29.o

120umol/ value for this test

L)
(F: 58100umol/
L)

is rarely a
concern. It can
occur with
decreased
muscle mass.

erythrocyte RBC

Conditions such

Count, Leukocyte

as muscular

WBC count RBC

dystrophy, which

indices and

is an inherited

differential white

defect in

cell count.

muscles, can
cause a low

CBC is one of the

value for this

most frequently

test.

ordered blood test,

it shows the
increase, and
decrease of the
blood cell count
that may be
associated with
different disorders,
and also
determines the
presence of
bacterial infection
or viral infections.
To asses for
electrolyte
imbalance.
Lympocytes

0.14

0.20-.0.3

Lymphocytes is

lower than
normal range
which may help
in fighting
against infection

Urinalysis

To determine

Color:

Pale yellow

The result is within

urinary

colorless

to Amber

normal values.

complications
and possible
abnormal
components

Transparency
: clear
Albumin:

Yellow

(e.g.

negative

CHON, glucose

Reaction:

blood, pus) or

Acidic

infection.

Clear

Specific
Gravity :
1.010
Pus cell 01/HPF
RBC 0-1.HPF

Chest X- Ray

Provides

Streaky

information

opacities are

about location

seen on both

and extent of

lung fields

pneumonia and

Heart and

cardiac

great vessels are

abnormalities.

normal in size
and
configuration.

The
visualized soft
tissue and
osseus
structures are
nremarkable

IMPRESSION:
Pneumonitis

NURSING RESPONSIBILITIES:

Normal lung

The result is

fields.

normal with

Normal heart
size and
configuration

no signs of
pneumonia
or heart
problems.

HEMATOLOGY (CBC)
Prior:
1. Explain the procedure to the S.O
2. Tell the S.O that no fasting is required
3. Assure S.O. that collecting blood sample take less than 3 minutes
4. Inform S.O that pt. will be experiencing pain on the site where the
needle was pricked.
During:
1. Collect 5-7 ml of venous blood in a lavender top tube
After:
1.

Apply pressure or a pressure dressing to the venipuncture site

2. Check the venipuncture site for bleeding

3. Fill- up the laboratory form properly or label the specimen and send to
the laboratory technician
4. Record all procedure done
URINALYSIS (U/A)
Prior:
1.

Explain the procedure to the S.O.

2.

Obtain the materials needed for the procedure

3.

Advise S.O. to wash the genital area of the pt. prior to collection of
specimen to prevent contamination

During:
1.

After:

Collect a fresh urine specimen using wee bag ( urine container)

1.

Label the specimen and transfer it to the laboratory immediately and

promptly.

CHEST X-RAY
Prior:
1. Verify doctors order
2. Explain to the S.O. the importance of the procedure
3. Ask the S.O. to remove any radiopaque objects (jewelry, metal
buttons)
During:
1. Client assumes various positions so that x-ray films can be obtained
from the most useful angles.
After:
1. Assist S.O. and patient to go back to his bed
Record all procedures done

8. ANATOMY AND PHYSIOLOGY

Central Nervous System

The central nervous system (CNS) is the largest part of the nervous
system, and includes the brain and spinal cord. The spinal cavity holds and
protects the spinal cord, while the head contains and protects the brain. The
CNS is covered by the meninges, a three layered protective coat. The brain is
also protected by the skull, and the spinal cord is also protected by the
vertebrae.
The central nervous system (CNS) is the part of the nervous system
that functions to coordinate the activity of all parts of the bodies of

multicellular organisms. In vertebrates, the central nervous system is enclosed

in the meninges. The meninges (singular meninx) is the system of
membranes which envelops the central nervous system. The meninges consist
of three layers: the dura mater, the arachnoid mater, and the pia mater. The
primary function of the meninges and of the cerebrospinal fluid is to protect
the central nervous system. It contains the majority of the nervous system and
consists of the brain (in vertebrates which have them), and the spinal cord.

The meninges (singular meninx) is the system of membranes which

envelops the central nervous system. The meninges consist of three layers: the
dura mater, the arachnoid mater, and the pia mater. The primary function of
the meninges and of the cerebrospinal fluid is to protect the central nervous
system. The space between these membranes is bathed with a spinal fluid
much like lymph, which serves as a protective cushion for the delicate nerve
tissue, and allows some expansion space for the brain when its blood supply is
increased.

3 layers of meninges:

Dura

mater

(also

rarely

called

meninx

fibrosa,

or

pachymeninx) is a thick, durable membrane, closest to the skull. It

consists of two layers, the periosteal layer, closest to the calvaria and the
inner meningeal layer. It contains larger blood vessels which split into the
capilliaries in the pia mater. It is composed of dense fibrous tissue, and its
inner surface is covered by flattened cells like those present on the
surfaces of the pia mater and arachnoid. The dura mater is a sac which
envelops the arachnoid and has been modified to serve several functions.
The dura mater surrounds and supports the large venous channels (dural
sinuses) carrying blood from the brain toward the heart.
The falx cerebri separates the hemispheres of the cerebrum. The falx
cerebelli separates the lobes of the cerebellum.
The tentorium cerebelli separates the cerebrum from the cerebellum.
The epidural space is a potential space between the dura mater and the
skull. If there is hemorrhaging in the brain, blood may collect here. Adults are
more likely than children to bleed here as a result of closed head injury.

The subdural space is another potential space. It is between the dura mater
and the middle layer of the meninges, the arachnoid mater. When bleeding
occurs in the cranium, blood may collect here and push down on the lower
layers of the meninges. If bleeding continues, brain damage will result from
this pressure. Children are especially likely to have bleeding in the subdural
space in cases of head injury.

Arachnoid mater - The middle element of the meninges is the

arachnoid

membrane,

so

named

because

of

its

spider

web-like

appearance. It provides a cushioning effect for the central nervous

system. The arachnoid mater exists as a thin, transparent membrane. It is
composed of fibrous tissue and, like the pia mater, is covered by flat cells
also thought to be impermeable to fluid. The arachnoid does not follow the
convolutions of the surface of the brain and so looks like a loosely fitting
sac. In the region of the brain, particularly, a large number of fine
filaments called arachnoid trabeculae pass from the arachnoid through
the subarachnoid space to blend with the tissue of the pia mater.
The

arachnoid

and

pia

mater

are

sometimes

together

called

the

leptomeninges.
The subarachanoid space lies between the arachnoid and pia mater. It is
filled with cerebrospinal fluid. All blood vessels entering the brain, as well as
cranial nerves pass through this space. The term arachnoid refers to the spider
web like appearance of the blood vessels within the space.

Pia mater - The pia or pia mater is a very delicate membrane. It is the
meningeal envelope which firmly adheres to the surface of the brain and
spinal cord. As such it follows all the minor contours of the brain (gyri and
sulci). It is a very thin membrane composed of fibrous tissue covered on
its outer surface by a sheet of flat cells thought to be impermeable to
fluid. The pia mater is pierced by blood vessels which travel to the brain
and spinal cord, and its capillaries are responsible for nourishing the brain.

Cerebrospinal fluid - is a clear liquid produced within spaces in the brain

called ventricles. Like saliva it is a filtrate of blood. It is also found inside the
subarachnoid space of the meninges which surrounds both the brain and the
spinal chord. In addition, a space inside the spinal chord called the central
canal also contains cerebrospinal fluid. It acts as a cushion for the neuraxis,
also bringing nutrients to the brain and spinal cord and removing waste from
the system.
Choroid Plexus
All of the ventricles contain choroid plexuses which produce cerebrospinal fluid
by allowing certain components of blood to enter the ventricles. The choroid
plexuses are formed by the fusion of the pia mater, the most internal layer of
the meninges and the ependyma, the lining of the ventricles.
The Ventricles
These four spaces are filled with cerebrospinal fluid and protect the brain by
cushioning it and supporting its weight.
The two lateral ventricles extend across a large area of the brain. The
anterior horns of these structures are located in the frontal lobes. They extend
posteriorly into the parietal lobes and their inferior horns are found in the
temporal lobes.
The third ventricle lies between the two thalamic bodies. The massa
intermedia passes through it and the hypothalamus forms its floor and part of
its lateral walls.
The fourth ventricle is located between the cerebellum and the pons.
The four ventricles are connected to one another.
The two foramina of Munro, which are also know as the interventricular
foramina, link the lateral ventricles to the third ventricle.
The Aqueduct of Sylvius which is also called the cerebral aqueduct connects
the third and fourth ventricles.

The fourth ventricle is connected to the subarachnoid space via two lateral
foramina of Luschka and by one medial foramen of Magendie.

ANATOMY OF THE CNS

BRAIN
The center of the nervous system. The brain is located in the head,
protected by the skull and close to the primary sensory apparatus of vision,
hearing, balance, taste, and smell.

The frontal lobe is concerned with higher intellectual functions, such as

abstract thought and reason, speech (Broca's area in the left hemisphere
only), olfaction, and emotion. Voluntary movement is controlled in the
precentral gyrus (the primary motor area).

The parietal lobe is dedicated to sensory awareness, particularly in the

postcentral gyrus (the primary sensory area). It is also concernes with
abstract reasoning, language interpretation and formation of a mental
egocentric map of the surrounding area.

The occipital lobe is responsible for interpretation and processing of

visual stimuli from the optic nerves, and association of these stimuli with
other nervous imputs and memories.

The temporal lobe is concerned with emotional development and

formation, and also contains the auditory area responsible for processing

and discrimination of sound. It is also the area thought to be responsible for

the formation and processing of memories.
The brain can be subdivided into several distinct regions:
1.

Brainstem consists of medulla oblongata, pons and midbrain.

Medulla oblongata - is the lower portion of the brainstem. It deals

with autonomic functions, such as breathing and blood pressure. The
cardiac center is the part of the medulla oblongata responsible for
controlling the heart rate.

Pons - relays sensory information between the cerebellum and

cerebrum; aids in relaying other messages in the brain; controls
arousal, and regulates respiration (see respiratory centres). In some
theories, the pons has a role in dreaming.

Midbrain (mesencephalon) - The mesencephalon is considered part

of the brain stem. Its substantia nigra is closely associated with motor
system pathways of the basal ganglia.

The human mesencephalon is archipallian in origin, meaning its general

architecture is shared with the most ancient of vertebrates. Dopamine
produced in the substantia nigra plays a role in motivation and habituation of
species from humans to the most elementary animals such as insects.
2. Cerebellum - is a region of the brain that plays an important role in the
integration of sensory perception, coordination and motor control. In
order to coordinate motor control, there are many neural pathways
linking the cerebellum with the cerebral motor cortex (which sends
information

to

the

muscles

causing

them

to

move)

and

the

spinocerebellar tract (which provides proprioceptive feedback on the

position of the body in space). The cerebellum integrates these
pathways, like a train conductor, using the constant feedback on body
position to fine-tune motor movements.
3.

Diencephalon - (or interbrain) is the region of the brain that includes

the thalamus, hypothalamus, epithalamus, prethalamus or subthalamus
and pretectum. The diencephalon is located at the midline of the brain,
above the mesencephalon of the brain stem. The diencephalon contains the

zona limitans intrathalamica as morphological boundary and signalling

center between the prethalamus and the thalamus.

Thalamus - plays an important role in regulating states of sleep and

wakefulness. Thalamic nuclei have strong reciprocal connections with
the cerebral cortex, forming thalamo-cortico-thalamic circuits that
are believed to be involved with consciousness. The thalamus plays a
major role in regulating arousal, the level of awareness, and activity.
Damage to the thalamus can lead to permanent coma.

Epithalamus is a dorsal posterior segment of the diencephalon (a

segment in the middle of the brain also containing the hypothalamus
and the thalamus) which includes the habenula, the stria medullaris
and the pineal body. Its function is the connection between the limbic
system to other parts of the brain.

Hypothalamus - is a small part of the brain located just below the

thalamus on both sides of the third ventricle. Lesions of the
hypothalamus interfere with several vegetative functions and some
so called motivated behaviors like sexuality, combativeness, and
hunger. The hypothalamus also plays a role in emotion. Specifically,
the lateral parts seem to be involved with pleasure and rage, while
the medial part is linked to aversion, displeasure, and a tendency to
uncontrollable

and

loud

laughing.

However,

in

general

the

hypothalamus has more to do with the expression of emotions

4.

Cerebrum - or top portion of the brain, is divided by a deep crevice,

called the longitudinal sulcus. The longitudinal sulcus separates the
cerebrum in to the right and left hemispheres. In the hemispheres you will
find the cerebral cortex, basal ganglia and the limbic system. The two
hemispheres are connected by a bundle of nerve fibers called the corpus
callosum. The right hemisphere is responsible for the left side of the body
while the opposite is true of the left hemisphere.

ANATOMY OF THE PNS

The peripheral nervous system includes 12 cranial nerves 31 pairs of spinal

nerves. It can be subdivided into the somatic and autonomic systems. It is a
way of communication from the central nervous system to the rest of the body
by nerve impulses that regulate the functions of the human body.

The twelve cranial nerves are

I Olfactory Nerve for smell
II Optic Nerve for vision
III Oculomotor for looking around
IV Trochlear for moving eye
V Trigeminal for feeling touch on face
VI Abducens to move eye muscles
VII Facial to smile, wink, and help us taste

VIII Vestibulocochlear to help with balance, equilibrium, and hearing

IX Glossopharengeal for swallowing and gagging
X Vagus for swallowing, talking, and parasympathetic actions of digestion
XI Spinal accessory for shrugging shoulders
XII Hypoglossal for tongue more divided into different regions as muscles

The 10 out of the 12 cranial nerves originate from the brainstem, and mainly
control the functions of the anatomic structures of the head with some
exceptions. CN X receives visceral sensory information from the thorax and
abdomen, and CN XI is responsible for innervating the sternocleidomastoid and
trapezius muscles, neither of which is exclusively in the head.

Spinal nerves take their origins from the spinal cord. They control the functions
of the rest of the body. In humans, there are 31 pairs of spinal nerves: 8
cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal. The naming
convention for spinal nerves is to name it after the vertebra immediately above
it. Thus the fourth thoracic nerve originates just below the fourth thoracic
vertebra. This convention breaks down in the cervical spine. The first spinal
nerve originates above the first cervical vertebra and is called C1. This
continues down to the last cervical spinal nerve, C8. There are only 7 cervical
vertebrae and 8 cervical spinal nerves.

Precipitataing factors
Predisposing Factors:
Age (1 year old)

Male high
incidence

Malnutrition
Weight=6.7kg below
normal

Low economic
Status
(P400/day)

Immature immune
system
Low immune
response

Stiffening of the
neck
Meningeal
Vomiting
7.17.09-7.23.09
irritation
7.14.09

fever

Decrease
quantity and
quality of food

bind
Invasion of microorganismsNeutrophils
to
to cerebral
nasopharyngeal area
Bulging fontanelle
endothelial cell
of blood brain
level
of
(nisserea
meningitides) Disrupts
Congestion
of
Cerebral
Release
Increase
Obstruction
Formation of
of
Release
Release
of
of
toxic of
Increase
permeability
07.17-07.23.09
barrier
blood
brainendotoxins
barrier
Infection
Invasion
Colonization
Microorganism
Hematogenous
Inflammatory
to
leads
the
of
to
subarachnoid
microorganisms
systemic
enter
responce
spread
systemic
affection
space
surrounding
tissues
edema
Increase
ICP
lymphocytes
.63
Inflammation
of
meninges
adhesion
CSF
flow
cytokines
products
of blood brain barrier

Crowded
environment
(5members, 25sq
m)

High risk for

contagious or
communicable disease

Set the
Increase body
hypothalamus
Increase
basal
Release
of
temperature
center
metabolic
rate
interleukins

Release of
Increase
histamine and
vascular
serotonin
permeability

SYNTHESIS OF THE DISEASE

DEFINITION OF THE DISEASE
Tuberculous

(TB)

meningoencephalitis,

as

meningitis
it

affects

is
not

correctly
only

characterized

meninges

but

also

as

brain

parenchyma and vasculature. The primary pathologic event is formation of

thick TB exudate within subarachnoid space, most prominently at the base of

the brain. Accompanying this exudate is inflammation affecting adjacent blood
vessels. Ischemic cerebral infarction, resulting from vascular occlusion, is a
common sequela most often found in the distribution of the middle cerebral
artery (reflecting presence of TB exudate within sylvian fissure) and striate
arteries as they penetrate the base of the brain. Another characteristic feature
of TB meningitis is hydrocephalus secondary to CSF dynamic disturbance.
TB meningitis is divided into three clinical stages:
Stage

I (early)

Neurologic syndrome
Nonspecific (e.g., generalized
malaise)
Lethargy

II

Meningismus

(intermediate)

Moderate focal neurologic deficits

(e.g., cranial nerve palsies)
Seizures

III (advanced)

Severe neurologic deficits (e.g.,

paresis)
Stupor or coma

Tuberculous meningitis is also known as TB meningitis or tubercular

meningitis. Tuberculous meningitis is Mycobacterium tuberculosis infection of
the meningesthe system of membranes which envelops the central nervous
system. It is the most common form of CNS tuberculosis. Fever and headache
are the cardinal features. Confusion is a late feature and coma bears a poor
prognosis. Meningism is absent in a fifth of patients with TB meningitis.
Patients may also have focal neurological deficits.
Causes are Tension headaches are due to contraction (tightness) of the
muscles in your shoulders, neck, scalp, and jaw. They are often related to

stress, depression, or anxiety. Overworking, not getting enough sleep, missing

meals, and using alcohol or street drugs can make you more susceptible to
headaches. Foods that can trigger a headache include chocolate, cheese, and
monosodium glutamate (MSG), a flavor enhancer. People who drink caffeine
can have headaches when they don't get their usual daily amount.
Mycobacterium tuberculosis of the meninges is the cardinal feature and
the inflammation is concentrated towards the base of the brain. Infection
begins in the lungs and may spread to the meninges by a variety of routes.
Predisposing factors:

Not completing the childhood vaccine schedule increases your risk of

meningitis

Age. People that are too young or too old are prone to develop
meningitis due to immature or weakened state of immune system. Most
cases of meningitis occur in children below 5 years old(about 70%).

Compromised Immune system. People with underdeveloped immune

systems are susceptible to any infection. Since the immune system is
immature, it cannot readily defend itself from invasion thus babys are
required to drink breast milk because the mother at that point transfers
her immunoglobulins to the baby thus strengthening the immune system
while babies who rely on bottle milk have lower immunity.

Sex. Male (95% of cases) are more prone to meningitis than to female.

Newborns and infants are at a higher risk of contracting certain types of

bacterial meningitis, not only because they are more commonly exposed
to some of the bacteria, but also because they may not yet have
received all the preventive immunizations. Infant meningitis is frequently
attributed to Group B streptococcus infections or exposure to E.coli or
listeria in milk or food products

Precipitating Factors

a. Low Economic Status (contractual salary of Php 200/day)

usually those who cant afford a healthy diet are in relation to
malnutrition are susceptible to develop meningitis
b. Crowded area (5 members living in one house of 25 sq.
meters) close proximity in congested areas is a contributing
factor of meningitis due to easy transmission of disease
c. Malnutrition people are susceptible to infection due to lack of
energy production and immune-builders

Signs and Symptoms

1. Fever and leukocytosis (an increase in the number of WBCs) are
the initial signs and symptoms of a systemic reactions caused by
inflammation. WBC increases as the body respond to the invasion
within the host.
2. Nuchal rigidity due to the invasion of microbes in the meninges.
3. Elevated CSF protein infection or inflammatory process that
interrupts the blood-brain barrier increases protein because there
is greater diffusion.
4. Increase intracranial pressure (vomiting) may occur with an
increase in CSF volume, blood entering the CSF, cerebral edema,
space-occupying lesion such as trauma, hydrocephalus, infection,
Guillain-Barrie Syndrome (vomiting is triggered by the activation
of CTZ in the medulla this a forceful reflux of gastric content out
through the oral cavity)
5. Increase head circumference, bulging fontanels due to increase
intracranial pressure secondary to the inflammation of the
meninges.

VII. CONCLUSIONS

The central nervous system is of vital importance to sustain ones life,

since it coordinates the activities of all parts of the body. It is covered and
protected by the meninges. So if these meninges would fail to function, a
persons health would be at serious risk. Meningitis is such a condition, and it is
a fairly common illness that affects lots of children. The severity of the illness
will depend on the type of infection causing the disease, as well as the overall
health of the person who has it.
Outbreaks of meningitis can be a major health problem in the
community, especially when they occur in schools. A vaccine is available and is
recommended for those living in tight quarters, such as dormitories.
Considering that prevention is better than the cure, this could significantly
reduce morbidity and mortality.
And since it is common in the Philippines, the group decided to focus on
the interventions that could be rendered for the clients as well as to give health
teachings on how to prevent the occurrence of the said disease. The group
wanted to contribute in some ways in order to minimize the increasing number
of children who are infected through interventions and health teachings.
RECOMMENDATIONS
Surgery is very much recommended, but considering the parents
financial capabilities, it might not be performed unless it would be included in
their hospital bill. With that in mind, health teachings should be directed
towards maintaining the patients protocol for treatment, specifically the use of
antibiotics, since they have been known to reduce the death rate to less than
5% for all types of bacterial meningitis. It should also be stressed to the
patients parents that if untreated, their childs condition could be fatal within
days. With regards to nutrition, adequate fluid and electrolyte balance must be
maintained while adhering to the indicated diet. There should be a focus on IVF
fluids while the patient is on NPO status until he is able to feed through NGT or
OGT. Neurologic status should also be frequently assessed as indicated to
detect early manifestations of increasing ICP and seizures. Anticonvulsants
may be prescribed for seizure prevention.

BIBLIOGRAPHY

Seeley, Stephens & Tate. Essentials of Anatomy and Physiology. (Fifth

Edition). Mc. Graw Hill Co. Inc., 2005.

Robert S. Feldman, Understanding

Mc.GrawHill Co. Inc., 2005

Amy M. Karch. Nursing Drug Guide. 2009 Lippincotts William and Wilkins
George R. Spratto. Adrienne L. Woods. Nurses Drug Handbook. (2008

edition)
Kozier. Fundamentals of Nursing: Concepts, Process and Practice. (Eighth

edition). Pearson education Inc., 2008.

Adelle Pillitteri. Maternal and Child Health Nursing: Care of the

Psychology.

(Seventh

Edition).

Childbearing and Childrearing Family. (Fifth edition). Lippincotts William

and Wilkins 2008

Doenges, Marilynn E. Nursing Care Plans: Guidelines for Individualizing

Patient Care. (6th edition). F.A. Davis Co., 2002.

Bacterial Meningitis two hours by Ria Rose Celis/2006
Dengue Hemorrhagic fever grade 3 by Emmanuel yambao02007
Acyte myecolytic leukemia by jenalyn Cao02005

Internet source:
http://www.scribd.com
http://pediatrics.about.com/cs/commoninfections/a/meningitis.htm
http://www.mims.com