Meningitis, Encephalitis, and Seizures

Meningitis

• Meningitis can affect individuals of all ages, but young children and adolescents are often most at risk.
• Symptoms can vary but common ones include:
  • Fever
  • Severe headache
  • Stiff neck (nuchal rigidity)
  • Sensitivity to light (photophobia)
  • Nausea and vomiting
  • Confusion or altered mental state
  • Seizures
• Different forms of meningitis are named according to the type of pathogen causing the infection:
  • Viral meningitis: Most common, caused by viruses such as enteroviruses, herpes simplex virus, and mumps virus.
    • Symptoms are often milder than bacterial meningitis.
    • Symptoms include mild fever, headache, sensitivity to light, muscle/joint aches, and fatigue.
    • Usually resolves on its own without specific treatment.
  • Bacterial meningitis: Less common but more severe and requires immediate medical attention.
    • Caused by bacteria such as meningococcus, pneumococcus, and haemophilus influenzae.
    • Symptoms can develop rapidly and may include high fever, severe headache, neck stiffness, altered mental state, skin rash, and sometimes seizures.
    • Other symptoms include cold hands and feet, joint and muscle pains, rapid breathing, diarrhea, and dark purple or red rashes.
    • Symptoms in newborns and infants can differ, including:
      • Being less active and difficult to wake
      • Being irritable or crying
      • Poor feeding
      • Stiff or floppy body
      • Swelling in the soft spot on the head (fontanel)
• Prompt treatment of meningitis is crucial to avoid severe complications, including permanent neurological damage or death.
• Meningitis can also result from non-infectious causes, including chemical reactions, head injuries, and allergies.
• Treatment:
  • Viral meningitis: Treat symptoms, keep hydrated, and ensure comfort. Antiviral drugs may be used in severe cases.
  • Bacterial meningitis: Requires droplet precautions due to being droplet spread. Vaccination is encouraged for high-risk individuals (e.g., those in schools or military barracks).

Kernig's Sign and Brudzinski's Sign

• These are clinical signs that indicate possible meningitis.
• Kernig's sign:
  • Patient lies flat on their back.
  • Flex the hip, then try to straighten the knee.
  • Positive sign: Pain or inability to straighten the knee.
  • Mnemonic: Kernig starts with 'K', Knee starts with 'K'.
• Brudzinski's sign:
  • Patient lies flat on their back.
  • Lift the patient’s head, bringing the chin to the chest.
  • Positive sign: Automatic flexion at the hips and knees.
  • Mnemonic: Brudzinski’s has a 'Z' in the middle, and the body makes a 'Z' shape.
• These signs occur because stretching the inflamed meninges causes pain and a protective reaction.

Patient Case: Mr. B

• Mr. B presents to the ER with:
  • Severe headache
  • Fever
  • Neck stiffness (nuchal rigidity)
• Onset of symptoms: Sudden, over 24 hours.
• Baseline: Healthy, no significant history.
• Fever: 102°F (38.9°C), which is concerning and can indicate bacterial meningitis.
• Recent history: Attended a crowded event in the past week.
• Physical Exam:
  • Uncomfortable, lying still in bed
  • Temperature: 101.8°F (38.8°C)
  • Heart rate: 110 (elevated due to fever and pain)
  • Blood pressure: 130/80 (slightly high but acceptable)
  • Respiratory rate: 20 breaths per minute (slightly high, needs monitoring)
  • Significant nuchal rigidity
  • Pain with neck flexion
  • Positive Kernig’s and Brudzinski’s signs
• Assessment:
  • Classic meningitis symptoms: Stiff neck, fever.
  • Suspicion: Possible bacterial meningitis due to fever and symptom onset.
• Nursing Actions:
  • Immediately place the patient in droplet isolation.
• Diagnostic Tests:
  • CT scan of the head (to rule out contraindications for lumbar puncture such as increased intracranial pressure)
  • CBC (complete blood count) to look for elevated white blood cell count
  • Blood cultures and spinal fluid cultures
  • Lumbar puncture (LP) to analyze cerebrospinal fluid
• Lumbar Puncture Contraindication: Increased intracranial pressure.
• LP Analysis:
  • Appearance: Cloudy (should be clear)
  • Pressure: Elevated
  • White blood cell count: 12,000 in spinal fluid (abnormal)
  • Glucose: Low (indicates bacteria are consuming glucose. Bacteria loves glucose.)
  • Protein: High
  • Gram stain: Gram-positive cocci in pairs
• CBC: Elevated white blood cell count.
• CT of the Head: Normal.
• Diagnosis: Bacterial meningitis.
• Treatment:
  • Start on broad-spectrum antibiotics immediately (e.g., ceftriaxone IV and vancomycin).
  • Administer IV fluids to maintain hydration.
  • Treat pain.
  • Frequent vital signs (every 3 hours).
  • Hourly neurological checks.
• Importance of Rapid Antibiotic Administration: The longer the pathogen reproduces, the worse the patient's outcome.
• Possible Complications:
  • Sepsis
  • Neurological deficits
  • Hearing loss
  • Cranial nerve problems
  • Hydrocephalus
  • Motor deficits
  • Death
• Nursing Care Focus:
  • Fever reduction (cooling measures)
  • Monitoring for increased intracranial pressure
  • Administering antibiotics on time
  • Watching for signs and symptoms of allergic reactions
  • Seizure precautions
  • Droplet precautions
  • Fall risk precautions
  • Educating the patient and family

Encephalitis

• Encephalitis is inflammation of the functional tissue (parenchyma) of the brain.
• Typically caused by viral infections.
• Leads to brain swelling and neurological symptoms.
• Requires immediate medical attention to reduce long-term complications or death.
• Causes:
  • Brain infections (usually viral)
  • Autoimmune reactions (immune system mistakenly attacks brain tissue)
• Primary Brain Infections:
  • Often caused by viral invasion (e.g., herpes simplex, varicella-zoster [chickenpox/shingles], enteroviruses).
  • Viruses can be carried by mosquitoes, ticks, or other animals.
  • Herpes simplex virus (HSV), including HSV-1 and HSV-2, is a common cause.
    • HSV encephalitis affects people younger than 20 or older than 40 and is often fatal if not treated promptly.
• Autoimmune Encephalitis:
  • Occurs as a secondary complication after infections or vaccinations.
  • Immune system produces antibodies against brain proteins.
  • Examples include anti-NMDA receptor encephalitis and DGKC complex antibody encephalitis.
• Symptoms:
  • Vary depending on the cause and affected brain area.
  • Fever
  • Headache
  • Stiff neck
  • Sensitivity to light
  • Altered mental status
  • Cognitive problems
  • Seizures
  • Infectious encephalitis: Starts with flu-like symptoms, progresses over several days.
  • Autoimmune encephalitis: Evolves over several weeks.
• Diagnosis:
  • Physical exam and medical history.
  • Brain imaging (MRI) to detect edema and affected brain regions.
  • Cerebrospinal fluid analysis to identify the causative agent.
  • MRI helps rule out other conditions with similar symptoms.
• Treatment:
  • Prompt treatment is critical for survival.
  • Antiviral medications (e.g., acyclovir) are often initiated immediately.
  • Empiric antibiotics may be given until bacterial causes are ruled out.
  • Treatment for autoimmune encephalitis may include corticosteroids, intravenous antibodies, and plasma exchange.
  • Supportive therapy includes fever and inflammation reducers, intravenous fluids, and antiseizure medications.
• Key Differences from Meningitis:
  • Meningitis: Sudden onset.
  • Encephalitis: Usually preceded by a viral illness, with a longer-term deterioration.
• Symptoms and Monitoring:
  • Changes in level of consciousness.
  • Increased intracranial pressure.
  • Sensory and motor changes.
  • Changes in speech.
  • Frequent focused neuro assessments.
• Lumbar Puncture: May not be safe due to increased intracranial pressure.
• Treatment Summary:
  • Bacterial Meningitis: Aggressive antibiotics, droplet isolation.
  • Viral Meningitis: Treat like the flu (rest, fluids, symptom management), antiviral drugs if severe.
  • Encephalitis: Antiseizure precautions, symptom management, supportive care, therapies (PT, OT, speech) based on affected brain areas.

Seizures

• Seizures: Sudden change in behavior caused by electrical hyperactivity in the brain.
• Can range from large storms affecting the whole brain to small disturbances in specific areas.
• Prolonged seizures, especially tonic-clonic, can cause brain damage.
• Causes and Triggers (STOP SEIZURE mnemonic):
  • Stress
  • Trauma
  • Overexertion
  • Periods/Pregnancy (hormonal changes)
  • Sleep loss
  • Electrolyte/Metabolic issues
  • Illness
  • Visualization disturbances (flashing lights)
  • Recreational drugs
  • Ethanol (alcohol withdrawal)
• Stages of a Seizure:
  • Prodromal: Symptoms before the seizure (hours or days), such as headache, sensitivity to light/sound, behavioral changes, fatigue.
  • Aura: Warning sign before the seizure (strange taste/smell, altered vision, dizziness). Not all patients experience an aura.
  • Ictus (Ictal Phase): Actual seizure activity. May exhibit fluttering/rolling eyes, increased oral secretions, impaired sensory/motor function, loss of bowel/bladder control (incontinence), increased body temperature, and diaphoresis.
  • Postictal: Recovery after the seizure (headache, fatigue, confusion). Assess for injuries (mouth, head) and perform a full-body assessment.
• Types of Seizures:
  • Myoclonic: Brief jerks of one large muscle group. Patient is fully conscious, alert, and oriented. Usually nothing to do unless injury occurs.
  • Absence (Petit Mal): Typically starts in children. Patient stops mid-sentence, appearing vacant, then resumes as if nothing happened. Usually lasts up to 15 seconds. Nothing usually needs to be done unless injury occurs.
  • Tonic-Clonic (Grand Mal):
    • Call 911 if:
      • The patient is not known to have a seizure disorder, and they have a seizure.
      • The seizure lasts more than 5 minutes (risk of status epilepticus).
      • The patient has a second seizure before recovering from the first (status epilepticus).
      • The patient does not start breathing regularly after the seizure stops.
      • The patient is diabetic.
      • The seizure occurs in water.
      • The patient is pregnant.
      • The patient is injured during the seizure.
    • Diagnostic tests: CT scan (to rule out distal problems) and EEG.
    • Assessment: Note what was happening before, describe what they're doing during, note the loss of bowel and bladder control, and describe the postictal phase.
• Status Epilepticus:
  • Continuous seizures or repeated seizures in rapid succession lasting 30 minutes or more.
  • Depletes glucose and oxygen stores, causing potential brain damage.
  • Call for help at 5 minutes.
  • Treatment in Textbook World:
    • IV anticonvulsant (usually Keppra)
    • If no response, use a neuromuscular blocker to stop convulsions and provide an artificial airway and general anesthesia.
  • Treatment in Real World:
    • Broad-spectrum anticonvulsant (Keppra) with benzodiazepines (e.g., IV Ativan).
    • At home, nasal benzos or benzodiazepine suppositories may be used.
• Goal: Fix the underlying cause.
• Anticonvulsants: Do not stop taking them suddenly to not drop it below the threshold.
  • Triggers include stress, trauma, overexertion, periods/pregnancy, sleep loss, electrolyte/metabolic issues, illnesses, visualization disturbances, recreational drugs, ethanol.
• Seizure Precautions:
  • Have oxygen and suction available.
  • Provide privacy.
  • Raise and pad the side rails.
  • Place the client in a side-lying position immediately post-seizure.
  • Place the client laying down with a pillow under the head to protect their head.
  • Loosen restrictive clothing.
  • Keep the bed in the lowest position.
  • Note the time and duration of the seizure.
  • Never restrain the client.
  • Never force the jaw open or place anything in the client's mouth.
  • Never leave the client alone.
• Real World Implementation of Seizure Precautions:
  *If you dont find the seizure pads around, use fat blankets, protective rails, or even a roll of pillows as a temporary fix until seizure pads are located.
  *A curtain is sufficient for privacy, no private room needed.
  *Dont insert anything between a patients teeth.
• Seizure pads on the rails are the only answer on the exam.
• Teach trigger management.
• Medical Alert Bracelets/Pendants: Strongly encouraged so healthcare providers know about the seizure disorder.

Delirium and Dementia

• Delirium:
  • Acute/sudden change in mental state (hours or days).
  • Affects attention, memory, cognition, and consciousness level.
  • Decreased awareness of the environment, confusion.
  • Poor ability to remember things.
  • Hallucinations or extreme emotions (fear, anxiety, anger, depression) possible.
  • Symptoms fluctuate throughout the day.
  • Usually temporary and reversible.
  • Caused by disruption in normal brain signal sending and receiving due to lack of oxygen or other substances.
  • Common in the elderly due to decreased acetylcholine and the body's decreased ability to filter toxins.
  • Stressful Situations are triggers as well as withdrawal and medications.
  • Treatment depends on the underlying cause (e.g., fluids and electrolytes for dehydration). Removal of drugs and supportive care.
  • WHERE mnemonic:
    • Where are you? (disorientation)
    • Hallucinations
    • Energy changes
    • Remory deficits
    • Energy changes (hyperactive/hypoactive)
  • FAITHMED mnemonic:
    • Fluctuating course
    • Acute onset
    • Intoxicants
    • Thought disorganization
    • Hallucinations
    • Medical causes
    • Energy changes
    • Disorientation
• Dementia:
  • Gradual change in brain function (years).
  • Affects memory, cognition, and attention.
  • Permanent, not reversible, gets worse over time.
  • In early stages, patients may realize they have a problem and try to hide it.
• Comparison:
  • Delirium: Rapid onset, temporary, reversible, trouble paying attention. Fluctuating.
  • Dementia: Gradual onset, permanent, trouble with memory. Stable.
• Mild Neurocognitive Disorder (Mild Dementia):
  • Early stage, patients may miss appointments or get overwhelmed easily.
  • Goal: Compensate for declining function and help them stay at home.
  • Use big calendars, big clocks, and medication organizers.
  • Sleep disturbances and hallucinations may occur.
  • Keep them in familiar places.
• Major Neurocognitive Disorders (Advanced Dementia):
  • Problems with mobility and activities of daily living.
  • None of the Alzheimer's/dementia drugs are curative.
  • Donepezil (Aricept) is for early-to-middle Alzheimer's.
  • Memantine (Namenda) is for late-stage Alzheimer's.
  • Manage depression, which can mimic dementia in the elderly.
  • Alzheimer's is the most common form of dementia and is an organic brain disease. *Nursing Interventions with Dementia:
    • Keep them as functional as possible and ensure safety.
    • Assess how well they can manage. Establish routines.
    • Toileting schedules every two hours and schedule feeding as much as possible.
    • Remove distractions during meals and engage them one-on-one.
      *Utilize finger foods and protein rich food.
    • Manage sleep disturbances with caution.
    • Potential for injury: Keep them safe.
    • Trackers are a good idea to keep track of patient.
    • Agitation from the illness is common.
    • Give patients limited and easy choices to let them feel in control of a situation.
• Treat adults with dignity. Acknowledge that they are NOT giving you a hard time, they are having a hard time.