CASE PRESENTATION:

CNS Infection

PREPARED BY:

NURSING GROUP PEDIATRIC WARD R1MC

I. INTRODUCTION

What is a Central Nervous System Infection?

The CNS comprises the brain, the spinal cord and

the associated membranes. Under some
circumstances, bacteria may enter areas of the CNS.

Bacterial infection of the CNS can result in abscesses

and empyemas (accumulation of pus) and they are
classified according to the location where they occur.
As pus and other material from an infection
accumulate, pressure is exerted on the brain or
spinal cord. This pressure can damage the nervous
system tissue, possibly permanently.
CAUSES AND SYMPTOMS

Typically, bacterial invasion results from the spread

of nearby infection, like chronic sinus or otitis media
that extend beyond its initial site. Or, bacteria can
spread from distant sites via the bloodstream. In
some rare cases, bacterial infection can be acquired
via head trauma or surgical procedures.
MENINGITIS

Meningitis is an infection of the protective

membranes that surround the brain and
spinal cord.

This infection causes these membranes (the

meninges) to become inflamed, which in some cases
can damage the nerves and brain.
In older children, teenagers and adults, the symptoms of meningitis can include:

a fever, with cold hands and feet

vomiting
drowsiness and difficulty waking up
confusion and irritability
severe muscle pain
pale, blotchy skin, and a distinctive rash (although not everyone will have
this)
a severe headache
stiff neck
sensitivity to light (photophobia)
convulsion or seizures
II. OBJECTIVES

General Objectives:
The goal of this case study is to determine the pathological
mechanism of CNS infection with subsequent meningitis in a
10 year old patient, who is hospitalized in Region 1 Medical
Center. Aside from that, studying the signs and symptoms of
CNS infection that which varies with people, medical
interventions and drug therapy, and also, nursing
interventions.

In all, this case study has the purpose of learning how to

rationalize, analyze and reaching sound medical conclusions
by a step by step approach to clinical problem solving.
Specific Objectives:

Determine the past and present health history of the patient

Interpret data given in patients medical chart
Define the complete diagnosis of the patient
Understand the pathophysiology of the disease/infection
Obtain and interpret the doctors orders and diagnosis
Interpret the laboratory results of the patients condition
Determine the nature and function of the drugs given for
therapy
Provide nursing care plans appropriate for patients
condition and care
IIIa. PATIENTS PROFILE

Name: M.J.G
Address: Lingayen, Pangasinan
Age: 10 y/o
Birthdate: 08/19/2005
Sex: Male
Civil Status: single
Nationality: Filipino
IIIa. PATIENTS PROFILE

Religion: Roman Catholic

Admission date: 03/07/2016
Admission time: 10: 00 AM
Room/ward: Pedia
Admitting Diagnosis: CNS infection probably
acute supportive meningitis
Admitting Physician: Dr. Octaviano/
Nerona/Castro
Chief complaint: Fever and seizure
IIIb. PATIENTS HISTORY

Present illness:
The patient is a 10 year old male from Lingayen,
Pangasinan. He was admitted to Region 1 Medical
Center diagnosed with CNS infection with secondary
meningitis. His chief complaint was that of a seizure
episode a few hours earlier and is now manifesting a
fever that has been going on and off. He was given
paracetamol for it.
IIIb. PATIENTS HISTORY

He had a blood pressure of 100/60 mmHg, 71 CR

regular, 45 RR (tachypnea) and T of 37.5C upon
admission.

He has (+) pallor but (-) cyanosis and jaundice but

(+) vomiting. Patient displayed (+) Babinsky reflex
but (-) Kernigs and Brudzinskys sign, full ROM, no
deformities in extremeties and a GCS of 13.
IIIb. PATIENTS HISTORY

Past Medical History:

There is no relevant past health history. Nor
allergies.

Family History:
There is no family history stated.
IV. LABORATORY RESULTS

Clinical Chemistry Result Form

PARAMETER RESULT UNIT REF. RANGE

Sodium 137.80 mmol/L 135.00 148.00
Potassium 3.50 mmol/L 3.50 5.30
chloride 106.20 mmol/L 98.00 107.00
IV. LABORATORY RESULTS
Hematological Results
PARAMETER RESULT UNTI REF. RANGE
WBC 10.5 x10^9/L 4.0 11.0
Differential Count

Neutrophils 82.0 % 45.0 55.0

Lymphocytes 8.6 % 38.0 45.0
Monocytes 9.3 % 3.0 6.0
Eosinophils 0.0 % 2.0 5.0
Basophils 0.1 % 0.0 0.1
Erythrocytes 4.3 X10^9/L 3.8 5.4
Hemoglobin 121 g/L 115 148
Hematocrit 0.35 0.38 0.44
MCV 81.4 fL 80.0 100.0
MCH 28.1 pg 27.0 34.0
MCHC 346 g/L 310 - 370
IV. LABORATORY RESULTS

PARAMETER RESULT UNIT REF. RANGE

RDW-CV 0.013 % 0.110 0.160
RDW-SD 38.1 fL 35.0 56.0
Platelet count 135 X10^9/L 150 450
MPV 11.8 fL 6.5 12.0
PDW 14.0 9.0 17.0
PCT 0.16 mL/L 1.08 2.82
IG# 0.1 X10^3/uL
CFS ANALYSIS

Bottle #1
CFS Sugar: 5.4 mmol/L (N: 2.0 4.0 mmol/L)
CFS Protein: -- g/L (N: 80 - 430 mmol/L)

Bottle #2
Acid Fast Stain: --
Grams Stain: NO MICROORGANISMS SEEN
India Ink: --
Bottle #3

Color: COLORLESS
Appearance: CLEAR
Volume: APPROX 0.5 ML
RBC count: 5/ cu.mm
Total WBC count: 2/cu.mm

DIFFERENTIAL COUNT
Segmenters: 1 cell
Lymphocytes: 1 CELLS
V. HEALTH ASSESSMENT

Vital Signs
BP: 100/60 mmHg
RR: 45 cpm
CR: 71 bpm
T: 37.5C
GENERAL: RESPIRATORY: PAST DISEASES:
(+) tiredness (-) SOB none
(+) fever
(+)CHKG GASTROINTESTI
(+) drowsiness Hx OF CANCER:
NAL:
none
SKIN (+) vomitus
(-) rash
GENITOURINARY PALPATION : Flat
EENT: : soft abdomen
(+) HA --
MUSCULOSKELE
TAL: NERVOUS
-- SYSTEM:
VI. ANATOMY AND PHYSIOLOGY
VI. ANATOMY AND PHYSIOLOGY
Meninges:
The bony covering around the
brain is called the cranium,
which combines with the facial
bones to create the skull. The
brain and spinal cord are
covered by a tissue known as the
meninges, which is made up of
three layers: dura mater,
arachnoid layer, and pia mater.

The dura mater is a whitish and nonelastic membrane which, on its outer
surface, is attached to the inside of the cranium. This layer completely
covers the brain and the spinal cord and has two major folds in the brain,
that are called the falx and the tentorium.
 The arachnoid layer is a thin
membrane that covers the
entire brain and is
positioned between the dura
mater and the pia mater,
and for the most part does
not follow the folds of the
brain.
The space between the arachnoid layer and the pia mater is called the
subarachnoid space and it contains the CEREBROSPINAL FLUID.
Cerebrospinal Fluid (CSF): CSF is a clear fluid that
surrounds the brain and spinal cord, and helps to cushion
these structures from injury. This fluid is constantly made
by structures deep within the brain called the choroid
plexus which is housed inside spaces within the brain called
ventricles.

If the delicate balance between production and absorption of

CSF is disrupted, then backup of this fluid within the
system of ventricles can cause hydrocephalus.
Ventricles: Brain ventricles are a
system of four cavities, which are
connected by a series of tubes and
holes and direct the flow of CSF
within the brain. These cavities
are the lateral ventricles (right and
left), which communicate with the
third ventricle in the center of the
brain through an opening called
the interventricular foramen.

This ventricle is connected to the fourth ventricle through a long tube called the
Cerebral Aqueduct. CSF then exits the ventricular system through several holes in
the wall of the fourth ventricle (median and lateral apertures) after which it flow
around the brain and spinal cord.
 Brainstem: The brainstem is the
lower extension of the brain
which connects the brain to the
spinal cord, and acts mainly as
a relay station between the
body and the brain. It also
controls various other
functions, such as wakefulness,
sleep patterns, and attention;
and is the source for ten of the
twelve cranial nerves.

It is made up of three structures: the midbrain, pons and medulla oblongata.

VII. PATHOPHYSIOLOGY
VII. PATHOPHYSIOLOGY
VIII. MEDICAL MANAGEMENT

Medical management:

Upon being admitted to the Pediatric Ward, the attending

physician ordered O2 inhalation therapy at 1-2 lpm IMC, to
prevent hypoxemia and successive pneumonia. Vital signs were
taken and monitored every 2 hours and I&O every 4 hours. The
physician instructed CSF analysis for sugar, protein and cell
differential count, as well as CBC and lumbar puncture (170
mg/dl). For post LP, patient needed to remain NPO for 4 hours and
laid flat on bed.

The patient received IV therapy, D5NSSiL and later D5LR,

adjusted with time accordingly.
VIII. MEDICAL MANAGEMENT

The medications administered were:

Chloranphenicol 750 mg/IV q (-) ANST

Diazepam 5 mg/IV (PRN for active seizures)

Paracetamol 300 mg TID

Benzylpenicillin (pen G) 2.5 ml u/SIVP 30 mg q 6

(-) ANST
XI. DISCHARGE PLANNING

Medicines:

Antibiotics: This medicine is given to fight an

infection caused by bacteria. Give patient this
medicine exactly as ordered by his healthcare
provider.
IX. DRUG STUDY

GEN. NAME: Diazepam

Brand Name:
Diastat
Diazemuls
Diazepam Intensol
Novo-Dipam
Valium

Func. Class: Antianxiety, anticonvulsant, skeletal muscle

relaxant, central acting
 CONTRAINDIC DOSAGE &
ACTIONS USES ATIONS SIDE EFFECTS ROUTE
Potentiates the actions Anxiety, acute alcohol Pregnancy CNS: dizziness, Injection: 5 mg/ml
of GABA, especially in withdrawal, adjunct for (D),hypersensitivity to drowsiness, confusion, Oral solution: 5 mg/5
seizures disorders; benzodiazepines, headache, anxiety ml, 5 mg/ml
the limbic system, preoperatively as a closed-angle glaucoma, tremors, stimulation, Rectal gel twin
reticular formation; relaxant for skeletal coma, myasthenia fatigue, depression, packs: 2.5 mg
enhances muscle relaxation; gravis, ethanol insomnia, (pediatric), 5 mg
presympathetic rectally for acute intoxication, hepatic hallucinations, ataxia, (pediatric), 10 mg, 15
inhibition, inhibits repetitive seizures. disease, sleep apnea. fatigue. mg (adult), 20 mg
spinal polysynaptic (adult)
Off label uses: Precautions: CV: Orthostatic Tablets: 2 mg, 5 mg,
afferent paths Agitations, Breastfeeding, geriatric hypotension, ECG 10 mg
benzodiazepine patients, debilitation, changes, tachycardia,
withdrawal, renal disease, asthma, hypotension. Children age 6
choloroquine overdose, bipolar disorder, COPD, months and older: 1
insomnia, seizure CNS depression, labor, EENT: blurred vision, to 2.5 mg P.O. t.i.d.
prophylaxis. parkinsons disease, tinnitus, mydriasis, or q.i.d., increase
neutropenia, psychosis, nystagmus. gradually, as needed
seizures, substance and tolerated.
abuse, smoking GI: constipation, dry
mouth, nausea,
vomiting, anorexia,
diarrhea.

HEMA: neutropenia

INTEG: rash,
dermatitis, itching

RESP: respiratory
depression
IX. DRUG STUDY

Gen. name: Chloramphenicol

Brand Name:
Sodium succinate

Func. Class: Antibiotic

 CONTRAINDIC DOSAGE &
ACTION USES ATIONS SIDE EFFECTS ROUTE

Bacteriostatic Serious infections Allergy to CNS: headache, mild Available forms:

for which no other depression,mental Powder for injection 1
effect against chloramphenicol g/vial
antibiotic is effective confusion, delirium
susceptible
bacteria; prevents Use caustiously with GI: nausea, vomiting, Pediatric:
Acute infection renal failure, hepatic 50-100 mg/kg/day IV in
cell replication caused by glossitis, stomatitis,
divided doses every 6
failure, G6PD diarrhea
salmonella typhi hours
deficiency, Meningitis: 50-100
intermittent HEMA: blood mg/kg/day IV in
Serious infection porphyria, dycrasias divided doses every 6
caused by pregnancy (may hours
Salmonella cause gray Other: fever, macular
haemophillus syndrome in rashes, urticaria, IV LINES
influenza, premature infants anaphylaxis, gray
rickettsiae, baby syndrome Prep: dilute with 10 ml
and newborns), of sterile water for
lymphogranuloma,-- abdominal distention,
lactation injection, or 5%
psittacosis group pallid cyanosis,
dextrose injection.
vasomotor collapse,
Cystic fibrosis irregular respirations; Infusion: administer as
superinfections a 10% solution over 3-5
regimen
min. single dose
infusion over 30-60
min.
IX. DRUG STUDY

Gen. name: Paracetamol

Brand Name: Calpol

Func. Class: Analgesics, muscle relaxants

 CONTRAINDIC DOSAGE &
ACTION USES ATIONS SIDE EFFECTS ROUTE

Decreases fever by Relief of mild- Hypersensitivity Stimulation, Oral: 10 to 15

inhibiting the effects drowsiness, nausea, mg/kg/dose every 4
of pyrogens on the
to-moderate vomiting, abdominal to 6 hours as
pain; treatment Intolerance to
hypothalamus heat pain, hepatotoxicity, needed; do not
tartrazine (yellow
regulating centers & of fever hepatic exceed 5 doses in 24
by a hypothalamic dye #5), alcohol, seizure(overdose, hours.
action leading to table sugar, Renal failure(high,
sweating & saccharin prolonged doses), IV: 2 to 12 years: 15
vasodilatation. leucopenia, mg/kg every 6 hours
Contraindicated neutropenia, or 12.5 mg/kg every
Relieves pain by with allergy to hemolytic anemia 4 hours.
inhibiting (long term use)
acetaminophen
prostaglandin thrombocytopenia, Rectal: 10 to 20
synthesis at the CNS pancytopenia, rash, mg/kg/dose every 4
but does not have urticaria, to 6 hours as
anti-inflammatory hypersensitivity, needed
action because of its cyanosis, anemia,
minimal effect on jaundice, CNS,
peripheral stimulation,
prostaglandin delirium followed by
synthesis vascular collaps,
convulsions, coma,
death.
IX. DRUG STUDY

Gen. Name: Benzylpenicillin

Brand name: Pfizerpen

Func. Class: broad-spectrum antiinfective

 CONTRAINDIC DOSAGE &
ACTION USES ATIONS SIDE EFFECTS ROUTE

Interferes with cell Respiratory Hypersensitivity to CNS: lethargy, CHILD <12yo

wall replicationof infections, scarlet hallucinations, anxiety,
penicillins, corn depression, twitching,
susceptible fever, erysipelas, IV 150,000-
coma, seizures,
organisms; lysis is otitis media, Precautions: hyperreflexia 300,000
mediated by cell wall pneumonia, skin Pregnancy (B), GIT: nausea, vomiting, units/kg/day in 4-6
autolytic enzymes, and soft tissues breastfeeding, diarrhea, increased divided doses; max
results in cell death. infections, AST, ALT, abdominal 24 million units per
hypersensitivity to pain, glossitis, colitis,
gonorrhea, effective cephalosporins, day.
pseudomembranous
for gram positive carbapenems, colitis,
cocci, gram negative sulfites, severe renal GU: oliguria, Available forms:
cocci, gram positive disease, GI disease, proteinuria, hematuria,
bacilli, gram asthma. vaginitis, monoliasis, Powder for inject
negative bacilli and glomerulonephritis, 1,5, 20 million units
spirochetes. renal tubular damage per vial
HEMA: anemia,
increased bleeding Inject 1,2,3, million
time,bone marrow units/50 ml
depression,
granulocytopenia,
hemolytic anemia
META:
hypo/hyperkalemia,
alkalosis,
hypernatremia
MISC: anaphylaxis,
serum sickness, stevens-
johnson syndrome, local
pain, tenderness and
fever with IM inject.
X. NURSING CARE PLANS
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective: Hyperthermia related to Short term: within 1 Independent: After all the nursing
Mataas pa rin ang positive bacterial hour of nursing Established rapport intervention the clients
lagnat nya hanggang infection as manifested intervention the to mother to gain body temp subsided
ngayonas verbalized by by flushed and warm to patients elevated trust and within the normal range.
the patients mother. touch skin. temperature of 36.2 will cooperation.
Objective: lessen to 37.4 degree Promote surface
Flushed skin Celsius. cooling by means of
Skin is warm to touch Long term: within 3 undressing ( heat
Temp: 38.2*C consecutive days of loss by radiation
PR: 109 nursing intervention, and conduction)
RR: 34 the patients body Demonstrate on
temperature will return how to do a proper
to its normal range. tepid sponge bath
using wet and dry
cloth.
Provide nutritious
diet to meet
increase metabolic
demands
Dependent: Administer
antipyretic as ordered.
X. NURSING CARE PLANS
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective: Acute pain related to Within 3 hours of Independent: After 3 hours of nursing
Umiiyak yan kapag meningeal infection with nursing intervention the Use pain rating intervention there is no
nahahawakan yung spasm of extensor patients pain from 8 scale appropriate to sign of facial grimace
batok nya saka nung muscle (neck, shoulder will reduce to 4 using its age and irritability in the
may ginawa yung doctor and back) as manifested the facial pain rating Assess for patient.
nya as verbalized by the by positive kernigs and scale. neurologic exam
mother. brudzinskis sign. and vital signs
Objective: Position on the side
Facial grimace with head gently
Irritable supported in
(+) Brudzinskis extension
sign Promote rest in the
(+)Kernigs sign room by keeping
stimulation and the
room to minimum
Institute
respiratory
isolation
Monitor and record
carefully intake and
output.
 X. NURSING CARE PLANS
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION Rationale EVALUATION
Subjective: Risk for ineffective After 8 hrs. of Independent: After 8 hrs. Of
masakit ang ulo ko cerebral Tissue nursing R: Provides calming nursing
Decrease extraneous
as verbalized by the perfusion related to interventions, the effect, reduces interventions,
stimuli and provide
patient. cerebraledema client will Adverse physiological the client
comfort measures like response and
Objective: demonstrate stable demonstrated
back massage, quiet promotes rest to
Restlessness stable Vital signs
Vital signs and environment, soft voice. maintain or lower
Change in motor or and absence of
absence of signs of intracranial pressure.
sensory responses signs of
intracranial
Difficulty in intracranial
pressure. Instruct patient to avoid R: These activities
swallowing increase thoracic and
pressure.
or limit coughing,
skin discoloration intra-abdominal
Vomiting, straining at
decrease motor pressure which can
Demonstrate defecation, bearing down
response increase intracranial
behaviours/lifestyle as possible.
pressure.
changes to improve
circulation.
R: to promote
Elevate head and
circulation/venous
maintain head/neck in
drainage
midline neutral position
 X. NURSING CARE PLAN
INTERVENTION AND RATIONALE cont.
Prevention:
Observe for seizure activity and protect patient from injury. (R: Seizure can occur as result of cerebral irritation,
hypoxia or increase intracranial pressure.)
Maintain head or neck in midline or neutral position, support with small towel rolls and pillows
(R: Turning head to
one side compresses the jugular veins and inhibits cerebral venous drainage, thereby increasing intracranial
pressure. )
Provide rest periods between care activities and limit duration of
procedures. (R: Continual activity can increase
intracranial pressure)
Curative:
Administer supplemental oxygen as indicated ( R: Reduces hypoxemia.)
Investigate reports of pain out of proportion to degree of injury (R: May reflect developing compartment syndrome)

Administer medications(antihypertensive, diuretics) (R: used to decrease edema.)

Rehabilitation:
Encourage quiet, restful
atmosphere: (R: Conserves energy and lower oxygen demand)
Limit daily activities and caution client to avoid strenuous activities (R: over exertion may cause dizziness)

XI. DISCHARGE PLANNING

Medicines:

Antibiotics: This medicine is given to fight an infection

caused by bacteria.
Give patient this medicine exactly as ordered by his
healthcare provider.
Do not stop giving antibiotics unless directed by healthcare
provider.
Never save antibiotics or give leftover antibiotics that were
given to patient for another illness.
Ibuprofen or acetaminophen: These medicines
are given to decrease the patients pain and fever.
They can be bought without a doctor's order.

Instruct parents to ask how much medicine is safe to

give and how often to give it.
Give patients medicine as directed.

Do not give aspirin to patient.

Rest:

Patient should rest as much as possible. Have the

patient rest in a dark, quiet room if he still has
headaches. The patient may slowly return to normal
activity as directed.
Infection prevention:

Make sure patient discards tissue after he wipes or

blows his nose.
Have the patient wash his hands often with soap and
water.
Do not let patient share food or drinks.
Contact healthcare provider if:

The patient has a fever.

The patient is more fussy or sleepy than usual.
If someone in the family has bacterial meningitis.
If parent has questions or concerns about your
child's condition, medicine, or care.
Seek care immediately if:

Patient is hard to wake.

Has a headache and stiff neck.
Patient is confused.
Has a seizure.
Has a red or purple skin rash.
Helpful sources:
www.nhs.uk
www.webmd.com
www.drugs.com