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Meningitis Case Study

Meningitis Case Study

General Information
1. Setting - Emergency Department and Hospital
2. Keywords - Meningitis, assessment, diversity, barriers, laboratory values and interpretation, cerebrospinal fluid, dosage calculation, growth and development, immunizations, discharge planning

Scenario: JH is a 2-week-old infant brought to the emergency department (ED) by his mother (MH), who speaks little English. Her husband is at work. She is young and appears frightened and anxious. Through a translator, MH reports that JH has not been eating, sleeps all of the time, and is "not normal."

1. What are some of the obstacles you need to consider, recognizing that MH does not speak or understand English well?

2. You perform your primary assessment and question MH with a translator. Which of these findings are abnormal and need to be reported? (Select all that apply and state rationale.)

a. Anterior fontanel palpable and tense
b. Pupils equal and +3
c. Temperature 36°C (96.8°F) rectally
d. Heart rate: 85 beats/min
e. Positive Babinski's reflex
f. High-pitched cry
g. Refusal of po intake per mom

Case Study Progress: JH is admitted to the medical unit with the diagnoses of meningitis and rule out sepsis. The ED physician orders the following:

Emergency Department Orders
CBC with differential
Blood culture
Complete metabolic panel (CMP)
Urinalysis (UA)
Cerebrospinal fluid (CDF) for culture, glucose, protein, cell count (following lumbar puncture)
Ceftriaxone (Pocephin) 260 mg IV now (loading dose)
Acetaminophen (Tylenol) 50 mg suppository per rectum for irritability

3. Prioritize the order of your interventions, with 1 being your first action and 7 being your last action.
_____ Administer ceftriaxone (Rocephin)
_____ Place IV
_____ Straight catheterization for urine specimen
_____ Place on contact isolation and droplet precautions
_____ Assist with lumbar puncture
_____ administer Tylenol
_____ Obtain blood culture, CMP

4. Before administering the ceftriaxone (Rocephin), you must verify the dose with another RN. The therapeutic range is 100 mg/kg/day divided in two doses. JH weighs 3.5 kg. Is the dose ordered safe? (Show your work.)

a. Safe dose range for ceftriaxone (Rocephin) for infants and children is: _______________.
b. What dose will you give JH and how often?

5. Interpret JH's lab findings, and explain the rationale for abnormal results.

Chart View: Laboratory Results
• Urine
o ph 7.2
o color Clear
o Leukocytes Negative
• Complete blood count
o Hct 32%
o HgB 10.5 g/dL
o WBC 22,000/mm3
o Sodium

6. Interpret the CSF findings. Would you suspect bacterial or viral meningitis? Why?

Chart View: Cerebrospinal Fluid Analysis
• CSF Clear
• Gram stain Pending
• Protein 300m g/dL (elevated)
• Leukocytes 1030 cells/microliter (elevated)
• Glucose 40 mg/dL (decreased)

7. What are the most common pathogens in this age group?

Case Study Progress: JH is diagnosed with Escherichia coli meningitis. His medical care plan will include 14 to 21 days of antibiotic therapy. You are developing his nursing plan of care.

8. Outline a plan of care for JH, describing nursing interventions that would be appropriate for managing pain and infection, maintaining hydration, assisting with increased intracranial pressure (ICP), and teaching to review with his parents.

Case Study Progress: MH, through her translator, asks you what could have caused her baby to be sick since he had an immunization when he was born. She asks whether he should get "more shots" so this won't happen again. You reinforce to MH that infants have immature immune systems, and they are vulnerable to infections until they have been immunized. MH asks when JH will get more shots and what will they be?

9. According to the CDC immunization schedule, which of the following immunizations will JH receive at 2 months? Refer to http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html for guidance.

a. HIB
b. MMR
c. OPV
d. IPV
e. Rotovirus
f. DTaP
g. Varicella
h. Hep B
i. Pneumococcal

10. What is the impact of hospitalization on JH's growth and development?

11. JH is being discharged after 3 weeks of IV antibiotic therapy. What educational topics will be important to discuss with JH's parents when he is discharged?

Case Study Outcome: JH is discharged to home with his parents. He will continue po antibiotics for 1 week and receive a home health visit for infant care follow-up. He is to return to his PCP in 1 week or call for any concerns.

Solution Preview

Meningitis Case Study

General Information
1. Setting - Emergency Department and Hospital
2. Keywords - Meningitis, assessment, diversity, barriers, laboratory values and interpretation, cerebrospinal fluid, dosage calculation, growth and development, immunizations, discharge planning

Scenario: JH is a 2-week-old infant brought to the emergency department (ED) by his mother (MH), who speaks little English. Her husband is at work. She is young and appears frightened and anxious. Through a translator, MH reports that JH has not been eating, sleeps all of the time, and is "not normal."

1. What are some of the obstacles you need to consider, recognizing that MH does not speak or understand English well?

A parent with a child who is does not speak or understand English well needs an interpreter as soon as possible. Well working with the crises situation, obtain a person who is a medical interpreter to be with the mother and child throughout the period where there will be testing and procedures. This will be a very distressing time and the mother needs to understand what is happening and why.

2. You perform your primary assessment and question MH with a translator. Which of these findings are abnormal and need to be reported? (Select all that apply and state rationale.)

a. Anterior fontanel palpable and tense - the bulging fontanel occurs from infection of the membranes covering the brain. The brain swells leaving less room for the fluid circulation with bulging of the fontanels.
b. Pupils equal and +3 - Childs pupils are equal is size and respond at a +3 amount of pupillary restriction to light.
c. Temperature 36°C (96.8°F) rectally -Meningitis usually will cause an elevated fever.
d. Heart rate: 85 beats/min - the normal heart rate for a two week old is between 140-180 and meningitis will exhibit a fast heart rate.
e. Positive Babinski's reflex - Children have a sign that occurs when their neck is bent and their knees automatically come toward the body called the Brudzinski sign.
f. High-pitched cry - This is a typical cry with meningitis.
g. Refusal of PO intake per mom - a sick child will normally be reluctant to take in fluids due to feeling nauseous. The child is unable to verbalize this but exhibits this symptom by not eating and drinking.

Case Study ...

Solution Summary

This outlines a case of an infant who has meningitis.

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