Meningitis Case Study Name _________________________________ Date _______________ Scenario J.H. is a 5-week-old infant brought to the emergency department (ED) by his mother, who speaks little English. Her husband is at work. The mother is young and appears frightened and anxious. Through a translator, Mrs. H. reports that J.H. 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 Mrs. H. does not speak or understand English well? ANS: 2. You perform your primary assessment and question Mrs. H. with a translator. Which findings are abnormal and need to be reported? Select all that apply and state rationale. a. High-pitched cry b. Pupils equal and +3 c. Heart rate: 85 beats/min d. Positive Babinski reflex e. Refusal of PO intake per mother f. Anterior fontanel palpable and tense g. Temperature 36\deg C (96.8\deg F) rectally ANS: 3. Describe where you would assess the Babinski reflex on an infant. ANS: CASE STUDY PROGRESS J.H. is admitted to the medical unit with the diagnoses of meningitis and rule out sepsis. The ED physician gives the orders shown in the chart. Chart View Emergency Department Orders CBC with differential Blood culture CMP UA Cerebrospinal fluid (CSF) for culture, glucose, protein, cell count (after lumbar puncture) Ceftriaxone (Rocephin) 260 mg IV now (loading dose) Ampicillin 400 mg IV now Acetaminophen 50 mg suppository per rectum for irritability D5W 0.45% NS to infuse at 15 mL/hr 4. Prioritize the order of your interventions, with 1 being your first action and 7 being your last action. ______ 1. Administer ceftriaxone (Rocephin) and Ampicillin ______ 2. Place IV ______ 3. Straight catheterization for urine specimen ______ 4. Place on contact isolation and droplet precautions ______ 5. Assist with lumbar puncture ______ 6. Administer acetaminophen ______ 7. Obtain blood culture, CMP Your initial intervention would be to place the patient with suspected meningitis on contact and droplet precautions. Droplet precautions may usually be discontinued after 24 hours on antibiotics. The patient should be in a private room. Place IV to obtain IV access. The LP, blood tests, and urine specimen should be collected and then the antibiotic administered as soon as possible. 5. You have a difficult time placing the IV line, and the physician writes an order to give the ceftriaxone IM while you wait for the vascular access team to place the IV. Name the appropriate site for an IM injection for an infant. ANS: 6. Before administering the ceftriaxone (Rocephin) and Ampicillin, you verify the dose with another RN. The therapeutic range is for Rocephin 100 mg/kg loading dose and then 80 to 100 mg/kg daily. The therapeutic range for Ampicillin is 200 to 400 mg/kg/day in 4 divided doses with a maximum daily dosage of 12 g/day. J.H. weighs 3.5 kg. Is the loading dose ordered for Rocephin safe? Is it therapeutic? Is the ordered dose for Ampicillin, if given every 6 hours, safe and therapeutic? Show your work. ANS: 7. Interpret J.H.’s laboratory findings, and explain the rationale for abnormal results. Chart View Laboratory Test Results Urinalysis pH 7.2 Color Clear Leukocytes Negative Blood Tests Hct 32% HgB 10.5 g/dL (105 g/L) WBC 22,000 cells/mm3 (22 x 109/L) Sodium 136 mEq/L (136 mmol/L) ANS: 8. Interpret the CSF findings. Would you suspect bacterial or viral meningitis? Why? Chart View Cerebrospinal Fluid Analysis CSF Clear Gram stain Pending Protein 300 mg/dL (elevated) (3.0 g/L) Leukocytes (cell count) 1030 (elevated) Glucose 40 mg/dL (decreased) (2.2 mmol/L) ANS: 9. What are the most common bacterial pathogens in this age group? ANS: CASE STUDY PROGRESS J.H. is diagnosed with Escherichia coli meningitis. His medical care plan will include 21 days of antibiotic therapy with ceftriaxone. You are developing his nursing plan of care. 10. Outline a plan of care for J.H., describing at least 2 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. ANS: CASE STUDY PROGRESS Mrs. H., through her translator, asks you what could have caused her baby to be sick, given that 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 Mrs. H. that infants have immature immune systems, and they are vulnerable to infections until they have been fully immunized. Mrs. H. asks when J.H. will get more shots and what will they be. 11. According to the CDC immunization schedule, which immunizations will J.H. receive at 2 months? You can refer to the current immunization schedules posted at www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf h. Hib i. IPV j. OPV k. MMR l. DTaP m. Hep B n. V