Meningitis Ein 3

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CHAPTER 1

INTRODUCTION

1.1 Background

Disorders of the nervous system can occur at any time during the life span and can vary

from mild, self-limiting symptoms to devastating, life-threatening disorders.

Meningitis is an infection of the meninges, the paper- thin membranes that cover and

protect the brain and spinal cord, usually as a result of an infection of the CSF. While the term

spinal meningitis is sometimes used, it is inaccurate. Because CSF circulates through the brain as

well as the spinal canal, an infection of the fluid cannot be limited to the spinal area. While

meningitis can strike anyone, it is most common in children, teens, and young adults. Meningitis

strikes fear into the hearts of parents and health care workers because it often affects the

youngest and most vulnerable people.

Meningitis can cause a long list of symptoms. But it is best known for its triad of

symptoms- fever, stiff neck, and impaired level of consciousness (such as confusion,fatigue, and

irritability). Most people recover from meningitis. A few others are left with serious permanent

problems, such as speech and learning disabilities, brain damage, deafness, or loss of fingers,

toes, hands, and feet. Even with best medical care, some forms of meningitis kill one or two out

of every ten people who get it.

Meningitis is different from a disease such as Lyme disease, in which only one kind of

bacterium is the culprit. Meningitis can be used by many kinds of dangerous microorganism.

These microorganism include bacteria, viruses and fungi. The most dangerous type of bacterial

meningitis may kill people within twenty-four hours after they start feeling sick. People with

mwningitis by viruses usually are not as sick as those with bacterial meningitis. However, both

types require prompt medical attention because only a doctor can tell the difference.

Health care has made great strides over the past twenty years in the prevention and

treatment of meningitis. Even though some forms of meningitis can be prevented with

vaccination, its important to learn about meningitis so you can help protect yourself, your

family, and your friends from this terrible disease. While meningitis is not as contagious (easily

spread among people) as a cold or the flu, it can be passed by something as simple as sharing a

cookie, a coke, or a kiss.


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In the past, most cases of meningitis were in children younger than the age of 5, and most

often the causative agent wasHaemophilus influenza. Since 1990, a vaccine againstH. influenza

has become available and is administrated to most children in the United States and other

countries as a series of injections, beginning in the second month of life. As result of this

important intervention, the incidence of meningitis in children aged 1 month to 2 years has

decreased 87 %. Because of the dramatic decline inH. influenza-type meningitis in this

population, cases of bacterial meningitis overall in the United States have dropped 55 %.

Meningitis now occurs mast commonly in adults ages 19 to 59. In this age group, the

most common cause of bacterial meningitis is Streptococcus pneumonia (pneumococcal

meningitis). The next greatest incidence is in children ages 2 to 18, and cause is most often

Neisseria meningitides (meningococcal meningitis). In the neonate, the cause is most often group

B streptococcus, in infants aged 1 to 23 months the cause are split almost equally between S.

pneumonia andN.meningitides. while college students in general are no more likely to develop

meningitis than other young adults of that age group, subgroups of college students are at

increased risk. In particular, college freshman living in dormitories have a 6-fold greater risk of

developing meningococcal meningitis than those not living in a dormitory. While most colleges

now require vaccination against meningococcal meningitis, the vaccination is not effective

against all strains.

1.2 Problem Formulation

1. What are the functions of the nervous system?2. What are the two main divisons of the nervous system? How are these divisions

subdivided?

3. What is the general structure of a neuron, and what are the functions of three differenttypes of neurons?

4.

What is meningitis disease?5. What are types and classification of meningitis?6. How is etiology of meningitis?7. How does the Nursing Care Plan solve meningitis?


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CHAPTER 2

NEUROLOGIC SYSTEM

2.1 Anatomy and Physiology of Nervous SystemThe nervous system has three specific functions :

1. Sensory input. Sensory receptors present in skin and organ respond to external andinternal stimuli by generating nerve impulses that travel to the brain spinal cord.

2. Integration .The brain and spinal cord sum up the data received from all over the bodyand send out nerve impulses.

3. Motor output. The nerve impulses from the brain and spinal cord go to the effectors,which are muscles and glands. Muscle contractions and gland secretions are responses tostimuli received by sensory receptors.

The nervous system has two major divisions : the central nervous system and the

peripheral nervous system. The central nervous system (CNS) includes the brain and spinal

cord, which have a centrallocation. They lie in the midline of the body. The peripheral nervous

system (PNS) which is further divided into the somatic division and the autonomic division,

includes all the cranial and spinal nerves. Nerves have aperipheral location in the body,

meaning that they project out from the central nervous system. The divison between the central

nervous system and the peripheral nervous system is arbitrary; the two systems work together as

we shall see.


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The nervous system approximately 10 million sensory neurons that send information

about the internaland external environment to the brain and 500.000 motor neurons that control

the muscles and glands. The brain itself contains more than 20 billion nerve cells that link the

motor and sensory pathways, monitor the bodys processes, respond to the internal and external

environment, maintain homeostasis, and direct all psychological, biologic, and physical activity,

through complex chemical and electrical messages (Bradley, Daroff, Fenichel, and Marsden,

2000).

2.2 Cells of The Nervous System

A view through a microscope reveals that the nervous system is made up of two types of

cells; neurons and neuroglial cells.

Neurons are the cells that send information from one part of the body to another. Heat,

sight, smell, and touch are some examples of the types of communication passed along by

neurons. Neurons produce chemicals called neurotransmitters to send information from one


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neuron to another. Neurons also use these chemical messengers to control how muscles flex and

how the digestive system breaks down food.

Neurons located in organs called sensory structures produce nerve impulse after they

receive information from environment. Instead of responding to internal neurotransmitters, they

react to chemicals, light, and pressure. Healthy sensory structures are able to send information

from the environment to neurons. Damage to sensory structures does not usually affect how the

signal stimulates the neurons. Rather, injury to these neurons interferes with how the signal is

passed along to the brain.

Most neurons release one neurotransmitter, although some neurons may also release a

cotransmitter. Frequently, contransmitter, called neuromodulators, are a slightly different type

of chemical than the neurotransmitter. Neuromodulators typically take longer to act than

neurotransmitters, and may function to increase or decrease DNA transcription and protein

synthesis. Neuromodulators often affect the response of a post-synaptic cell to a

neurotransmitter, and are associated with long-term functions such as learning, mood, and

development.

Table. Major Neurotransmitter

Neuroglial cells are the other type of cell that makes up the nervous system. They protect

neurons and help them function. There is a different type of neuroglial cell for each function.

The most common type of neuroglial cell is called a Schwann cell. These cells wrap around

neurons, helping the neuron send faste impulses. Without Schwann cells, the nervous system

would react very slowly, if at all. Aside from helping with impulses, scientist have discovered


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that Scwhann cells also help damaged neurons heal. Other types of neuroglial cells protect

neurons from disease and poisons. Neurons would quickly die without the assistance of these

cells. Infectious microorganisms can damage neuroglial cells as well as neurons. Injury to

neuroglial cells can impair neuron function and even lead to the death of neurons in the brain.

2.2.1 Neuron Structure

Neurons vary in appearance, but all of them have just three parts : a cell body, dendrite

(s), and an axon.

The cell body contains the nucleus as well as other organelles. The nucleus, which

contains the genetic information of the neuron, orchestrates the production of the proteins,

enzymes, and neurotransmitters required by the nerve for its proper function. Nerve cell bodies

occurring in clustsers are called ganglia or nuclei. A cluster of cell bodies with the same function

is called a center (eg, the respiratory center). The cell body delivers these substances as needed to

the rest of the neuron. Although neural excitation typically begins with excitation to the

dendrites, a cell body sometimes may be stimulated directly by incoming stimuli from other

neurons and by chemical and electrical stimuli. The cell body delivers the electrical signal to the

next segment, the axon.

The dendrite is a branch-type structure with synapses for receiving electrochemical

messages. The dendrites are the many short extensions that receives signals from sensoryreceptors or other neurons. At the dendrites, signals can resulting nerve impulses that are then

conducted by an axon. Excitation of a neuron typically begins at the dendrite. The dendrite

passes its excitation on to the adjacent segment, the cell body.

The axon is a long projection that carries impulses away from the cell body. The axon is

the portion of neuron thath conducts nerve impulses. Any long axon is also called a nerve


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fiber.Long axons are covered by an insulating, lipid sheat,called myelin sheath formed from the

membranes of tightly spiraled neuroglia. In the PNS, neuroglial cell called a neurolemmocyte

(Schwann cell) performs this function, leaving gaps called neurofibril nodes (nodes of Ranvier).

In the central nervous system, myelin is produced by a specialized type of cell, the

oligodendrocytes. Myelin increases the velocity with which an electrical signal is transmitted

down an axon, as described. Another type of neuroglial cell performs a similar function in the

CNS.

Axon terminals at the end of each main axon stem and collateral, the branching becomes

extensive. These final divisions of the axon are called axon terminals. It is through axon

terminals that an electrical signal is passed to the dendrites or the cell body of a second neuron.

In the peripheral nervous system, the signal also may pass to a muscle or glandular cell.

The synapse is the point of junction between two neurons. Neurons communicate with

each other by releasing chemicals into the small cleft (synaptic cleft) separating one from the

other. The chemical released from a particular neuron is called a neurotransmitter. Usually, a

neurotransmitter is released from the axon terminal of one neuron, diffuses across the synaptic

cleft, and binds to a receptor on the dendrite or cell body of the other neuron. The cell that

releases the neurotransmitter is called the presynaptic neuron. The neuron that completes the

synapse is called the postsynaptic neuron.


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2.2.2 Types of Neurons

Neurons can be classified according to their function and shape.

Motor neurons or efferent neurons take nerve impulses from the CNS to muscles or

glands. Motor neurons are said to be multipolar because they have many dendrites and a single


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axon. Motor neurons cause muscle fibers to contract or glands to secrete, and therefore they are

said to innervate these structure.

Sensory neurons or afferent neurons take nerve impulses from sensory receptors to the

CNS. The sensory receptor, which is the distal end of the long axon of a sensory neuron, may be

as simple as a naked nerve ending (a pain receptor), or it may be a part of a highly complex

organ, such as the aye or ear. These neurons are the only type of nerve cell that do not have

dendrites. Almost all sensory neurons have a structure that is termed unipolar. In unipolar

neurons, the extension from the cell body divides into a branch that comes to the periphery and

another that goes to the CNS. Because both branches are long and myelinated and transmit nerve

impulses, it is now generally accepted to refer to them collectively as an axon.

Interneurons , also known as association neurons, occur entirely within the CNS.

Almost 99 % of all neurons in the body are interneurons. Interneurons, which are

typically,convey nerve impulses between various parts of the CNS. Some lie between sensory

neurons and motor neurons, and some take messages from one side of the spinal cord and vice

versa. They also form complex pathways in the brain where processes accounting for thinking,

memory, and language occur.

2.3 Central Nervous System

The central nervous system, consisting of the brain and spinal cord, is composed of gray

matter and white matter. Gray matter is gray because it contains cell bodies and short,

nonmyelinated fibers. White matter is white because it contains myelinated axons that run

together in bundles called tracts.

2.3.1 Meninges and Cerebrospinal Fluid

Both the spinal cord and the brain are wrapped in protective membranes known as

meninges (sing., meninx). The outer meninx, the duramater, is though, white, fibrous

connective tissue that lies next to the skull and vertebrae. The dural sinuses collect venous blood

before it returns to the cardiovascular system. Bleeding into the space between the duramater and

bone is called an epidural hematoma. The arachnoid consist of weblike connective tissue with

thin strands that attach it to the piamater, the deepest meninx. The subarachnoid space is filled


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with cerebrospinal fluid, a clear tissue fluid that forms a protective cushion around and within

the CNS. The pia mater is very thin and closely follows the contours of the brain and spinal cord.

Cerebrospinal fluid is stored within the central canal of the spinal cord and in the brains

ventricles,which are interconnecting chambers that also produce cerebrospinal fluid. Normally,

any excess cerebrospinal fluid drains away into the cardiovascular system. However, blockages

can occur.

2.3.2 The Spinal Cord

The spinal cord is a cylinder of nervous tissue that begins at the base of the brain and

extends through a large opening in the skull called the foramen magnum. The spinal cord is

protected by the vertebral column, which is composed of individual vertebrae.

A cross section of the spinal cord shows a central canal, gray matter, and white matter.

The central canal contains cerebrospinal fluid, as do the meninges that protect the spinal cord.

The gray matter is centrally located and shaped like the letter H. Portions of sensory neurons and

motor neurons are found there, as are interneurons that communicate with these two types of

neurons.

The white matter of the spinal cord contains ascending tracts taking information of thebrain (primarily located posteriorly) and descending tracts taking information from the brain

(primarily located anteriorly). Because the tracts cross just after they enter and exit the brain, the

left side of the brain controls the right side of the body, and the right side of the brain controls

the left side of the body.


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Functions of the Spinal Cord

The spinal cord provides a means of

communication between the brain and the peripheral

nerves that leave the cord.

When someone touches your hand, sensory

receptor generate nerve impulses that pass through

sensory fibers to the spinal cord and up one of

several ascending tracts to a sensory area of the

brain. When you voluntarily move your limbs,

motor impulses originating in the brain pass down

one of several descending tracts to the spinal cors

and out to your muscles by way of motor fibers.

The spinal cord is also the center for

thousands of reflex arcs : A stimulus cause sensory

receptor to generate nerve impulses that travel in

sensory neurons to the spinal cord. Interneurons

integrate the incoming data and relay signals to

motor neurons. A response to the stimulus occurs

when motor axons cause skeletal muscles to

contract. Each interneuron in the spinal cord has

synapses with many other neurons, and therefore

they send signals to several other interneurons in

addition to motor neurons.


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2.3.3 Anatomy of The Brain

The brain is divided into three major areas : the cerebrum, the brain stem, and the

cerebellum. The cerebrum is composed of two hemispheres, the thalamus, the hypothalamus,

and the basal ganglia. Additionally, connections for the olfactory (cranial nerve I) and optic

(cranial nerve III) nerves are found in the cerebrum. The brain stem includes the midbrain, pons,

medulla, and connections for cranial nerves II and IV through XII. The cerebellum is located

under the cerebrum and behind the brain stem. The brain accounts for approximately 2% of the

total body weight; it weights approximately 1.400 g in an average young adult (Hickey, 2003). In

the elderly, the average brain weights approximately 1.200 g.

A. Cerebrum

The cerebrum consists of two hemispheres that are incompletely separated by the great

longitudinal fissure. This sulcus separates the cerebrum into the right and left hemispheres. The


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two hemispheres are joined at the lower potion of the fissure by the corpus callosum. The

outside surface of the hemispheres has a wrinkled appearance that is the result of many folded

layers or convolutions called gyri, which increase the surface area of the brain, accounting for

the high level of activity carried out by such a small-appearing organ. The external or outer

portion of the cerebrum (the cerebral cortex) is made up of gray matter approximately 2 to 5 mm

in depht; it contains billions of neurons, giving it a gray appearance. White matter makes up the

innermost layer and is composed of nerve fibers and neuroglia that form tracts or pathways

connecting various parts of the brain with one another (transverse and association pathways) and

the cortex to lower portions of the brain and spinal cord (projection fibers). The cerebral

hemispheres are divided into pairs of frontal, parietal, temporal, and occipital lobes.

1. Frontal- the largest lobe.it contains the motor and premotor areas. The major functionsof this lobe are concentration, abstract thought, information storage or memory, and

motor function. It also contains Brocas area is in the left frontal lobe, critical for motor

control of speech. Many association areas in the frontal lobe receive information from

throughout the brain and incorporate that information into thoughts, plans and

behavior.The frontal lobe is also responsible in large part for an individuals affect,

judgment, personality, and inhibitions.

2. Parietal- a predominantly sensory lobe. The primary sensory cortex, which analyzessensory information and relays the interpretation of this information to the thalamus and

other cortical areas, is located in the parietal lobe. The parietal lobe receives sensory

input for touch and pain. It is also essential to an individuals awareness of the body in

space, as well as orientation in space and spatial relations.

3. Temporal- contains the auditory receptive areas and includes Wernickes area, wherelanguage is interpreted. Contains a vital area called the interpretive area that provides

integration of somatization, visual, and auditory areas and plays the most dominant role

of any area of the cortex in cerebration. It is also involved in the interpretation of smelland is important for the formation and storage of memory. The hippocampus is part of the

temporal lobe.

4. Occipital- the posterior lobe of the cerebral hemisphere is responsible for visualinterpretation. The occipital lobe receives information that originated as signals in the

retina of the eye.


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The corpus callosum is a thick collection of nerve fibers that connects the two

hemispheres of the brain and is responsible for the transmission of information from one side of

the brain to the other. Information transferred includes sensation, memory, and learned

discrimination. Right-handed people and some left-handed people have cerebral dominance on

the left side of the brain for verbal, linguistic, arithmetical, calculating, and analytic functions.

The nondominant hemisphere is responsible for geometric, spatial, visual, pattern, and musical

functions.

The dienchephalon structures lie deep between the cerebral hemispheres. The

diencephalon includes the basal ganglia, the thalamus, and the hypothalamus.

The basal ganglia are masses of nuclei located deep in the cerebral hemispheres that are

responsible for control of fine motor movements, including those of the hands and lower

extremities. The basal ganglia are composed of several structures that can be anatomically or

physiologically separated, including the caudate nucleus, the putamen, and the globus pallidus.

Virtually all projections to and from the basal ganglia go through the thalamus. Lesions of the

basal ganglia cause repetitive movements, grimaces, and tremors, as seen with Huntingtons

disease (chorea) and Parkinsons disease.


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The thalamus lies on either side of the third ventricle and acts primarily as a relay station

for all sensation except smell and in turn relays the information through numerous afferent tracts

to the rest of the cerebral cortex. Function of the cerebral cortex depends on thalamic relay. All

memory, sensation, and pain impulses also pass through this section of the brain.

The hypothalamus is located anterior and interior to the thalamus. The hypothalamus

lies immediately beneath and lateral to the lower portion of the wall of the third ventricle. The

hypothalamus plays an important role in the endocrine system and neural organ responsible for

maintaining homeostasis (constancy of the internal environment) because it regulates the

pituitary secretion of hormones that influence metabolism, reproduction, stress response, and

urine production. It works with the pituary to maintain fluid balance and maintans temperature

regulation by promoting vasoconstriction or vasodilatation. The hypothalamus is the site of the

hunger center and is involved in appetite control. It contains centers that regulate the sleep-wake

cycle, blood pressure, aggressive and sexual behavior,and emotional responses. The

hypothalamus also controls and regulates the autonomic nerveous sytem.

The pituitary gland is located in the sella turcica at the base of the brain and is

connected to the hypothalamus. The pituitary is a common site for brain tumors in adults;

frequently they are detected by physical signs and symptoms that can be traced to the pituitary,

such as hormonal imbalance or visual disturbances secondary to pressure on the optic chiasm.

The posterior portion of each hemisphere (ie, the occipital lobe) is devoted to all aspects

of visual perception. The lateral region, or temporal lobe, incorporates the auditory center. The

midcentral zone, or parietal zone, is concerned with sensation; the anterior portion is concerned

with voluntary muscle movements. The large area behind the forehead (ie, the frontal lobes)

contains the association pathways that determine emotional attitudes and responses and

contribute to the formation of thought processes. Damage to the frontal lobes as a result of

trauma or disease is by no means incapacitating from the standpoint of muscular control orcoordination, but it affects a persons personality, as reflected by basic attitude, sense of humor

and propriety, selfrestaint, and motivations.

The Limbic System. The limbic system is a diffuse grouping of neurons from different

areas of the brain. Neurons in the limbic system include fibers from all lobes of the cerebrum and


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extensive connections from the hypothalamus and thalamus. Midbrain (the pons, medulla

oblongata, and mesencephalon) and hindbrain (cerebellum) areas also sends projections that

contribute to the limbic system. The hippocampus is considered part of the limbic system and

plays an important role in coding and consolidating memories. The amygdale, also considered

part of the limbic system, is involved in the production of emotions, aggression, and sexual

behavior. Learning and behavior are also influenced by several limbic system structures and

connections.

B. Brain Stem

The brain stem consists of the midbrain, pons, and medulla oblongata. The midbrain

connects the pons and the cerebellum with the cerebral hemispheres; it contains sensory and

motor pathways and serves as the center for auditory and visual reflexes. Cranial nerves III and

IV originate in the midbrain. The pons is situated in front of the cerebellum between the

midbrain and the medulla and is a bridge between the twos halves of the cerebellum, and

between the medulla and the cerebrum. Cranial nerves V through VIII connect to the brain in the

pons. The pons contains motor and sensory pathways. Portions of the pons also control the heart,

respiration, and blood pressure.

The medulla oblongata contains motor fibers from the brain to the spinal cord and

sensory fibers from the spinal cord to the brain. The medulla oblongata lies just superior to the

spinal cord, and it contains tracts that ascend or descend between the spinal cord and higher brain

centers.Most of these fibers cross, or decussate, at this level. Cranial nerves IX through XII

connect to the brain in the medulla. The medulla oblongata contains a number of reflex centers

for regulating heartbeat, breathing, and vasoconstriction. It also contains the reflex centers for

vomiting, coughing, sneezing, hiccupping, and swallowing.


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C. Cerebellum

The cerebellum is separated from the cerebral hemispheres by a fold of duramater, the

tentorium cerebella. The cerebellum has both excitatory and inhibitory actions and is largely

responsible for coordination of movement. It also controls fine movement, balance, position

sense (awareness of where each part of the body is), and integration of sensory input.

The cerebellum receives sensory input from the eyes, ears, joints, and muscles about the

present position of body parts. It also receives motor input from the cerebral cortex about where

these parts should be located. After integrating this information, the cerebellum sends motor

impulses by way of the brain stem to the skeletal muscles. In this way, the cerebellum maintains

posture and balance. It also ensures that all of the muscles work together to produce smooth,

coordinated voluntary movements.

2.4 Peripheral Nervous System

The peripheral nervous system (PNS) lies outside the central nervous system and is

composed of nerves and ganglia. Nerves are bundles of myeilinated axons. Ganglia (ganglion)

are swellings associated with nerves that contain collections of cell bodies. As with muscles,

connective tissue separates axons at various levels of organization.

The PNS is subdivided into the somatic system and the autonomic system. The somatic

system serves the skin, skeletal muscles, and tendons. It includes nerves that take sensory

information from external sensory receptors to the CNS and motor commands away from the

CNS to the skeletal muscles. The autonomic system, with a few exceptions, regulates the

activity of cardiac and smooth muscles and glands.

2.4.1 Types of Nerves

The cranial nerves are attached to the brain, and the spinal nerves are attached to the

spinal cord.

A. Cranial Nerves

Humans have 12 pairs of cranial nerves. By convention, the pairs of cranial nerves are

referred to by roman numerals. Most of the cranial nerves belong to the somatic system. Some of


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these are sensory nerve. That is, they contain only sensory fibers. Some are motor nerves,

containing only motor fibers and others are mixed nerves, so called because they contain both

sensory and motor fibers. Cranial nerves are largely concerned with the head, neck, and facial

regions of the body. However, the vagus nerve (X),which has branches to most of the internal

organs, is a part of the autonomic system.

B. Spinal Nerves

Humans have 31 pairs of spinal nerves. One each pair is on either side of the spinal cord.

The spinal nerves are grouped because they are at either cervical, thoracic, or lumbar regions of

the vertebral column. The spinal nerves are designated according to their location in relation to

the vertebrae because each passes through an intervertebral foramen as it leaves the spinal cord.


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Many spinal nerves carry fibers that belong to either the somatic or the autonomic

system. However, the spinal nerves are called mixed nerves because they contain both sensory

fibers that conduct impulses to the spinal cord from sensory receptors and motor fibers that

conduct impulses away from the cord to effectors. The sensory fibers enter the cord via the

posterior root, and the motor fibers exit by way of the anterior root. The cell body of a sensory

neuron is in a posterior (dorsal)- root ganglion. Each spinal nerve serves the particular region

of the body in which it is located .


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2.4.2 Subdivided of The PNS

A. The Au tonomic Nervous System

Autonomic nerve fibers leave the spinal cord and innervate smooth and cardiac muscle

and the endocrine and exocrine glands. Autonomic nerves fibers are considered involuntary

because there is little conscious control over their function. These two divisions of the autonomic

nervous system, the sympathetic and parasympathetic. Sympathetic and parasympathetic

nerves innervate many of the same organs but typically cause opposite responses. The cell bodies

of these neurons lie in the brain or spinal cord. In both divisions of the autonomic system, two

nerve fibers participate in the efferent pathway.

1. The sympathetic nervous system. The first fibers of the sympathetic nerves, called thepreganglionic fibers, leave from the thoracic or lumbar regions of the spine. Soon after

leaving the spine, a preganglionic fiber joins other preganglionic fibers to form an

autonomic ganglion. At this point, the preganglionic fiber synapses on the second nerve

fiber of the system, the postganglionic fiber, and releases acetylcholine, which causes the

postganglionic fiber to fire an action potential. From the autonomic ganglia, the

postganglionic fiber travels to its target organ, the muscle or gland. The sympathetic

postganglionic fiber usually releases the neurotransmitter norepinephrine. Target organ

receptors for norepinephrine are called adrenergic receptors.

2. The parasympathetic nervous system. The fibers of the parasympathetic nervoussystem leave the brain in the cranial nerves or leave the spinal cord from the sacral area.

The preganglionic fiber of the parasympathetic system is typically long and travels to an

autonomic ganglion located near the target organ. Preganglionic parasympathetic nerves

release acetylcholine that then stimulates the postganglionic fiber. The parasympathetic

postganglionic fiber then travels a short distance to its target tissue, a muscle or a gland.

This nerve also releases acetylcholine. Preganglionic acetylcholine receptors for

sympathetic and parasympathetic fibers are called nicotinic receptors. Postganglionicacetylcholine receptors are called muscarinic receptors. These names relate to the

experimental stimulation of the receptors by nicotine and muscarine (a mushroom

poison).


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B. The Somatic Nervous System

Somatic nerves of the peripheral nervous system consist of efferent motor neurons that

leave the brain or spinal cord and synapse directly on skeletal muscle cells. Motor neurons are

large myelinated nerves that release acetylcholine at the neuromuscular junction. Acetylcholine

binds to receptors on a specialized area of the muscle cell, called the end plate. Binding of

acetylcholine causes the muscle cell to reach threshold, resulting in an action potential and the

opening of calcium channels (gates) in the membrane. This leads to an increase in intracellular

calcium and contraction of the skeletal muscle fiber. There are no inhibitory motor neurons.


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CHAPTER III

MENINGITIS

3.1 Introduction of Meningitis

The meninges (dura, archnoid, and pia meter)are the coverings surrounding the brain.

The purpose of meninges is to protect the brain and spinal cord from invading organism.

Meningitis is the inflammation of the meningeal coverings of the brain and spinal cord,

most commonly due to bacterial or viral cause, although it can also be caused by fungus,

protozoa, or toxic exposure. Infection and inflammation (caused by pathogens releasing toxins)

can progress rapidly due to the circulating CSF around the brain and spinal cord. Bacterial

meningitis is the most common and is typically due to Streptococcus pneumonia

(pneumococcal), Neisseria meningitides (meningococcal), or Haemophilus influenza. The

incidence ofH. influenza meningitis infections has decreased since the vaccine againstH.

influenza began to be used routinely in infants in the early 1900s. Other organisms that can cause

bacterial meningitis include Staphylococcus aureus, Escherichia coli and Pseudomonas. Organis

typically travel either through the bloodstream to the central nervous system or enter by direct

contamination (skull fracture or extension from sinus infections). The body is normally home to

many types of microorganisms that live on the skin and the inner mucous membrane surfaces of

the digestive system, reproductive tract, respiratory system and urinary tract. Bacterial meningitis

is more common in colder months when upper respiratory tract infections are more common.

People in close living conditions, such as prisons, military barracks, or college dorms are at

greater risk for outbreaks of bacterial meningitis due to likelihood of transmission.

Viral meningitis may follow other viral infections, such as mumps, herpes simplex or

zoster, enterovirus and measles. Viral meningitis is often a self-limiting illness.

The pathogens that cause meningitis are very attracted to the nervous system and must

overcome many barriers to get there (invade the CNS). The pathogens usually colonize and

multiply in the nasopharyngeal area, break into the bloodstream, and then break through the

blood-brain barrier. In addition, the pathogen must be able to survive the bodys natural immune

response and the inflammatory response as well. These pathogens are very determined.


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Patients who are immunocompromised have an increased risk for contracting a fungal

meningitis. This may travel from bloodstream to the central nervous system or by direct

contamination. Cryptococcus neoformans may be the causative organism in the patients.

Diseases that are difficult to predict and that appear without warning cause what

scientists call silent outbreaks. The term outbreaks refers to the rapid spread of a disease among

many people living within a certain area. Almost all cases of meningitis were confirmed across

the metropolitan area.

3.2 Pathophysiology

Meningeal infections generally originate in one of two ways : through the bloodstream as

consequence of other infections, or by direct extension, such as might occur after a traumatic

injury to the facial bones, or secondary to invansive procedures.

N.meningitidis concentrates in the nasopharynx and is transmitted by secretion or aerosol

contamination. Bacterial or meningococcal meningitis also occurs as an opportunistic infection

in patients with acquired immunodeficiency syndrome (AIDS) and as a complication of Lyme

disease.S.pneumoniae the most frequent causative agent bacterial meningitis associated with

AIDS (Rosenstein, Perkins, Stephens et al.,2001).

Once the causative organism enters the bloodstream,it crosses the blood-brain barrier and

causes an inflammatory reaction in the meninges. Independent of the causative

agent,inflammation of the subarachnoid space and piamater occurs. Since there is little room for

expansion within the cranial vault,the inflammation may cause increased intracranial pressure.

Cerebrospinal fluid (CSF) flows in the subarachnoid space, where inflammatory cellular material

from the affected meningeal tissue enters and accumulates in the subarachnoid space,thereby

increasing the CSFcell count (Coyle, 1999).

Some bacteria that cause meningitis, especially meningococci, shed bubbles of poisonous

endotoxin as they circulate in the blood. The bubbles seem to act as decoys, making it difficult

for the immune system to identify the bacteria. Antibiotics have no effect on endotoxin. In fact,

bacteria release even more endotoxin as they die, making the patient even sicker.

Endotoxin has two major effects on the body. First, it weakens the myocardium, leading

to decreased cardiac output, systemic hypoxia and shock. Second, endotoxin leads to

disseminated intravascular coagulation.


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As white blood cells engulf the bacteria, endotoxin makes them sticky, causing them to

adhere to and damage the linings of the blood vessels. The body tries to repair the damaged

blood vessels, but endotoxin disrupts clotting mechanisms. Tiny blood clots form in vessels all

over the body. The vessels walls disintegrate, letting blood leak into surrounding tissue and

damaging organs, such as the kidneys and lungs. The distinctive petechial rash of meningococcal

sepsis results from bleeding under the skin. Unlike rashes caused by other diseases (for example,

measles), the rash caused by meningococcal infection doesnt blanch when pressed.

The prognosis for bacterial meningitis depends on the causative organism,the severity of

the infection and illness,and the timeliness of treatment. In acute fulminant presentations there

may be adrenaldamage, circulatory collapse, and widespread hemorrhages (Waterhouse-

Friderichsen syndrome).this syndrome is the result of endothelial damage and vascular necrosis

caused by the bacteria. Complications include visual impairment,deafness,seizures,paralysis,

hydrocephalus,and septic shock.

Bacterial meningitis still has a significant mortality rate and these patients need to be

managed in the hospital. Some patients will have permanent neurologic effects following the

acute episode. Viral meningitis is typically self-limiting. Fungal meningitis often occurs in

patients who are immunocompromised. Patients who are have comorbidities or are eldery have

greater difficulty with the symptoms of meningitis.

3.3 Types and Classification of Meningitis

3.3.1 Viral Meningitis

One of the most common, but least dangerous, forms of meningitis is a viral meningitis in

the spring and fall seasons. Viral meningitis will normally clear up by itself without

complications. Viral meningitis is sometimes called aseptic meningitis when doctors attempt but

fail to produce a positive identification of the underlying virus. Nearly every aseptic meningitis

is caused by a virus. The condition generally lasts 7 to 10 days and although serious, is rarely

fatal in people with normal immune systems.

Many different viruses can cause meningitis, including herpes simplex types 1 and 2,

mumps, influenza, Epstein-Barr, measles, rubella, and polio, among other. The most common

causes of viral meningitis are enteroviruses. These viruses normally live in the intestines.

Enteroviruses like Coxsackie and Echovirus are often the cause of viral meningitis. Since many


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people who have it do not get sick enough to seek medical attention, it is difficult to know how

wide-spread viral meningitis might be.

In populations where vaccinations are common, some of these causes of meningitis are

rare. Other viruses that may cause meningitis include those spread by mosquitoes, ticks and other

insects.

3.3.2 Fungal Meningitis

Fungi can also cause meningitis. Candida, Histoplasma, Coccidioides, and Cryptococcus

fungi have all been responsible for meningitis infections. Most cases of fungal meningitis occur

in people who are already sick with a disease like AIDS, which has suppressed their immune

systems and the loss of immunity associated with aging. The fungi that cause meningitis are

found in the environment and are spread on air currents. Healthy people will not develop

meningitis from breathing in these particles. Several of these fungi are found in soil, and others,

like Candida, are found everywhere, including on human skin and inside the intestine.

The most common fungal meningitis is cryptococcal meningitis due to Cryptococcus

neofarmans.in Africa, cryptococcal meningitis is estimated to be the most common cause of

meningitis and it accounts for 20-25 % of AIDS-related deaths in Africa.Meningitis caused by

Coccidiodes immitis is called coccidiodal meningitis. If left untreated, it is usually fatal. This

fungus lives in the soil.

3.3.3 Bacterial Meningitis

The most common form, can be community acquired or associated with prior infection.

Other causes include injury, facial or basilar skull fractures, shunt occlusion /malfunction,

craniotomy, otitis media, sinusitis, or bacteremia (e.g., endocarditis, pneumonia).

Streptococcus pneumonia, a gram-positive cocci, has been the leading cause of adult

meningitis in United States.Pneumococcal meningitis occurs in crowded conditions and is

spread seasonally (fall and winter). This organism is not prevalent as a cause of meningitis since

the development of Pneumovax and Prevnar vaccines. Pneumococcal meningitis may occur

following an upper respiratory tract infection (URI) or nasopharyngeal colonization with

pneumococcal strain, is a complication of conditions associated with CSF leaks, is associated

with asplenia and is more prevalent in immunocompromised persons and in older adults.


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Neisseria meningitidis, is a gram-negative cocci, is the second leading cause of

meningitis in adults. Infection is more likely to occur in patients with complement component

deficiencies (e.g., conginetal or associated with nephritic syndrome, hepatic failure, systemic

lupus erythematosus, multiple myeloma).

Haemophilus influenza,a gram-negative bacilli, is the most common cause in children.

However it may affect adults. Predisposing factors include URIs, hypogammaglubulinemia,

diabetes mellitus, alcoholism, and head trauma.

Listeria monocytogenes, a gram-positive bacilli, is being seen more frequently as a cause

of meningitis, especially in immunocompromised patients and those of extreme ages. Outbreaks

have been linked to consumption of contaminated dairy products, undercooked chicken, fish, and

meats.

Gram-negative species (E.Coli. Klebsiella, Proteus, and Pseudomonas) are increasing in

prevalence as a nosocomial cause secondary to trauma or neurosurgical procedurs. Spontaneous

gram-negative meningitis is found in older adults, the immunocompromised, or persons with

underlying conditions such as cirrhosis, diabetes, malignancy, or splenectomy. The urinary tract

is the usual portal of entry of bacteria.

Other microbes :Mycobacterium pneumonia, B. burgdorferi, and Treponeme pallidum

are also associated with meningitis.

Other surgical procedures complicated by gram-negative infections are

ventriculoperitoneal shunts, craniofacial repair, ventriculostomy, hypophysectomy, reservoir

insertion, and myelography.

The types of bacteria that cause bacterial meningitis vary according to the infected

individual's age group.

In premature babies and newborns up to three months old, common causes aregroup Bstreptococci(subtypes III which normally inhabit the vagina and are mainly a cause

during the first week of life) and bacteria that normally inhabit the digestive tract such as

Escherichia coli(carrying the K1 antigen).Listeria monocytogenes(serotype IVb) may

affect the newborn and occurs in epidemics.
http://en.wikipedia.org/wiki/Premature_birthhttp://en.wikipedia.org/wiki/Infanthttp://en.wikipedia.org/wiki/Group_B_streptococcushttp://en.wikipedia.org/wiki/Group_B_streptococcushttp://en.wikipedia.org/wiki/Group_B_streptococcushttp://en.wikipedia.org/wiki/Group_B_streptococcushttp://en.wikipedia.org/wiki/Vaginahttp://en.wikipedia.org/wiki/Gastrointestinal_tracthttp://en.wikipedia.org/wiki/Escherichia_colihttp://en.wikipedia.org/wiki/Escherichia_colihttp://en.wikipedia.org/wiki/Listeria_monocytogeneshttp://en.wikipedia.org/wiki/Listeria_monocytogeneshttp://en.wikipedia.org/wiki/Listeria_monocytogeneshttp://en.wikipedia.org/wiki/Listeria_monocytogeneshttp://en.wikipedia.org/wiki/Escherichia_colihttp://en.wikipedia.org/wiki/Gastrointestinal_tracthttp://en.wikipedia.org/wiki/Vaginahttp://en.wikipedia.org/wiki/Group_B_streptococcushttp://en.wikipedia.org/wiki/Group_B_streptococcushttp://en.wikipedia.org/wiki/Infanthttp://en.wikipedia.org/wiki/Premature_birth


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Older children are more commonly affected byNeisseria meningitidis(meningococcus)andStreptococcus pneumoniae(serotypes 6, 9, 14, 18 and 23) and those under five by

Haemophilus influenzae type B (in countries that do not offer vaccination).

In adults,Neisseria meningitidis and Streptococcus pneumoniae together cause 80% ofbacterial meningitis cases. Risk of infection withListeria monocytogenes is increased in

persons over 50 years old. The introduction of pneumococcal vaccine has lowered rates

of pneumococcal meningitis in both children and adults.

Recent skull traumapotentially allows nasal cavity bacteria to enter the meningeal space.

Similarly, devices in the brain and meninges, such as cerebral shunts, extraventricular drains or

Ommaya reservoirs, carry an increased risk of meningitis. In these cases, the persons are more

likely to be infected with Staphylococci, Pseudomonas, and otherGram-negativebacteria. Thesepathogens are also associated with meningitis in people with an impaired immune system. An

infection in the head and neck area, such as otitis media ormastoiditis, can lead to meningitis in

a small proportion of people. Recipients ofcochlear implants for hearing loss risk more a

pneumococcal meningitis.

Tuberculous meningitis, which is meningitis caused byMycobacterium tuberculosis, is

more common in people from countries where tuberculosis is endemic, but is also encountered in

persons with immune problems, such as AIDS.

Recurrent bacterial meningitis may be caused by persisting anatomical defects, either

congenital or acquired, or by disorders of the immune system. Anatomical defects allow

continuity between the external environment and the nervous system. The most common cause

of recurrent meningitis is a skull fracture, particularly fractures that affect the base of the skull or

extend towards the sinuses and petrous pyramids. Approximately 59% of recurrent meningitis

cases are due to such anatomical abnormalities, 36% are due to immune deficiencies (such as

complement deficiency, which predisposes especially to recurrent meningococcal meningitis),

and 5% are due to ongoing infections in areas adjacent to the meninges.
http://en.wikipedia.org/wiki/Neisseria_meningitidishttp://en.wikipedia.org/wiki/Neisseria_meningitidishttp://en.wikipedia.org/wiki/Neisseria_meningitidishttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Haemophilus_influenzaehttp://en.wikipedia.org/wiki/Haemophilus_influenzaehttp://en.wikipedia.org/wiki/Physical_traumahttp://en.wikipedia.org/wiki/Cerebral_shunthttp://en.wikipedia.org/wiki/Extraventricular_drainhttp://en.wikipedia.org/wiki/Ommaya_reservoirhttp://en.wikipedia.org/wiki/Staphylococcihttp://en.wikipedia.org/wiki/Pseudomonashttp://en.wikipedia.org/wiki/Gram-negativehttp://en.wikipedia.org/wiki/Immunodeficiencyhttp://en.wikipedia.org/wiki/Otitis_mediahttp://en.wikipedia.org/wiki/Mastoiditishttp://en.wikipedia.org/wiki/Cochlear_implanthttp://en.wikipedia.org/wiki/Tuberculous_meningitishttp://en.wikipedia.org/wiki/Mycobacterium_tuberculosishttp://en.wikipedia.org/wiki/Mycobacterium_tuberculosishttp://en.wikipedia.org/wiki/Mycobacterium_tuberculosishttp://en.wikipedia.org/wiki/Tuberculosishttp://en.wikipedia.org/wiki/AIDShttp://en.wikipedia.org/wiki/Congenitalhttp://en.wikipedia.org/wiki/Immune_systemhttp://en.wikipedia.org/wiki/Nervous_systemhttp://en.wikipedia.org/wiki/Skull_fracturehttp://en.wikipedia.org/wiki/Paranasal_sinuseshttp://en.wikipedia.org/wiki/Petrous_pyramidshttp://en.wikipedia.org/wiki/Complement_deficiencyhttp://en.wikipedia.org/wiki/Complement_deficiencyhttp://en.wikipedia.org/wiki/Petrous_pyramidshttp://en.wikipedia.org/wiki/Paranasal_sinuseshttp://en.wikipedia.org/wiki/Skull_fracturehttp://en.wikipedia.org/wiki/Nervous_systemhttp://en.wikipedia.org/wiki/Immune_systemhttp://en.wikipedia.org/wiki/Congenitalhttp://en.wikipedia.org/wiki/AIDShttp://en.wikipedia.org/wiki/Tuberculosishttp://en.wikipedia.org/wiki/Mycobacterium_tuberculosishttp://en.wikipedia.org/wiki/Tuberculous_meningitishttp://en.wikipedia.org/wiki/Cochlear_implanthttp://en.wikipedia.org/wiki/Mastoiditishttp://en.wikipedia.org/wiki/Otitis_mediahttp://en.wikipedia.org/wiki/Immunodeficiencyhttp://en.wikipedia.org/wiki/Gram-negativehttp://en.wikipedia.org/wiki/Pseudomonashttp://en.wikipedia.org/wiki/Staphylococcihttp://en.wikipedia.org/wiki/Ommaya_reservoirhttp://en.wikipedia.org/wiki/Extraventricular_drainhttp://en.wikipedia.org/wiki/Cerebral_shunthttp://en.wikipedia.org/wiki/Physical_traumahttp://en.wikipedia.org/wiki/Haemophilus_influenzaehttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Neisseria_meningitidis


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3.3.4 Parasitic Meningitis

A parasitic meningitis is more common in underdeveloped countries and usually is

caused by parasites found in contaminated water, food, and soil.

A parasitic cause is often assumed when there is a predominance ofeosinophils (a type

of white blood cell) in the CSF. The most common parasities implicated are Angiostrongylus

cantonensis, Gnathostoma spinigerum, Schistosoma as well as the conditions cysticercosis,

taxocariasis, baylisascariasis, paragonimiasis, and a number of rare infections and noninfective

conditions.

3.3.5 Non-infectious Meningitis

Non-infectious meningitis may develop as a complication of another illness (e.g., mumps,

tuberculosis, syphilis ). A break in the skin and/ or bones in the face or skull (caused by birth

defect, brain surgery, head injury) can allow bacteria to enter the body.

Meningitis may occur as the result of several non-infectious causes : spread of cancer to

the meninges (maglinant or neoplastic meningitis) and certain drugs (mainly non-steroidal, anti

inflammatory drugs, antibiotics and intravenous immunoglobulins). It may also be caused by

several inflammatory conditions, such as systemic lupus erythematosus, and certain forms of

vasculitis (inflammatory conditions of the blood vessel wall), such as Behcets disease.

Epidermoid cysts and dermoid cysts may cause meningitis by releasing irritant matter into

subarachnoid space. Mollarets meningitis is a syndrome of recurring episodes of aseptic

meningitis. It is thought to be caused by herpes simplex virus type 2. Rarely, migraine may cause

meningitis, but this diagnosis is usually only made when other causes have been eliminated.

3.4 Etiology of Meningitis

Meningitis is a particularly dangerous infection because of the very delicate nature of the

brain. Brain cells are some of the only cells in the body that, once killed, will not regenerate

themselves. Therefore, if enough brain tissue is damaged by an infection, serious, life-long

handicaps will remain.

In order to learn about meningitis, it is important to have a basic understanding of the

anatomy of the brain. The meninges are three separate membranes, layered together, which

encase the brain and spinal cord:


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The dura is the toughest, outermost layer, and is closely attached to the inside of theskull.

The middle layer, the arachnoid, is important because of its involvement in the normalflow of the cerebrospinal fluid (CSF), a lubricating and nutritive fluid that bathes both the

brain and the spinal cord.

The innermost layer, the pia, helps direct blood vessels into the brain. The space between the arachnoid and the pia contains CSF, which helps insulate the brain

from trauma. Many blood vessels course through this space.

CSF, produced within specialized chambers deep inside the brain, flows over the surface

of the brain and spinal cord. This fluid serves to cushion these relatively delicate structures, as

well as supplying important nutrients for brain cells. CSF is reabsorbed by blood vessels locatedwithin the meninges. A careful balance between CSF production and reabsorption is important to

avoid the accumulation of too much CSF.

Because the brain is enclosed in the hard, bony case of the skull, any disease that

produces swelling will be damaging to the brain. The skull cannot expand at all, so when the

swollen brain tissue pushes up against the skull's hard bone, the brain tissue becomes damaged

and may ultimately die. Furthermore, swelling on the right side of the brain will not only cause

pressure and damage to that side of the brain, but by taking up precious space within the tight

confines of the skull, the left side of the brain will also be pushed up against the hard surface of

the skull, causing damage to the left side of the brain as well.

Another way that infections injure the brain involves the way in which the chemical

environment of the brain changes in response to the presence of an infection. The cells of the

brain require a very well-regulated environment. Careful balance of oxygen, carbon dioxide,

sugar (glucose), sodium, calcium, potassium, and other substances must be maintained in order

to avoid damage to brain tissue. An infection upsets this balance, and brain damage can occur

when the cells of the brain are either deprived of important nutrients or exposed to toxic levels of

particular substances.

The cells lining the brain's tiny blood vessels (capillaries) are specifically designed to

prevent many substances from passing into brain tissue. This is commonly referred to as the


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blood-brain barrier. The blood-brain barrier prevents various substances that could be poisonous

to brain tissue (toxins), as well as many agents of infection, from crossing from the blood stream

into the brain tissue. While this barrier is obviously an important protective feature for the brain,

it also serves to complicate treatment in the case of an infection by making it difficult for

medications to pass out of the blood and into the brain tissue where the infection is located.

3.5 Clinical Appearance

3.5.1 Assessment Meningitis

A complete neurologic examination should be performed to establish the patients

baseline neurologic function. One or more tests for meningitis usually are positive. Examination

of associated systems (head, eye, ear, nose, and throat and pulmonary ) provides additional data.

Bacterial meningitis presents with classic symptoms of fever, altered mental status, headache,

and nuchal rigidity. Immediate diagnosis and isolation of the organism are paramount in this life

threatening disease. Delay in obtaining necessary information needed to diagnosis and threat the

underlying organism will increase more morbidity and mortality.

A. History and Risk Factors

a. History of presents illness1. Times courses for symptoms development.2. Recent infection (respiratory/ ear)3. Recent trauma to the head.4. Exposure of the meningitis.5. Use of antibiotics.6. Petechial or ecchymotic rash.7. Ear or nose drainage.

b. Medical / social history1. Drug allergies.2. Past medical history.3. Recent surgical procedure.4. Immune compromising condition.5. IV drug use6. HIV status or risk behaviors


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7. Travel to endemic meningococcal areaB. Vital Sign

a. BP, HR, and RR changes : may further alter cerebral tissue perfusion. Monitored, rhythm,and death of respiration for changes or abnormal breathing patterns.

b. Hipertermia : may be associated with injury or irritation of the hipotalamic temperatureregulating center, presents of blood on the CSF, or infection. Elevated temperature

increases the metabolic needs of the brain, potentially leading to increased blood flow to

the area, with concomitant cerebral hyperemia.

C. Observations

Level of consciousness (LOC): when assessing LOC it is important to not use subjective term

such as stuporor lethargy but rather to assess and communicate clearly the description

patients of the spontaneous activity response, response to verbal stimuli and reaction to painfull

stimuli, and how this differs from previous assessment. Assess for an acute changes in mental

status or fluctuation in mental status ; voriuos scale can be used that include LOC and other key

indicators. Examples are the Richmond Agitation and Seadtion Score (RASS) and GCS.

Pupillary changes: Examine puppils for size (In mm), shape, simetry, reactivity, contriction,

consensual response, and accommodation. Pupillary abnormalitys can indicate unilateral or

bilateral brain disfunction, interruption of sympathetic or parasympathetic pathways, damage in

the brainstem, cranial nerve damage, and herniation.

Clinical Presentation

a. S.pneumoniae: The classic presentation of pneumococcal meningitis is fewer, headache,meningismus, and altered mental status that prograsses quickly to coma. Nuchal regality

an Kernig or Brudzinski sign. Nousea, fomitting, profuse sweats, weakness, myalgia,

seizures, and cranial nerve palsies also may be present.

b. N. meningitidis : Patients may quickly deteriorate, beginning with fever and earlymacular erythematous rash that progresses rapidly to petechial and purpuric states,

conjunctival petechiae, and aggressive behavior. Dysfunctions of cranial nerves VI, VII,


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and VIII and aphasia, ventriculitis, subdural empyema, cerebral venous thrombosis, and

disseminated intravascular coagulation (DIC) may occur.

c. H. influenza : The most distinguishing sign is early development of deafness, which canoccur within 24 to 36 hours after onset. A morbilliform or petechial rash may be present.

d. L. monocytogenes : Seizures and focal deficits such as ataxia, cranial nerve palsies, andnystagmus are seen early in the course of infection. Conclusive diagnosis may require

serology testing.

e. Gramnegative species : In older adults, fever may be absent or low grade and headachemay not be reported. Meningeal signs may be subtle, but confusion, severe mental status

changes, and pneumonia are commonly reported. Nuchal rigidity in older adults must be

differentiated from degenerative changes of the cervical spine.

f. B. burgdorferi : The symptoms of meningitis may be preceded by symptoms of Lymedisease, which occur in three stages. The first stage is a bulls eye rash within a few

days of the tick bite followed by headache, stiff neck, lethargy, irritability, and changes in

mental status, especially memory loss. Stage two , weeks to months after the tick deficits,

mental status changes, peripheral neuropathies, and myalgias. In the last or third stage ,

arthritic types of symptoms and brain parenchymal changes are apparent.

g. Acute meningitis with negative Gram stain : Fever and neck stiffness are the mostfrequent findings. The Gram stain for bacteria is negative, but CSFWBC count elevated.

Symptoms are similliar to those for other types of meningitis.

h. M. tuberculosis : A slow-onset process that causes neurologic damage before treatment issought. Symptoms include headache, lethargy, confusion, nuchal rigidity, cranial nerve

abnormalities, SIADH, weight loss, and night sweats. Kernig and Brudzinki sign are

present. The chest radiographic results may be clear, and purified protein derivative

(PPD) may be nonreactive.

i. Cryptococcus neoformans : Because the infection is subacute, fever and headache mayhave a subtle pattern lasting for weeks while other symptoms of meningitis accur,

including positive meningeal signs, alterations in mental status (e.g hyperactivity, bizarre

behavior, emotional lability, poor judgment), photophobia, focal cranial nerve deficits,

nausea, vomiting and rarely seizures.


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j. Aseptic meningitis syndrome : Fever, headache, stiff neck, fatigue, anorexia, and alteredLOC are seen several hours after ingestion of causative drug. Severity varies with amount

of drug taken and previous exposure. CSF glucose may be slightly elevated.

D. Functional Assesment

1. Assess motor function and sensory responsesa. Motor : Assess motor movement in extremities related to strength, symmetry of

movement and coordination. Assess for abnormal motor movements unilaterally

and bilaterally, such as decorticate posturing, decerebrate posturing, or flaccidity.

Motor deficits (weakness or paralysis) are caused by injury or edema to the

primary motor cortex and corticospinal (pyramidal) tracts.

b. Sensory : Assess perception of touch, proprioception, pain, temperature, andvibration. Superficial and deep reflexes are tested on symmetrical side of the body

and compared noting the strength of contraction. Sensory deficits occur when the

primary sensory cortex, the sensory association areas of the parietal lobe, or

spinothalamic tracts are injured or edematous.

2. Assess for cranial nerve impairment : Cranial nerve deficits may improve as cerebraledema resolves or may be permanent. Nursing assessment of cranial nerve dysfunction is

important.

E. Screening Labwork

1. CSF analysis : Evaluates the color, WBC count, differential, glucose content, and proteinlevel.

2. Complete blood count, electrolytes, and coagulation studies : Evaluate for anemia, hypoor hyperglycemia; potential for hemorrhage or infection.

3.5.2 Diagnostic Tests

Bacterial meningitis presents with classic symptoms of fever, altered mental status,

headache, and nuchal rigidity. Immediate diagnosis and isolation of the organisms are

paramount in this life-threatening disease. Delay in obtaining the necessary information

needed to diagnosis and treat the underlying organism will increase morbidity and mortality.


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Diagnostic Tools

1. In patients with suspected acute bacterial meningitis for whom there is no clinicalcontraindication, the CSF is collected through lumbar puncture and examined for white

blood cells and microorganism sensitivity. Elevated protein, elevated neutrophils, and

low glucose in the CSF indicate meningitis.

2. Laboratory studies for viral meningitis are not indicated (e.g., normal glucose, elevatedlymphocytes).

3. Rapid diagnostic of CNS infection is essential. This is especially true of meningitis. CTscan and MRI may be used to evaluate the degree of swelling and sites of necrosis. CT is

very rapid and is most useful in emergency situations.

4. Corticosteroid (dexamethasone) therapy to reduce inflammation appears to be beneficialfor the adjuvant treatment of most adults with suspected pneumococcal meningitis.

3.5.3 Collaborative Management

Care Priorities

1. Control Prioritiesa. Antibiotic therapy: There are two major caveats to treating bacterial meningitis. First, the

bactericidal agent must be effective against the organism and second, the agent must

achieve a bacteriodical effect within the CSF. Only IV antibiotics should be used, expect

for fifampin which is useful as synergistic agent.

b. Rapid sterilization of the CSF via appropriate pharmacologic thingerapy (Table 7-4) :Prophylaxis, using appropriate antimicrobials for people to N. meningitidis (rimfampin or

spiramycin) or H. influenza meningitis, is recommended.

2. Rapid inflammation with adjunctive pharmacologic therapies: Dexamethasone may decrase

inflammation by reducing cytokines produced by bacterial products. In recent study result,improvement in outcome, decrease in neurologic sequelae, and reduction in mortality with

the use of dexamethasone have been reported. Recommended dosing is 0.15 mg/kg ever 6

hours for 4 days. Start dose with or just prior to first antibiotic dose.


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Table . Common Drug Therapy For The Management of Meningitis

Causative agent Characteristic Therapy

Bacterial Meningitis

S. pneumonia Gram-positive cocci Penicillin (PCN), ceftriaxone,

cefotaxime, vancomycin with

ceftriaxone if beta-lactam

resistance; chloramphenicol

for PCN allergies

H. influenza Gram-negative bacilli Cefotaxime or ceftriaxone,

add rifampin if pharyngeal

colonization

N. meningitides Gram-negative cocci Penicillin G, add rifampin,

fluoroquinolones, or

chepalosporin if pharyngeal

colonization; alternative is

thirdgeneration

chepalosporin (cefotaxime)

L. monocytogenes Gram-positive bacilli Penicillin G or ampicillin with

gentamycin for synergy; ifallergi to PCN, the

trimethoprim-

sulfamethoxazole

M. tuberculosis Acid-fast bacteria Isoniazid, rifampin,

ethambutol, pyrazinamide

B. burgdorferi Spirochete Ceftriaxone or penicillin G

Fungal

C. neofarmans Fungus Amphotericin B + flucytosine,

fluconazole, or itraconazole

Cocci Gram-positive Vancomycin + penicillin G +

aminoglycosides


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Gram-negative Penicillin G

Bacilli

Gram- positive Ampicillin, penicillin +

aminoglycosides

P. aeruginosa, Klebsiella, E.

coli, Citrobacter,

Acinetrobacter, Enterobacter,

Serratia marcescens

Gram-negative High doses of third-generation

cephalosporins +

aminoglycosides

3. Maintain fluid and electrolyte balance: Overhydration and underhydration can lead toadverse effects. Research supports the use of IV maintance fluids over fluid restriction during

the first 48 hours of treatment of bacterial meningitis. Electrolyte imbalance should be

corrected.

4. Provide adequate nutrition: Oral feeding should be encouraged when possible. Enteral orparenteral feeding may be initiated. Parenteral nutrition is used if enteral feeding is not

tolerated. Hydration should be maintained. Several nutrients can help strengthen the immune

system, possibly helping to prevent meningitis or build up the immune system after

meningitis has been treated, though scientific studies have not examined these nutrients

specifically for meningitis.5. Control seizures with anticonsulvant therapy : used prophylactically or if seizures occur.

Seizures increase metabolic rate and cerebral blood flow, which may cause deterioration in

patients with cerebral edema and intracranial hypertension.

6. Maintain normothermia/ control fever : helps prevents intracranial hypertension associatedwith increased metabolic rate. Fever should be controlled by antipyretics such as

acetaminophen or use of other cooling measures such as tepid baths.

7. Prevent infection : Vaccines are currently avalaible for meningitis prophylaxis, including thefollowing : (1) influenza type B (Hib), given as a childhood immunization; (2) bacillus

Calmette-Guerin (BCG), used for tuberculosis, also prevents tuberculosis meningitis; (3)

pneumococcal vaccine recommended for those who are chronically ill and adults over 65

years of age, and (4)N.meningitides vaccine for specific or combined prophylaxis for five


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investigational subgroups. The CDC guidelines recommend Transmission- Based

Precautions be implemented until effectiveness of antimicrobial treatment is established.

8. Facilititate mobility : Physical therapy (PT), occupational therapy (OT), and speech therapyshould be initiated as soon as patient is stable, to minimize physical and cognitive

complications.

9. Monitor neurologic function at least every 2 to 4 hours, changes in mental status, level ofconsciousness, pupil reactions, speech, facial kovement symmetry, and signs of increased

intracranial pressure.

10.Respiratory isolation (until pathogen identified and for 24 hours after antibiotics started).11.Evaluate the need for support services : Evaluate the need for home health care, support

groups, and social services.


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CHAPTER 4

CONCLUSION

4.1 Conclusion

The nervous system permits sensory input, performs integration and stimulates motor

output. The nervous system is divided into the central nervous system (brain and spinal cord) and

the peripheral nervous system (somatic and autonomic nervous system). The CNS lies in the

midline of the body, and the PNS is located peripherally to the CNS. The CNS, consisting of the

spinal cord and brain, is protected by the meninges and the cerebrospinal fluid. The PNS, in the

somatic system, cranial nerves take impulses to and/or from the brain. Spinal nerves take

impulses to and from the spinal cord. The autonomic nervous system controls the functioning of

internal organs. The autonomic nervous system consisting of the sympathetic divion and the

parasympathetic divion. Nervous tissue contains neurons and neuroglia. Each type of neuron

(motor, sensory, and interneuron) has three parts (dendrites, cell body, and axon). Neuroglia

support, protect, and nourish the neurons.

The diverse group of neurologic disorders that make up infectious and autoimmune

disorders. Infectious processes of the nervous system sometimes cause death permanent

dysfunction.The infectious disorders of the nervous system include meningitis.

Meningitis as a serious inflammation of the meninges, the thin, membranous covering of

the brain and the spinal cord. Meningitis is most commonly caused by infection (by bacteria,

viruses, or fungi), although it can also be caused by bleeding into the meninges, cancer, diseases

of the immune system, and an inflammatory response to certain types of chemotherapy or other

chemical agents. The most common infectious causes of meningitis vary according to an

individuals age, habits, living environment, and health status.

The nurse who cares for patients with these disorders must have clear understanding of

the pathologic processes and the clinical outcomes. Some of the issues nurses must help patients

and families confront include adaptation to the effects of the disease, potential changes in family

dynamics, and possibly end of life issue.The clinical manifestations, assessment, and diagnostic

finding as well as the medical and nursing management are related to the specific infectious

process.


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BIBLIOGRAPHY

Baird, Marianne Saunorus. 2005.Manual of Critical Care Nursing, Fifth Edition. St.Louis,

Missouri : Elsever Mosby. Page : 644.Brunner and Suddarths Textbook of Medical-Surgical Nursing. Pages: 1821-1833, 1943-1945.

Corwin, Elizabeth J. 2008.Handbook of Pathophysiology, Third Edition.Ohio : Lippincott

Williams & Wilkins. Pages: 186-242.

Goldsmith, Connie.2008.Meningitis. Minneapolis: Lerner Publishing Group,Inc.Pages :8-9.

Kneib, Martha.2005. Meningitis, First Edition. New York : The Rosen Publishing Group,Inc.

Mader, Sylvia.S. 2004. Understanding Human Anatomy and Physiologi, Fifth Edition. The

McGraw-Hill Companies. Pages: 144-158.

Shmaefsky, Brian., Hilary Babcock. 2010.Meningitis, Second Edition. New York : Infobase

Publishing.


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PAPER ENGLISH IN NURSING

NEUROLOGIC SYSTEM

MENINGITIS

By :

1. Hannik Rahmaningrum (131211132061)2. Nasischa Ayu Wardhanie (131211132062)3. Rega Setiananda (131211133007)4. Haiva Dwi Puspha Nur Indra (131211133008)5. Gebyar Hafit S. (131211133016)6. Dyah Khusnul Fadhilah (131211133017)7. Qamila Anindita (131211133025)8. Jen Riko Dewantoro (131211133026)9. Dimas Hadi Prayoga (131211133034)

NURSING FACULTY

AIRLANGGA UNIVERSITY

SURABAYA

2013


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PREFACE

All praise to Allah who has given blessing and guidance, so we can complete this paper

about Neurogical System with Meningitis well.

We wanna say thank for all of you who have helped and supported in making this paper.

We hope this paper can be brought the advantages to all especially for students of the Nursing

Faculty, Airlangga University.

We realize this paper still further from perfectly , thus we expect the critism and

suggestion for improving this paper. Hopefully this paper can be utilized and useful to expand

the knowledges readers.

Surabaya, May 2013

Authors

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