Child and Adolescent Health Assessment Evidence Based Case Study

Question: Discuss about the Child and Adolescent Health Assessmentfor Evidence Based Case Study. Answer: Introduction Meningitis refers to inflammation of meninges (lining or membranes around brain and spinal cord) in the brain. The disease can be of viral or bacterial etiology, apart from other causes such as cancer and fungal infection. The disease caused due to viral or bacterial infection is most common among all types of meningitis and can spread through close contact with the patient. Among viral and bacterial meningitis, symptoms caused as a result of bacterial meningitis are considered more extreme and are a large cause of mortality in patients (Cunningham et.al 2014). Different bacterial types of meningitis include meningitis of hemophilus influenza type as well as Neisseria meningitis type (meningococcal meningitis). Typically, children and babies are affected by meningitis of Streptococcus pneumoniae, Neisseria meningitis, Hemophilus influenza and group B Streptococcus type. Key symptoms critical to diagnose meningitis include looking for neck stiffness in patient, which may be leading to automatic response in limbs, primarily knees; this reflex is known as Brudzinskis sign. Other diagnostic tests for meningitis include detection of inflammation in brain CT scan, antibodies in blood tests and testing of cerebrospinal fluid through lumbar puncture (Polit Beck, 2008). Globally, more than 1.2 million bacterial meningitis cases are estimated to surface every year (WHO Manual, 2011). While people from all age groups are susceptible to meningitis infection, children below 5 years and infants are at higher risk of viral and bacterial meningitis respectively. Generally, community setting such as college campuses are key sites for spread of meningitis infection. Bacterial meningitis of meningococcal nature typically spread through respiratory fluids, passed as a result of coughing, sneezing, or kissing. Treatment of bacterial and fungal agents depends on administration of anti-microbial nature which are best suitable, while viral meningitis is typically not treated with anti-microbial agents (Cunningham et.al 2014). Immunization against the disease in early age is considered the best way to prevent occurrence of this disease. Interpretation of Physical Assessment Details The assessment record of the child patient, Sophia, indicates normal gastrointestinal and genitourinary symptoms. However, loss of appetite has been recorded in the patient, which is one of the signs of infection of meningitis nature (Polit Beck, 2008). Patients heart rate is normal, while the blood pressure shows reduced diastolic pressure at 60 mm Hg, which may be indicative of reduced body fluid volume. Body temperature is high at 39.7 degrees C, indicating presence of fever. However, abnormalities in neurological symptoms including irritation, sluggishness, and reluctance of move extremities indicate neurological nature of the disease. Sensitivity to light and stiffness in neck indicate towards meningitis of hemophilus influenza type B, as initial diagnosis has indicated. However, presence of purpuric rash indicates that meningitis of meningococcal nature may be present, as rashes are not typically present in meningitis of hemophilus B type infection. Typically, rashes of dark purple color may appear, in case of advanced stage meningococcal meningitis (Polit Beck, 2008). Unlike meningitis of hemophilus influenza type, meningococcal meningitis is caused by Neisseria meningitis. According to research, meningococcal meningitis is more common than other types of meningitis in children. Chances of infection spreading is also very high in case of meningococcal meningitis and care should be provided with promptness (Cunningham et.al 2014). The child has also not been indicated to be immunized, which enhances the possibility of meningitis due to infection. Additionally, diminished urine output indicates patients may be experiencing dehydration, which is a common and dangerous occurrence in these infections (Tae-Wan K. et al, August 2010). Presence of dry mouth, as shown in initial physical assessment also indicates that patients is experiencing dehydration of severe nature. To add to this, reduction in diastolic blood pressure to 60 mm Hg is also indicative of dehydration in patient. Immediate provision and control of body circulatory fluids would be required for the patient in this case (Polit Beck, 2008). In case dehydration goes out of control, the patient may experience seizures or brain damage and even death. Lethargy and high proneness to sleep are also additional indications, conforming the presence of meningitis. Other symptoms confirming to meningitis include pale skin type and reduced breathing rate (at 11 br eaths per minute), as these are also typically observed in such infections. Key Problems In the described case of the patient Sophia, it is important to establish the exact nature of meningitis infection quickly and provide medical care appropriate to the infection type. In case, infection is of meningococcal nature, and different from hemophilus influenza type, risk of septicemia (poisoning of blood by meningitis causing pathogens) may also be there. Darkening of skin around light colored skin areas such as extremities of limbs is indicative of spreading septicemia and should be looked for in the patient. Extraction of cerebrospinal fluid through lumber puncture and subsequent analyses would be required to pinpoint the exact nature of meningitis. Within the CSF, analysis is done to determine number of white blood cells, proteins and glucose in the sample. It is understood that bacterial type of meningitis shows larger number of neutrophils and low glucose quantity. A lumbar puncture or spinal tap requires collection of CSF from patients back for analysis (Cunningham et.al 2014). However, in case blood pressure of the patient falls quickly and the patient is anticipated to be falling in a state of shock, extracting cerebrospinal fluid would be contraindicated and has to be done away with. Typically, increased white blood cells count and protein level along with low sugar levels in the CSF are indicative of meningitis infection. Imaging techniques involving magnetic resonance imagery or CT scan may also be utilized to determine the extent and nature of infection already in patients system. It is important to start the patient on broad spectrum antibiotics, until the exact nature of meningitis infection is determined and a more specific treatment in provided. As patient is suffering from severe dehydration, immediate fluid resuscitation is required to avoid the risk of shock. Isotonic saline solution or colloid bolus administration may be warranted to provide normal circulatory volume to the patients body (Tae-Wan K. et al, August 2010). Different parameters should be continuously monitored including blood pressure and other normal body functions to check severity of dehydration and progression of the state of shock. Best Practices It is important to analyze the cerebrospinal fluid (CSF) of the patients extracted through a lumber puncture, to identify the exact nature of meningitis. Rich neutrophil content and low glucose content in the CSF would be indicative of meningitis of bacterial etiology. At the same time, time should not be wasted in starting preliminary care and patient should be immediately started on antibiotics and steroids. Delay in starting the patient on antibiotics may results in aggravation of infection and also death (Polit Beck, 2008). Recommended antibiotics at the outset are ceftriaxone or cefotaxime, and best antibiotic to administer should be determined based on consideration of resistance and any prior sensitivity on the part of patient. Steroid therapy is also required in certain cases, to avoid coagulation in blood. However, in some cases, patients already on anti-microbial therapy may not require steroid administration, as effect would necessarily be complimentary to each other. Non -steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen may help alleviate symptoms such as pain, inflammation, and fever (Cunningham et.al 2014). It is important to maintain sufficient fluid circulatory volume at all times and patient should be immediately started on fluid therapy, with constant monitoring of blood pressure. In case the blood pressure continues to fall despite fluid therapy, vasoactive agents including dopamine may be injected to maintain blood pressure. Milrinone and dobutamine are other agents of vasoactive nature which may be useful in such a situation. In some patients, hyperglycemic condition may result due to meningitis, which may warrant the use of insulin for control of sugar level in blood. Increase in blood sugar levels combined with shock condition has been found to be one of the key reasons for death in meningitis patients (Polit Beck, 2008). Additionally, blood transfusion may also be required in case hemoglobin level falls below required levels. Family and Child Care Considerations As the child is unimmunized, close family members should also be checked for any abnormal symptoms as infection could have spread to such members. Typically, close family members are at highest risk of infection and infection could spread through respiratory or throat based secretions. It may be advisable to start patients family members on an antimicrobial therapy for prophylaxis against meningitis (Polit Beck, 2008). It also needs to be determined if any of the family members have been earlier vaccinated against meningitis, in which case prophylactic treatment with anti-microbials may not be required for such family members. In general, the family members need to be educated against risks of contamination and should be advised and keep cleanliness, including washing hands, using separate utensils and avoiding very close contact with the patient at all times. The patients mouth should also be covered at all times to prevent risk of respiratory fluids transfer of infection. Until the time that child shows symptoms of infection such as fever and rashes, these measures are to be continued with urgency (Polit Beck, 2008). It is also important for the laboratory personnel to follow guidelines and take necessary protection steps to prevent any contamination to themselves. Lab staff needs to be properly trained before handling the pathogenic samples for testing, while nursing staff also needs to take required precautions before dealing with the patient (WHO Manual, 2011). It is warranted that the child patient be admitted immediately to hospital and antibiotics are started. Once antibiotics are started, the patient needs to be monitored for 5-7 days and in case condition worsens, shifting to intensive care unit should be promptly considered. In the scenario of symptoms getting aggravated, support for breathing and other medications (for instance, to control blood pressure) could also be required. In typical cases, benefits of anti-microbial therapy should start to show within 2-3 days, while fever is expected to persist beyond five days. It may be possible that the child develop complications such as deafness, seizures or delayed development even after cure of meningitis (Polit Beck, 2008). Avoidance of such symptoms would depend on early and prompt care, as well as disease progression at the time of admission. At the time of discharge, the child should be examined for hearing tests to check if any symptoms related to deafness have appeared. Also, family should be educated on the symptoms which are typically seen after discharge in such patients including tiredness, problems with hearing, frequent head aches and in some patients, hearing problems (WHO Manual, 2011). It is important for the family to follow-up with specialists regularly to get the childs recovery tested, post discharge. The patient may also experience mood swings and feel good on certain days followed by days of bad mood and uneasiness. Disturbances in sleep, depression and bed wetting may also surface as after effects of meningitis. Proper counselling on psychological level may also help the patient recover from these after effects (Polit Beck, 2008). Conclusion Meningitis is a disease of high mortality risks and should be treated promptly and appropriately at a quick pace. In the given case study for patient Sophia, all symptoms indicate towards meningitis, such as neck stiffness, presence of rash, reducing blood pressure, reluctance to move extremities and dislike towards light (Polit Beck, 2008). Presence of a purpuric rash indicates more towards meningococcal meningitis caused by Neisseria meningitis. Exact nature of meningitis is prescribed to be confirmed through pathological examination of CSF obtained through lumbar puncture. It is important meanwhile to start the patient on appropriate anti-bacterial therapy and closely monitor the vital symptoms in intensive care unit (Cunningham et.al 2014). Moreover, because of possibility of cross-contamination, close family members need to be monitored for any signs of meningitis. It may be advisable to administer antimicrobial therapy to such family members for prophylaxis. Close family also needs to be educated on different ways to avoid contamination until the child shows symptoms of infection. After discharge, the nursing staff also needs to provide proper counselling to the patients family on post discharge care and tackling the after effects of the disease such as mood swings experienced by the patient, deafness, depression, lethargy, and lack of concentration (WHO Manual, 2011). References CDC Website: https://www.cdc.gov/meningococcal/about/symptoms.html Cunningham, F., Leveno, K., Bloom, S., Spong, C. Y., Dashe, J. (2014). Williams Obstetrics, 24e. McGraw-Hill.https://www.cdc.gov/meningitis/lab-manual/full-manual.pdf N.d. (2011). Laboratory Methods for the Diagnosis of Meningitis caused by Neisseria meningitis, Streptococcus pneumoniae, and Haemophilus influenza. WHO Manual, Second Edition. Retrieved fromhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989465/ Polit, D. F., Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice. Lippincott Williams Wilkins. Polit, D. F., Beck, C. T. (2013). Nursing research: Generating and assessing evidence for nursing practice. Lippincott Williams Wilkins. Tae-Wan K., Whang J., Lee S., Choi J., Park S., Lee J. (August 2010). Acute Urinary Retention due to Aseptic Meningitis: Meningitis-Retention Syndrome. International Neurological Journal, 14 (2), 122-124, doi 10.5213/inj.2010.14.2.122. Retrieved from: