TUBERCULAR MENINGITIS

A CASE STUDY
Critical Care Nursing

Tanzeel Ul Rahman
B.S.N Final year
 By Tanzeel Ul Rahman
BSN Final Year

AKNOWLEDGMENT

bow my head before Almighty ALLAH in gratitude for giving me the opportunity to Make this
Case study and further for sustaining the interest, which many times did oscillate.

First and foremost, My utmost gratitude to Dr. Bernice B. Taverner, Dean College of Nursing
Shalamar Institute of Health Sciences, whose sincerity and encouragement i shall never forget, who
permitted me to take start of this activity.

We deem it as our honor to express our heartiest gratitude and to acknowledge the total support and
standards of excellence provided by Sir Sonny B. Dechavez, Clinical Instructor, College of Nursing
Shalamar Institute of Health Sciences. For continued patience, all the moral support, inspiring guidance
and stimulating criticism throughout my case study. I am highly indebted to him for his graciously
offered help to complete this tedious task. May God bless him with health, happiness and long life.

I would also like to thank my institution and faculty members of College of Nursing Shalamar Institute of
Health Sciences without whom this project would have been distinct reality. I also extend my heartfelt
thanks to my fellows, seniors and well wishers. It would be unfair if I would not say thanks to my patient
and his family for their co-operation. And at the end special thanks to my brother Armaghan ur Rahman
for his kind time and help for this beautiful formatting of the document.

Tanzeel Ul Rahman

Final year B.S.N

2
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
 By Tanzeel Ul Rahman
BSN Final Year
SHALAMAR INSTITUTE OF HEALTH SCIENCES
COLLEGE OF NURSING
\

CASE STUDY CONTENT

Content Page
no
Introduction 4
Objectives 6
Nursing Process 8
a. Nursing Health History 9
1. Demographic data
2. Chief complaint
3. History of present illness
4. Past medical history
5. Family history
6. Social and personal history
b. Nursing Assessment (Gordon’s Functional Health Patterns) 11
1. General description of client
2. Health perception – Health management pattern
3. Nutritional – Metabolic pattern
4. Elimination pattern
5. Activity – Exercise pattern
6. Sleep – Rest pattern
7. Cognitive – Perceptual pattern
8. Self-perception – Self- concept pattern
9. Role relationship pattern
10. Sexual reproductive pattern
11. Coping – Stress tolerance pattern
12. Value – Belief pattern
c. Physical Examination 14
d. Laboratory Findings 18
e. Review of Anatomy and physiology 21
f. Pathophysiology (highlight patient manifestation) 27
B. CCM 31
C. Medical and Nursing Management 33
D. Drug Study 36
E. Discharge Plane 40
F. References 42

3
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Case
Study Introduction

4
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Introduction
Background:

I choose T.B meningitis as my case to be studied out of curiosity. It is my 1 st time to

encounter this kind of case and because of that; I was so interested in it. I was willing to do this
case to challenge my mind in analyzing the problem and to enhance my hidden knowledge and
also to gain new experiences which would bring new learning for me.

Significance of study:

The case study will help me in understanding the disease process of the patient. This
would also help the group in identifying the primary need of the patient with Meningitis. By
identifying such needs and health problems we can now formulate an individualized care plan for
the patient that would address the needs and problems effectively. Effective management of the
problems identified will help the patient to recover faster and maintain a holistic sense of
wellness even while in the hospital

This case study would also provide knowledge skills and attitude on how to manage a
future patient with the Tubercular Meningitis.

Scope:

This case study was conducted in the Shalamar hospital Lahore on 18 year old male
patient in cooperation o the patient’s family.

Goals:

I aim to develop essential as well as skillful nursing care which is based on better and
effective approach. That will serve as catalyst to promote health, reduce illness and prevent
/eliminate such infectious diseases.

This case study will describe what TB meningitis is, its causes, how it is acquired and
how it can be prevented and treated, with its medical and nursing management.

5
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Case
Study Objectives

6
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Objectives
By the end of this case study we will be able to learn and discuss:

 Define what TB Meningitis is.

 A brief review of Anatomy and Physiology of the related body system (Nervous system).

 Pathophysiology of TB Meningitis.

 What are the sign and symptoms of TB Meningitis?

 Medical and nursing management of patient with TBM.

 Prioritize things which are essential in assessing and developing proper interventions in
treating TBM.

 Formulation and application of nursing care by utilizing nursing process.

 To learn and sharpen clinical skills which are required in the management of the patient
with TBM.s

 Apply the core and fundamental systematic approach of the nursing profession in
promoting health and preventing illness.

7
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Case Nursing
Study
Process

8
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Nursing Process
Nursing Health History

1. Demographic data
Name: Mr. X
Age: 18 years old
Sex: Male
Marital Status: Single
Nationality: Pakistani
Religion: Islam
Occupation: Student
Admission Date: 14 November 2012 – 08:37 Pm
Date of Discharge: 23 November 2012 –12:14 Pm
Admitting Impression: Pyrexia of Unknown origin / TB Meningitis
Diagnosis: TB Meningitis

2. Case scenario and Chief complaint:

This is a case of an 18 year old male patient received on 16 November 2012 from Male Medical
Ward to ICU of Shalamar Hospital Lahore in drowsy condition with chief complaints of:
 Fever from last 3 months on and off.
 Headache from last 2 month on and off.
 Vomiting and abdominal pain from last 10 days.
 Abdominal pain from 7 days.
 Irritable behavior from 3 days.
 Drowsiness from 1 day.

3. History of present illness

3 month before patient was healthy when he developed low grade fever i.e. 100F. He started
treatment with Panadol ( Paracetamol ) at home. But after 1 month of that fever became high
grade and client took treatment from some general practitioner. Then client was having headache
after 1 month of fever. Nausea and vomiting occurred 10 days before admission in Shalamar
hospital Lahore. Then Patient came to Emergency department of Shalamar hospital Lahore with
high grade fever (102 F) and was diagnosed of PUO (pyrexia of unknown origin) by a ER
medical officer, Treatment given in ER was Infusion Provas and Inj. Gravinate. Then patient was
admitted in Male medical Ward of Shalamar hospital Lahore at 14 November 2012 – 08:37 Pm.
Following treatment was given in Male Medical Ward:
Inj. Rociphin 2g BD

9
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Inj. Gravinate BD
Inj. Omega 40g BD
Ringer Lactate 1000ml OD
5 % Dextrose water 1000 ml OD
Inj. Provas 1g BD
Inj. Decadron 2cc TDS
Tab. Myrin P 5 Tablets OD
In Male medical ward patient developed drowsiness and drop in blood pressure (90/ 60mmHg)
and shifted to Intensive care unit of Shalamar hospital Lahore.

4. Past medical history:

Past medical history:
There is no significant Past medical history except that patient got exposed
to Mycobacterium Tuberculosis when his father got Pulmonary
Tuberculosis
Past Surgical History:
There is no significant past surgical history.
5. Family history:
FATHER MOTHER
DIABETES (+) (-)
HYPERTENSION (+) (-)
ASTHMA (-) (-)
Pulmonary TB (+) (-)

6. Social and Personal History:

Patient belongs to a Middle class family. He is recently studying at intermediate
level.
7. Parameters:
 Foleys Catheter
 IV line
 Cardiac Monitor
 Vital Signs 1 hourly
 Input and Output Chart

10
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Nursing
Case
Assessment
Study (Gordon’s Functional Health
Patterns)

11
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Nursing Assessment
(Gordon’s Functional Health Patterns)

This portion of the study will present normal and regressed health functions of patient.
1. General description of client:
An ill looking young client lying on bead in supine position, patient is drowsy, there is
incoherent speech, appeared to be cleaned and hygienic. There is no observable physical
deformity or abnormality.
2. Health perception – Health management pattern:
• Rarely visits a doctor to have a check-up and seek for medical assistance.
• Uses herbal medicines.
• Buys and takes over the counter drugs.
• When sick, goes to the general practitioner or just waits for the sickness to heal.
• Practices healthy lifestyle.
• No history of drug or substance abuse.
3 month before patient was healthy when he developed low grade fever i.e 100F.
He started treatment with Panadol ( Paracetamol) at home . But after 1 month of that
fever became high grade and client took treatment from some General practitioner. Then
client was having headache after 1 month of fever. Nausea and vomiting occurred 10
days before admission in Shalamar hospital Lahore. Then Patient came to Emergency
department of Shalamar hospital Lahore with high grade fever (102 F) Diagnose of PUO
(pyrexia of unknown origin) was made by medical officer of ER, Then patient was
admitted in Male medical Ward of Shalamar hospital Lahore at 14 November 2012 –
08:37 Pm. In Male medical ward patient developed drowsiness and drop in blood
pressure (90/ 60mmHg) and shifted to Intensive care unit of Shalamar hospital Lahore.
3. Nutritional – Metabolic pattern:
• Eats more of fruits and vegetables.
• Eats her meals 3x a day with snack in between. But there is loss of apatite since his
admission to hospital.
• Drink up to 1.5L of water or 4-5 glasses a day.
• Takes tea in the morning and in the afternoon.
• Patient is on soft diet.
4. Elimination pattern:
• No pain or burning sensation during urination before admission.
• In ICU Foley catheter used which is attached to the urobag draining well with dark
yellow urine with an output of 50ml/hour.
• Vomiting 3 episodes at 1st day of his admission in hospital.
• Defecates 1 day, no constipation.

5. Activity – Exercise pattern:

• Decreased strength; becomes weak in prolonged activities.

12
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

• Decreased speed of movement.

• Can perform the activities of daily living.
6. Sleep – Rest pattern:
• Can sleep for 7-9 hours per night.
• Straight hours of sleep.
• Earliest time in going to sleep is at 9:30 PM.
• Latest time in waking up is at 5:00 AM.
• Sometimes takes a nap at noon for about 1-3 hours.
• No difficulties in going to sleep.
• Doesn’t use any medication to promote sleep.
• Feels drowsy after hospital admission.
7. Cognitive – Perceptual pattern:
• No sensory deficits.
• Oriented to people, time, and place but drowsy.
• Responds to stimuli verbally and physically.
• Pain felt in head.
• Intact memory and cognition.
8. Self-perception – Self- concept pattern:
• Manages to practice healthy lifestyle so as not to seek medical assistance.
• Recently, He believed that admission will be helpful to assist his needs, to alleviate the
illness.
• Hopeful to be relieved and treated.
• Major concern is his recovery.
9. Role relationship pattern:
• Well – supported and loved by her family with close relationship.
• Patient is unmarried.
• Satisfactory in his studies.
• Verbalizes desires to recover.
• Able to accept situation by cooperating with the medical advices and procedures.
10. Sexual reproductive pattern:
Patient is unmarried male.
11. Coping – Stress tolerance pattern:
• Copes up with stress by taking a nap or sleep.
• Copes up with problems by talking about it with the family and finds ways to resolve it
together.
• No traumatic events experienced before.
12. Value – Belief pattern:
Patient is Muslim and goes to mosque to offer prayers Most of the time. Have strong faith
in God.

13
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Case Physical
Study Examination

14
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Physical Examination
General appearance of client:
An ill looking young client lying on bead in supine position, patient is drowsy, there is
incoherent speech, appeared to be cleaned and hygienic. There is no observable physical
deformity or abnormality.
Physique:
Normal
Consciousness:
Drowsy with GCS of 12/15.
Skin:

General color Pallor

Texture Smooth
Turgor Poor
Temperature Warm
Moisture dry

Nails:

Pallor +ve
Cyanosis -ve
Clubbing -ve

Eyes:

Lids Symmetrical
Conjunctiva Pallor
Sclera Normal
Reaction to light R- brisk
L - brisk

Nose:

Mucosa Pink
Patency Both nostrils patent
Smell Normal
Sinuses Not tender

15
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Mouth:

Mucosa Pink
Teeth no missing teeth
Gums pink

Vital Signs:

Temperature 101 F
Blood Pressure 110/70 mmHg
Pulse Rate 76 beats per min
Respiratory Rate 19 breath per min

Cardiovascular System:

Heart Rate 76 beats per min

Heart sound Regular rhythm, absent
murmurs
Peripheral pulses Regular
Capillary refill 2 sec brisk.
Blood pressure 110/70 mmHg

Respiratory System:

Respiratory rate 19 breath per min

Breathing pattern Regular
Type of respiration Abdomino - thoracic
Shape of chest Elliptical
Position of trachea Midline
Lung expansion Symmetrical
Percussion sound Resonant
Adventitious breath Absent
sounds

Abdomen:

Shape Normal
Scar Absent
Bowel sounds Normoactive

Extremities:
16
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Deformity Absent
Range of motion Normal
Muscular tone and Fair
strength
Gait Coordinated

Neurological assessment:

Communication Slurred speech

Level of consciousness Drowsy
GCS 12/15
Behavior Irritable and anxious

Sign of Meningeal Irritation:

(+) Neck rigidity

(+) Brudzinki’s sign
(+) Kernig’s sign

17
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Case Laboratory
Study Findings

18
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Laboratory Findings
Complete Blood Examination:

Component Reference Unit 17/11/2012 18/11/2012 19/11/2012

value
ESR 10-20 mm/hour 37 30 20
Hemoglobin 14-17 G/dl 12.3 12.6 12.1
WBC 4-11 *10.e 3/uL 3.8 9.3 7.6
RBC 4-6 *10.e 6/uL 4.95 4.95 4.71
Platelet 150-450 *10.e 3/uL 293 346 292

Renal Profile:

Component Reference Unit 15/11/2012 17/11/2012 19/11/2012

value
Urea 10-50 mg/dl 28 26 21
Creatinine 0.50-1.30 mg/dl 0.5 0.6 0.5

Serum Electrolytes:

Component Reference value Unit Patient value

Sodium 135-145 mmol/L 124
Potassium 3-5 mmol/L 4.1
Chloride 96-108 mmol/L 91
Calcium 8-10 mg/dl 7.2

Liver Function Test:

Component Reference value Unit Patient Value

Bilirubin Total 0.10-1.10 Mg/dl 0.9
Bilirubin Direct 0.10-0.40 Mg/dl 0.6
Bilirubin indirect 0.10-0.70 Mg/dl 0.4
Alkaline 80-270 U/L 220
phosphatase
SGPT 5-40 U/L 12
SGOT 5-40 U/L 15
Albumin 4-5 G/dl 4.1

HCV:

19
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Negative.

Typhidot:

Negative.

Malarial Parasite:

Negative.

X-Ray:

Patchy shadowing in left apex and upper zone chronic inflammatory disease
Normal cardiac size
Diaphragm is normal

CT SCAN:

Rather effected sulci and gyri however no significant parenchymal and meningeal
enhancement at time of examination. No associated ischemic changes or hemorrhage or any
subfalcine herniation. Findings likely represent meningitis / encephalitis partially treated.

20
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Case Anatomy and

Study Physiology

21
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Anatomy and Physiology

Central Nervous System:
The central nervous system (CNS) is the largest part of the nervous system, and includes
the brain and spinal cord. The spinal cavity holds and protects the spinal cord, while the head
contains and protects the brain. The CNS is covered by the meninges, a three layered protective
coat. The brain is also protected by the skull, and the spinal cord is also protected by
the vertebrae.
The central nervous system (CNS) is the part of the nervous system that functions to
coordinate the activity of all parts of the bodies of multicellular organisms. In vertebrates, the
central nervous system is enclosed in the meninges. The meninges (singular meninx) is
the system of membranes which envelops the central nervous system. The meninges consist of
three layers: the dura mater, the arachnoid mater, and the pia mater. The primary function
of the meninges and of the cerebrospinal fluid is to protect the central nervous system. The space
between these membranes is bathed with a spinal fluid much like lymph, which serves as a
protective cushion for the delicate nerve tissue, and allows some expansion space for the brain
when its blood supply is increased.
Meningis:
3 layers of meninges:

• Dura mater (also rarely called meninx fibrosa, or pachymeninx)

Is a thick, durable membrane, closest to the skull.
The epidural space is a potential space between the dura mater and the skull. If there
is hemorrhaging in the brain, blood may collect here. Adults are more likely than children to
bleed here as a result of closed head injury.
The subdural space is another potential space. It is between the dura mater and the
middle layer of the meninges, the arachnoid mater. When bleeding occurs in the cranium, blood
may collect here and push down on the lower layers of the meninges. If bleeding continues, brain

22
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

damage will result from this pressure. Children are especially likely to have bleeding in the
subdural space in cases of head injury.
• Arachnoid mater
The middle element of the meninges is the arachnoid membrane, so named because of its
spider web-like appearance. It provides a cushioning effect for the central nervous system. The
arachnoid mater exists as a thin, transparent membrane. The arachnoid and pia mater are
sometimes together called the leptomeninges.
The subarachanoid space lies between the arachnoid and pia mater. It is
filled with cerebrospinal fluid. All blood vessels entering the brain, as well as cranial nerves pass
through this space.
• Pia mater
The pia or pia mater is a very delicate membrane. It is the meningeal envelope which
firmly adheres to the surface of the brain and spinal cord
Cerebrospinal fluid
Is a clear liquid produced within spaces in the brain called ventricles. Like saliva it is a
filtrate of blood. It is also found inside the subarachnoid space of the meninges which surrounds
both the brain and the spinal chord. In addition, a space inside the spinal chord called the central
canal also contains cerebrospinal fluid. It acts as a cushion for the neuraxis, also bringing
nutrients to the brain and spinal cord and removing waste from the system.
Choroid Plexus All of the ventricles contain choroid plexuses which produce
cerebrospinal fluid by allowing certain components of blood to enter the ventricles. The
choroid plexuses are formed by the fusion of the pia mater, the most internal layer of the
meninges and the ependyma, the lining of the ventricles.

The Ventricles
These four spaces are filled with cerebrospinal fluid and protect the brain by cushioning it
and supporting its weight.
Components of CNS:
Following are the components of CNS:

23
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Spinal Cord:
The spinal cord is a long bundle of neural tissue continuous with the brain that occupies
the interior canal of the spinal column and functions as the primary communication link between
the brain and the rest of the body. The spinal cord receives signals from the peripheral senses and
relays them to the brain.
Brain:
The brain can be subdivided into several distinct regions:

Brain Stem
The brain stem is the part of the brain that connects the cerebrum and diencephalons with the
spinal cord.
Medulla Oblongata
The medulla oblongata is located just above the spinal cord. This part of the brain is responsible
for several vital autonomic centers including:
 The respiratory center, which regulates breathing.
 The cardiac center that regulates the rate and force of the heartbeat.
 The vasomotor center, which regulates the contraction of smooth muscle in the blood
vessel, thus controlling blood pressure.
The medulla also controls other reflex actions including vomiting, sneezing, coughing and
swallowing.
Pons
continuing up the brain stem, one reaches the Pons. The pons lie just above the medulla and acts
as a link between various parts of the brain. The pons connect the two halves of the cerebellum
with the brainstem, as well as the cerebrum with the spinal cord. The pons, like the medulla
oblongata, contain certain reflex actions, such as some of the respiratory responses.
Midbrain
The midbrain extends from the pons to the diecephalon. The midbrain acts as a relay center for
certain head and eye reflexes in response to visual stimuli. The midbrain is also a major relay
center for auditory information.
Diencephalon
The diencephalons is located between the cerebrum and the mid brain. The diencephalons houses
important structures including the thalamus, the hypothalamus and the pineal gland.

24
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Thalamus
The thalamus is responsible for "sorting out" sensory impulses and directing them to a particular
area of the brain. Nearly all sensory impulses travel through the thalamus.
Hypothalamus
The hypothalamus is the great controller of body regulation and plays an important role in the
connection between mind and body, where it serves as the primary link between the nervous and
endocrine systems. The hypothalamus produces hormones that regulate the secretion of specific
hormones from the pituitary. The hypothalamus also maintains water balance, appetite, sexual
behavior, and some emotions, including fear, pleasure and pain.
Cerebellum
The functions of the cerebellum include the coordination of voluntary muscles, the maintenance
of balance when standing, walking and sitting, and the maintenance of muscle tone ensuring that
the body can adapt to changes in position quickly.
Cerebrum
The largest and most prominent part of the brain, the cerebrum governs higher mental processes
including intellect, reason, memory and language skills. The cerebrum can be divided into 3
major functions:
 Sensory Functions - the cerebrum receives information from a sense organ; i.e., eyes,
ears, taste, smell, feelings, and translates this information into a form that can be
understood.
 Motor Functions - all voluntary movement and some involuntary movement.
 Intellectual Functions - responsible for learning, memory and recall.
Peripheral Nervous System
Nerves
Nerves are made up of specialized cells, which act as little wires, transmitting information to and
from the central nervous system and brain. Nerves form the network of connections that receive
signals (known as sensory input) from the environment and within the body, and transmit the
body's responses, or instructions for action, to the muscles, organs, and glands. Nerve cells are
located outside the central nervous system or spinal cord.

Eyes
The eyes are organs that provide us with visual information from the external world, which is
transmitted and interpreted by the brain.

25
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Ears
The ears are the organs used for both hearing and equilibrium. The ear can be divided into three
sections: the outer that includes the parts of the ear we see, and the ear canal, which connects the
external ear to the middle ear. It is separated from the middle ear by the tympanic membrane or
eardrum. The middle ear contains three small bones that conduct sound waves. The inner ear
contains sensory receptors and the mechanisms responsible for equilibrium.
Taste
The sense of taste is perceived through the taste buds, which are located in various parts of the
mouth, but are primarily concentrated on the tongue. Taste is experienced in four different ways
- sweet, sour, salty or bitter. It is interesting to note, that only substances in solution can be
perceived by the taste buds.
Smell
The receptors for smell are located in the upper part of the nasal cavity in the olfactory
epithelium. The sense of smell can distinguish a greater variety of substances than the sense of
taste. Here too, substances that are detected by these receptors must be in solution.
Tactile sensation
There are several other types of receptors located throughout the body. They are considered
general senses and provide us with tactile sensations including the feeling of pressure, heat, cold,
pain and touch.

26
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Case
Study Pathophysiology

27
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Pathophysiology
Tubercular Meningitis:
“It is the inflammation of the Leptomeninges (pia-arachnoid) by mycobacterium
tuberculosis.”
Pathophysiology:
Droplet Infection

Primary Focus Bacteraemia

Meninges &
brain

Rich Focus

Rupture
into
Subarachno

Encephalitis
Adhesion Vasculit

Cerebral
Stroke Edema
Basal Interpendicul Especially
cister ar fossa Basal ganglia
Internal
ICP
carotid
Cerebral
Cranial
arteries
Hydrocephalu nerve

Incidence:
 TBM accounts for 1-2% hospital admissions.
28  Highest incidence- below 5 years of age.
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Clinical Stages:
Clinically the course of TB Meningitis is divided into following 3 stages:

 Stage 1 ( Prodromal phase) :

 Child does not play as usual.
 Irritable, Restless or drowsy.
 Anorexia or vomiting.
 May complain headache.
 Last for 1-3 week

 Stage 2 ( meningeal phase) :

 Meningism
 +ve Brudzinski’s sign
 +ve kerning sign
 Muscles twitching
 Convulsions
 Lethargy

 Stage 3 (Paralytic phase) :

 Seizure
 Opisthotonus
 Dilated pupil
 High grade fever
 Advance to stupor, coma

Opisthotonus

29
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Investigations:

 Blood :
 ESR increased
 DLC normal
 X-ray chest:
 may show evidence of pulmonary TB
 CSF Examination:
 Physical
 Raised pressure
 Clear to straw colored
 Usually lymphocytic pleocytosis
 Biochemical
 Elevated protein with severely depressed glucose
 Microbiology
 Repeated specimens for AFB culture necessary
 Brain imaging – demonstrates hydrocephalus.

Prognosis:

 Overall Poor
 Pts presenting in Stage I have
19% mortality
 Pts presenting in Stage III
have 69% mortality
 Only 1/3 - 1/2 of patients
demonstrate complete
neurologic recovery
 Up to 1/3 of patients have
residual severe neurologic
deficits such as hemiparesis,
blindness, seizure

Complications:

 Hydrocephalus.
 Blindness, deafness.
 Coma/stupor.
 Motor deficits-CN palsies (, hemiparesis , hemiplegia)
 Seizures, Epilepsy.
 Mental impairment.
 Abnormal behavior.
 Brain damage.
 High morbidity and mortality.

30
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Case Critical Care

Study Map (CCM)

31
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

TBM: “It is the inflammation of the

Leptomeninges (pia-arachnoid) by
mycobacterium tuberculosis.”
Name: Mr. X
Age: 18 years old
Sex: Male

Key

Sign and Symptoms:

Nursing Diagnosis:

Assessment:

Medical Management:

Nursing Interventions:

Diagnosis and
Demographic data:

32
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Medical and
Case
Nursing
Study Management

33
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Medical Management
Anti-tuberculosis Treatment:
High doses of the appropriate antibiotic are administered intravenously. Following anti
tuberculosis medications are used in while treating TB Meningitis:
 Intensive Phase:
4 drug regimen of Isoniazid, Rifampin, Pyrazinamide, and Ethambutol or
Streptomycin for 2 months
 Continuation Phase:
Isoniazid and Rifampin for another 7 – 10 months
Adjunctive Therapy:
 Steroids:
Glucocorticoids:
These are given to reduce Cerebral edema. Dexamethasone has been
shown to be beneficial as adjunct therapy in the treatment of acute bacterial
meningitis and in pneumococcal meningitis if given 15 to 20 minutes before the
first dose of antibiotic and every 6 hours for the next 4 days. Studies indicate that
dexamethasone improves the outcome in adults and does not increase the risk of
gastrointestinal bleeding.
 Anticonvulsants:
Phenobarbiturates:
To prevent convulsions. Seizures, which may occur in the early course of
the disease, are controlled with phenytoin (Dilantin). Increased ICP is treated as
necessary.
 Antipyretics:
Paracetamol.
 Dehydration and shock are treated with fluid volume expanders.
 Duration of therapy —9 to 12 months in drug-sensitive infections. If Pyrazinamide is
omitted or cannot be tolerated, treatment should be extended to 18 months.
Surgical Intervention:
Patients with hydrocephalus may require surgical decompression of the ventricular
system by shunt. Mostly Ventriculoperitonial shunt Is made.
Ventriculoperitonial shunt:
This is a device which drains the extra fluid in the brain into
the peritoneal cavity where the fluid can be absorbed. The
Ventricular Catheter may enter from various positions of the skull,
most commonly from the right front top of the skull or from the
right back side of the skull just above and behind the ear. . From the
valve, the distal shunt tubing is tunneled underneath the skin down
to the abdomen. It is placed into the peritoneal cavity. The fluid is
released into this cavity and absorbed.
Ventriculoperitonial shunt

34
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Nursing Management
The patient may be critically ill; therefore, so many of the nursing interventions are
collaborative with those of the physician, respiratory therapist, and other members of the health
care team. The patient’s prognosis may depend on the supportive care provided.
Neurologic status and vital signs are continually assessed. Pulse oximetry and arterial
blood gas values are used to quickly identify the need for respiratory support as the increasing
ICP compromises the brain stem. Insertion of a cuffed endotracheal tube (or tracheotomy) and
mechanical ventilation may be necessary to maintain adequate tissue oxygenation. Arterial blood
pressures are monitored to assess for incipient shock, which precedes cardiac or respiratory
failure. Rapid intravenous (IV) fluid replacement may be prescribed, but care is taken to prevent
fluid overload. Fever also will increase the workload of the heart and cerebral metabolism. ICP
will increase in response to increased cerebral metabolic demands. Therefore, measures are taken
to reduce body temperature as quickly as possible.
Other important components of nursing care include:
• Monitoring body weight, serum electrolytes, and urine volume, specific gravity, and
osmolality, especially if the syndrome of inappropriate antidiuretic hormone (SIADH) secretion
is suspected.
• Protecting the patient from injury secondary to seizure activity or altered level of
consciousness.
• Preventing complications associated with immobility, such as pressure ulcers and pneumonia.
• Instituting droplet precautions until 24 hours after the initiation of antibiotic therapy (oral and
nasal discharge is considered infectious).
Any sudden, critical illness can be devastating to the family. Because the patient’s
condition is often critical and the prognosis guarded, the family needs to be informed about the
patient’s condition and permitted to see the patient at intervals, even though the priority is to
address the patient’s need for immediate and intensive treatment. An important aspect of the
nurse’s role is to support the patient and to assist the family in identifying others who can be
supportive to them during the crisis.
Prevention: Vaccination with BCG vaccine is strictly recommended. Proper hygiene techniques
and avoid contact with patient suffering from tuberculosis is recommended.
Hydration: A minimum of 2.5 litres over 4 hours should be encouraged orally or, if necessary,
administered intravenously. Natural fluid loss occurs via the kidneys, skin and through
respiration and can be increased considerably via the latter two with fever and a raised
respiratory rate.
Pressure area care: This is particularly important for the debilitated patient and those with
paralysis or neuromuscular disease. Pressure relieving techniques and mattresses are important to
ensure adequate oxygenation of body tissues.
Hand washing: It is important for patients with Meningitis to wash their hands. Healthcare
workers should practice strict infection control measures such as hand washing, the use of
alcohol hand wipes or gels and changing aprons and gloves between caring for/treating patients.

35
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Case
Study Drug Study

36
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Drug Study
Following treatment was prescribed in ICU:

o Inj. Oxidil 2g BD o Inj. Manitol 150cc TDS

o Inj. Omega 40 mg OD o Tab. Vita-6 BD
o Inj. Decadron 1cc TDS o Inj. Provas 1g BD
o Tab. Myrin P 5 Tablets OD o Inj Gravinate SOS
o Inj Ringer Lactate 1000ml OD

Brand Generic name Mechanism of Rout Side effects Special

Name action considerations

Inj. Oxidil Ceftriaxone Inhibits I/V Hypersensitivity, Caution in using

bacterial cell increased liver with known case
wall synthesis, enzymes, of
leading to cell diarrhea, Rash. Hypersensitivity,
death or Renal or
Hepatic
insufficiency

Inj. Omega Omeprazole Gastric proton I/V Hypersensitivity, Caution in using

pump inhibitor, headache, with
suppress gastric diarrhea, hypersensitivity.
acid secretion abdominal
pain,trouble
awakening and
sleep deprivation

[Link] Dexamethasone Antiinflamatory I/V GI disturbance, Warn patient

n glucocorticoid, hypertension, about easy
suppresses edema, delayed bruising, instruct
immune system wound healing, to take medicine
and stabilize susceptibility to with meal.
leucocyts infection

37
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Brand Generic Mechanism of action Rout Side effects Special

Name name considerations

Tab. Myrin Rifampicin inhibits Oral Disorders of the Contraindicated

Rifampicin1 bacterial DNA dependent blood lymphatic in Alcoholism,
50mg, RNA synthesis by
Ethambutol system, immune optic neuritis,
inhibiting bacterial DNA-
275mg, dependent RNA system, impaired
Isoniazid polymerase metabolism hepatic
75mg, nutrition, , GI function, severe
Pyrazinamid . Ethambutol inhibits Disturbance , renal
e bacterial cell wall hepatobiliary, insufficiency,
400mg synthesis. skin SC tissues, hyperuricemia,
Isoniazid & musculoskeletal, gouty arthritis,
Pyrazinamide inhibits connective jaundice,
the synthesis of mycolic tissue bone, retrobulbar
acid required for renal/urinary. neuritis.
the mycobacterial cell Fever, malaise, Pregnancy
wall. flu-like lactation
syndrome,
dryness of
mouth.

Inj. Manitol Manitole Osmotic diuretic, I/V Dizziness, Monitor for

increase osmotic headache, electrolyte
pressure of plasma and hypotension, imbalance and
increase GRF and inhibit nausea, sign and
tubular reabsorption of vomiting , symptoms of
water diarrhea, dehydration.
polyurea,
dehydration,
electrolyte
imbalence

38
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Brand Generic Mechanism of action Rout Side effects Special

Name name considerations

Tab. Vita-6 Vitamin B Adjuvant therapy in Oral Hypersensitivit Consider in

complex. tuberculosis patients. y to pyridoxine. hypersensitivity to
Nausea and pyridoxine.
Proved beneficial in
correcting the vomiting

sideroblastic anaemias.
Acts as an antidote for
the seizures and acidosis
in patients who have
ingested an overdose
isoniazid.

Inj. Provas Paracetamol Antipyretic action, act I/V Hepatotoxicity, It can cause
by inhibiting nephrotoxicity, serious
hepatotoxicity
cycloxygenase enzyme. Gestrointestinal
while taken in
disturbance high doses.

39
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Case Discharge
Study Plan

40
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

Discharge Plan
Medication:
 Myrin –P 5 Tab OD.
 Prednisolone 5mg 3 Tab TDS for 2 week.
 Vitamin-B6 1 Tab HS.
 Omega-40mg 1 Capsule TDS for 1 month.
Environment/ Exercise:
 Instruct the family to provide clean and fresh air.
 Encourage mild exercise to promote good circulation and healthy self concept.
Treatment:
 Advise patient to take medication with heavy meals and on time.
 Teach patient and his family members that adherence to prescribed treatment is very
necessary and important for total recovery of the patient.
 Instruct about side effects of medications.
Health Teachings:
 Instruct patient to take adequate fluid intake up to 8 Glass per day.
 Report any worsening of condition to physician.
 Advice for the comfortable sleeping pattern.
 Continuous weight monitoring and report any sudden change in weight.
 Instruct for bed rest with tolerable mobility.
 Instruct for the side effects of medicines, disease process and treatment regimen.
Out patient follow up:
 Advise patient to have follow up on 04/12/2012.
Diet:
Diet plays an important role in the recovery of patient so instruct patient and family to:
 To take diet as tolerated
 Eat nutritious food i.e fruits and vegetables
 Not to eat junk and fast food instead encourage healthy foods


41
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

References
1. Brunner & Suddarth’s, Text book of Medical And Surgical nursing, 12th Ed.

2. Black M. Joyce, hawks jane and keene Annabelle, medical-surgical Nursing, clinical
management for positive outcome, 6th Ed.

3. Robbins and Cotran, Pathologic Basis of Disease, 8th Ed.

4. Davidsons Practice of medicine, 21st Ed.

5. Danish, Inam. The text book of medical diagnosis and management, 8th Ed.

6. Haneef, S.M. text book of Pediatrics, Pakistan pediatric association, 5th Ed.

7. Ross and Wilson, Anatomy and Physiology, 10th Ed.

8. Central Nervous System Tuberculosis. [Link].

9. Wikipedia, The free encyclopedia.

10. [Link]

42
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College
By Tanzeel Ul Rahman
BSN Final Year

43
Case Study By Tanzeel Ul Rahman , Shalamar Nursing College