Nursing Care for Patients with TB Meningitis

I. INTRODUCTION

Tuberculous meningitis is the most severe form of tuberculosis. It causes severe neurologic deficits or death in more than half of cases. In areas with much tuberculosis, tuberculous meningitis usually affects young children. It develops typically 3 to 6 months after the primary tuberculosis infection.

By contrast, in areas with less tuberculosis, tuberculous meningitis tends to strike adults. It may follow a primary infection but, more frequently, is due to reactivation of an old focus of tuberculosis that had been dormant, sometimes for many years.

Tuberculous meningitis begins insidiously with a gradual fluctuating fever, fatigue, weight loss, behavior changes, headache, and vomiting. This early phase is followed by neurologic deficits, loss of consciousness, or convulsions. A dense gelatinous exudate (outpouring) forms and envelops the brain arteries and cranial nerves.

It creates a bottleneck in the flow of the cerebrospinal fluid, which leads to hydrocephalus. The development of arteritis and infarctions of the brain can cause hemiplegia or quadriplegia.

Treatment involves chemotherapy to control and eradicate the infection, management of hydrocephalus and elevated intracranial pressure, and immunomodulation with corticosteroids (cortisone-like drugs such as prednisone).

The World Health Organization (WHO) recommends a two-month intensive course of isoniazid, rifampin, pyrazinamide, and ethambutol followed by 4 months of isoniazid and rifampin.

A. OBJECTIVES

At the end of the case study the students will be able to: 1. Enhance our knowledge and understanding about the case TB Meningitis. 2. Discuss the factors of acquiring the disease and the disease process.

3. Enumerate signs and symptoms of TB Meningitis. 4. Apply the skills/nursing intervention in caring for TB Meningitis patient. 5. As a nurse, that we may provide a holistic care for our patients. 6. Appreciate the role of the nurse in the care of patient afflicted with TB Meningitis.

B. PATIENTS PROFILEPatients Name: Patient X Sex: M Civil Status: S Birth Date: 12/28/1995 Age: 15yr(s) Birth Place: manila City Nationality: Filipino Religion: Catholic Occupation: Student Address: sta. cruz manila Admission Date: 12/18/2011 Time: 05:31 AM

Pertinent Physical Findings:Temp: 37.6 CR: 66 RR: 29 BP: 110/70 Wt. (kg): 35 Not in CP distress, carried, anicteric sclerae, pink palpebral conjunctivae, (+) palpable cervical lymph node (L), (+) nuchal r igidity, symmetrical chest expansion, adynamic precordium, pulses full and equal, (-) cyanosis, (-) edema , (+) kernig sign

CLINICAL HISTORY

ADMITTING HISTORY Brief History: Chief Complaints: Headache

13 days PTA- increasing headache severity with undocumented fever, unable to go to school, consulted local M.D given unrecalled medications. 10 days PTA- still with headache and intermittent fever, (+) vomiting of previously ingested food (nonprojectile), chest x-ray done, results showing PTB and was given unrecalled medications.

8 days PTA- symptoms persisted, CT scan of the cranium (plain and contrast) showed normal results hence was given Ibuprofen and antibiotics. 3 days PTA- increasing severity of headache, was unable to stand and ambulate without assistance with poor appetite. 2 days PTA- patient became bed ridden, lethargic but still able to follow commands, sips through straw for food, few hours prior, increased sleeping time, decreased sensorium, consulted at Amang Rodriguez. Diagnosed with tuberculous meningitis and advised admission.

REVIEW OF SYSTEMSCNS: Headache, Behavioral Changes MUSCULOSKELETAL:Weakness RESPIRATION: Cough GASTROINTESTINAL:Vomiting PAST MEDICAL HISTORY Previous Hospitalization: None Immunization History: unrecalled Growth and Development: Normal, at par with age Family History: (+) HPN- father, (-) PTB, DM, heart dse, renal dse, cancer PERSONAL AND SOCIAL HISTORY 3rd year HS student, does well in school (-) smoker, (-) alcoholic beverage drinker, no illicit drug use.

Physical Examination General Survey: lethargic, bed ridden, not in CP distressExtremities No lesions, (-) edemal cyanosis, pulses full and equal Pink palpebral conjuctivae, anicteric sclerae, (+) cervical lymph node, (+) nuchal rigidity symmetrical Head and Neck

Chest :

Lungs Heart Abdomen

Clear breath sounds Asymmetrical precordium, no murmurs Flat abdomen, (-) palpable masses

Genitourinary Skin Neurologic

(-) cr tenderness Warm moist skin, (-) active dermatoses Cerebrum lethargic 6CS 12 (E4V2M6)

Cranial Nerves I II, III III, IV, VI V VII

NA Right pupil 5mn Left pupil 3mn Lateral gaze to right (+) corneal blink (-) facial asymmetry

VIII IX, X XI XII(+) Nuchal Rigidity (+) Babinski , bilateral (+) Brudzinski (+) ankle Clonus Motor can move all extremeties Sensory withdraws to painful stimuli DTRS H on all extremities

NA Weak gag NA tongue midline

Probable Diagnosis/Clinical Impression: TB Meningitis / Pulmonary TB

Final Diagnosis: TB Meningitis

Final Diagnosis: TB Meningitis

Initial Summary

II. THEORETICAL FRAMEWORK

Lydia Eloise Hall (1906-1969) THE CORE CARE CURE THEORY

LYDIA HALL Definition of Nursing: Nursing is participation in care, core and cure aspects of patient care, where CARE is the sole function of nurses, whereas the CORE and CURE are shared with other members of the health team. The major purpose of care is to achieve an interpersonal relationship with the individual that will facilitate the development of the core.

CORE(PATIENT)

In the patients case, the patient himself is the core component. As nurses, we always emphasize the importance of the therapeutic use of self for a speedy recovery. If the patient feels good about himself and cooperates with the medication process, the medical team, including the patient will achieve the goals of his recovery.

CARE(HEALTH CARE TEAM)

Care comes from within; as nurses we have the responsibility of dedicating ourselves in giving the best type of care in a very morale and professional way.

CURE(MEDICATION)

Care and cure comes hand in hand with the core. As nurses we provide the most suitable cure modalities to foster wellness.

If this component worked together, recovery will definitely be achievable, not only for patients, but also for the healthcare team.

III. ANATOMY

III. ANATOMY OF THE MENINGES

The Meninges The meninges (singular, meninx) are protective coverings of the brain (cranial meninges) and spinal cord (spinal meninges). They consist of three layers of membranous connective tissue:

The dura mater is the tough outer layer lying just inside the skull and vertebrae. Some characteristics follow: In the brain, there are channels within the dura mater, the dural sinuses, which contain venous blood returning from the brain to the jugular veins.

In the spinal cord, the dura mater is often referred to as the dural sheath. A fat-filled space between the dura mater and the vertebrae, the epidural space, acts as a protective cushion to the spinal cord.

The arachnoid (arachnoid mater) is the middle meninx. Projections from the arachnoid, called arachnoid villi, protrude through the dura mater into the dural sinuses. The arachnoid villi transport the CSF from the subarachnoid space to the dural sinuses. Two cavities border the arachnoid:

The subdural space occurs outside the arachnoid (between the arachnoid and the dura mater). The subarachnoid space lies inside the arachnoid. This space contains blood vessels and circulates CSF. The fine threads of tissue that spread across this space resemble the web of a spider and give the arachnoid layer its name (arachnid means spider).

The pia mater is the innermost meninx layer. It tightly covers the brain (following its convolutions) and spinal cord and carries blood vessels that provide nourishment to these nervous tissues.

ANATOMY OF THE LUNGS

LUNGS The lungs are a pair of cone-shaped bodies that occupy the thorax. The mediastinum, the cavity containing the heart, separates the two lungs. The left and right lungs are divided by fissures into two and three lobes, respectively. Each lobe of the lung is further divided into bronchopulmonary segments (each with a tertiary bronchus), which are further divided into lobules (each with a terminal bronchiole). Blood vessels, lymphatic vessels, and nerves penetrate each lobe.

The following superficial features of the lungs The apex and base identify the top and bottom of the lung, respectively. The costal surface of each lung borders the ribs (front and back). On the medial (mediastinal) surface, where each lung faces the other lung, the bronchi, blood vessels, and lymphatic vessels enter the lung at the hilus.

The pleura are a double membrane consisting of inner pulmonary (visceral) pleura, which surround each lung, and outer parietal pleura, which lines the thoracic cavity. The narrow space between the two membranes, the pleural cavity, is filled with pleural fluid, a lubricant secreted by the pleura.

IV.Pathophysiology

Precipitating Factors: yEnvironment yLifestyle yClose repeated contact with someone who has active TB yAny person without adequate healthcare.

Mycobacterium tubercle enters the host by droplet inhalation.

Bacteria are transmitted through the airways of alveoli, where they are deposited and multiply.

Primary TB

Secondary TB Development of cell-mediated immunity

Cell mediated hypersensitivity response

Re-infection

Granulomatous inflammatory response

Positive skin Test

Ghons Complex

Progressive or disseminated TB

Erode into blood vessels giving rise to hematologic dissemination

Healed dormant lesions This dissemination can involve almost any organ particularly kidneys, liver, brain and meninges

Reactivated TB Miliary TB

Bacilli seeds to meninges

Encephalitis

Meningeal Irritation

Cerebral Edema Nuchal rigidity, Kernigs sign and Brudzinkis sign

Increased intracranial pressure

Vomiting, seizure, and headache

V. Laboratory

ADMITTED: July. 25, 2010 DATE: July. 27, 2010TEST REMARKS DESCRIPTION Plain contrast enhanced axial 64-VCT Scan images of the head show diffuse undue enhancement of leptomeningitis. Ventricles are mildly dilated, with transependymal edema in cerebral hemispheres. ANALYSIS Thickening of the leptomeninges, throughout entire length of spinal cord. Ct Scan Of The Diffuse Head Leptomeningitis

Mild communicating hydrocephalus of increase intravenous pressure.

Does not arise from visible blockage in flow of cerebrospinal fluid and accompanied by accumulation of CSF within the skull.

Chronic mastoiditis bilateral.

Rest of supra of infratentorial brain parenchyma is normal in attenuation. No evident mass, hemorrhagic extravasations or abnormal enhancement of brain parenchyma. A non-enhancing CSF isointense cyst is seen in the right cerebello pontin angle measuring 1.7 X 1.5 cm.

Normal

Normal

Indicates the infection of the middle ear and mastoid.

Consider a small right cerebello pontin angle arachnoid cyst.

The sella extracellular and intraorbital structure left cerebello pontin angle and bony calvarium and intact.

CT SCAN FINDINGS: There is increase leptomeningeal enhancement. There is prominence of the temporal horn of the right lateral ventricle. The rest of the ventricles are not dilated. No abnormal mass or density seen in the brain parenchyma. No shift of the midline structure posterior fossa structures is normal.

Impression: Findings suggestive Leptomeningitis. Leptomeningitis = A condition which is characterized by inflammation of the leptomeninges, and inflammation of the arachnoid membrane and adjacent subarachnoid space. Also called piaarachnitis

CSF Analysis Date: 08/03/10Components Color, Appearance Result Bloody Normal Significance Implication Value Colorless, Xanthrochromic Indicates presence clear of hemoglobin pigment from lysed RBCs, Subarachnoid intraventricular hemorrhages, Spinal cord obstruction, traumatic tap. No RBC Present Red cells in CSF signal subarachnoid hemorrhage, stroke, or traumatic tap.

Total RBC

15/cumm

Total WBC

417/cumm 0-5 cumm

Increased

Neutrophil

1%

38 80 %

Decreased

An increase in WBCs may occur in many conditions including infection (viral, bacterial, fungal, and parasitic). Increase active disease meningitis, onset of chronic illness, tumor, abscess, infarction, demyelinating disease. Neutrophil is lower than normal indicates risk for infection.

Lymphocyte

99 %

15 40 %

Increased

Total Protein

261.48 mg/dL

15 50 mg/dL

Increased

An increase in lymphocyte concentration is usually a sign of a viral infection CNS diseases, syphilis and TB. High protein levels seen in infection and infiltration disorders (falsely high results are seen if the sample is contaminated with blood). Increase blood in CSF, Tumor, DM, and polyneuritis.

Glucose

29.32 mg/dL

40 80 mg/dL

decreased

No No microorga microorgani nism seen sm AFB Stain No AFB No AFB seen CSF Aerobic No growth Cult after 5 days inculcation

GS

A glucose level below 40 mg/dL is significant and occurs in bacterial and fungal meningitis and in malignancy The result is within normal The result is within normal

Hematology Date: 08/0710Compone nts WBC Result 7.98 cumm Normal Signific Implications Value ance 9.8-10.8 decreas Presence cumm e of an infections and medication s that weakened the immune system.

RBC

4.66 cumm

9.7 10.6 cumm

decrease

A low RBC count may indicate anemia, bleeding, kidney disease, bone marrow failure (for instance, from radiation or a tumor), malnutrition, or other causes. A low count may also indicate nutritional deficiencies of iron, folate, vitamin B12, and vitamin B6.

Hemoglobin Hematocrit MCV (Mean Corpuscular Volume)

13.67 % 41.55 % 89.09 cumm

13-17 % 40-52 % 82-98 cumm 28-33 pg/cell

MCH (Mean 29.03 Corpuscular pg/cell Hemoglobin ) MCHC 32.89 g/dl (Mean Corpuscula r Hemoglobi n Concentrati on)

33-36 g/dl decrease It may indicate iron deficiency anemia but other factors will be measured.

Platelet Count

446,000/cumm

150,000 400,000/cumm

increase

Can be either reactive or essential. A high platelet count is a reaction to inflammation, infection, injury, anemia, or cancer. Indicates that genetic conditions or hormone imbalances are causing irregular platelet formation.

Neutrophil Lymphocyte Eusinophil Monocyte Basophil

58.2 ul 29.08 ul 3.8 ul 7.8 ul 0.4 ul

40-70 ul 19-48 ul 2-8 ul 3-9 ul 0-5 ul

Blood Chemistry Date: 08/07/10Result Creatini 0.54 ne mg/dL Normal Significan Implications Value ce 0.8- 1.2 Low level May be mg/dL caused by late stage muscular dystrophy,my asthenia gravis and over dehydration.

Sodium

134.00 mg/dL

135-145 mg/dL

Low level

Indicates hyponatremia which may cause edema. Results inadequate sodium intake or excessive sodium loss due to profuse sweat, GI suctioning, diuretic therapy, diarrhea, vomiting and adrenal insufficiency, burns, chronic renal insufficiency with acidosis.

Fecalysis Date: 08/09/10Components Odor color Result brown Normal Value Yellow brown Significance Implications Its brown coloration comes from a combination of bile and bilirubin, which comes from dead red blood cells Soft stools may indicate one of several conditions and may depend on the diet.

consistency

soft

formed

Epithelial Few cell present Leukocyte Few s present RBC none Mucles moder Few fibers ate present Food Varies with particle diet Mucous Few present Parasites none

Depends on the diet

Urinalysis Date: 08/09/10Components Result Normal Value Significance Implications

Color

Yellow

Yellow to Amber

Transparency Slightly Turbid

Clear

Turbidity or cloudiness may be caused by excessive cellular material or protein in the urine or may develop from crystallization or precipitation of salts upon standing at room temperature. Clearing of the specimen after addition of a small amount of acid indicates that precipitation of salts is the probable cause of turbidity

pH

Acidic

4.5 8

Acid urine pH is associated with intake large amount of meat, renal tuberculosi s, pyrexia, phenylketo nuria, alkaptoton uria, and acidosis.

Specific Gravity Albumin Sugar

1.030 -

1.005 1.035

RBC

0-3/hpf

None

Hematuria

Pus Cell Squamous Cell

0.2/hpf Few

None None

Present Present

Indicates bleeding within the genitourinary tract and may result to infection, inflammation, obstruction, tumours or trauma. Indicates an infection. May suggest renal tubular degeneration.

VI. Drug Analysis

Drug Name Ranitidine

Action Potent anti-ulcer drug that competitively and reversibly inhibits histamine action at H2 receptor sites on parietal cells, thus blocking gastric acid secretion. Indirectly reduces pepsin secretion but appears to have minimal effect on fasting and postprandial serum gastrin concentrations or secretion of gastric intrinsic factor or mucus

Indication Short-term treatment of active duodenal ulcer; maintenance therapy for duodenal ulcer patient after healing of acute ulcer; treatment of gastroesophageal reflux disease; short term treatment of active, benign gastric ulcer; treatment of pathologic GI hypersecretory conditions

Contraindication Ranitidine Tablets, is contraindicated for patients known to have hypersensitivity to the drug or any of the ingredients

Side Effects Chest pain, fever, shortness of breath, coughing up green or yellow mucus; Easy bruising or bleeding, unusual weakness; Fast or slow heart rate;problems with vision;sore throat, and headache Severe blistering, peeling, and red skin rash; Stomach pain,loss of appetite, Dark urine, clay colored stools, jaundice (yellowing of the skin or eyes). Mild diarrhea; mild pain, swelling, or redness at the injection site; nausea; vomiting

Nursing Intervention Inform the patient to avoid taking alcohol because it can increase the damage in the stomach Assess for any allergies to the drugs

Ceftriaxone

A cephalosporin antibiotic. It works by interfering with the formation of the bacteria's cell wall so that the wall ruptures, resulting in the death of the bacteria.

used to treat many kinds of bacterial infections, including severe or life threatening forms such as meningitis.

Pain, warmth, and/or minor swelling at injection site Severe or watery diarrhea Blood in stools if have had a Itching severe allergic Wheezing Rashes reaction (eg, severe rash, hives, Difficulty breathing difficulty breathing, or swallowing Swelling of the dizziness) to a throat penicillin antibiotic (eg, amoxicillin) or other beta-lactam antibiotic diarrhea, stomach or bowel problems (eg, inflammation, infection), a blood clotting problem, gallbladder disease, low vitamin K levels, or poor nutrition history of liver or kidney problems currently using a medicine or supplement that contains calcium if pregnant, planning to become pregnant, or breast-feeding

Check any medical conditions that is contraindicated to the use of the drug

Isoniazid

is an antibiotic. It prevents tuberculous bacteria from multiplying in the body.

used to treat and to prevent tuberculosis (TB).

had an allergic reaction to isoniazid, kidney disease, or liver disease.

an allergic reaction (difficulty breathing; closing of the throat; swelling of the lips, tongue, or face; or hives);

Instruct the patient to avoid alcohol while taking this drug Inform the patient about certain foods that should be eaten with caution while unusual taking the drug weakness or like: fatigue; cheeses nausea, vomiting, or loss sour cream and yogurt of appetite; beef or chicken abdominal pain; liver avocados, yellow skin or eyes; bananas, raisins, soy sauce, miso dark urine; soup,ginseng numbness or chocolate foods tingling in your with caffeine, hands or feet beer

Quadtab (rifampin+ pyrazinamide+ Izoniazid+ ethambutol)

is an antibiotic. It prevents tuberculous bacteria from multiplying in the body.

Intensive phase of Hypersensitivity. all pulmonary and Severe hepatic extra pulmonary TB damage & acute gout. Pre-existing optic neuritis from any cause.

Rifampicin: Flu-like syndrome; hematopoietic reactions; GI & hepatic reactions; shortness of breath; shock & renal failure. Hypersensitivity reactions. INH: Disturbances of hepatic function, convulsions, optic neuritis & atrophy, memory impairment, toxic psychosis, hepatitis & peripheral neuropathy. Pyrazinamide: Hyperuricemia. Ethambutol: Decreased visual acuity due to optic neuritis; joint pain, anaphylactoid reactions, dermatitis, pruritus, anorexia, nausea, vomiting, abdominal pain, fever, GI upset, malaise, headache, dizziness, mental confusion, disorientation, hallucinations.

Assess for any possible drug interactions Assess for any conditions which require any precaution or contraindication Instruct patient to report any discomfort after taking the drug

Oxacillin paracetamol

VII. NCP

NURSING DIAGNOSIS SUBJECTIVE: Altered Masakit ang ulo comfort related ko. as verbalized to meningeal by the client. irritation or OBJECTIVE: inflammatory -Restlessness. response as -facial grimace evidenced by -irritable pain scale of 6, -guarding facial grimace behavior and guarding -pain scale of behavior. 6(moderate) - V/S taken as follows: T: 37.4 P:118 R: 30 Bp: 100/70

ASSESSMENT

NURSING INTERVENTION Short-Term Independent: After 4 hours of -Monitor vital collaborative signs including nursing the pain scale intervention the - position the patient pain will patient in the be reduced from most 6 to 4. comfortable Long-Term: position of the After a week of patient - provide quiet collaborative environment nursing intervention the -encourage the use of relaxation patient will: techniques such -verbalize and as focused report less breathing frequent kpain -encourage adequate rest periods Dependent: -Giving analgesic as prescribed by the physician

PLANNING

RATIONALE -to have a baseline comparison -to promote comfort to the patient -to promote rest -provide nonpharmacological method to relieve pain -to prevent fatigue -provide pharmacological relief of pain

EVALUATION Short-Term After 4 hours of collaborative nursing intervention the patient pain was reduced from scale of 6 to 4. Long- Term After a week of collaborative nursing intervention the patient was: -verbalized and reported less frequent pain.

Assessment Subjective: Kinukumbulsyon ang anak ko As verbalized by the mother. Objective: y Body weakness y Pale looking y Facial grimace y Irritability y V/S taken: Temp: 37.4 RR: 30 PR: 118 BP: 100/70

Diagnosis Risk for injury related to clonictonic movements, secondary to seizures, as evidence of brief attacks of altered consciousness, motor activity, and or sensory phenomena

Planning After 3-4 hours of nursing intervention the patient will be able to y Demonstrate appropriate lifestyle changes to reduce risk of injury y Recognize need for seek assistance to prevent accidents/ injuries

Intervention Independent y Keep padding side rails up w/ bed in lowest portion y Locked wheels on bed y Provide quite environment and reduce stimulation as indicated Dependent y Give anticonvulsants as prescribe by the physician. Collaboration: y Assist for treatment for endocrine/ for electrolytes imbalance condition. y

Rationale Minimized injury should seizure occur while patient in bed. For patients safety To prevent such conditions that will trigger seizure attack Anti convulsant drugs are use to prevent seizures May improved cognition muscle tone, and general well being

Evaluation After 3-4 hours of nursing intervention the patients safety was improved as evidenced by negative report of injury y Responses to intervention/ teaching and action y Demonstrate appropriate lifestyle changes to reduce risk of injury y Recognize need for seek assistance to prevent accidents/ injuries y Modification to plan of care

y y

y

y

Assessme Diagnosis nt Subjective: Parang pinabayaan ng Diyos ang anak ko, hindi pa sya gumagaling as verbalized by the mother Objective: Decreased affect Decreased initiative to communicat e Risk for spiritual distress related to prolonged illness of the child

Planning

Intervention

Rationale

Evaluation

After 5 days of nursing intervention patients mother spiritual well being will be improved

Independent : -be available to listen to patients mothers feelings -be open to patients mothers feeling about illness -facilitate patients mother use of prayer

After 5 days of -to express nursing the mothers intervention feeling patients mothe r was able to -to promote improve trust and spiritual well lessen agony being -to provide spiritual strength

VIII. Discharge Planning

Discharge teaching for the patient following the medications and with proper environment prior to the discharge. It is also important is to consider the signs and symptoms of productive cough regarding the tuberculosis. The nurse must be sure that the patient and family understand all the aspects of home care. MEDICATION Teach the family members to assist medication regimen as necessary. Take the medications regularly in very strict way.

EXERCISE Patient may have isometric and isotonic exercises . TEACHING Instruct the family should continually assess the frequently monitor the patient airway patency. The family should be aware of productive coughing of the patient. Instruct also the family by proper handling of the patient. HYGIENE Teach the family by proper bathing of the patient. And also have clean environment.

OUT PATIENT / FOLLOW UP Encourage the family and also the patient the importance of follow up check up DIET Instruct the family to give only warm fluids and avoid cold fluid as well. Eat healthy food that contain essential nutrients. SAFETY Instruct the family members to assist the patient when moving and standing.

IX. HEALTH TEACHING

1. Proper nutrition is needed such as vitamin C to increase body resistance / eating healthy foods that contain essential nutrients. 2. Advice patient to drink warm fluids for normal physiological functioning of the body. 3. Avoid foods that trigger seizures like coffee, tea, cocoa, chocolate ( which are rich in caffeine ) and flavored-enhances monosodium glutamate. 4. Anticonvulsants may be prescribed for seizure prevention such as phenytoin (Dilantin) or carbamazepine (Tegretol) 5. Antibiotics is prescribed since they have been known to reduce the death rate to less than 5% for all types of bacterial meningitis.

6. Provide dim light environment for the prevention of photophobia. 7. Avoid cold weather as much as you can for prevention of drying skin because to know if the patient is dehydrated or not. 8 Neurologic status should also frequently assessed as indicated to detect early manifestations of increasing ICP and seizures. 9. Strict compliance on medication. 10. Monitor I and O for possible bacteria.

X. RECOMMENDATION

For the improvement of the quality of every families health our groups staunchly concur the following recommendations: Monitor Vital Signs Isolation of the patient Provide quite environment to give comfort and relaxation of the patient Recommendation for the relatives to wear mask because TB Meningitis is a communicable disease.

School based TB screening programs should be implemented only if they include complete plans for providing necessary clinical treatment, as indicated for students identified with latent TB infection or TB disease. The centers for disease control and prevention (CDC ) has created guidelines to know what vaccines they and their children should receive. Children 11 to 18 y/o should get one dose of the meningococcal vaccine. The best time to immunize a child with the meningococcal vaccine is when they are 11 or 12 yrs of age.

XI. Conclusion

TB meningitis is a disease caused by mycobacterium tuberculosis that disseminated in the meninges. It is a very rare disease usually affecting children. Our patient is 13 years old boy who typically loves to play outdoors. In our environment there are many factors that could cause infectious diseases. So proper hand washing is very important in our daily activities especially to children.

In TB meningitis the central nervous system is affected particularly the meninges which serve as a protective covering of the brain and spinal cord. If the meninges fail to function, the person s health would be at serious risk. Proper drug compliance is monitored and holistic approach for the child and parents must be given.

As nurses we wanted to initiate learning to help minimize the increasing number of children who have been through this illness by making use of our knowledge as a nurses. Nursing is not only an occupation but a caring profession, that makes us different from any other professionals. At present our patient has discharge and was sent home.