NURSING CARE PLAN FOR NURSING CARE PLAN FOR PATIIENTS WITH PATIIENTS WITH MENINGITISMENINGITIS

By Diane Kathryn S. Nierva, RNBy Diane Kathryn S. Nierva, RN..

GOOD AFTERNOON!!!!!!! GUYS!!

• ARE YOU STILL THERE???

Objective:• RR: 50• O2 saturation: 89%• GCS= 11• Pale and weak in

appearance• Use of accessory muscles• With nasal flaring• With chest retractions

INEFFECTIVE BREATHING PATTERN RELATED TO DECREASED LEVEL OF CONSCIOUSNESS AND RESPIRATORY FATIGUE AS EVIDENCED BY ALTERED RESPIRATORY RATE

Plan of Action

• At the end of nursing intervention the patients respiration will be reestablished and it’s rate return to normal range.

Nursing Interventions:• Assess the condition of patient. Check for the

level of consciousness. • Identify if there is an impending respiratory

failure by monitoring respiration changes. Note respiratory rate, depth, rhythm, symmetry of chest movement and use of accessory muscles.

• Assess Arterial blood gas level and oxygen saturation.

• Provide oxygen therapy .

• Notify the attending physician of the patient’s current condition.

• Assist with the implementation of ventilatory support as indicated. Check ventilator alarms if functioning. Look if oxygen line is connected to the proper outlet.

• Administer medications as ordered. Check patients response to the medication.

• SUBJECTIVE:• “ Masakit ang ulo ko” as

verbalized by patient

• Objective:• Pain scale: 9/10• With facial grimace• Irritable• Restless• With high pitched cry• BP: 120/70 mmHg

ALTERATION IN COMFORT, PAIN RELATED TO MENINGEAL IRRITATION SECONDARY TO DISEASE CONDITION.

Plan of action

• At the end of nursing intervention, pain level experienced will be decreased or alleviated.

Nursing Interventions

• Assess patients pain scale.• Place child on a comfortable position. Be

careful not to flex the childs neck when turning or positioning her. Allow the child to assume a comfortable position. (mostly opisthotonic position wherein the neck and head is hyperextended to relieve discomfort.)

• Provide rest periods to facilitate comfort, sleep, and relaxation.

• Keep the lights dim and maintain quiet environment.

• Provide pain medication as ordered and check effectiveness of medication given.

• OBJECTIVE:• Restlessness• Irritable• GCS= 12• High pitched cry• Tensed bulging anterior fontanelle upon palpation• Pulse rate 70 bpm• RR= 18 • With unequal pupil size L= 4, R= 2

ALTERED CEREBRAL TISSUE PERFUSION RELATED DECREASED BLOOD FLOW TO THE BRAIN DUE TO CEREBRAL EDEMA/ INCREASED ICP SECONDARY TO DISEASE CONDITION.

Plan of Action

• At the end of nursing intervention, optimal tissue perfusion will be improved in the brain as evidenced by increase in the level of consciousness.

Nursing Interventions:• Assess patients condition. Check for signs of increased ICP

like restlessness and irritability, high pitched cry, vomiting, and headache.

• Check for the Level of consciousness. • Monitor vital signs. Get the temperature, Respiratory rate,

Heart Rate and Blood Pressure. Note: Increased Blood pressure, bradycardia and Wide pulse pressure are indicators of increased ICP.

• Measure child’s head circumference.• Weigh him or her daily. • Give oxygen inhalation via nasal cannula.

• Place child head positioned on midline to encourage jugular venous drainage and the head of the bed is elevated to 15[degrees] to 30[degrees]. The child's head should be maintained midline to prevent impairment in drainage from the external jugular veins and the head of bed should be maintained at 30[degrees] with alterations based on the child's response. The child must be euvolemic prior to placing in this position to avoid orthostatic hypotension.

• Regulate IV fluids properly at the rate ordered.• Provide medication as prescribed like mannitol.

Subjective• “Parang mainit ang katawan

nya” as verbalized by mother

Objective:• With flushed face• Skin warm to touch• Pale and weak in

appearance• temperature= 39 C• RR= 46 breaths/min• HR= 96

Alteration in Body temperature; hyperthermia; related to presence of pyogenic microorganisms in the thermoregulating center of the brain.

Plan of Action

• At the end of nursing intervention, temperature will decrease or return to normal range.

Nursing Interventions:

• Assess for the possible contributing factors.• Monitor vital signs• Render continuous tepid spongebath and teach

significant others on proper provision.• Provide adequate ventilation. Remove overly

constricting or thick clothing.• Maintain a quiet and restful environment.• Regulate IV fluids properly.• Administer antipyretics as ordered.

• Subjective:• “Nurse nanginginig

yung anak ko at tumatarak ang mata”

• Objective:• With Upward rolling of

the eye• With tonic clonic

seizure of 2 minutes duration

• Pale in appearance• With drooling noted• with cyanotic lips noted• With cyanotic nailbeds

Risk for injury related to seizure episodes secondary to disease condition

Plan of Action

• At the end of nursing intervention, significant others will understand and demonstrate ways on how to manage patient when seizure occurs

Nursing Interventions:• Monitor Childs vital signs.• Remove unnecessary articles on patients’ bed.• Provide oxygen to patient.• Place child on side lying position to avoid aspiration.• Do not put anything on child's mouth when there is a

seizure attack. Do not restrain child.• Provide a quiet non stimulating environment and dim

the lights.• Teach parents on management of patient with seizure.

Subjective

“Nasasamid siya pag pinapadede ko, hidi sya masyadong makalunok” as verbalized by mother.

objective

• GCS= 11• With poor sucking

and swallowing reflex noted

• With increased accumulation of saliva in the mouth.

RISK FOR ASPIRATION RELATED TO DECREASE LEVEL OF CONSCIOUSNESS AND POOR SECRETION CONTROL.

Plan of Action

•At the end of nursing intervention, the risk for aspiration will be minimized as exhibited by proper feeding of mother.

Nursing Interventions:• Assess patient’s level of consciousness. Assess

patient’s ability to swallow and strength of gag and cough reflex.

• Instruct significant other not to feed patient on lying position.

• Maintain operational suction equipment at bedside.• Suction oral cavity and nose as needed.• Place patient’s head of bed at 30 degrees elevation.

• Teach significant others on proper feeding with head slightly elevated and propped on right side after feeding.

• Provide oral care after meals.• Notify the physician or other health care

provider immediately of noted decrease in cough and/or gag reflexes or difficulty in swallowing

• When feeding per orem is not possible: • Assist in insertion of nasogastric tube as ordered.

Prepare the necessary materials needed.• Check for patency of NGT prior to tube feeding. • Check for any residual in the tube• Flush NGT with 20-30 cc of water• Feed patient with head part of bed elevated.

For Family and Other Persons safety

Risk for Infection related to presence of pathogenic microorganism in the cerebrospinal fluid as evidenced by lab result.

Plan of Action

• At the end of Nursing Intervention, Significant others will demonstrate ways and means to prevent spread of infection.

Nursing Interventions:• Assess family’s level of understanding of child’s

current condition.• Demonstrate proper hand washing technique to

relatives and stress out its importance.• Instruct significant others to wear protective gears

such as face mask.• Isolate patient as quickly as possible.• Minimize room visits as much as possible.• Discard any articles or body secretions from the

patient in the proper waste disposal bin.• Acquire prophylaxis by taking prescribed medications

or vaccination.