NCP Meningitis

ASSESSMENT

ASSESSMENT PLANNING PLANNING INTERVENTION INTERVENTION EXPECTED OUTCOMEEXPECTED OUTCOME S> ³Mainitsiya´

S> ³Mainitsiya´ O>

O>



 febr febr ililee 38.138.1



 ww_{aarmrm to touchto touch}



 mmild sild sww_eeatingating



 CSF WBC = 33 cCSF WBC = 33 ceells/culls/cu mm(

mm(nonormrmal valual value:e: 1-91-9 cceells/culls/cu mm,mm, TPHTPH la

la b boor r atoator r y)y)



 WWeeak in appak in appeeaar r ancancee



 With NGTWith NGT A> Hyp

A> Hyper er ththermermiaia rerelatlateed tod to in

infefectious pctious pr r ococeessss Sci

Scieentintif f ic Explanationic Explanation

Within 1 hou

Within 1 hour r oof f ppr r opoper er nunur r singsing int

inter er vveentionntion,, ththee cliclieentntww_{illill be be} aa b bllee toto mmaintain coaintain corere

ttemem p per er atuaturereww_{ithin noithin normrmalal} r 

r angangee..



 PPr r oommototee susurf rf acacee coolingcooling b byy me

means oans of f ttee pid spong pid spongee  b bath.ath. To decrease temperature by To decrease temperature by means through evaporation and  means through evaporation and  conduction

conduction



 AdAdmministinister er rere plac placemeementnt f 

f luids andluids and eelleectctr r olytolytees.s. To support circulating volume To support circulating volume and tissue perfusion.

and tissue perfusion.



 ChangChangee clothing to loosclothing to loosee and co

and comf mf oor r tata b bllee ononeess To promote heat loss To promote heat loss



 EstaEsta b blish andlish and mmaintain coolaintain cool and co

and comf mf oor r tata b bllee eenvinvir r ononmementnt To promote heat loss To promote heat loss



 K K _{ee pee p  b back dack dr r yy}

To prevent pneumonia and  To prevent pneumonia and   further complications  further complications



 AdAdmministinister er papar r acaceetatammol asol as o

or r ddereeredd b by thy thee physicianphysician To facilitate fast recovery. To facilitate fast recovery.

A

Af f tter er 1 hou1 hour r oof f ppr r opoper er nunur r singsing int

inter er vveentionntion,, ththee cliclieentntww_{illill be be} aa b bllee toto mmaintain coaintain corere

ttemem p per er atuaturereww_{ithin normithin normalal} r 

ASSESSMENT PLANNING INTERVENTION EXPECTED OUTCOME S> O>  febr ile 38.1  CSF WBC = 33 cells/cu mm (normal value: 1-9 cells/cu mm, TPH la bor ator y)  Immo bile

A>infection related to vir al invasion to meninges Scientif ic Explanation

Within 1 hour of pr oper nur sing inter vention, the clientw_ill be free fr om f ur ther  infection.

 Maintain ster ile technique w_{hen pr oviding care}  P revents introduction of 

bacteria, reducing risk of  nosocomial infection

 Pr ovide isolation and monitor visitor s as indicated

To prevent spread of infection

 Tur n patient ever y 2 hour s To prevent pneumonia and bed   sores

 If the patient has seizures, tak e precautions.

to protect from injury

 Measure and recor d intak e and output

To have baseline data

 Administer anti biotic (cef tr iaxone) as prescr i bed To prevent further spread of  infection

Af ter 1 hour of pr oper nur sing inter vention, the clientw_ill be free fr om f ur ther  infection as evidenced by decreased CSF WBC

ANALYSIS PLANNING INTERVENTION EXPECTED OUTCOME Su bjective:

Ø O bjective:

 Headache noted

 Pale andw_{eak in} appear ance  Limited movement noted  Tachypneic; RR of 39 cpm  Easy f atiga bility

  Needs assistance fr om signif icant other in ever y activity Diagnosis:

Im paired physical mo bility r /t altered CNS

Scientif ic Explanation: The client is exper iencing w_{eakness and headache due to} infection of meninges and cannot a ble to toler ate too much movement, upon moving it aggr avates the client¶s condition.

Within 4 hour s of render ing  pr oper nur sing inter vention the

clientw_{ill re por t an increase in}  physical mo bility.

As evidenced by:

 Will be a ble to toler ate w_alkingw_{hen going to} cer tain area.

 Increased a bility to move

 Elevate head of patient and im plement ener gy saving technique

To prevent overexertion

 Increase exer cise/activity level gr adually.

 E  xercises maintain muscle  strength and joint ROM 

 R efr ain fr om perf orming nonessential pr ocedures.  P atients with limited movement 

need to prioritize tasks

 Assistw_{ith ADLs as} indicated; how_{ever, avoid} doing f or patientw_{hat he or}  she can do f or self .

 Assisting the patient with ADLs allows for conservation of  energy. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patient's activity tolerance and self-esteem

 Pr ovide quiet envir onment

Af ter 30minutes to 1 hour of  render ing pr oper nur sing inter vention

As evidenced by:

 Will be a ble to toler ate w_alkingw_{hen going to} cer tain area.

 Administer anti biotic (cef tr iaxone) as prescr i bed To prevent further spread of  infection

II. Nur sing Pr ocess

A. Demogr aphic Data

 Name

: Child X

Age

: 2 year s old

Sex

: Female

Address

: Capas, Tar lac

Date of Bir th

: May 2008

Place of Bir th

: Tar lac City

R eligion

: Catholic

 Nationality

: Filipino

Date of Admission

: December 27, 2010

Place of Admission

: Tar lac Pr ovincial Hospital

2. Family Health Histor y of Illness

Pater nal Side Mater nal Side

A&W A&W A&W A&W

A&W A&W

A&W A&WA&WMng

LEGEND:

= Living Male

= Living Female

A&W = Alive andw_ell Mng = Meningitis = Point to patien 60 ₆₂₂ 64 ₆₂₂ 33 ₃₁₂ 9 7 5 2 Analysis:

The diagr am show_{s that the patient¶s condition is not} inher ited fr om her parents and relatives.

3. Histor y of Past Illness

Child X has no kno

_{n aller gies on f ood, medication, animals and other envir onmental}

agents. Her mother stated that Child X doesn¶t exper ienced chick en pox, measles and mum ps at

her age no

_{. She exper ienced cough, colds and lo}

_{gr ade fever and consults ³hilot´ as claimed}

 by her  mother . It is her  f ir st hospitalization.

4. Histor y of Present Illness

Seven days pr ior to consultation the patient developed pr oductive cough.

Five days pr ior  to admission, patient exper ienced on and off fever and no other  signs and

sym ptoms noted. Self -medication of  Par acetamol

_{as rendered  by her  mother  and aff or ds no}

relief . No consultation done.

Fe

_{hour s pr ior  to admission Child X exper ienced chills, fever, r ash and o bser ved neck} 

r igidity. They r ushed the patient  by her  parents at OspitalNingCapas and

_{as then referred at}

Tar lac Pr ovincial Hospital on December 27, 2010 and

_{as then diagnosed having meningitis.}

8.

_{Pathophysiology}

Client-Based

Non-Modifiable

R

isk

F

actors:

-

Age

(< 5y/

o)

= 2 y/

o

-

Compromise immune s

y

stem

Modifiable

R

isk

F

actors:

-

Living in communit

y

setting

-

Living

w

ith farm animals and

pets

E

ntr

y

of virus

(

enterovirus) to the

naso har n eal area

I

nvasion of virus to the respirator

y

tract: cough

Accumulates to blood stream going to

the brain and spine

V

irus colonize in the Cerebro

S

pinal

F

luid and Meninges

R

elease p

y

rogenic c

y

tokines

G

oes to blood vessle and signals the