ASSESSMENT PLANNING INTERVENTION EXPECTED OUTCOME

S> “Mainit siya” Within 1 hour of proper nursing  Promote surface cooling by After 1 hour of proper nursing
O> intervention, the client will be means of tepid sponge bath. intervention, the client will be
 febrile 38.1 able to maintain core To decrease temperature by able to maintain core
 warm to touch temperature within normal means through evaporation and temperature within normal
 mild sweating range. conduction range.
 CSF WBC = 33 cells/cu
mm (normal value: 1-9  Administer replacement
cells/cu mm, TPH fluids and electrolytes.
laboratory) To support circulating volume
 Weak in appearance and tissue perfusion.
 With NGT
 Change clothing to loose
A> Hyperthermia related to and comfortable ones
infectious process To promote heat loss

Scientific Explanation  Establish and maintain cool

and comfortable
environment
To promote heat loss

 Keep back dry

To prevent pneumonia and
further complications

 Administer paracetamol as
ordered by the physician
To facilitate fast recovery.
 ASSESSMENT PLANNING INTERVENTION EXPECTED OUTCOME
S> Within 1 hour of proper nursing  Maintain sterile technique After 1 hour of proper nursing
O> intervention, the client will be when providing care intervention, the client will be
 febrile 38.1 free from further infection. Prevents introduction of free from further infection as
 CSF WBC = 33 cells/cu bacteria, reducing risk of evidenced by decreased CSF
mm (normal value: 1-9 nosocomial infection WBC
cells/cu mm, TPH
laboratory)  Provide isolation and
 Immobile monitor visitors as
indicated
A> infection related to viral To prevent spread of infection
invasion to meninges
 Turn patient every 2 hours
Scientific Explanation To prevent pneumonia and bed
sores

 If the patient has seizures,

take precautions.
to protect from injury

 Measure and record intake

and output
To have baseline data

 Administer antibiotic
(ceftriaxone) as prescribed
To prevent further spread of
infection
 ANALYSIS
Subjective:
Ø proper nursing intervention the
Objective:
 Headache noted
 Pale and weak in
appearance
 Limited movement
noted
 Tachypneic; RR of 39
cpm
 Easy fatigability
 Needs assistance from
significant other in
every activity
Diagnosis:
Impaired physical mobility r/t
altered CNS
Scientific Explanation:
The client is experiencing
weakness and headache due to
infection of meninges and
cannot able to tolerate too
much movement, upon moving
it aggravates the client’s
condition.
PLANNING
Within 4 hours of rendering
client will report an increase in
physical mobility.
As evidenced by:
 Will be able to tolerate
walking when going to
certain area.
 Increased ability to move
INTERVENTION EXPECTED OUTCOME
 Elevate head of patient and After 30minutes to 1 hour of
implement energy saving rendering proper nursing
technique intervention
To prevent overexertion
As evidenced by:
 Increase exercise/activity  Will be able to tolerate
level gradually. walking when going to
Exercises maintain muscle certain area.
strength and joint ROM  Increased ability to move.
 Refrain from performing
nonessential procedures.
Patients with limited movement
need to prioritize tasks
 Assist with ADLs as
indicated; however, avoid
doing for patient what he or
she can do for 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
 Provide quiet environment
and adequate rest periods
To prevent fatigue
 Administer antibiotic
(ceftriaxone) as prescribed
To prevent further spread of
infection
II. Nursing Process

A. Demographic Data

Name : Child X

Age : 2 years old

Sex : Female

Address : Capas, Tarlac

Date of Birth : May 2008

Place of Birth : Tarlac City

Religion : Catholic

Nationality : Filipino

Date of Admission : December 27, 2010

Place of Admission : Tarlac Provincial Hospital

Chief Complaint : Fever

Diagnosis : Meningitis

B. Environmental Status

Child X lives at Capas, Tarlac together with her parents and three siblings. According to
her mother, their house is located at a barrio and far from farm. Their source of drinking water is
coming from a forced pump which is owned by them. Her mother also stated that they have two
ducks and chickens which is found at their yard. They bury their garbage at their backyard.

C. Lifestyle

According to her mother, Child X loves to eat candies, takes about two glasses of coffee
everyday as well as chocolate drink but she drinks milk very seldom. They usually eat two times
a day, at their breakfast and dinner. Child X is fond of playing around their yard with her siblings
as stated by her mother. She usually wakes up at around 6:00 in the morning and sleeps at around
7:00-8:00 in the evening.
2. Family Health History of Illness

Paternal Side Maternal Side

60 62 64 62
2 2
A&W A&W A&W A&W

33 31
2
A&W A&W

9 7 5 2

A&W A&W A&W Mng

LEGEND:
Analysis:
= Living Male
The diagram shows that the patient’s condition is not
inherited from her parents and relatives.
= Living Female

A&W = Alive and well

Mng = Meningitis
= Point to patien
3. History of Past Illness

Child X has no known allergies on food, medication, animals and other environmental
agents. Her mother stated that Child X doesn’t experienced chicken pox, measles and mumps at
her age now. She experienced cough, colds and low grade fever and consults “hilot” as claimed
by her mother. It is her first hospitalization.

4. History of Present Illness

Seven days prior to consultation the patient developed productive cough.

Five days prior to admission, patient experienced on and off fever and no other signs and
symptoms noted. Self-medication of Paracetamol was rendered by her mother and affords no
relief. No consultation done.

Few hours prior to admission Child X experienced chills, fever, rash and observed neck
rigidity. They rushed the patient by her parents at Ospital Ning Capas and was then referred at
Tarlac Provincial Hospital on December 27, 2010 and was then diagnosed having meningitis.
 8. Pathophysiology

Client-Based
Modifiable Risk Factors:
Non-Modifiable Risk Factors:
- Living in community setting
- Age (< 5y/o) = 2 y/o - Living with farm animals and
- Compromise immune system pets

Entry of virus (enterovirus) to the

nasopharyngeal area

Invasion of virus to the respiratory

tract: cough

Accumulates to blood stream going to

the brain and spine

Virus colonize in the Cerebro Spinal

Fluid and Meninges

Release pyrogenic cytokines Destruction of cells in the meninges

Goes to blood vessle and signals the

brain Release of chemical mediators: Entry of basophils
cytokin, pyrogen and macrophages
Stimulates hypothalamus to increase
thermostats Menigeal irritabil Accumulation of fluid
and pus
Fever
Pain: headache
ity
Inflamation

Increased Intracrainal
pressure

Compression of brain and

Spine: Altered motor activity

Compressed Compression of Pons,

Compressed
Cervical 2 (C2) hypothalamus,
Thoracic 6 (T6)
cerebrum
Stiff neck Stomach
upset:vomitting
Drowziness Blank coma
Staring