IDENTIFIED NURSING DIAGNOSES AND PRIORITIZATION

Date Identified 01/02/2012 Nursing Diagnosis Hyperthermia Rationale Hyperthermia is an elevated body temperature due to failed thermoregulation. Hyperthermia occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperatures are sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability or death. The inability to clear secretions or impediment of the respiratory tract to maintain the cleanliness of the airway. This might lead to further complications and in worst cases, can cause death. Once resolved, then the Gas Exchange follows thru. The state in which the individual experiences an actual or potential decreased passage of gases (oxygen and carbon dioxide) between the alveoli of the lungs and the vascular system The state in which an individual experiences or is at risk of experiencing a decrease in nutrition and respiration at the peripheral cellular level because of a decrease in capillary Date Resolved

01/02/2012

Ineffective Airway Clearance

01/02/2012

Impaired Gas Exchange

01/02/2012

Ineffective Tissue Perfusion

blood supply. 01/03/2011 Impaired Skin Integrity A state in which the individual experiences or is at risk for damage to the epidermal and dermal tissue.

Altered Nutrition, Less than Body Requirements

A state in which an individual experiences pr is at risk of experiencing reduced body weight related to inadequate intake or metabolism of nutrients for metabolic needs

MEDICAL AND NURSING MANAGEMENT

Treatment for meningitis depends on the organism causing the infection, your age, the extent of the infection, and the presence of other medical conditions or complications of meningitis. Most people with viral meningitis usually start getting better within 3 days of feeling sick and recover within 2 weeks. But it is important to see your doctor if symptoms of meningitis develop so that he or she can rule out bacterial meningitis, which is more serious. With mild cases of viral meningitis, you may only need home treatment, including fluids to prevent dehydration and medicine to control pain and fever. If you do not get better or if symptoms get worse, you may need further testing to check for other causes of illness. Bacterial or severe viral meningitis may require treatment in a hospital, including: Antibiotics. These medicines usually are given through a vein (intravenously, or IV) to treat meningitis. Antibiotics are given only when bacteria are causing the infection. Giving antibiotics when they are not needed may cause drug resistance. Measures to reduce pressure within the brain. If meningitis is causing pressure within the brain, corticosteroid medicines such as dexamethasone may be given to adults or children. Measures to reduce fever. Medicines such as acetaminophen (Tylenol), fluids, and good room ventilation reduce fever. If you have a high fever, you also may need a device such as a cooling pad placed on the bed. Measures to prevent seizures. If you have seizures, your surroundings will be kept quiet and calm. Medicines such as phenobarbital or Dilantin can help stop seizures Oxygen therapy. Oxygen may be given if you have trouble breathing and to increase the amount of oxygen in all parts of the body. Oxygen may be delivered by a hood or tent placed over the body, a face mask placed over the nose and mouth, a nose piece (nasal cannula) held loosely under the nose, or, in severe cases, a tube through the mouth into the trachea (windpipe). Monitoring fluids. You may need to drink extra liquids because infections increase the body's need for fluids. Increasing liquids also reduces the possibility of dehydration. Liquids are given into a vein (IV) if you have an infection and are vomiting or are not able to drink enough. Doctors control the amount of fluids given because people with meningitis may develop problems if they have too much or not enough fluid. Monitoring blood chemicals. Frequent blood tests are done to measure essential body chemicals, such as sodium and sugar in the blood.

A person who has severe meningitis may need to be treated in the intensive care unit (ICU) of a hospital. Doctors watch the person closely and provide care if needed. See the Other Treatment section of this topic for more information on intensive care in a hospital.

Nursing Management

(1) Administer intravenous fluids and medications, as ordered by the physician. (a) Antibiotics should be started immediately. (b) Corticostertoids may be used for the critically ill patient. (c) Drug therapy may be continued after the acute phase of the illness is over to prevent recurrence. (d) Record intake and output carefully and observe patient closely for signs of dehydration due to insensible fluid loss. (2) Monitor patient's vital signs and neurological status and record. (a) Level of consciousness. Utilize GCS for accuracy and consistency. (b) Monitor rectal temperature at least every 4 hours and, if elevated, provide for cooling measures such as a cooling mattress, cooling sponge baths, and administration of ordered antipyretics. (3) If isolation measures are required, inform family members and ensure staff compliance of isolation procedures in accordance with (IAW) standard operating procedures (SOP). (4) Provide basic patient care needs. (a) The patient's level of consciousness will dictate whether the patient requires only assistance with activities of daily living or total care. If patient is not fully conscious, follow the guidelines for care of the unconscious patient (Part 5). (b) Maintain dim lighting in the patient's room to reduce photophobic discomfort.