tb meningitis adult1.pdf - Nursing Crib

NURSING CARE PLAN
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
“Masakit ang ulo
ko.” as verbalized
by the client.
Objective:
• Restlessness.
• Changes in
motor or
sensory
responses.
• V/S taken as
follows:
T: 37.7
P: 50
R: 12
Bp: 130/90
• Risk for
ineffective
cerebral
tissue
perfusion
related
cerebral
edema.
• Tuberculous
meningitis is the
most severe form
of tuberculosis. It
causes severe
neurologic deficits
or death in more
than half of cases.
Tuberculois
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.
• After 4 hrs.
Of nursing
interventions,
the client will
demonstrate
stable vital
signs and
absence of
signs of
intracranial
pressure.
Independent:
• Maintain head or
neck in midline or
neutral position,
support with small
towel rolls and
pillows.
• Provide rest
periods between
care activities and
limit duration of
procedures.
• Decrease
extraneous
stimuli and
provide comfort
measures like
back massage,
quiet
environment, soft
voice.
• Help patient avoid
or limit coughing,
vomiting,
straining at stool,
bearing down as
possible.
• Turning head to
one side
compresses the
jugular veins
and inhibits
cerebral venous
drainage,
thereby
increasing
intracranial
pressure.
• Continual
activity can
increase
intracranial
pressure.
• Provides
calming effect,
reduces
adverse
physiological
response and
promotes rest
to maintain or
lower
intracranial
pressure.
• These activities
increase
thoracic and
intra-abdominal
pressure which
can increase
intracranial
pressure.
• After 4 hrs.
Of nursing
intervention
s, the client
was able to
demonstrate
stable vital
signs and
absence of
signs of
intracranial
pressure.

• Observe for
seizure activity
and protect
patient from
injury.
Collaborative:
• Restrict fluid
intake as
indicated.
• Administer
supplemental
oxygen as
indicated.
• Seizure can
occur as result
of cerebral
irritation,
hypoxia or
increase
intracranial
pressure.
• Fluid restriction
may be needed
to reduce
cerebral
edema.
• Reduces
hypoxemia.