NURSING CARE PLAN

ASSESSMENT
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

DIAGNOSIS
• Risk for ineffective cerebral tissue perfusion related cerebral edema. •

INFERENCE
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. •

PLANNING

INTERVENTION

RATIONALE
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.

EVALUATION
• After 4 hrs. Of nursing intervention s, the client was able to demonstrate stable vital signs and absence of signs of intracranial pressure.

Independent: After 4 hrs. • • Maintain head or Of nursing neck in midline or interventions, neutral position, the client will support with small demonstrate towel rolls and stable vital pillows. signs and absence of signs of intracranial pressure. • • 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.

Observe for seizure activity and protect patient from injury.

Seizure can occur as result of cerebral irritation, hypoxia or increase intracranial pressure.

Collaborative: • Restrict fluid intake as indicated. •

Administer supplemental oxygen as indicated.

Fluid restriction may be needed to reduce cerebral edema. Reduces hypoxemia.

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer for students: Only $4.99/month.

Master Your Semester with a Special Offer from Scribd & The New York Times

Cancel anytime.