Assessment

Subjective:
Sumasakit ang
kaliwang tenga
ko, as
verbalized by
the client.
Objective:
Positioning to
avoid pain
Irritable
Facial
grimace
Pain rated as
7 out 10
V/S
PR-120
beats/min
RR-26
breaths/min
Temp- 37.1C

Nursing
Diagnosis
Acute pain
related to ear
problem

Inference
Bacteria
enters the the
bloodstream

Outcome
Identification

Implementation

After 1 hour of

nursing
interventions, the
client will:

Establish

rapport to the
client

report pain as

reduced.
verbalize
nonpharmacolog
ic methods that
Host immune
provide relief.

Assess the

clients current
health status

Crosses the
blood-brain
barrier and
proliferates in
the CSF

response
stimulation

Cell wall
fragment &
lipopolysacch
aride released
Inflammation
of
subarachnoid
& pia mater

Increase ICP

Erythematous
Bacteria
Perforation
and
invades
bulgingof
tympanic
Eustachian
of
the
Meningitis
Pain
occurs
membrane
membrane
tube

Determine

pain
characteristics
through
clients
description
Use pain

rating scale
appropriate for
age
Monitor skin
color and vital
signs
Encourage to
increase fluid
intake
Provide quiet
environment
and adequate

Rationale

Evaluation

To enhance the
clients
cooperation
toward nursing
management
To provides data
about the proper
management of
the said patient
To establish
baseline for
assessing
improvement/
changes.

Goal was met.

After 1 hour of
nursing
interventions, the
client reported
pain as reduced
and verbalized
nonpharmacologic
techniques that
provide relief.

To assess level of
pain
To note any
changes in bodys
behavior towards
pain
To decrease
susceptibility to
infection
To promote
nonpharmacologic
al pain

CSF
circulates &
accumulates
the
subarachnoid
space

Meningitis

Bacteria
invades
Eustachian
tube

Perforation
of tympanic
membrane

Erythematous
and bulging
of the
membrane

Pain occurs

rest
Encourage to
listen to
music, have
focused
breathing,
socializing to
others or other
diversional
activities
Provide

comfort and
safety
Administer

analgesics as
ordered by the
physician

management.
To distract
attention and
reduce tension
towards pain

To prevent any
injury may
happen
To lessen the pain.