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NAME: Andria Arechita DATE OF ADMISSION: March 23, 2012

ASSESSMENT S : sakit akong ulo as verbalized by patient O: >Restlessness. >Changes in motor or sensory responses. > Difficulty Swallowing >Skin discolorations >decreased motor response V/s- T: 37.7 P: 50 R: 12 Bp: 130/90 NURSING DIAGNOSIS Nursing Diagnosis: Risk for ineffective cerebralTissue perfusion related to cerebraledema. INFERENCE Theoretical Basis: Bacterial meningitis begins insidiouslywith a gradual fluctuating fever, fatigue,weight loss, behavior changes,headache, and vomiting. This earlyphase is followed by neurologic deficits,loss of consciousness, or convulsions. Adense gelatinous exudates (outpouring)forms and envelops the brain arteriesand cranial nerves. It creates abottleneck in the flow of thecerebrospinal fluid, which leads tohydrocephalus.

PLANNING After 8 hrs. of nursinginterventions, the client willa. demonstrate stable vitalsigns and absence of signs of intracranial pressure.b. Demonstrate behaviours/ lifestylechanges to improve circulation INTERVENTION Promotion: : Decrease extraneous stimuli andprovide comfort measures like back massage,quiet environment, softvoice. Instruct patient to avoid or limit coughing,Vomiting, straining at defecation, bearing downas possible. elevate head and maintain head/neck inmidline neutral position Prevention: Observe for seizure activity and protectpatient from injury. I : Maintain head or neck in midline orneutral position, support with smalltowel rolls and pillows I RATIONALE EVALUATION

R: Provides calming effect, reducesAdverse physiological response andpromotes rest to maintain or lowerintracranial pressure. R: These activities increase thoracic and intra-abdominal pressure which can increaseintracranial pressure. R: to promote circulation/venous drainage

R: Seizure can occur as resultof cerebral irritation, hypoxia or increaseintracranial pressure. .R: Turning head to one side compresses the jugular veins and inhibits cerebral venousdrainage, thereby increasing intracranialpressure. R: Continual activity can increase intracranial pressure.

: Provide rest periods between care activitiesand limit duration of procedures.

CATABAY. RN SENIOR NURSE . MAMARIL.Curative: I : Administer supplemental oxygen as indicated.R: Reduces hypoxemia. MAN OIC-ASSISTANT CHIEF NURSE FOR TRAINING MS. CORAZON AQUINO/ MS. ROSAURO P.diuretics) Rehabilitation: : Encourage quiet. R: May reflect developing compartmentsyndrome R: used to decrease edema . . CORAZON CASTRO NURSE TRAINEE OIC-CHIEF NURSE NOTED BY: MS. restful atmosphere : Limit daily activities and caution client toavoid strenuous activities. RN. FERNANDEZ APPROVED BY: MR.R: Conserves energy and lowers oxygendemands R: over exertion may cause dizzines SIGNED BY: CHRISTINE V. LIZA P. Investigate reports of pain out of proportionto degree of injury : Administer medications (antihypertensive.