ASSESSMENT

Subjective cue:
The patient reported initial clinical manifestations such as headache and skin rash.

Objective cues:
-nausea and vomiting
-fatigue
-headache
-neck pain
-photophobia
-purpuric lesions
-positive of Brudzinski sign
-positive of Kernig's sign
-vital signs:
Tachycardia: 114 bpm
Tachypnea: 24 cpm
Hypotension: 88/34 mmHg

NURSING DIAGNOSIS
 Acute Pain related to meningeal irritation with spasm in extensor neck muscles as
manifested by positive Kernig's and Brudzinski’s signs

RATIONALE
 Neisseria meningitidis concentrates in the nasopharynx and is transmitted by secretion
or aerosol contamination. Once the causative agent enters the bloodstream, it travels
towards the spinal cord and the brain specifically invading the meninges, three
connective tissue membranes covering the formerly said nervous organs. The damaged
tissue stimulates the release or activation of chemical mediators resulting to
chemotaxis, increased vascular permeability and blood flow allowing fibrinogen and
complement, which enhances inflammatory response, to enter the tissue from the
blood. Pain associated with inflammation is produced in several ways. Nerve cell
endings are stimulated by direct damage and by some chemical mediators to produce
pain sensations. In addition, the increased pressure in the tissue caused by edema and
pus accumulation can cause pain. In meningitis, traction on the inflamed meninges is
painful, resulting in limited range of motion through the spine (especially in the cervical
spine)
Source: Seeley's Essentials of Anatomy and Physiology 10th Edition
PLANNING:
After 7 hours of nursing intervention the patient will be able to:
 Address if pain had relieved, lessen or worsen
 Express methods on how to alleviate pain
 Follow infection control precaution

NURSING INTERVENTIONS:
Independent:
1. Maintain head/neck in midline or neutral position, support with small towel rolls and pillows.
Avoid placing head on large pillows. Periodically check position or fit of cervical collar when
used.
Rationale: Turning head to one side compresses the jugular veins and inhibits cerebral venous
drainage, thereby increasing ICP. Tight-fitting collar can also limit jugular venous drainage.

2. Provide rest periods between care activities and limit duration of procedures.
Rationale: Continual activity can increase ICP by producing a cumulative stimulant effect.

3. Decrease extraneous stimuli and provide comfort measures; e.g., quiet environment, soft
voice and gentle touch.
Rationale: Provides calming effect, reduces adverse physiologic response, and promotes rest to
maintain or lower ICP.

4. Help client avoid or limit coughing, vomiting, straining at stool or bearing down, when
possible. Reposition client slowly, prevent client from bending knees and pushing heels against
mattress to move up in bed.
Rationale: These activities increase intrathoracic and intra-abdominal pressures, which can
increase ICP.

5. Avoid or limit use of restraints.

Rationale: Mechanical restraints may enhance fight response, increasing ICP.

6. Observe for seizure activity and protect client from injury.

Rationale: Seizures can occur as a result of cerebral irritation, hypoxia, or increased ICP;
additionally, seizures can further elevate ICP, compounding cerebral damage.
7. Keep the lights dim
Rationale: Stimulation of light can increase ICP.

Dependent: Administer medications, as indicated:

1. Ceftriaxone;
Rationale: Ceftriaxone is a cephalosporin antibiotic. Ceftriaxone is used to treat many kinds of
bacterial infections, including severe or life-threatening forms such as E. coli, pneumonia, or
meningitis.
Source: Brunner and Suddarth's. Textbook of Medical-Surgical Nursing. 11th edition
2. Vancomycin hydrochloride;
Rationale: To reduce the development of drug-resistant bacteria and maintain the effectiveness
of vancomycin and other antibacterial drugs, vancomycin should be used only to treat or
prevent infections that are proven or strongly suspected to be caused by bacteria.
Source: ibid
3. Narcotics and analgesics;
Rationale: Relieves pain and agitation and their negative effects on ICP, enhances comfort, and
promotes rest. Pain can interfere with client's ability to fall or remain asleep. Timely medication
can enhance rest/sleep. Note: Pain pathways to the brain lie near the sleep center and may
contribute to wakefulness.
Source: ibid
4. Antipyretics; e.g., acetaminophen (Tylenol);
Rationale: Reduces or controls fever and its deleterious effect on cerebral metabolism or
oxygen needs and insensible fluid losses.
Source: ibid
5. Osmotic diuretic, e.g., Mannitol;
Rationale: Osmotic diuretics work by expanding extracellular fluid and plasma volume,
therefore increasing blood flow to the kidney. Diuretics may be used in acute phase to draw
water from brain cells, reducing cerebral edema and ICP. Note: Loop diuretics, e.g., Lasix, also
reduce production of CSF, which can contribute to increased ICP when cerebral edema impairs
CSF circulation.
Source: ibid
6. Dexamethasone

Rationale: To blunt inflammatory response secondary to bacterial lysis

Collaborative:
1. Administer hypertonic intravenous fluids, as ordered.
Rationale: Fluids should not be routinely restricted, but should be administered to maintain
normal intravascular volume, systemic blood pressure, and cardiac output in order to maintain
brain perfusion and decrease cerebral edema and ICP.
Source: ibid
2. Administer supplemental oxygen via appropriate route to maintain O2 saturation >94%, as
indicated.
Rationale: Reduces hypoxemia, which is known to increase cerebral vasodilation and blood
volume, elevating ICP.
Source: ibid
3. Elevate head of bed gradually to 10-29 degrees as tolerated or indicated. Avoid hip flexion
greater than 90 degrees.
Rationale: Promotes venous drainage from head, thereby reducing cerebral congestion and
edema, and further increase of ICP.

Evaluation:
After 7 hours of nursing intervention the patient was be able to:
 Address if pain had relieved, lessen or worsen
 Express methods on how to alleviate pain
 Follow infection control precaution