ASSESSMENT NURSING SCIENTIFIC
DIAGNOSIS RATIONALE
SUBJECTIVE CUES: Acute Pain related to The meninges are the
“Nagsisinakit ito an iya Meningeal irritation protective layers
liog dapit ngan baga and increased ICP as covering the brain and
kuno naninig-a” as evidenced by neck spinal cord. The
verbalized by the stiffness, irritability cranial meninges
patient’s mother and nuchal rigidity cover the brain and
cushion it from the
skull; the spinal
OBJECTIVE CUES: meninges cover the
spinal cord and protect
 Increased ICP it from direct contact
 Positive with the cervical spine
Brudzinki’s sign (neck) and thoracic
 Neck stiffness spine (chest). In
 Irritability addition to protecting
 Nuchal rigidity the brain and spinal
cord, the meninges
also help direct the
flow of blood to the
skull and brain, as
well as transport
cerebrospinal fluid.
Cerebrospinal fluid is
formed in the brain
and flows freely
through the cranial
meninges and into the
spinal meninges. the
cerebrospinal fluid and
its surrounding
meninges, the
arachnoid mater and
pia mater are infected
and inflamed. While
the dura mater may
have little to no
inflammation, its
nerve fibers may
GOALS NURSING INTERVENTIONS RATIONALE EVALUATION
After 8 hours of Independent: After 8 hours of nursing
nursing intervention, 1. Assess for headache and  When the intervention, patient
patient will express photophobia. meninges of the expressed feelings of
feelings of comfort brain become comfort and relief of
and relief of pain infected, it can pain
lead to
inflammation
that triggers
severe
headaches;
Meningitis also
causes
hypersensitivity
to bright lights
2. Assess for Kernig’s sign  These are used
(pain and resistance on to assess for any
passive knee extension sign of
with hips fully flexed) meningeal
and Brudzinski’s sign irritation.
(hips flex on bending the
head forward).
3. Maintain a quiet  Darkening the
environment and keep room may
child’s room darkened. decrease
photophobia.
4. Prevent stimulation and  Stimulation can
restrict visitors. increase
intracranial
pressure, hence
intensifying the
pain.
 Environmental
5. Control environment to changes such as
encourage rest. increased noise
and glaring light
become activated and cause sensory
contribute to neck pain overload that
and nuchal rigidity. promotes
cerebral
irritation leading
to convulsions.

6. Turn the client often and  Promotes

position the client comfort and
carefully reduce irritation
and agitation.
7. Assist ROM exercises.  Prevent joint
stiffness and
neck pain
Collaborative:  Antibiotic and
1. Administer antibiotic corticosteroid
and corticosteroid as therapy are used
prescribed. to reduce the
inflammation
and therefore
decrease pain.
2. Administer analgesics  NSAIDs are
such as acetaminophen given to relieve
or NSAIDs as pain
prescribed.