Submitted to:

Ma’am Shiela Dancel, RN, MAN

 Introduction
The human nervous system is the organ of consciousness, cognition, ethics, and behavior; as
such, it is the most intricate structure known to exist. One-third of the 35,000 genes encoded in the
human genome are expressed in the nervous system. Each mature brain is composed of 100 billion
neurons, several million miles of axons and dendrites, and >1015 synapses. Neurons exist within a dense
parenchyma of multifunctional glial cells that synthesize myelin, preserve homeostasis, and regulate
immune responses. Measured against this background of complexity, the achievements of molecular
neuroscience have been extraordinary.
A central nervous system viral disease is a viral infection that affects the central nervous
system. An infection of the central nervous system may primarily affect its coverings, which is called
meningitis. It may affect the brain parenchyma, called encephalitis, or affect the spinal cord, called
myelitis. A patient may have more than one affected area, and if all are affected, the patient has
"meningoencephalomyelitis". The nervous system may also suffer from localized pockets of infection.
Within the brain or spinal cord there may be an abscess, and outside them there may be an epidural
abscess or subdural empyema. Each may present with a nonspecific prodrome of fever and headache,
which in a previously healthy individual may initially be thought to be benign, until (with the exception
of viral meningitis) altered consciousness, focal neurologic signs, or seizures appear. Key goals of early
management are to emergently distinguish between these conditions, identify the responsible pathogen,
and initiate appropriate antimicrobial therapy.
In Children, they may have weakness of an arm or leg, vision or hearing loss, mental
retardation, or recurring seizures. These symptoms may not be apparent until the child is old enough for
the problem to appear during testing. Often the symptoms resolve with time, but occasionally they are
permanent.
Objectives:
The objectives of the study are:
• To obtain baseline measures for assessment in the prevalence and severity of
disease in children.
 • To comprehensively get more knowledge about CNS infections in children and
to develop appropriate intervention and treatment with these cases.

Anatomy of Central Nervous System

I. Biographic Data
Name: JMTN
Address: San Jose Del Monte Bulacan
Age: 14 years old
Gender: Female
Religious Affiliation: Roman Catholic
Marital Status: Single
Occupation: none
Room and Bed #:5067 C
Chief Complain: body weakness, fever & projectile vomiting
Provisional Diagnosis: t/c CNS Infection
Attending Physician: Dr. Sevenno
 II. Nursing History
a. Past Health History

JMTN had childhood illness like chicken pox and measles. Her sister said that JMTN is
fully immunized. She has no allergies to any type of food or medications. No accident has
happen to JMTN. This was JMTN’s first time to be hospitalized. She took medications such as
Biogesic 500 mg and Mefenamic acid 500mg every time that she has fever. Currently taking
medications are Ceftriaxone, Amikacin, Mannitol, Citicholine, isonicotinylhydrazine (INH),
rifampin (RIF) , pyrazinamide (PZA), Ethambutol (EMB) combination tablet, Dexamethasone
and prn medications such as Paracetamol and Diazepam. No foreign travels yet.

b. History of present Illness

JMTN was admitted for the first time last June 27, 2010 with a chief complaint of change in
sensorium, body weakness, fever and projectile vomiting. According to the sister of the patient,
when JMTN was 11 years old she had ear discharges treated by otic drops. After 1month, still
with ear discharge and on and off fever sought to consult the same EENT and was given
Flucinolone otic drops 3gtts TID. Her sister said, “Sabi kasi nung doctor pag may lumabas na
discharge tanggalin daw. Hinatak ni tatay. Hindi naman namen alam na ear drum nya na pla
yon”. Removal of her eardrum resulted to inability to hear. Her sister stated: hindi na makarinig
yung kapatidko gawa ng nahila ang ear drum nia kaya may hindi naiwasang nagkaroon ng
impeksyon na yung kapatid ko sa tenga nia, nilalagnat pa rin yan madalas” Her sister also said,
“Nahihirapan syang huminga minsan at nauubo pa sya minsan pero di lang nahahalata”

They just continued her check ups for 2 months only. After 3 years, she was rushed to
EAMC referred by their private doctor because her condition was already severe. Her doctor
prescribed medications such as Ceftriaxone, Amikacin, Mannitol, Citicholine,
isonicotinylhydrazine (INH), rifampin (RIF) , pyrazinamide (PZA), Ethambutol (EMB)
combination tablet, Dexamethasone and prn medications such as Paracetamol and Diazepam.

C. Family History
In the health history of our client, both of his grandparents in her mother’s side are
already deceased having TB and UTI while his grandfather on his father side. Her mother has 7
siblings, 2 are already deceased because of kidney failure and liver failure. Her father has 8
siblings 2 of her father’s siblings has hypertension.

III. Patterns Of Functioning

A. Psychological Health
According to the sister of JMN she is very shy to other people especially to the boys but she’s willing
to interact in fact she wants to have a best friend in school. Her sister stated “okay naman siya sa
school, nakakausap ko yung mga teachers’ niya. When JMTN is still studying , her sister said that
“Line of 8 naman yung mga grades niya at top 9 siya sa class”. JMTN is attending a normal
Elementary class. But she is a lip breather. She is understood what is saying only through lips. Her
sister stated also that “mababaw lang yung kaligayahan niya pag dinalan ko siya ng pasalubong tuwang
tuwa na siya”. When her mother died her sister said “syempre umiyak siya pero sandali lang natanngap
naman niya agad yung pag kamatay ni mama pero malungkot pa din siya”. If JMTN is angry, her sister
stated, “ pag galit yan, minsan nag dadabog pero maya maya wala na.” Her sister also said that her
sister had difficulty in coping with the death of her mother but as the time goes by, she said that she is
accepting it. In the Family, her sister said that “ okay naman siya sa family, siya ang pinakababy
namin,” her sister also stated, sa ngayon hindi na sya nakakakain ng sapat. Halos puro prutas nalang
kinakain nya.“parang wala na syang gana kumain minsan eh. Her sister verbalized “Hindi sya
makakain ng magisa nia, pati sa pagtayo, pagpunta sa banyo kung kinakailangan at tska pati magayos
sa sarili ay di nia kaya. Kailangan na laging inaalalayan sya sa mga ginagawa nya.”

Interpretation:
JMTN is makes the transition from childhood to adolescents, she plays
in the adult world. Initially, she experiences some role confusion- mixed ideas and
feelings about the specific ways in which they will fit into society- and may
experiment with a variety of behaviors and activities.

Analysis:
The adolescent is newly concerned with how they appear to others.
Superego identity is the accrued confidence that the outer sameness and
continuity prepared in the future are matched by the sameness and continuity of
one's meaning for oneself, as evidenced in the promise of a career. The ability to
settle on a school or occupational identity is pleasant. In later stages of
Adolescence, the child develops a sense of sexual identity.

Reference: (Maternal and Child Health Nursing, Pilleterri, pg.465-467)

B. Socio-Cultural Pattern
Our patient is a 14 year old female and still plays with his cousins. Her sister stated,
“Nakikipaglaro at nkakapagtulungan siya sa pag gawa ng assignments at project sa mga pinsan niya
kasi malapit lang sa bahay naming maliban dun din a siya lumlabas ng bahay.” According to her sister,
our patient does not have any problems in her relationship with her relatives. Her pass time is texting.
And with regards to our client’s environment, their family lives in a subdivision, and their house has 4
windows, 2 electric fans, and has enough space for their whole family. Our client’s hospitalization
made an impact in the economic status of their family, because according to her sister, “Bago siya ma-
ospital, ayos naman ang budget namin, di naman kami kinakapos sa mga gastusin. Pero nung ma-
osptial na siya, medyo kinakapos na kami ng pang gastos.”

Interpretation:

Living in a subdivision is an indication that the family of JMTN is an indicator that they have a
good economic status. They can sustain their necessities. However, during the hospitalization of JMTN
they said that they have difficulty in budgeting because of the medications that they have to buy. In
terms of her relationship with her family members, JMTN doesn’t have any difficulties even thought
she is a lip breather. In their house, she is able to express herself and live through the values of the
Filipinos which they have inherited to their parents.

Analysis:

An important aspect of culture is whether children are raised in an environment where they are
urged to be active participants in learning or whether they are encouraged to be “watchers”. The
environment also tells you on how the child was raised by her parents. Family members play a vital
role in honing their children not only in educating them but also the values that are a standard for them.

Reference: Maternal & Child Health Nursing 4th edition by Adele Pillitteri
volume 2 pages 1009-1010

C. Spiritual Pattern
Our patient is a Catholic, and she is aware of the practices and culture of Catholics here in our
country, Our patient participates in most religious events, as our client’s sister stated, “tulad din kami
ng ibang Katoliko kasi nagsisimba naman ako pati yung kapatid ko, tapos sumasali naman kami sa mga
religious events. The patient’s sister also added, when seeking for cure, their family prefers to consult
first the faith healers rather than a medical practitioner when dealing with health problems. The
patient’s sister stated, “kailangan ipaalbularyo muna bago injection kasi hindi na gagaling.”

Interpretation:
Our patient being a Catholic, she acts upon the practices and beliefs of their religion in terms of
our patient’s lifestyle, especially when dealing with health and illness. According to Kozier & Erb’s,
practices and beliefs can be passed down by the family to their offspring. For our patient, she adopted
some of her practices and beliefs from his family, and that can significally affect our patient’s lifestyle
and health.

Analysis:
The family passes on patterns of daily living and lifestyle to offspring. Culture and social
interactions also influence how a person perceives, experiences, and copes with health and illness. Each
culture has ideas about health, and these are often transmitted from parents to children.

Reference: Kozier & Erbs Fundamental of Nursing 8th edition volume 1 page 302

IV. Activities Of Daily Living

Before Hospitalization During Hospitalization Interpretation Analy
Nutrition Fruits, milo, biscuit, 1 day NGT then soft diet The client before A
adobong baboy, 6-8 Fluid intake= approx hospitalization recom
glasses of liquids a day 1000 ml frequently eats adobong situatio
(see in 24 hr diet recall baboy because it’s her some
 before hospitalization) favourite. Fruits serve as(diffic
her dessert after eating. surger
Milo and biscuit is her jaw,
usual breakfast everyday. gastroi
A soft
During hospitalization, many
she had her NGT for 1 mashe
day the doctor ordered to combi
have soft diet. gravy,
soups,
curries

Sourc

A clie
disord
mainta
and ele

Sourc
Surgic
edition

Elimination Urination= 5 times a day U= 1640 ml Before hospitalization Elimin

Stool=once a day S= 0 since the day of the the client urinates 5 describ
hospitalization times a day or more and contro
defecates at least once a by-pro
day. in the
usually
During hospitalization movem
the client urinates at least urine,
6 times a day or more body.
with about 1640 ml but
she does not defecate During
since the day she client
admitted. in
urinati
new en
foods
is takin

Sourc
Erb’s
Nursin
Vol.2 p

There
freque
 movem
genera
times
week.
movem
indicat
and m
stools
indicat

Source
Guide

The
produc
numer
includ
hydrat
enviro
size,
averag
about

Source
Exercise Household chores Repositioning and Before hospitalization, Exerci
turning the client’s daily exercise becaus
is her household chores mainta
like sweeping the floor, physic
washing the dishes, in
watering the plants. It System
also includes walking tone
and running as daily muscle
exercise. with m
increas
During hospitalization, exercis
the client’s exercise is Cardio
turning or repositioning (for p
every 2 hrs. of
cardio
place
physic
Respir
(ventil
intake
exercis
improv
; Gastr
(exerc
appetit
 gastroi
tone,
perista
Endoc
( exer
metabo
increas
of bod
produc
and U
respira
muscu
increas
gravity
postur
fluid i
pumpe
lymph
vessels
body.

Sourc
Erb’s
Nursin
Vol.2 p

Turn
every
tissue
promo
preven
aspirat

Sourc
Erb’s
Nursin
Hygiene Take a bath & brushes Sponge bath method Before hospitalization Hygien
teeth once a day everyday (further the client takes a bath, health
Handwashing before and assessment seen in P.A) brushes her teeth change mainte
after eating clothes once a day and hygien
having hand washing by wh
before and after eating. to su
bathin
During hospitalization, genera
the client does not take a and g
bath, her parents is doing is high
it for her by sponge bath determ
method from head to toe. values
Even in the perineal area involv
 and anal area the parents hair, n
are the one who’s taking nasal c
care of. Brushing teeth is and
not yet done during the areas.
stay in the hospital.
Sourc
Erb’s
Nursin
742.

In hos
the ca
mobili
demen
bath m
people

Sourc
Sleep and Rest 8-9 hrs of sleep More than 9 hours Before hospitalization, Adoles
Nap= 1-2 hrs Nap= 2-3 hrs the client has 8-9 hrs of of ag
sleep everyday. She hours
sleeps at 9 pm and wakes night;
up at 5 am when she actuall
have her school, if it’s sleep.
weekend, she sleeps at -The
10 pm and awakes at 6 Found
or 7 am. She’s also that te
having her naps at least 2 times
hrs a day and during they
weekends. awake
home,
During hospitalization, This c
the client is having more grades
than 9 hrs of sleep a day and i
and 2-3 hrs of naps also. for car

Sourc
Erb’s
Nursin
Vol.2 p

Substance Use Biogesic and Mefenamic Cefriaxime, amikacin, Before hospitalization, Bioges
acid mannitol, ciricitoline, her previous doctor in fever,
dexamethazone, EENT, ordered her to pains.
paracetamol, diazepam take biogesic and Mefen
(drug study) mefenamic acid because Pain a
of her auditory problem.
During hospitalization, Sourc
the doctor ordered her to
 take Cefriaxime, During
amikacin, mannitol, drugs
ciricitoline, study)
dexamethazone,
paracetamol, diazepam.

24 hr. Diet Recall

Breakfast Morning Snack Lunch Merienda

1 cup Milo (50 ml) 1 pack voice biscuit 3 tbsp steam rice 1 pack voice biscuit 4 tb
strawberry flavor strawberry flavor

Skyflakes (1 pack) 1 glass water (140 ml) Sinigang soup 1 pc. Banana Sin

1 glass water (140 ml) Papaya (2 slice) 2 glasses water (280 ml) Pap

1 cup juice (50 ml) 1g

1 glass water (140 ml)

urement Norms Findings Interpretation/Analysi

t
The weight of a child mu
Using the formula for 6-
old is wt. In lbs=(age in
x 7) + 5 ( G and A 2nd e
by Palma and Oseda 200
t The school age chil
annual average
Signs
erature 36.5-37.5 C 36.7 The temperature of the
is in the normal range.

Rate 75-110 bpm (FON pg 98 bpm The pulse rate of the cl

825, Taylor 5th edition) in the normal range.

atory Rate 18-20 cycles/min 28 cycles/min The respiratory rate o

(FON pg 825, Taylor 5 th
client is not normal.
edition) indicate her to be
breather,
Pressure The ventricular pressure 100/70 The blood pressure o
must have an equivalent client is in the normal ran
of 20 by subtracting
systolic from diastolic
(FON pg 825, Taylor 5th
edition)

Norms Findings Interpretation /Analys

al Appearance
ure/ gait Relaxed, erect posture, The patient lies flat on
coordinated movement bed all throughout the
physical assessment
since she is not capable
of getting up on bed
because the patient
feels weak and not yet
in good condition.
Varies from light to deep The patient has a dark
brown from ruddy pink skin tone. There are no
to light pink from yellow edema seen and have a
overtone to olive. No capillary refill of 2
signs of edema. seconds.
onal hygiene Clean and neat Unkept
Abnormal finding.
A sense of humor is p
social and cooperative.
(Maternal and Chil
edition, Vol 2 pg 91
Adele Pillitteri 2007)
Normal since the client has eve
tone and there are no signs of
increased or decreased pigmen
and there are no edemas.
Varies from light to deep brown
ruddy pink to light pink; from y
to overtones of olive.
(kozier & erbs fundamental o
nursing 8th edition, p.579)
Not normal since “adoles
are conscious to their pe
hygiene. They comb the
to make it look shiny an
a bath everyday to make
appearance apptopriate
accepted to others.
(Maternal and Child
 edition, Vol 2 pg 92
Adele Pillitteri 2007)
ming Clean and neat The patient appears Not normal be
untidy having a dirty “adolescents are capab
finger nails, uncombed total self-care and, beca
hair, dressed with t-shirt their body awareness,
and pants, wears dirty even be over conscie
ring and having about personal hygiene
unpleasant odor. appearance. Adole
mainly dress exactly
everyone else does to
the trend.”
(Maternal and Child
edition, Vol 1 page 95
Adele Pillitteri 2007)
itional status Regular diet Soft diet The patient might be lac
the appropriate nutrient
since the ordered diet fo
is soft diet.

An adolescent needs an
increased number of calo
to support the rapid body
growth that occurs.
(Maternal and Child 5t
edition, Vol 2 pg 921
Adele Pillitteri 2007)
appropriateness Appears to be her stated The patient is 14 years A 12 year old child must
chronologic age old. the 6 grade level
(Maternal and Child 5t
edition, Vol 2 pg 911
Adele Pillitteri 2007)
al behaviour Speech is clear, The patient does not In the case of the patien
moderately paced and actively participate just normal to not re
culturally appropriated during the physical verbally since she is
assessment. She does reader and not yet gain
not respond to questions developed much self-e
asked and cannot speak due to her condition.
well with clarity. The
patient is a lip reader “Fourteen-year-olds are
since she is deaf for 3 quieter and
years already. introspective than they w
year ago. They are bec
used to their changing b
have more confidenc
themselves and feel mo
esteem.”
 (Maternal and Child 5
edition, Vol 2 page 94
Adele Pillitteri 2007)
or behaviour Coordinated movements The patient lies flat on Not normal since “Adoles
appropriate for age bed and makes are interested in chatting
numbered movements. their peers and engaging
various activities. They lo
engage into entertaining
activities like listening to
music and watching to th
favourite television show
(Maternal and Child 5t
edition page 949 by A
Pillitteri 2007)
 Body Part Norms Actual Findings Interpretation and Analysis
(Technique
Used)
Normocephalic Interpretation:
without The client experiences difficulty when it comes to turning
obvious the head in different positions. The head also shows
Inspection of the lesions. abnormal appearance than the normal since it slightly
The right side of the
head, neck and Maintains head bulges in the right side.
head slightly bulges.
back. position. Spine Analysis:
Positive nuchal rigidity.
in straight Normocephalic without obvious lesions. Maintains head
The spine is in straight
alignment with position. Spine in straight alignment with normal cervical,
alignment with the
normal thoracic and lumbar curves. Neck and back have full range
normal cervical,
cervical, of motion
thoracic and lumbar
thoracic and (Medical-Surgical Nursing by Black page 1775)
curve.
lumbar curves.
Neck and back
have full range
of motion.
Cranial Nerves PERRLA, Pupil does not react to Interpretation:
III, IV and VI direct and light and As the penlight was flashed to the client’s eyes, the pupils
consensual. accommodation is not did not reacted to light and did not constricted as what
Accommodatio present. Positive EOM. normal eyes do when light is introduced. The client is also
n present. Positive nystagmus. positive of having nystagmus and positive extraocular
EOMs intact movement. As the corneal reflex was done, it didn’t respond
without symmetrically.
nystagmus or
strabismus. Analysis:
Cover-uncover PERRLA, direct and consensual. Accommodation present.
test negative. EOMs intact without nystagmus or strabismus. Cover-
Corneal light uncover test negative. Corneal light reflections symmetrical.
reflections
symmetrical. (Medical-Surgical Nursing by Black page 1775)

Cranial Nerve V Opens and Opens and closes Analysis:

closes mouth; mouth as asked to do Opens and closes mouth; chews, clenches teeth and moves
chews, so. Moves jaw side to jaw side to side voluntarily. Sensation intact to forehead,
clenches teeth side with unequal cheeks and chin. Corneal reflexes present.
and moves jaw strength. Absent corneal (Medical-Surgical Nursing by Black page 1775)
side to side reflexes.
voluntarily.
Sensation
intact to
forehead,
cheeks and
chin. Corneal
reflexes
present.
Cranial Nerve Face Facial asymmetry. Interpretation:
VII movements Abnormal since the client was not able to perform the task
symmetric with asked to do. She smiles asymmetrically, raises left eyebrow
smiling, faster than the right and perform puffing of the cheek as
frowning, well as lip pursing in a slow pace.
eyebrow Analysis:
raising, lip Face movements symmetric with smiling, frowning,
pursing and eyebrow raising, lip pursing and cheek puffing. Discerns
cheek puffing. sweet, salty, sour and bitter tastes.
 COMPONENTS Result

WBC 11.4
Hemoglobin 127
Hemotocrit .0370
DIFFERENTIAL
Neutrophils 0.84
Lympocyes 0.14
Monocytes 0.02
Platelet 328
MCV 86.5
MCH 29.7
MCHC 344
RDW 14.6

Diagnostics:

June 27, 2010 ER

BUN 3.2
Creatinine 43 Low
 Interpretation:

The patient has a Low WBC which is 11.4 where in the normal is 5-10. And her creatinine level
also is Low 43 which the normal is 53-115.

Analysis:

High WBC indicates that there is an infection. Creatinine is a substance that

is produced during the body's natural activity (metabolism). Creatinine is usually
excreted (got rid of) from the body through the kidneys. If the kidneys start to
become diseased, for whatever reason, the level of creatinine rises in the blood
stream.
Generic Dosage/Freque Classificatio Mechanism Indication Contraindica Side Nursing
Name ncy n of Action tion effects responsibilit
ies
1500 mg TIV Cephalospori Ceftriaxone Treatment of Hypersensitivi None • Asses
every 12 hours binds to one or susceptible ty to
Ceftriaxo ANST (-) ns more of the infections cephalosporin s pt.’s
ne Anti penicillin- including s and previous
binding proteins chancroid, penicillins, sensitivity
Infectives
(PBPs) which gastroenteritis lidocaine or reaction to
inhibits the final any other local penicillin
transpeptidation anaesthetic or other
step of product of the cephalosp
peptidoglycan amide type. orins.
synthesis in Neonates or • Asse
bacterial cell premature
ss pt.
wall, thus infants with
for
inhibiting bilirubin
biosynthesis and encephalopath s/sx of
arresting cell y infection
wall assembly before and
resulting in during
bacterial cell treatment.
death.
• Obta
in
C&S
before
beginning
drug
therapy to
identify if
correct
treatment
has been
initiated.
• Asse
ss for
allergic
reactions.
• Asses
s renal
function
before and
during
therapy.
• Asses
s for
possible
superinfectio
n

Amikacin 150 mg TIV q 8 Aminoglycos None

 Physiology of Central Nervous System
• The cerebrum is the largest part of the brain and controls voluntary actions, speech,
senses, thought, and memory.

Each hemisphere is divided into four lobes, or areas, which are interconnected.

• The frontal lobes are located in the front of the brain and are responsible for voluntary
movement and, via their connections with other lobes, participate in the execution of sequential
tasks; speech output; organizational skills; and certain aspects of behavior, mood, and memory.
• The parietal lobes are located behind the frontal lobes and in front of the occipital lobes. They
process sensory information such as temperature, pain, taste, and touch.
• The temporal lobes are located on each side of the brain. They process memory and auditory
(hearing) information and speech and language functions.
• The occipital lobes are located at the back of the brain. They receive and process visual
information.
• The cortex, also called gray matter, is the most external layer of the brain and predominantly
contains neuronal bodies (the part of the neurons where the DNA-containing cell nucleus is
located).
• Fibers that leave the cortex to conduct impulses toward other areas are termed efferent fibers,
and fibers that approach the cortex from other areas of the nervous system are termed afferent
(nerves or pathways).

Central Structures of the Brain

• The thalamus integrates and relays sensory information to the cortex of the parietal, temporal,
and occipital lobes. The thalamus is located in the lower central part of the brain (that is, upper
part of the brainstem) and is located medially to the basal ganglia. The brain hemispheres lie on
 the thalamus. Other roles of the thalamus include motor and memory control.
• The hypothalamus, located below the thalamus, regulates automatic functions such as appetite,
thirst, and body temperature. It also secretes hormones that stimulate or suppress the release of
hormones (for example, growth hormones) in the pituitary gland.

• The pituitary gland is located at the base of the brain. The pituitary gland produces hormones
that control many functions of other endocrine glands. It regulates the production of many
hormones that have a role in growth, metabolism, sexual response, fluid and mineral balance,
and the stress response.
• The ventricles are cerebrospinal fluid-filled cavities in the interior of the cerebral hemispheres.

The Base of the Brain

The base of the brain contains the cerebellum and the brainstem. These structures serve complex
functions. Below is a simplified version of these roles:

• Traditionally, the cerebellum has been known to control equilibrium and coordination and
contributes to the generation of muscle tone. It has more recently become evident, however, that
the cerebellum plays more diverse roles such as participating in some types of memory and
exerting a complex influence on musical and mathematical skills.
• The brainstem connects the brain with the spinal cord. It includes the midbrain, the pons, and
the medulla oblongata. It is a compact structure in which multiple pathways traverse from the
brain to the spinal cord and vice versa. For instance, nerves that arise from cranial nerve nuclei
are involved with eye movements and exit the brainstem at several levels. Damage to the
brainstem can therefore affect a number of bodily functions. For instance, if the corticospinal
tract is injured, a loss of motor function (paralysis) occurs, and it may be accompanied by other
neurologic deficits, such as eye movement abnormalities, which are reflective of injury to
cranial nerves or their pathways in the brainstem.

o The midbrain is located below the hypothalamus. Some cranial nerves that are also
responsible for eye muscle control exit the midbrain.
o The pons serves as a bridge between the midbrain and the medulla oblongata. The
pons also contains the nuclei and fibers of nerves that serve eye muscle control, facial
muscle strength, and other functions.
o The medulla oblongata is the lowest part of the brainstem and is interconnected with the
cervical spinal cord. The medulla oblongata also helps control involuntary actions,
including vital processes, such as heart rate, blood pressure, and respiration, and it
carries the corticospinal (that is, motor function) tract toward the spinal cord.
The Spinal Cord

The spinal cord is an extension of the brain and is surrounded by the vertebral bodies that form the
spinal column (see Multimedia File 3). The central structures of the spinal cord are made up of gray
matter (nerve cell bodies), and the external or surrounding tissues are made up of white matter.

Within the spinal cord are 30 segments that belong to 4 sections (cervical, thoracic, lumbar, sacral),
based on their location:

• Eight cervical segments: These transmit signals from or to areas of the head, neck,
shoulders, arms, and hands.
• Twelve thoracic segments: These transmit signals from or to part of the arms and the anterior
and posterior chest and abdominal areas.
• Five lumbar segments: These transmit signals from or to the legs and feet and some pelvic
organs.
• Five sacral segments: These transmit signals from or to the lower back and buttocks, pelvic
organs and genital areas, and some areas in the legs and feet.
• A coccygeal remnant is located at the bottom of the spinal cord
 VIII. Pathophysiology

Precipitating
Factor

Predisposing
Factor Ear infection

Systemic
Predisposing
infections
Precipitating Contributing
Age (13y/o) factors:
factors: Entry of
factors: Antibiotic use
Gender meningococci Age(child>adults)
Immunocompromised Bacteria: Immunocompete
Environment(dirty) (neisseria
Invasion occur through
N. Meningitidis, S. nce
the choroid
meningitidis)
Pneumococcus, H.
plexus (across the blood brain barrier)
influenzae
or directly through
Organisms an opening
colonize in thein the
CSF leadingdura.
to inflammation
of the
Open canal; meninges
Otrorrhea Bloodstream
Exudates forms, and the
meninges become thickened, Subarachnoid
and adhesions Space
The arteries form, leading
supplying the to
hydrocephalus Subcapsular
Cranial Nerves impairement: subarachnoid space may also
continents
Trochlear Nerve- left hemianopsia become inflamed leading to
Vestibulocochlear Nerve- hearing Penetration to blood brain barrier,
rupture or thrombosis of blood
impairement If severe enoughvessel endotoxin
underlying brainand
caninflammatory
Glasgow Coma Test=7/15 mediator
become inflamed leading to cerebral
Eye: Open eyes in response to CSF
voice=3 edema and increased ICP
inflammation
Verbal: No verbal response=1
Motor:decorticate=3

CSF drainage
Damage in
the Cranial Cerebral edema and cerebral vascular
nerves thromnosis
Blood flow in Contarction of
white dura Hydrocephalus
cerebral blood
matter that volume
can be Increase ICP
located at the
4 regions of
IX. Ecologic Model
A. Hypothesis
The patient is female 13y/o and is diagnosed of having a CNS infection. Bacterial meningitis is
an acute purulent infection within the subarachnoid space. It is associated with a CNS inflammatory
reaction that may result in decreased consciousness, seizures, raised intracranial pressure (ICP), and
stroke. The meninges, the subarachnoid space, and the brain parenchyma are all frequently involved in
the inflammatory reaction (meningoencephalitis).

B. Predisposing Factors

1. Genetic Predisposition
2. Age

C. Ecologic Model: Lever meningitis)

(bacterial
CNS infection
female with
Host: 13y/o

Agent – Neisseria Meningitidis is a heterotrophic gram-negative diplococcal bacterium best known for
its role in meningitis and other forms of meningococcal disease such as meningococcemia.
Meningitidis
Host- 13 y/o female with CNS infection. Neisseria

Agent Biologic
Environment- Biologic environment consisting of living microorganisms
environment:
Biologic that is present in the
environment. consisting of living
microorganisms
that is present in
D. Analysis the environment
 Meningitis is an infection or inflammation of the meninges covering the brain and spinal cord.
Children are more prone than adults because of their greater propensity for respiratory infection.

Medical Surgical Nursing 8th edition by Black and Hawks

E. Recommendations

1. Administer prescribed medications which include I.V antibiotics. If seizures occur, anticonvulsants
are prescribed. If cerebral edema occurs, osmotic diuretics are prescribed.
2. Preventing respiratory complications resulting from altered consciousness. Implement such
measures as oxygen, ABG, pulmonary toileting and pulse oximetry.
3. Apply a hypothermia blanket to relieve hyperthermia, as prescribed.
4. Promote measures to help prevent recurrence of meningitis.
A. Persons in close contact with the client should be considered for prophylactic antibiotic therapy if
appropriate.
B. Administer vaccinations as indicated. A vaccination can be administered to prevent meningitis in
pediatric client.
5. Intervene as appropriate to reduce increased ICP.

X. Problem Prioritization

Nursing Diagnosis Rank Cues Jus

Ineffective Airway Clearance 1 S>
related to retained secretions The Sister Stated: >it is an actu
secondary to Pulmonary >it is the 1st p
Infection “Nahihirapan syang huminga ABC(airway,
minsan at nauubo pa sya circulation)
minsan pero di lang >it needs imm
nahahalata.” > it is modifi
>according to
O> hierarchy of n
Difficult vocalization physiologic n
Dyspnea >it needs an i
adventitious breath sound intervention.
(wheezing) present >man, money
Changes in respiratory available
rate/rhythm
RR: 28 cpm
Infection related to 2 S> >it is an actu
microorganism invasion into Sister Stated: >it can be Mo
the CNS secondary to time
occurrence of Ear infection “hindi na makarinig yung anak >it requires im
ko gawa ng nahila ang ear intervention o
drum nia kaya may hindi prevent the c
naiwasang nagkaroon ng complication
impeksyon na yung kapatid ko >man, mone
sa tenga nia, nilalagnat pa rin are available
yan madalas”

O>
Appears weak
Altered mental status
Difficulty in swallowing
Loss of appetite
Increase body temperature

Imbalanced nutrition less than 3 S> >it is an actu

body requirements r/t inability Sister stated: >it is modifia
to ingest foods time to regain
“hindi na sya nakakakain ng >according to
sapat. Halos puro prutas nalang hierarchy of n
kinakain nya. “ physiologic n
>it requires m
“parang wala na syang gana only to health
kumain minsan eh.” also to the su
>man, money
O> available
Loss of weight
Appears Weak
Loss of appetite

Self care Deficit r/t body 4 S>

weakness The Sister verbalized: >it is an actu
>it is modifia
“Hindi sya makakain ng magisa >according to
nia, pati sa pagtayo, pagpunta hierarchy of n
sa banyo kung kinakailangan at safety need.
tska pati magayos sa sarili ay di >it requires a
nia kaya. Kailangan na laging and health ca
inaalalayan sya sa mga the patient ne
ginagawa nya.” comfortable.
>man, money
O> available
Inability to handle utensils to
get food.
Inability to pick up glass
Inability to access bathroom
Looks untidy
Can’t maintain appearance at a
 satisfactory level.
Has Dry skin
Inability to get to toilet

XI. Nursing care Plan

Cues Nursing Rationale Goals and Nursing Rationale
diagnosis Objectives intervention

S> Ineffective Inability to Goal: Independent:

Airway clear
The Sister Stated:
Clearance secretions After 3 days of 1. Auscultate 1. Some degree o
“Nahihirapan syang related to or nursing breath broncho spasm
huminga minsan at retained obstructions intervention the sounds. Note is present with
nauubo pa sya secretions from the patient will for obstructions in
minsan pero di lang secondary to respiratory demonstrate adventitious airway and
nahahalata.”
pulmonary tract to behaviors to breath sounds may or may
O> infection. maintain a improve airway like wheezes, not be
clear clearance. crackles and manifested in
Difficult airway. rhonchi. adventitious
vocalization Objectives: 2. Elevate head breath sounds.
Dyspnea of the bed. 2. Elevation of
adventitious breath After 8 hours of Have patient the bed
sound (wheezing) nursing lean over facilitates
present intervention: bed, table or respiratory
has shallow sit on edge of function by use
breathing 1. the client the bed. of gravity.
Changes in will be able 3. Keep 3. Precipitators of
respiratory
rate/rhythm
to maintain environmenta allergic type of
Vital signs Taken as airway l pollution to respiratory
follows: patency a minimum reaction that
Temp: 37.2 like dust, can trigger or
RR: 28 2. the client smoke and exacerbate
BP: 120/70
CR: 86
will be able feather onset of acute
to pillows episode.
expectorate according to 4. To monitor if
secretions individual any alterations
readily situation. in vtal signs.
4. Monitor Vital
3. the client signs
will be able
to
demonstrat 5. Monitor 5. To determine
e reduction Intake and the level of
of output hydration
congestion 6. Assist with 6. Coughing is
with clear measures to most effective
breath improve in an upright
sounds effectiveness position after
of cough chest
4. the client effort. percussion.
will be able 7. Increase fluid 7. Hydration
to Report intake to helps increase
diminished 3000 ml/day. the viscosity of
wheezes Provide the secretions
warm or and improve
5. the client tepid liquids. secretion
will be able clearance,
to facilitating
demonstrat expectoration.
e behaviors using warm
to improve Collaborative: liquids may
or maintain decrease
clear 1. Administer bronchospasm.
airway Antibiotics,
expectorants 1. To combat the
6. The client or bacteria
will be able
to show
bronchodilato causing the
appreciation rs as infection and
regarding prescribed. reduce
the viscosity and
knowledge secretions.
given.

Discharge Plan
METHODS

M: >continue medications prescribed; antibiotics for her infection. PRN meds like paracetamol for
fever.
E: >Avoid exhaustion, prohibits strenuous activity. May do ROM exercises. Turning every 2 hours if
still bed ridden in house.
T: > May do CPT after nebulization as prescribed. May do deep breathing or coughing exercises .
General health measures: adequate sleep and rest, good diet, avoidance of stressful situations, fatigue or
anxiety.
H: Teach Relatives in proper hygienic Practices; hand washing before and after caring. Proper
administration and compliance of her medications.
O: Continue follow check up
D: highly nutritious food such as fruits and vegetable. Emphasize the importance of eating nutritious
food.