DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.

COLLEGE OF NURSING
2nd Semester, S.Y. 2020-2021

CLINICAL DUTY REQUIREMENT

Case Presentation: Bacterial Meningitis

Submitted by:
Pamat. Parrilla. Presnilla. Ramo. Sabejon. Saldaña.
Sarsoza. Serrano. Sevilla. Suarez. Sumbeling. Yu.
Group B

Submitted to
Mr. Paul Michael L. Poblete RN
Clinical Instructor
 CASE SCENARIO
General Data
Patient Esperas, a resident of Brgy. 96 Calanipawan, Tacloban City was referred to Eastern Visayas Regional
Medical Center last March 20, 2021 due to prolonged completion of medication.

History of Present Illness

Prior to referral to Eastern Visayas Regional Medical Center, patient was admitted at ACE Medical Center due to
Bacterial Meningitis and Subdural Empyema. Patient had undergone craniectomy last March 11,2021.

Two weeks prior to admission at ACE Medical Center patient had an on and off fever associated with headache.
They seek for consultation and was managed for sinusitis and was given Clarithromycin for 1 week.

One day prior to admission, persistence of sign and symptoms noted thus recommended the admission at Biliran
Provincial Hospital. "Dida han March 8 ban gab-i tigda la hiya waray kilala ha amon. Tas an iva la nayayakan
kay “nanay” pero kun ginpapakianhan kun hino iya nanay diri hiya nakakatudlok. Tas kun nasurat hiya Letter A
la an nasusurat.” as verbalized by his mother.

PRIORITY SIGNS AND SYMPTOMS

• Seizure
• Fever
• Headache
• Subdural Empyema
• Altered Mental Status
 LABORATORY EXAMNINATION

NORMAL RESULT CLINICAL SIGNIFICANCE

EXAMINATION RANGE

CREATININE 80-115 34 LOW

g/dL g/dL This may be due to the medication. There are
certain antibiotics that may cause to decrease
the secretion of creatinine.

Probable Laboratory Exam:

Culture and Sensitivity Presence of H. influenza, N. meningitidis or S.

Test pneumonia
 BACTERIAL MENINGITIS
PRECIPITATING FACTOR: PREDISPOSING FACTORS:
- SINUSITIS - SEX (MALE)
Pathogens attach to nasopharyngeal mucosal epithelium.

Colonization of pathogens in the upper respiratory tract LEDGEND:

DISEASE PROCESS
Activation of the complement system
SIGNS & SYMPTOMS MANIFESTED BY THE PATIENT

SIGNS & SYMPTOMS NOT MANIFESTED BY THE PATIENT

Proteases produced by bacteria cleaves IgA antibodies
MEDICATIONS / TREATMENT

COMPLICATIONS
Inactivates local antibody defense
LABORATORY/ DIAGNOSTIC EXAMS

Migration of bacteria to blood circulation

Bacteria cross blood brain barrier

Fever
Increases body’s
metabolic rate Proliferation of Pathogens in subarachnoid space Ceftriaxone
Tachycardia

Bacterial components in the CSF trigger inflammatory cascade Culture and Craniectomy
Confusion Sensitivity
Interferes with
normal CNS
Stupor function
Lethargy Macrophages release cytokinesdinterleukin that migrates neutrophils to CSF Subdural
Empyema Phenytoin
Delirium Seizure Oxcarbezipine
Coma Inflammation of the Meninges
Increased ICP Herniation of the brain
Death
BACTERIAL MENINGITIS Vancomycin
Inflamed meninges Metronidazole
Photophobia around CN 2 affects
visual pathways Meningeal
irritation

Cranial nerves Stimulate Dural Brudzinski sign Kernig sign

exiting inflamed nociceptor
meninges
become irritated

cranial nerve
palsies

Around the Around the Around the

brain brain stem spinal cord

Headache Stiff neck Sore Back

 NARRATIVE

Bacterial or pyogenic meningitis is an acute meningeal inflammation secondary to a

bacterial infection that generally evokes a polymorphonuclear response in the CSF. Meningitis can
occur at any age and in previously healthy individuals. The precipitating factor is sinusitis, which
is an inflammation of the lining of the paranasal sinuses. While the predisposing factor is sex, the
reported attack rate for bacterial meningitis is 3.3 male cases per 100000 population, compared
with 2.6 female cases per 100000 population.

Pathogens that cause meningitis are able to colonize the upper respiratory tract by
attaching to the host’s nasopharyngeal mucosal epithelium. This now activates the complement
system that will clear microbes and attack the pathogen's cell membrane. However, bacteria that
cause meningitis have properties that enhance their virulence, which accounts, at least partly, for
their ability to cause meningitis. The bacteria: H influenza, N meningitidis, and S pneumoniae, all
produce immunoglobulin A proteases. Such proteases inactivate the host’s immunoglobulin A by
cleaving the antibody. This destruction of immunoglobulin A antibody inactivates the host’s local
antibody defense. Survival of bacteria and migration to blood circulation. Once the bacteria are
in the bloodstream, bacterial adhesion to structures of the blood–brain barrier are aided by
structural qualities of the bacteria because of poor host defenses in the CSF, the bacteria quickly
multiply after gaining entry to the CSF. Bacterial components in the CSF trigger an inflammatory
cascade in the host. Proinflammatory cytokines interleukin (IL)-1, tumor necrosis factor (TNF),
and others are released by various cells including macrophages, microglia, meningeal cells, and
endothelial cells. Cytokines, in turn, promote the migration of neutrophils into the CSF by several
mechanisms. Cytokines increase the binding affinity of leukocytes for endothelial cells, and induce
adhesion molecules that interact with leukocyte receptors. Because the host defense mechanisms
within the CSF are poor, the pathogens can proliferate. In an attempt to defend against the
invading organisms, a cascade of inflammatory events is set into motion by the body’s immune
defense mechanisms. This results in the inflammation of the meninges or Bacterial meningitis.
Because of the inflammatory cascade it increases the body’s metabolic rate which results in fever
and tachycardia. The inflammatory cascade also interferes with the normal CNS function which
leads to confusion, stupor, lethargy, delirium and coma. This also causes the meninges around
the CN 2 (Optic Nerve) to become inflamed, affecting the visual pathways causing increased
sensitivity to light, thus photophobia can be observed.

As neutrophils continue to combat the bacteria present as part of the inflammatory

process, cell death of both the white blood cells and bacteria result in the accumulation of debris
forming pus. With the increased formation of pus between the dura mater and underlying
arachnoid mater, this leads to subdural empyema. As an added result, increased intracranial
pressure arises causing the occurrence of seizures. At this point, it was managed by medications
Phenytoin and Oxcarbazepine. If not treated immediately, the development of herniation of the
brain occurs and in severe cases, even death. Craniectomy was performed in order to relieve the
pressure.

Inflammation of the meninges also causes meningeal irritation which can be detected
through physical exam maneuvers with notable kernig and brudzinski signs present. The
meningeal irritation stimulates dural nociceptors having increased sensitivity to pain in different
areas mainly: around the brain, causing headache; around the brainstem, causing stiff neck; and
around the spinal cord, causing sore back. All of which would increase in severity if no intervention
would be done.
 DRUG CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE NURSING
ACTION EFFECTS/ SIDE RESPONSIBILITIES
EFFECTS
Generic Name: Antibiotic, Vancomycin is a Vancomycin is used for Hypersensitivity CV: BEFORE:
Vancomycin Glycopeptide glycopeptide the treatment and Hypotension • Obtain culture prior to
antibiotic that prevention of various Used cautiously in starting therapy
Brand Name: exerts its bacterial infections caused patients with renal CNS: • Assess patient for
Vancocin bactericidal effect by gram-positive bacteria, impairment Headache, fatigue, possible
by inhibiting the including methicillin- dizziness, vertigo contraindications and
Route: IV polymerization of resistant Staphylococcus any known allergy.
peptidoglycans in aureus (MRSA). It is also DERMATOLOGIC: • Assess patient’s
Dosage: 10 mg/kg the bacterial cell effective for streptococci, Drug rash with medication history to
every 12 hours. wall. This enterococci, and eosinophilia, determine possible
inhibition weakens methicillin- exfoliative drug interactions and
bacterial cell walls susceptible Staphylococcus dermatitis, pruritus, allergies.
and ultimately aureus (MSSA) infections. rash, Stevens- • Check the label of the
causes leakage of Johnson Syndrome, drug to be
intracellular Bacterial meningitis urticaria, vasculitis administered.
components, • Check the prescribed
resulting in EENT: dosage of the drug to
bacterial cell Hearing loss, be administered.
death. Vancomycin tinnitus (rare) • Ensure that the
is only active medication is not past
against gram- GI: its expiry date.
positive bacteria. Nausea, abdominal • Verify identity of
pain, diarrhea, patient using at least
vomiting, flatulence two patient identifiers.
• Obtain baseline vital
GU: signs from the patient,
UTI, nephrotoxicity especially the BP.
including increased • Reconstituted powder
blood creatinine, must be further diluted
renal failure and prior to administration
renal impairment,
increased BUN,
interstitial nephritis DURING:
• Consider right
HEMATOLGIC: approach, right route,
Reversible right frequency/time,
agranulocytosis, right principle of care
eosinophilia, • Administer over a
reversible period of no less than
neutropenia, 60 minutes by
thrombocytopenia intermittent infusion
• Avoid rapid infusion,
RESPIRATORY: which may cause
Dyspnea, wheezing sudden hypotension
• Monitor IV site closely;
necrosis and tissue
sloughing will result
from extravasation
• Monitor signs of
hypersensitivity
reactions and
anaphylaxis, including
pulmonary symptoms
(tightness in the throat
and chest, wheezing,
cough dyspnea) or skin
reactions (rash,
pruritus, urticaria).
Notify physician or
nursing staff
immediately if these
reactions occur.
• Assess blood pressure
periodically and
compare to normal
values. Report low
blood pressure
(hypotension),
especially if patient
experiences dizziness,
fatigue, or other
symptoms.
• Monitor for signs of
eosinophilia (fatigue,
weakness, myalgia) or
leukopenia (fever, sore
throat, signs of
infection). Report
these signs to the
physician.
 • Monitor signs of
ototoxicity (hearing
loss, tinnitus, disturbed
balance, vertigo).
Report these signs to
the physician.

AFTER:
• Teach patient’s parent
to check access site
daily for phlebitis and
irritation and to report
any pain at infusion
site to avoid
extravasation.
• Review and discuss
actions and side
effects with the patient
and caregiver and
document on the
patient visit record.
• Consider right
evaluation and right
documentation
 DRUG CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE NURSING
ACTION EFFECTS/ SIDE RESPONSIBILITIES
EFFECTS
Generic Name: 3rd Generation Cephalosporins are CNS infections Contraindicated to Hypersensitivity BEFORE
Ceftriaxone Cephalosporin chemically and caused by patients hypersensitive to reactions range • Obtain culture prior to
pharmacologically susceptible strains cephalosporins and from mild rashes, starting therapy
Brand Name: similar to penicillin; of Neisseria related antibiotics. fever, and • Assess patient for
Forgram they act by meningitidis eosinophilia to fatal possible contraindications
inhibiting bacterial Used cautiously in anaphylaxis and are and any known allergy.
Route: IV cell-wall synthesis, patients with renal or more common in • Assess patient’s
causing rapid cell hepatic impairment, patients with medication history to
Dosage: destruction. Their history of GI disease, or penicillin allergy. determine possible drug
2 gm q 2 hours sites of action are allergy to penicillins. interactions and allergies.
enzymes known as Adverse GI reactions • Check the label of the
penicillin-binding include abdominal drug to be administered.
proteins. The affinity pain, diarrhea, • Check the prescribed
of certain dyspepsia, glossitis, dosage of the drug to be
cephalosporins for nausea, tenesmus, administered.
these proteins in and vomiting. • Ensure that the
various medication is not past its
microorganisms Hematologic expiry date.
helps explain the reactions include • Verify identity of patient
differing actions of thrombocytopenia or using at least two patient
these drugs. They thrombocythemia, identifiers.
are bactericidal: transient • Obtain baseline vital
They act against neutropenia, and signs from the patient.
many aerobic gram- reversible
positive and gram- leukopenia. DURING:
negative bacteria • Consider right approach,
and some anaerobic Adverse renal right route, right
bacteria but don't effects may occur frequency/time, right
kill fungi or viruses. with any principle of care
cephalosporin; they • Watch for seizures; notify
are most common in physician immediately if
older patients, those patient develops or
with decreased renal increases seizure activity.
function, and those • Monitor signs of
taking other pseudomembranous
nephrotoxic drugs. colitis, including diarrhea,
Some products abdominal pain, fever,
increased risk of pus or mucus in stools,
arrhythmia, chest and other severe or
pain, hypotension, prolonged GI problems
and hypertension. (nausea, vomiting,
heartburn). Notify
physician or nursing staff
immediately of these
signs.
• Monitor signs of allergic
reactions and
anaphylaxis, including
pulmonary symptoms
(tightness in the throat
and chest, wheezing,
cough dyspnea) or skin
reactions (rash, pruritus,
urticaria). Notify
physician or nursing staff
immediately if these
reactions occur.
• Monitor signs of blood
dyscrasias, including
eosinophilia (fatigue,
weakness, myalgia),
hemolytic anemia
(malaise, dizziness,
jaundice, abdominal
pain), leukopenia (fever,
sore throat, mucosal
lesions, signs of
infection),
thrombocytopenia
(bruising, nose bleeds,
bleeding gums, other
unusual bleeding), or
thrombocytosis
(headache, dizziness,
chest pain, fainting,
visual disturbances,
numbness or tingling in
the hands and feet).
Report these signs to the
physician.
 • Monitor injection site for
pain, swelling, and
irritation. Report
prolonged or excessive
injection site reactions to
the physician.
After:
• Instruct patient to notify
physician immediately of
signs of superinfection,
including black, furry
overgrowth on tongue,
vaginal itching or
discharge, and loose or
foul-smelling stools.
• Instruct patient and
family/caregivers to
report other troublesome
side effects such as
severe or prolonged
fever, skin problems
(rash, hives), diarrhea, or
signs of gallstones
(sudden intense pain in
the abdomen)
• Consider right evaluation
and right documentation
 DRUG CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS/ NURSING
ACTION SIDE EFFECTS RESPONSIBILITIES
Generic Name: Antibacterial Metronidazole diffuses Metronidazole is Hypersensitivity Common Side effects of BEFORE:
Metronidazole Antiprotozoal, into the organism, one of the Metronidazole include: • Obtain culture prior to
Nitroimidazole inhibits protein mainstay drugs Used cautiously in starting therapy
Brand Name: synthesis by for the treatment patients with severe • Appetite loss • Assess patient for
Flagyl interacting with DNA of anaerobic hepatic impairment and • Yeast possible
and causing a loss of bacterial renal failure infection (candidiasis) contraindications and
Route: IV helical DNA structure infections, • Diarrhea any known allergy.
and strand breakage. protozoal • Dizziness • Assess patient’s
Dosage: Therefore, it causes infections, and • Headache medication history to
500mg/100ml cell death in microaerophilic • Nausea determine possible
susceptible bacterial • Vomiting drug interactions and
organisms. infections. • Loss of control of bodily allergies.
movements • Check the label of the
• Dark urine drug to be
• Disulfiram-type reaction administered.
with ethanol • Check the prescribed
• Furry tongue dosage of the drug to
• Hypersensitivity be administered.
• Low white blood cell • Ensure that the
count (neutropenia) medication is not past
• Neuropathy its expiry date.
• Pancreatitis • Verify identity of
• Seizures patient using at least
• Blood two patient identifiers.
clot (thrombophlebitis) • Obtain baseline vital
• Dry mouth signs from the patient
• Brain disease
(encephalopathy) DURING:
• Aseptic meningitis • Consider right
• Optic neuropathy approach, right route,
• Stevens-Johnson right frequency/time,
syndrome right principle of care
• Toxic epidermal necrolysis • During and after
• prolonged therapy or
repeated courses,
complete blood count
(CBC) with differential
requires monitoring.
• Carefully observe
patients for the onset
 of
neurologic symptoms
and consider
discontinuation of
metronidazole when or
if new neurologic
symptoms occur.

AFTER:
• Instruct the patient
and caregiver to
monitor for symptoms
of encephalopathy
such as: dizziness,
problems with muscle
control or coordination,
shakiness or an
unsteady walk, slurred
speech, or trouble with
speaking
• Instruct the patient
and caregiver to
monitor for symptoms
of peripheral
neuropathy such as:
numbness, tingling, or
painful sensations in
the arms, hands, legs,
or feet.
• Instruct the patient
and caregiver to
monitor for symptoms
of aseptic meningitis.
such as: confusion,
drowsiness, fever, a
general feeling of
illness, a headache,
loss of appetite,
nausea, a stiff neck or
back, or vomiting
• Consider right
evaluation and right
documentation.
 DRUG MECHANISM OF INDICATIONS CONTRAINDICATION ADVERSE EFFECTS/ NURSING
ACTION SIDE EFFECTS RESPONSIBILITIES
Generic name: Blocks sodium channels, Monotherapy or adjunctive • Hypersensitivity to CNS: seizures, suicidal Before:
OXcarbazepine stabilizing hyperexcited therapy of partial seizures oxcarbazepine, thoughts, dizziness/vertigo, • Obtain baseline data.
Brand name: Oxtellar XR neural membranes, in adults and children 4 yr carbamazepine, or Drowsiness/fatigue, • Review history of
Pharmacotherapeutic: inhibiting and older with epilepsy. eslicarbazepine headache, cognitive seizure disorder
Carboxamide derivative, repetitive neuronal firing, Adjunctive therapy in • Lactation. symptoms. • Monitor closely for
anticonvulsant diminishing synaptic patients 2– 16 yr with EENT: abnormal vision, notable changes in
Dose & route: 2-5 mL q impulses Epilepsy. diplopia, nystagmus. Gi: behavior that could
RH PO abdominal pain, dyspepsia, indicate the emergence
nausea, vomiting, thirst. or worsening of suicidal
DERM: stevens-johnson thoughts or behavior or
syndrome, toxic epidermal depression.
Necrolysis, acne, rash, • Monitor patient for CNS
urticaria. changes. May manifest
ENDO: hypothyroidism, as cognitive symptoms.
hyponatremia. • Provide safety
NEURO: ataxia, gait precautions.
disturbances, tremor. During:
• Do not confuse
oxcarbazepine with
carbamazepine
• Implement seizure
precautions as
indicated
 • Shake oral suspension
well and prepare dose
immediately after.
• Assess for signs of
Hyponatremia.
• Assist with ambulation
if dizziness, ataxia
occur.
After:
• Do not abruptly stop
the medication.
• Instruct patient to take
oxcarbazepine in
equally spaced doses,
as directed.
• Report if rash, nausea,
headache, dizziness
occurs.
• Advise patients to carry
identification describing
disease and medication
regimen at all time.
• Advise patients to avoid
activities requiring
Davis’s Drug Guide for Nurses) alertness until response
to medication is known.
 DRUG MECHANISM OF INDICATIONS CONTRAINDICATION ADVERSE EFFECTS/ NURSING
ACTION SIDE EFFECTS RESPONSIBILITIES
Generic name: Limits seizure propagation Treatment/prevention of • Hypersensitivity to CNS: suicidal thoughts, Before:
Phenytoin by altering ion transport. tonic-clonic seizures and phenytoin, other ataxia, agitation, confusion, • Obtain baseline data.
Brand name: Dilantin May also decrease synaptic complex partial seizures. U hydantoins Dizziness, drowsiness, • Review history of
Pharmacotherapeutic: transmission. • Concurrent use of dysarthria, dyskinesia, seizure disorder
Hydantoin. Antiarrhythmic properties delavirdine extrapyramidal syndrome, • Monitor closely for
Dose & route: 380 mg IV as a result of shortening the headache, insomnia, notable changes in
then 60 mg IV q 8H. action potential and vertigo, weakness. behavior that could
decreasing automaticity EENT: diplopia, indicate the emergence
nystagmus. CV: or worsening of suicidal
hypotension, tachycardia. thoughts or behavior or
GI: acute hepatic depression.
Failure, gingival • Assess patient for
hyperplasia, nausea, phenytoin
constipation, vomiting. hypersensitivity
DERM: stevens johnson syndrome.
syndrome, toxic epidermal • CBC should be
necrolysis, rash, exfoliative performed before
dermatitis, pruritus, purple beginning therapy and
glove syndrome. periodically during
HEMAT: aplastic anemia, therapy
leukopenia, megaloblastic During:
anemia, • Observe frequently for
Thrombocytopenia. recurrence of seizure
MS: osteomalacia, activity.
osteoporosis
 • Monitor ECG for cardiac
arrhythmia.
• Assess for clinical
improvement
• Monitor for
signs/symptoms of
depression, suicidal
tendencies
• Monitor CBC with
differential, renal
function
After:
• maintain good oral
hygiene to prevent
gingival hyperplasia.
• Report sore throat,
fever, glandular
swelling, skin reaction
• Avoid tasks that require
alertness, motor skills
until response to drug is
established
• Do not abruptly
withdraw medication
after long-term use.
(Davis’s Drug Guide for Nurses) • Report any unusual
changes in behavior
 CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS RATIONALE

Subjective: Acute pain Mechanical SHORT TERM Independent Independent SHORT TERM
“Medyo masakit related to phlebitis occurs GOALS: 1. Perform a comprehensive 1. Assessment of pain by GOALS:
akon tiil, kun hain phlebitis as where the After 8 hours of assessment of pain. Determine conducting an interview helps the After 8 hours of
ako gin butangan evidenced by movement of a nursing intervention, via assessment the location, nurse in planning optimal pain nursing intervention,
han dextrose” as redness at foreign object patient/family will be characteristics, onset, duration, management strategies. patient/family was able
verbalized by the previous (cannula) within able to: frequency, quality, and severity to:
patient. insertion site a vein causes ● Demonstrate of pain. ● Demonstrate
friction and the use of the use of
subsequent appropriate 2. Use the Wong-Baker FACES 2. Some clients (e.g children, appropriate
venous diversional Rating Scale to determine pain language constraints) may not be diversional
inflammation. It activities and intensity. able to relate to numerical pain activities and
often occurs relaxation skills. scales and may need to use the relaxation skills.
when the size of ● Describe Wong-Baker Faces Rating Scale. ● Describe
the cannula is satisfactory satisfactory
Objective: too big for the pain control at pain control at
● Redness selected vein. a level less 3. Assess for the location of the 3. Using charts or drawings of the a level less than
● Swelling than 3 to 4 out pain by asking to point to the body can both help the patient 3 to 4 out of
● Warmth of 10 site that is discomforting. and the nurse in determining 10.
● Visible red specific pain locations
“streaking”
on foot LONG TERM GOALS: 4. Monitor the patient's vital signs 4. Rarely, infection can arise in the LONG TERM GOALS:
● Tenderness After 3 days of nursing and the I.V. site clotted veins, which is associated After 3 days of nursing
intervention, with high fever, and redness that intervention,
patient/family will be extends well past the affected patient/family was able
able to: vein. to:

● Display 5. Apply a warm, moist compress 5. Continuous application of moist ● Display

improved well- to the affected area as ordered. heat over 72 hours, along with improved well-
being such as administration of oral being such as
decreased nonsteroidal anti-inflammatory decreased
 redness, agents, is the best treatment. redness,
swelling, swelling,
tenderness and 6. Determine factors that alleviate 6. These may include, for example, tenderness and
warmth. pain. meditation, deep breathing warmth.
● Use exercises, praying, etc. ● Use
pharmacologica pharmacologica
l and 7. Provide measures to relieve 7. It is preferable to provide an l and non
nonpharmacolo pain before it becomes severe. analgesic before the onset of pain pharmacologica
gical pain-relief or before it becomes severe l pain-relief
strategies. when a larger dose may be strategies.
● Display required. ● Display
improvement in improvement in
mood, coping. Dependent Dependent mood, coping.
8. Give paracetamol as 8. Paracetamol are safe and
prescribed. effective painkillers for children.

CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION

DIAGNOSIS RATIONALE

Subjective: Impaired skin Bacterial Short-term: Independent: Client was able to:
integrity related meningitis is an
to mechanical After 1 hour of nursing
inflammation of
interruption of intervention, client will
“Diri naman masakit the meninges, 1. Reinforce initial dressing and 1. Protects wound from mechanical ✓ Demonstrate
skin secondary be able to:
an akon tinahian, tas in particular the change as indicated. Use strict injury and contamination of fluids behavior and
to craniectomy that may cause excoriations
kanina gintanggal na arachnoid and ✓ Demonstrate aseptic techniques. techniques to
an stapler,” As pia mater, behavior and promote
verbalized by the techniques to wound healing
associated with 2. Gently remove tape (in direction of 2. Reduces risk of skin trauma and
client. promote and to prevent
invasion of hair growth) and dressings when disruption of wound.
healing and to complications
bacteria into the changing.
Objective: sub- arachnoid prevent ✓ Verbalize
space. This complications understanding
- Dry post- 3. Can impair circulation to the wound
causes increase ✓ Verbalize 3. Check tension of dressings. Apply on how to care
operative site
intracranial understanding tape at center of incision to outer for incision site
- Incision site
pressure and in on how to care margin of dressing. ✓ Be free from
located at 4. Early recognition of delayed healing
for incision site. sighs of
frontotempor order to relieve or developing complication may
4. Inspect wound regularly, noting infection
al area the pressure, prevent a more serious situation
characteristics and integrity. ✓ Achieve timely
- Frequent craniectomy is Long-term:
wound healing
touching of performed. 5. Decreasing drainage suggests
After 3 days of nursing
the wound evolution of healing process.
intervention, client 5. Asses amount and characteristics
dressing GOALS FULLY MET
will: of drainage.
6. Prevents contamination of wound
✓ Be free of signs 6. Caution patient not to touch
of infection 7. May provide information about
Source: wound.
✓ Achieve timely presence of wound infection.
University of
Rochester wound healing 7. Note odors emitted from wound or
Medical center dressings.
(2021)
8. Removal of necrotic debris facilitates
8. Cleanse wound as needed with
prescribed solution and gently pat removal of contaminated exudate or
infected tissue and promotes wound
dry with gauze sponge.
healing.

9. Using the product correctly will

9. Apply wound dressing product
facilitate wound healing
according to manufacturer’s
directions.

10. Loosely fill wound with gauze. 10. Tightly packing the wound cavity
results in slow wound healing.
 CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS RATIONALE

Subjective: Risk for The skin is a Short-term: Independent: Patient and SO were
infection related natural barrier able to:
to post- After 1 hour of nursing
against infection.
operative intervention, the ✓ Identify the
“Gindredressignan Any surgery that 1. Note risk factors that may
incision patient and SO will be 1. This will help the patient and SO factors that
an iya tinahian kada causes a break contribute for the occurrence of
able to: identify the present risk factors that may contribute
aga, tapos kanina la in the skin can infection in the incision site.
may contribute to infection. to the
gintanggal an lead to infection. ✓ Identify the factors
development
stapler,” as A surgical site that may
of surgical site
verbalized by SO. infection contribute to the 2. Observe suture lines, noting
2. Early identification of developing infections
typically occurs development of characteristics of drainage and
infection permits prompt intervention ✓ Verbalize
after a surgery. surgical site presence of inflammation.
and prevention of further complications. understanding
Objective: infections
Bacterial about infection
✓ Verbalize 3. Monitor temperature routinely.
- Dry post- meningitis is an 3. May indicate developing sepsis control.
understanding Note presence of chills,
operative inflammation of requiring further evaluation and
about infection diaphoresis, and changes in
site the meninges, in intervention. GOALS PARTIALLY
control mentation.
- Sweats pool particular the MET
near the arachnoid and
4. Provide health teachings
incision site pia mater, Long-term: 4. This will help the patient and family
specifically in identification of
- Frequent associated with modify some of the environmental
After 3 days of nursing environmental risk factors that
touching of invasion of factors present which could reduce
intervention, the could contribute for infection to
dressing bacteria into the incidents of infection.
patient will: develop.
without subarachnoid
hands being space. Due to ✓ Maintain
inflammation, 5. Instruct family and patients to
sanitized normothermia 5. Hand-washing is the first line of
there is a build- maintain good hand-washing
✓ Be free of defense against nosocomial infections.
up of pressure techniques.
signs of
which increase infection
the intracranial ✓ Achieve timely
pressure. wound healing
Craniectomy is a
surgical
procedure
performed to
relieve pressure.

Sources:
- The John
Hopkins
University
(2021)
Surgical site
infection
- Hottman, O.,
Weber, R.
(2009)
Pathophysiol
ogy and
treatment of
bacterial
meningitis.
 CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS RATIONALE

Subjective: Anxiety related Anyone from all Short Term: Independent: The mother was able
“Nagwoworry gad to change in walks of life can After 1 hour of 1. Assess sources and level of 1. Provide information about the need for to:
ako ma’am kay health status of suffer from nursing intervention, anxiety how is anxiety intervention to relieve anxiety and ● Acknowledge and
maiha na kami na the child as anxiety the mother will be able manifested and need for concern discuss fears and
nakaadmit tapos evidenced by disorders. It to: information and support concerns
nayakan man adto reports of affects the poor, ● Acknowledge and ● Verbalize awareness
hi doc na after 4-6 concerns the rich, the discuss fears and 2. Assess oriental feelings of guilt, 2. Prevent or minimize feelings of blame of feelings of anxiety
weeks makakgawas young, the old, concerns encourage them to openly or guilt and healthy ways to
na kami pero the sick, the ● Verbalize discuss feelings deal with them
nagbago naliwat healthy, and awareness of
ngan nagyakan na more. However, feelings of anxiety 3. Encouraged to express 3. Provides an opportunity to vent feelings Goals partially met
may significant everyone and healthy ways concerns and asked to express , secure information needed to reduce
changes daw. Sana experiences to deal with them concerns and ask questions anxiety
maupay it anxiety regarding the condition of ill
kinagagawsan”, as differently. It can Long Term: child
verbalized by the be a result of After 2 days of
mother fear, uncertainty, intervention the 4. Teach about the disease 4. Relieves anxiety of parent
circular and mother will be able to process and behaviors , physical
Objective: racing thoughts, report decrease level effects and symptoms of
● Expresses and the of anxiety disease
concern about avoidance of
actual certain 5. Provide accurate information as 5. Parents come and/ or anxiety-provoking
hospitalization behaviors. It can appropriate and when information can be given in
● Expresses affect our ability requested by the family answer manageable amounts over an extended
concern about to function questions freely and honestly period . opportunities arise and facts
seriousness of normally, and and in language that is are given , individuals will accept what
illness even convince us understandable by all . repeat they are ready for . no , words and
that we’re losing information as necessary , phrases may have different meanings
our minds. And correct misconception for each individual , therefore ,
worst, it can clarification is necessary to ensure
even lead to understanding
 related
psychological 6. Encourage use of relaxation 6. Promotes release of endorphins and
conditions, like techniques such as use of music aids in developing internal focus of
substance abuse , deep breathing and control , reducing anxiety
and personality mindfulness
difficulties.

CUES NURSING SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION

DIAGNOSIS RATIONALE

Subjective: Deficient Health literacy is After 3 hours of Independent: After 3 hours of

“Diri ako maaram knowledge the degree to nursing interventions , 1. Assess motivation and 1. Learning requires energy a person must nursing interventions,
kay ano nga regarding which individuals the mother of the willingness of family member to see a need or purpose for learning . the mother was able
nakakakuha man condition have the patient will be able to: learn they also value the right to refuse to:
hiya hini na sakit. related to lack capacity to ● Participate in educational services ● Participate in
Healthy man hiya of exposure to obtain , process learning process learning process
tas inalagaan gihap information and understand ● State at least 3 2. Determine priority of learning 2. This is to know what needs to be ● State at least 3
para dir masakit. basic health risk factors that means within the overall care discussed especially if the parent has a risk factors that
Gin sipon man la information can predispose or plan background about the situation. can predispose or
adto hiyas tas tigda needed to make precipitate Knowing what to prioritize prevent precipitate
la na waray na hiya appropriate bacterial wasting valuable time bacterial
kikilala ha am dida health decisions. meningitis meningitis
han march 8 han Adequate health ● Verbalize her 3. Grant calm and peaceful 3. A calm environment allows the family ● Verbalize her
gabi,” as verbalized literacy may understanding of environment without member to concentrate and focus understanding of
by the mother increase a the disease interruption completely the disease
person's capacity process process
Objective: to take 4. Provide an atmosphere of 4. Conveying respect is important when
● Lack of source responsibility for respect , openness, trust and providing education to people with
of information their health and collaboration different values and beliefs about health
● Verbalize their families. and illness
concerns on Deficient
how her child knowledge is a 5. Discuss what is bacterial 5. Different people take in information in
contracted the state in which meningitis with the use of different ways
illness cognitive visual aids like pictures or
information or diagrams
psychomotor
skills required 6. Enumerate and explain 6. Focusing on Topics allows the learner to
for health thoroughly the risk factors that concentrate more completely to the
recovery , may predispose or precipitate material being discussed
maintenance or the illness such as extremes of
health promotion age , it is more likely to occur in
are lacking male, immunosuppressed
patience and recent exposure
to pathogens

7. Encourage questions 7. Questions facilitate open communication

between patients' family and healthcare
professionals and allow verification and
understanding of the information given .

8. Allow repetition of information 8. Repeating information help health care

or skills professional assess the level of
understanding
 DISCHARGE PLAN

DISCHARGE PLAN (METHODS)

● Advise client to strictly continue prescribed medication to ensure
Medicines optimum recovery.

● Instruct client to have plenty of bed rests.

Exercise

● Instruct client to cleanse wound as needed with prescribed solution

and gently pat dry with gauze sponge.
Treatment ● Instruct family and patients to maintain good hand-washing
techniques.

● Provide measures to relieve pain.

Health ● Provide health teachings specifically in identification of environmental
Education risk factors that could contribute to infection.

● Instruct client to adhere suggested dietary plan.

Diet
● Advise client to maintain a good and safe environment.
Spirituality ● Instruct client to pray and seek for the Lord’s guidance.