NCP for Meningitis - Nursing Diagnosis : Ineffective Tissue Perfusion (Cerebral)

Meningitis is a serious infection of the meninges, the membranes covering the brain and spinal cord. It is a devastating disease and remains a major public health challenge. The disease can be caused by many different pathogens including bacteria, fungi or viruses, but the highest global burden is seen with bacterial meningitis. (www.who.int)

Meningitis is usually caused by a viral or bacterial infection.

Viral meningitis is the most common and least serious type. Bacterial meningitis is rare, but can be very serious if not treated.

Several different viruses and bacteria can cause meningitis, including:

•     meningococcal bacteria – there are several different types, called A, B, C, W, X, Y and Z
•     pneumococcal bacteria
•     Haemophilus influenzae type b (Hib) bacteria
•     enteroviruses – viruses that usually only cause a mild stomach infection
•     the mumps virus
•     the herpes simplex virus – a virus that usually causes cold sores or genital herpes

A number of meningitis vaccinations provide protection against many of the infections that can cause meningitis. (www.nhs.uk)

The symptoms of viral and bacterial meningitis can be similar in the beginning. However, bacterial meningitis symptoms are usually more severe. The symptoms also vary depending on your age.

Viral meningitis in infants may cause: decreased appetite, irritability, vomiting, diarrhea, rash, respiratory symptoms

In adults, viral meningitis may cause: headaches, fever, stiff neck, seizures, sensitivity to bright light, sleepiness, lethargy, nausea and vomiting, decreased appetite, altered mental state

Bacterial meningitis symptoms develop suddenly. They may include: altered mental status, nausea, vomiting, sensitivity to light, irritability, headache, fever, chills, stiff neck, purple areas of skin that resemble bruises, sleepiness, lethargy (www.healthline.com)

 

Nursing Diagnosis :

Ineffective tissue perfusion (Cerebral) related to circulation status

NOC

a. Circulation status

Expected outcomes:

• Systolic and diastolic pressures within the expected range
• No orthostatic hypertension
• No signs of intracranial increase

b. Tissue perfusion: cerebral

Expected outcomes:

• Maintain intracranial pressure
• Blood pressure within normal range
• No headache
• No vomiting
• Monitor level of consciousness

NIC

a. Oxygen Therapy

• Examine the mouth, nose and tracheal secretions
• Maintain a patent airway
• Set oxygen equipment
• Monitor oxygen flow
• Maintain patient position

b. Intracranial Elevation Monitoring

• Monitor cerebral perfusion pressure
• Record the patient's response to stimulation
• Monitor the patient's intracranial pressure and neurologic response to activity
• Monitor fluid intake and output
• Minimize stimulation from the environment
• Collaboration in
• administration of antibiotics.

c. Vital Sign Monitoring

• Monitor BP, pulse, temperature, and respiratory rate
• Monitor vital signs when the patient is lying, sitting, and standing
• Auscultate BP in both arms and compare
• Monitor BP, pulse, respiratory rate, before during and after activity
• Monitor the quality of the pulse
• Monitor abnormal breathing patterns
• Monitor skin temperature, color, and moisture.