NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • Risk for • Tuberculous • After 4 hrs. • Maintain head or • Turning head to • After 4 hrs.
ineffective meningitis is the Of nursing neck in midline or one side Of nursing
“Masakit ang ulo cerebral most severe form interventions, neutral position, compresses the intervention
ko.” as verbalized tissue of tuberculosis. It the client will support with small jugular veins s, the client
by the client. perfusion causes severe demonstrate towel rolls and and inhibits was able to
related neurologic deficits stable vital pillows. cerebral venous demonstrate
Objective: cerebral or death in more signs and drainage, stable vital
edema. than half of cases. absence of thereby signs and
• Restlessness. Tuberculois signs of increasing absence of
meningitis begins intracranial intracranial signs of
• Changes in insidiously with a pressure. pressure. intracranial
motor or gradual fluctuating • Provide rest • Continual pressure.
sensory fever, fatigue, periods between activity can
responses. weight loss, care activities and increase
behavior changes, limit duration of intracranial
• V/S taken as headache, and procedures. pressure.
follows: vomiting. This • Decrease • Provides
early phase is extraneous calming effect,
T: 37.7 followed by stimuli and reduces
P: 50 neurologic deficits, provide comfort adverse
R: 12 loss of measures like physiological
Bp: 130/90 consciousness, or back massage, response and
convulsions. A quiet promotes rest
dense gelatinous environment, soft to maintain or
exudate voice. lower
(outpouring) forms intracranial
and envelops the pressure.
brain arteries and • Help patient avoid • These activities
cranial nerves. It or limit coughing, increase
creates a vomiting, thoracic and
bottleneck in the straining at stool, intra-abdominal
flow of the bearing down as pressure which
cerebrospinal fluid, possible. can increase
which leads to intracranial
hydrocephalus. pressure.
• Observe for • Seizure can
seizure activity occur as result
and protect of cerebral
patient from irritation,
injury. hypoxia or
increase
intracranial
pressure.

Collaborative:
• Restrict fluid • Fluid restriction
intake as may be needed
indicated. to reduce
cerebral
edema.
• Administer • Reduces
supplemental hypoxemia.
oxygen as
indicated.