Meningitis

1.Assessment Data

• 1.1 Subjective Data 
  • 1.1.1. Patient Statements: "I feel dizzy when I try to sit up." and "Sometimes my legs feel weak or numb."
  • 1.1.2. Family/Caregiver Observations: "He gets confused and tries to get out of bed alone." and "She’s been falling asleep suddenly or jerking."
• 1.2 Objective Data
  • 1.2.1 Vital Signs
    • Heart Rate: 52 bpm (Bradycardia)
    • Blood Pressure: Fluctuating between 100/60 and 160/90 mmHg
    • Temperature: 38.8°C (101.8°F)
  • 1.2.2 General examaination findings
    • Patient appears confused and agitated.
    • Observed sudden jerking movements of the limbs.
  • 1.2.3 Physical examination findings
    • Neurological: Glasgow Coma Scale (GCS) score of 13 (E3, V4, M6), positive Brudzinski's and Kernig's signs, photophobia, muscle weakness in lower extremities.
    • Musculoskeletal: Generalized muscle rigidity.
  • 1.2.4 Laboratory data
    • Serum Sodium: 128 mEq/L (Hyponatremia)
    • CT Scan: Evidence of cerebral edema.

2.Nanda diagnosis PES format

• 2.1 NANDA Label: Risk for Injury
• 2.2 Related Factor 1: Altered cerebral function and decreased level of consciousness secondary to meningeal inflammation and increased intracranial pressure.
  • Defining Characteristics: Confusion, disorientation, fluctuating GCS, bradycardia, fluctuating BP.
• 2.3 Related Factor 2: Neuromuscular impairment and seizure activity.
  • Defining Characteristics: Reported leg weakness and numbness, observed muscle rigidity, recent seizure activity, sudden jerking movements.
• 2.4 Related Factor 3: Treatment-related side effects and environmental hazards.
  • Defining Characteristics: Dizziness from medications, presence of IV lines and Foley catheter, unfamiliar hospital environment.

3.SMART Goals / Expected Outcomes

• 3.1 Short-Term Goals (24–72 hours):
  • The patient will remain free from falls, physical injury, or seizure-related complications throughout the hospital stay.
  • The patient's environment will be maintained with all safety precautions (bed alarms, low bed, padded side rails) without failure for 72 hours.
  • The family will correctly state two injury prevention measures they can assist with by the end of the shift.
• 3.2 Long-Term Goals (By Discharge):
  • The patient will demonstrate improved motor coordination and the ability to ambulate safely with appropriate assistance.
  • The patient and family will verbalize a plan for maintaining a safe home environment upon discharge.

4.Evidence-Based Nursing Interventions & Rationales 

4.1.Evidence-Based Nursing Interventions 
Managing the risk for injury in a patient with meningitis requires a proactive, multi-system approach focused on preventing falls, seizures, and other physical harm. The foundation of care involves creating a safe environment through rigorous fall and seizure precautions, coupled with continuous neurological monitoring to anticipate deterioration. Evidence-based interventions also include careful management of medications, early mobilization with therapy, and thorough education for both the patient and family to ensure safety is maintained throughout the recovery process.

• 4.2. Evidence-Based Nursing Interventions & Rationales

5.Evaluation

• 5.1 Goal Met
  • No falls or physical injuries occur during hospitalization.
  • Seizure activity is promptly recognized and managed without complication.
  • The patient's GCS score improves to 15, and they can ambulate with standby assistance.
  • The family correctly demonstrates use of the call bell and states the importance of the bed alarm.
• 5.2 Goal Not Met
  • A fall or injury event occurs (e.g., from attempting to get out of bed unassisted).
  • Seizures result in injury such as soft tissue damage or aspiration.
  • The patient remains confused and attempts to remove safety devices or lines.
  • The family is unable to articulate or participate in safety measures.

1.Assessment Data

• 1.1 Subjective Data 
  • 1.1.1. Patient Reports: "My head is pounding and I feel dizzy," "I can't think straight," and "My vision is blurry and I feel sick to my stomach."
  • 1.1.2. Family Observations: "He's not acting like himself; he's irritable and confused," and "She's hard to wake up and isn't making sense when she talks."
• 1.2 Objective Data
  • 1.2.1 Vital Signs
    • Blood Pressure: 170/90 mmHg (Hypertension with widened pulse pressure)
    • Heart Rate: 52 bpm (Bradycardia)
    • Respiratory Rate: 10 breaths/min and irregular (Cheyne-Stokes respirations)
    • Temperature: 39.1°C (102.4°F)
  • 1.2.2 General examaination findings
    • Patient is lethargic and only responsive to painful stimuli.
    • Observed decorticate posturing of the upper extremities.
  • 1.2.3 Physical examination findings
    • Neurological: Glasgow Coma Scale (GCS) score of 8 (E2, V2, M4). Pupils: Right 4mm and sluggish, Left 5mm and non-reactive. Positive Babinski reflex bilaterally.
  • 1.2.4 Laboratory data
    • Arterial Blood Gas (ABG): PaO2 72 mmHg, PaCO2 50 mmHg.
    • CT Head: Diffuse cerebral edema with effacement of the sulci and basal cisterns.
    • Invasive ICP Monitoring: Sustained ICP of 25 mmHg.

2.Nanda diagnosis PES format

• 2.1 NANDA Label: Ineffective Cerebral Tissue Perfusion
• 2.2 Related Factor 1: Increased intracranial pressure secondary to inflammatory meningeal response and cerebral edema.
  • Defining Characteristics: Decreased GCS (8), altered respirations, pupillary changes (sluggish/non-reactive), posturing, elevated ICP reading (25 mmHg).
• 2.3 Related Factor 2: Impaired autoregulation of cerebral blood flow.
  • Defining Characteristics: Presence of Cushing's triad (hypertension, bradycardia, irregular respirations).

3.SMART Goals / Expected Outcomes

• 3.1 Short-Term Goals (24–48 hours):
  • The patient will maintain an Intracranial Pressure (ICP) of less than 20 mmHg and a Cerebral Perfusion Pressure (CPP) greater than 60 mmHg.
  • The patient will demonstrate improved neurological status, evidenced by a GCS increase to 10 or higher within 24 hours.
  • The patient's pupils will remain equal and briskly reactive to light.
• 3.2 Long-Term Goals (By Discharge):
  • The patient will return to their neurological baseline or achieve maximum possible cognitive and motor function.
  • The patient will be free from complications of secondary brain injury, such as herniation or ischemic stroke.

4.Evidence-Based Nursing Interventions & Rationales 

4.1.Evidence-Based Nursing Interventions 

The management of ineffective cerebral tissue perfusion is a critical and time-sensitive priority in bacterial meningitis. The primary goals are to reduce intracranial pressure, maintain adequate cerebral perfusion, and prevent secondary neuronal injury. This is achieved through a meticulous, evidence-based protocol involving continuous neurological monitoring, strategic positioning, careful management of fluids and electrolytes, strict temperature and seizure control, and maintenance of optimal oxygenation. Nursing interventions are focused on minimizing stimuli that can elevate ICP while supporting the brain's metabolic demands to preserve neurological function.

4.2.Evidence-Based Nursing Interventions & Rationales

5.Evaluation

• 5.1 Goal Met
  • ICP is maintained below 20 mmHg and CPP above 60 mmHg.
  • GCS improves to 11 within 24 hours.
  • Pupils are 3mm and briskly reactive bilaterally.
  • Vital signs stabilize without evidence of Cushing's triad.
  • The patient remains normothermic and seizure-free.
• 5.2 Goal Not Met
  • ICP remains elevated (>25 mmHg) despite interventions.
  • GCS deteriorates further to a score of 6.
  • Pupils become fixed and dilated.
  • Signs of brain herniation (e.g., posturing, Cushing's triad) are present.
  • A seizure occurs, causing a spike in ICP.

1.Assessment Data

• 1.1 Subjective Data 
  • 1.1.1. Thermal Discomfort: "I feel burning up," and "I have chills one minute and am sweating the next."
  • 1.1.2. Constitutional Symptoms: Reports of "muscle aches all over," severe headache, fatigue, and general malaise.
  • 1.1.3. Neurological Symptoms: Reports of feeling "confused and irritable" as the fever intensifies.
• 1.2 Objective Data
  • 1.2.1 Vital Signs
    • Temperature: 39.8°C (103.6°F)
    • Heart Rate: 122 bpm (Tachycardia)
    • Respiratory Rate: 26 breaths/min (Tachypnea)
    • Blood Pressure: 98/58 mmHg (Hypotension, indicating potential dehydration)
  • 1.2.2 General examaination findings
    • Skin is flushed and diaphoretic.
    • Patient is restless and intermittently lethargic.
  • 1.2.3 Physical examination findings
    • Neurological: Patient is disoriented to time and place.
  • 1.2.4 Laboratory data
    • Complete Blood Count (CBC): Elevated White Blood Cell (WBC) count.
    • Inflammatory Markers: Elevated C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR).
    • Cerebrospinal Fluid (CSF): Positive for bacterial meningitis (elevated WBC, protein; low glucose).

2.Nanda diagnosis PES format

• 2.1 NANDA Label: Hyperthermia
• 2.2 Related Factor 1: Inflammatory process and infectious disease (bacterial meningitis).
  • Defining Characteristics: Elevated body temperature (39.8°C), flushed skin, tachycardia, tachypnea, elevated WBC and CRP.
• 2.3 Related Factor 2: Dehydration and impaired thermoregulation.
  • Defining Characteristics: Diaphoresis, hypotension, restlessness, and confusion.

3.SMART Goals / Expected Outcomes

• 3.1 Short-Term Goals (24–48 hours):
  • The patient's body temperature will decrease to below 38.0°C within 4 hours of antipyretic administration and remain below 38.5°C for the next 24 hours.
  • The patient will demonstrate improved comfort, as evidenced by a reduction in restlessness and the ability to rest, within 6 hours.
  • The patient will maintain a urine output of >0.5 mL/kg/hr and stable vital signs (HR <100, SBP >100 mmHg) within 24 hours.
• 3.2 Long-Term Goals (By Discharge):
  • The patient will remain afebrile (temperature 36.5-37.5°C) without the aid of antipyretics for 48 hours prior to discharge.
  • The patient or family will verbalize understanding of when and how to manage a fever at home.

4.Evidence-Based Nursing Interventions & Rationales 

4.1.Evidence-Based Nursing Interventions 

The management of hyperthermia in meningitis is critical to reduce cerebral metabolic demand, prevent seizures, and improve patient comfort. A multi-modal approach is essential, combining pharmacological antipyresis with non-pharmacological cooling and vigorous hydration. Evidence-based practice dictates scheduled antipyretics to prevent fever spikes, active cooling to facilitate heat loss, and close monitoring of neurological and fluid status to prevent complications. This comprehensive strategy directly addresses the inflammatory fever source and its systemic effects, aligning with established infectious disease and critical care protocols.

4.2. Evidence-Based Nursing Interventions & Rationales 

5.Evaluation

• 5.1 Goal Met
  • Patient's temperature is 37.8°C within 4 hours and remains below 38.5°C for 24 hours.
  • Patient is resting comfortably, vital signs are stable (HR 92 bpm, BP 112/74 mmHg).
  • Urine output is maintained at 60 mL/hr.
  • Patient is alert and oriented; no seizure activity.
• 5.2 Goal Not Met
  • Temperature remains >39.0°C despite antipyretics and cooling.
  • Tachycardia and hypotension persist, indicating ongoing dehydration or sepsis.
  • Patient becomes more lethargic or experiences a seizure.
  • Urine output drops below 30 mL/hr.

1.Assessment Data

• 1.1 Subjective Data 
  • 1.1.1. Patient/Family Concerns: "I’m worried about spreading this to my kids," and "Should I be in isolation?"
  • 1.1.2. Environmental/Social History: Patient lives in a university dormitory and reports a flu-like illness spreading through their dorm floor in the past two weeks.
• 1.2 Objective Data
  • 1.2.1 Vital Signs
    • Temperature: 39.0°C (102.2°F)
    • Heart Rate: 108 bpm
    • Respiratory Rate: 22 breaths/min
  • 1.2.2 General examaination findings
    • Patient appears acutely ill, with noted malaise and lethargy.
  • 1.2.3 Physical examination findings
    • Neurological: Positive Kernig's and Brudzinski's signs. Diagnosis of suspected bacterial meningitis.
  • 1.2.4 Laboratory data
    • Cerebrospinal Fluid (CSF) Culture: Pending.
    • Blood Culture: Positive for Neisseria meningitidis.
    • Immunization Status: Records indicate the patient has not received the MenACWY vaccine.

2.Nanda diagnosis PES format

• 2.1 NANDA Label: Risk for Infection (Transmission)
• 2.2 Related Factor 1: Presence of pathogenic microorganisms in respiratory droplets and secretions (Neisseria meningitidis).
  • Defining Characteristics: Positive blood culture for N. meningitidis, residence in a high-risk environment (dormitory), identified close contacts.
• 2.3 Related Factor 2: Lack of immunity in close contacts and healthcare personnel.
  • Defining Characteristics: Unvaccinated status of the patient and likely contacts, necessity for prophylactic treatment of contacts.

3.SMART Goals / Expected Outcomes

• 3.1 Short-Term Goals (24–48 hours):
  • Droplet precautions will be initiated immediately and maintained without breach for the duration of the infectious period.
  • 100% of identified household and close contacts will be listed and referred for chemoprophylaxis within 24 hours of diagnosis.
  • All healthcare staff entering the room will demonstrate correct PPE use.
• 3.2 Long-Term Goals (By Discharge):
  • There will be zero documented cases of secondary transmission to healthcare workers or close contacts.
  • The patient will receive the appropriate meningococcal vaccination prior to discharge or have a firm follow-up plan.

4.Evidence-Based Nursing Interventions & Rationales 

4.1.Evidence-Based Nursing Interventions 
Preventing the transmission of bacterial meningitis is a public health priority that requires strict adherence to infection control protocols. The cornerstone of management is the immediate initiation of droplet precautions to contain the pathogen at the source. This must be coupled with aggressive case-finding and post-exposure prophylaxis for all close contacts to break the chain of transmission. Simultaneously, ensuring both the patient and at-risk populations are vaccinated provides long-term immunity and is a critical component of outbreak control. These interventions are directly mandated by leading health organizations to prevent localized outbreaks and are non-negotiable in the management of this communicable disease.

4.2. Evidence-Based Nursing Interventions & Rationales 

5.Evaluation

• 5.1 Goal Met
  • Droplet precautions were maintained for the full 24 hours after IV antibiotics were started without any breaches in protocol.
  • All 12 identified close contacts from the patient's dormitory received chemoprophylaxis within 24 hours.
  • No healthcare workers or other patients developed symptoms of meningococcal disease.
  • The patient received the MenACWY vaccine prior to discharge.
• 5.2 Goal Not Met
  • A visitor entered the room without a mask, constituting a breach in droplet precautions.
  • Two close contacts were unreachable and did not receive chemoprophylaxis within the 24-hour window.
  • Post-discharge follow-up revealed a secondary case in an untreated close contact.
  • The patient refused the meningococcal vaccine at discharge.

1.Assessment Data

• 1.1 Subjective Data 
  • 1.1.1. Pain & Discomfort: Reports of a "worsening, pressure-like headache" and nausea.
  • 1.1.2. Sensory Disturbances: Complains of blurred vision and photophobia.
  • 1.1.3. Meningeal Signs: Reports persistent neck stiffness and pain.
• 1.2 Objective Data
  • 1.2.1 Vital Signs
    • Blood Pressure: 170/94 mmHg (Widened Pulse Pressure)
    • Heart Rate: 54 bpm (Bradycardia)
    • Respiratory Rate: 8 breaths/min and irregular (Cheyne-Stokes)
  • 1.2.2 General examaination findings
    • Patient is increasingly restless and agitated, progressing to lethargy.
    • Projectile vomiting observed.
  • 1.2.3 Physical examination findings
    • Neurological: Glasgow Coma Scale (GCS) decreased from 14 to 10. Pupils: Right 4mm and sluggish, Left 3mm and brisk. Positive Babinski reflex.
  • 1.2.4 Laboratory data
    • CT Head: Reveals diffuse cerebral edema with effacement of the ventricles.
    • Lumbar Puncture: Opening pressure of 28 cm H₂O (elevated).

2.Nanda diagnosis PES format

• 2.1 NANDA Label: Risk for Increased Intracranial Pressure
• 2.2 Related Factor 1: Cerebral edema and inflammation secondary to meningeal infection.
  • Defining Characteristics: Elevated opening pressure on LP, cerebral edema on CT, decreased GCS, headache, nausea.
• 2.3 Related Factor 2: Potential for disrupted cerebrospinal fluid (CSF) flow and absorption.
  • Defining Characteristics: Presence of Cushing's triad (hypertension, bradycardia, irregular respirations), pupillary changes, projectile vomiting.

3.SMART Goals / Expected Outcomes

• 3.1 Short-Term Goals (24–48 hours):
  • The patient will maintain a stable or improved GCS score of 13 or higher.
  • The patient's vital signs will remain stable without the full manifestation of Cushing's triad.
  • The patient will not experience seizure activity or further neurological deterioration.
• 3.2 Long-Term Goals (By Discharge):
  • The patient will be free from complications of increased ICP (e.g., brain herniation, ischemic stroke).
  • The family will correctly identify and report at least three signs of increasing ICP.

4.Evidence-Based Nursing Interventions & Rationales 

4.1.Evidence-Based Nursing Interventions 

The risk for increased intracranial pressure in meningitis is a life-threatening emergency requiring vigilant monitoring and proactive intervention. The primary goals are to reduce cerebral edema, maintain adequate cerebral perfusion, and minimize factors that can precipitate a rise in ICP. This is achieved through a systematic approach involving frequent neurological assessments, strategic positioning, meticulous management of ventilation and fluids, and prompt administration of specific medications. Creating a controlled environment and preparing for rapid response to deterioration are essential components of care to prevent secondary brain injury and ensure the best possible neurological outcome.

4.2. Evidence-Based Nursing Interventions & Rationales 

5.Evaluation

• 5.1 Goal Met
  • Patient's GCS improved to 13 and remained stable.
  • Vital signs normalized (BP 140/82, HR 78, regular respirations).
  • No seizures or further episodes of vomiting occurred.
  • The family correctly verbalized headache, vomiting, and drowsiness as key signs to report.
• 5.2 Goal Not Met
  • Patient's GCS further declined to 8.
  • Cushing's triad persisted or worsened.
  • A generalized tonic-clonic seizure occurred.
  • The family was unable to recall any warning signs of increased ICP.

1.Assessment Data

• 1.1 Subjective Data 
  • 1.1.1. Breathing Difficulty: Reports "feeling like I can't take a deep breath" and "I can't clear my throat."
  • 1.2.2. Secretions & Cough: Reports a weak, ineffective cough with thick sputum.
  • 1.1.3. Fatigue & Weakness: States feeling "too weak to cough hard."
• 1.2 Objective Data
  • 1.2.1 Vital Signs
    • Respiratory Rate: 28 breaths/min (Tachypnea)
    • Oxygen Saturation: 89% on room air
    • Heart Rate: 115 bpm (Tachycardia)
  • 1.2.2 General examaination findings
    • Use of accessory muscles (neck and intercostal) for breathing.
    • Appears fatigued and lethargic.
  • 1.2.3 Physical examination findings
    • Respiratory: Coarse crackles auscultated in the lower lung lobes bilaterally. Weak, non-productive cough.
    • Neurological: Glasgow Coma Scale (GCS) of 11, indicating a depressed cough and gag reflex.
  • 1.2.4 Laboratory data
    • Arterial Blood Gas (ABG): pH 7.30, PaCO2 50 mmHg, PaO2 60 mmHg (Respiratory Acidosis with Hypoxemia).
    • Chest X-Ray: Bilateral basilar atelectasis and infiltrates suggestive of retained secretions.

2.Nanda diagnosis PES format

• 2.1 NANDA Label: Ineffective Airway Clearance
• 2.2 Related Factor 1: Neuromuscular impairment and decreased level of consciousness secondary to meningeal inflammation.
  • Defining Characteristics: Depressed cough and gag reflex (GCS 11), weak cough effort, lethargy.
• 2.3 Related Factor 2: Thickened respiratory secretions and fatigue.
  • Defining Characteristics: Coarse crackles on auscultation, tachypnea, hypoxemia, patient report of weakness and inability to clear secretions.

3.SMART Goals / Expected Outcomes

• 3.1 Short-Term Goals (24–48 hours):
  • The patient will maintain a patent airway, evidenced by clear breath sounds and an oxygen saturation of 94% or greater on supplemental oxygen within 24 hours.
  • The patient will demonstrate an effective cough and ability to clear secretions with assistance within 48 hours.
  • The patient's respiratory rate will decrease to less than 22 breaths/min.
• 3.2 Long-Term Goals (By Discharge):
  • The patient will maintain clear lung fields and adequate oxygenation on room air.
  • The patient and family will verbalize understanding of techniques to maintain airway clearance.

4.Evidence-Based Nursing Interventions & Rationales 

4.1.Evidence-Based Nursing Interventions 
Managing ineffective airway clearance in a patient with meningitis is critical to prevent hypoxemia and respiratory complications like atelectasis and pneumonia. The inflammatory process can depress neurological function, impairing the cough and gag reflexes, while systemic illness leads to fatigue and thickened secretions. A comprehensive, evidence-based approach includes frequent respiratory assessment, aggressive pulmonary hygiene (positioning, breathing exercises, suctioning), and maintaining adequate hydration and humidification to mobilize secretions. Proactive intervention is essential to support the patient's compromised respiratory function and ensure adequate gas exchange.

4.2. Evidence-Based Nursing Interventions & Rationales

5.Evaluation

• 5.1 Goal Met
  • Breath sounds are clear to auscultation bilaterally.
  • Oxygen saturation is maintained at 95% on 2L nasal cannula.
  • Patient can effectively cough and clear secretions with minimal assistance.
  • Respiratory rate is 18 breaths/min with no accessory muscle use.
• 5.2 Goal Not Met
  • Coarse crackles and rhonchi persist on auscultation.
  • Oxygen saturation remains below 92% despite oxygen therapy.
  • Patient remains too lethargic to participate in coughing exercises.
  • Frequent suctioning is required to maintain a patent airway.

1.Assessment Data

• 1.1 Subjective Data 
  • 1.1.1. Visual Disturbances: “Things look blurry,” and “The lights hurt my eyes.” (Photophobia)
  • 1.1.2. Auditory Disturbances: “I can’t hear well anymore,” “I hear a constant ringing,” and “I’m hearing things that aren’t there.” (Hearing loss, Tinnitus, Auditory Hallucinations)
  • 1.1.3. General Perception: “Everything feels fuzzy or off.” (Tactile changes)
  • 1.1.4. Family Observations: Family notes the patient is not responding to their name and is startled by gentle touch.
• 1.2 Objective Data
  • 1.2.1 Vital Signs
    • Blood Pressure: 150/88 mmHg
    • Heart Rate: 105 bpm
  • 1.2.2 General examaination findings
    • Patient is disoriented to place and time.
    • Observed covering ears and eyes intermittently.
  • 1.2.3 Physical examination findings
    • Cranial Nerves: Decreased visual acuity, nystagmus, and decreased response to finger rub on the left side (Cranial Nerves II, VIII).
    • Behavioral: Inappropriate, fearful responses to normal environmental sounds and light touch.
  • 1.2.4 Laboratory data
    • MRI Brain: Shows enhancement of the meninges and inflammation adjacent to the auditory and visual cortex.
    • Audiogram: Confirms bilateral sensorineural hearing loss.

2.Nanda diagnosis PES format

• 2.1 NANDA Label: Disturbed Sensory Perception (Specify: Visual, Auditory, Kinesthetic)
• 2.2 Related Factor 1: Inflammation of the meninges and cranial nerves (II, VI, VIII) secondary to infection.
  • Defining Characteristics: Blurred vision, photophobia, nystagmus, sensorineural hearing loss, tinnitus.
• 2.3 Related Factor 2: Altered sensory integration and processing due to cerebral inflammation and edema.
  • Defining Characteristics: Disorientation, auditory hallucinations, inappropriate responses to stimuli, reports of "fuzzy" perception.

3.SMART Goals / Expected Outcomes

• 3.1 Short-Term Goals (24–72 hours):
  • The patient will report a decrease in sensory overload and discomfort within 24 hours of environmental modifications.
  • The patient will correctly identify the nurse in the room and respond appropriately to simple, direct verbal commands 75% of the time within 48 hours.
  • The patient will remain free from injury related to sensory-perceptual deficits.
• 3.2 Long-Term Goals (By Discharge):
  • The patient and family will verbalize an understanding of the sensory deficits and demonstrate three adaptive techniques for communication and safety.
  • The patient will have formal audiology and ophthalmology follow-up plans in place prior to discharge.

4.Evidence-Based Nursing Interventions & Rationales 

4.1.Evidence-Based Nursing Interventions 

Disturbed sensory perception in meningitis results from direct inflammation of sensory pathways and generalized cerebral dysfunction. Management requires a dual approach of reducing neurological irritation through medical treatment and creating a supportive, modified environment to prevent overstimulation and injury. Nursing care is focused on systematic assessment of sensory deficits, implementing protective strategies, facilitating clear communication, and coordinating rehabilitative services. This comprehensive approach helps the patient process sensory input more effectively, reduces fear and confusion, and lays the groundwork for adapting to any long-term deficits.

4.2. Evidence-Based Nursing Interventions & Rationales

5.Evaluation

• 5.1 Goal Met
  • Patient reports decreased discomfort with dim lights and a quiet room.
  • Patient makes eye contact and nods appropriately when given simple directions.
  • No falls or injuries occur.
  • Family correctly demonstrates how to get the patient's attention before speaking.
  • Referrals to Audiology and OT are completed.
• 5.2 Goal Not Met
  • Patient remains agitated and covers ears despite environmental modifications.
  • Patient is unable to respond to verbal commands and remains disoriented.
  • Patient attempts to get out of bed unassisted due to misperception of the environment.
  • Family appears overwhelmed and cannot describe safety precautions.

1. Assessment Data

1.1 Subjective Data

1.1.1. Neuromuscular Weakness

• "My legs feel heavy—I can't lift them."
• "Even sitting up makes me dizzy and weak."

1.1.2. Pain / Discomfort

• "I have this constant neck stiffness—it hurts to move."
• "Turning my head makes the headache worse."

1.1.3. Fatigue / Decreased Endurance

• "I feel too tired to even walk to the bathroom."
• "My whole body feels drained—like I just ran a marathon."

1.1.4. Cognitive / Emotional Impact

• "I'm scared something will happen if I move too much."
• "I'm embarrassed to ask for help getting to the toilet."

1.2 Objective Data

Laboratory & Imaging Data

2. NANDA Diagnosis (PES Format)

2.1 NANDA Label: Impaired Physical Mobility

2.2 Related Factor 1: Neuromuscular impairment and inflammatory response secondary to central nervous system infection.

Defining Characteristics: Decreased muscle strength (3/5), generalized weakness, dizziness, positive Kernig's and Brudzinski's signs.

2.3 Related Factor 2: Discomfort and pain with movement.

Defining Characteristics: Neck rigidity, reports of pain with head movement, guarding.

3.SMART Goals / Expected Outcomes

• 3.1 Short-Term Goals (24–72 hours):
  • The patient will transfer from bed to chair with moderate assistance of one person within 48 hours.
  • The patient will report a pain level of 3 or less during mobility activities within 24 hours.
  • The patient will maintain current muscle strength and joint range of motion through prescribed exercises.
• 3.2 Long-Term Goals (By Discharge):
  • The patient will ambulate at least 50 feet using a wheeled walker with standby assistance.
  • The patient will demonstrate independence in bed mobility and perform ADLs with minimal assistance.
  • The patient and family will verbalize the home exercise plan and safety precautions.

4.Evidence-Based Nursing Interventions & Rationales 

4.1.Evidence-Based Nursing Interventions 
Impaired physical mobility in meningitis stems from a combination of neuromuscular inflammation, systemic weakness, pain, and fear. Effective management requires a proactive, multi-faceted approach focused on preventing the complications of immobility while safely promoting functional recovery. This involves scheduled analgesia to facilitate movement, a structured and progressive activity plan guided by physical therapy, and consistent use of assistive devices and safety measures to prevent injury. Supporting the patient's physiological needs with nutrition and hydration, along with providing psychological encouragement and education, is essential for building endurance and confidence, ultimately leading to restored independence.

4.2.Evidence-Based Nursing Interventions & Rationales

5.Evaluation

• 5.1 Goal Met
  • Patient successfully transferred to a chair with moderate assistance on day 2.
  • Pain was rated 2/10 during mobility after pre-medication.
  • Full ROM maintained in all joints; no signs of contractures.
  • Patient ambulated 60 feet with a walker by discharge.
  • Patient and daughter correctly demonstrated a safe transfer technique.
• 5.2 Goal Not Met
  • Patient was unable to tolerate sitting on the edge of the bed due to dizziness and fatigue.
  • Pain remained at 6/10 during attempts to move, limiting participation.
  • Redness was noted on the patient's sacrum, indicating a stage 1 pressure injury.
  • Patient expressed continued fear of moving and refused PT on one occasion.