Assessment (functional health patterns) and Nursing Diagnosis for Meningitis

Nursing Care Plan for Meningitis

Assessment is an early stage of the nursing process and is a systematic process of collecting data from various sources and to evaluate and identify the health status of patients (Nursalam, 2001).

1. Identity
Includes names, gender, occupation, address and so on.

2. Health History
a) Past medical history.
Asked about the client's medical history that ever happened previously associated with the disease today. Is there any food allergies or certain drugs what immunizations are obtained when the client and the client habits at home.

b) History of present illness
Assessment of the course of the disease, ranging from the first until now, such as; fever, irritability, obstipation, and vomiting and apathy began when perceived. While the grievances felt from the beginning to today; Is there apathy, pupillary reflexes are slowed, weakened tendon reflexes, fever, and Kernig's sign, and positive Brudzinski, and what efforts have been made the client or family about this disease.

c) Family medical history
In the client's family, if anyone suffering from diseases such as those being suffered by the client.

Health maintenance history

1) Health Perception and Management
Objective Data:

• Ask the client's medical history, which was once experienced before.
• Are there any efforts made to maintain the health and self-protection.
• Ask the efforts made when symptoms arise.
• Are the expectations of clients or family admission to the hospital.

Objective Data :

• Observe the appearance or the physical state of the client.

2) Nutritional metabolic
Subjective Data:

• The type, frequency and amount of food and drinks in a day.
• Appetite and preferred food.
• Difficulties arise when eating, such as: nausea, vomiting, heartburn.
• Is there a certain adherence to the diet.

Objective Data :

• Observation of the client's ability to receive nutrients.
• Interavena therapy, is there a nose hose.

3) Elimination
Subjective Data:

• Bowel habits, such as regular or irregular frequency, consistency and a lot or a little.
• Smoothness defecation: need drugs or certain foods.
• Small bowel habits, such as: urine comes out smoothly or not, the color of urine.

Objective Data:

• Observation of the client's ability to defecate / urinate.
• Installation folley catheter.
• The client's Urine color.

4) Activity exercise
Subjective Data:

• Ask the client's daily activities at home, are like: bathing, dressing, make up their own, walk, eat, defecate or urinate.

Objective Data:

• Observation of the client's ability level in the move.

5) Sleep rest
Subjective Data:

• Ask the client's time to sleep and the number of hours of sleep a day.
• Things that become barriers to the clients during sleep.
• Ask the client to sleep atmosphere.
• Efforts what the client when it is difficult to sleep.

Objective Data

• Observation clients sleep patterns.

6) Cognitive-perceptual
Subjective Data:

• Ask if the client can try, calculate.
• Ask if there are clients using the tools.
• Ask if the client could hear the instruction of their parents.

Objective Data :

• Observation of the client's ability to hear the nurse or doctor's instructions.

7) Self perception/self concept
Subjective Data:

• The client's perception about themselves.
• Does the client never feel inferior or lacking in confidence.

Data Objective:

• Is there an expression of the clients about the show disruption of perception and self-concept.

8) Role relationship
Subjective Data:

• Ask if the client's role in the family.
• Ask if the client can adapt to the environment.

Data Objective:

• Observation of the client's ability to play an active role with the nurses and doctors for pain.

9) Value-Belief Pattern
Subjective Data:

• Ask the client to follow a religion.
• Does the client to be diligent in religious activities.

Data Objective:

• Observation of the client or family, if ever prayed for the sick.

Nursing Diagnosis for Meningitis

Nursing diagnosis is a statement that describes the human responses of individuals or groups-where nurses can identify and provide accountability for certain information to maintain health status, lower, limit, stop and change. (Nursalam quoted from Carpenito, p 35, 2000)

Nursing Diagnosis that may arise are:

1. Altered Levels of Consciousness related to the process of infection and neurological impairment.
2. Increased body temperature related to the inflammatory response of the central nervous system.
3. Ineffective airway clearance related to neuromuscular damage.
4. Imbalanced Nutrition Less than Body Requirements related to changes in the ability to digest nutrients.

Share :

Facebook Twitter Google+