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MENINGITIS - NURSING INTERVENTIONS Assess neurological status - CORRECT ANSWER -1. LOC 2. Pupillary reaction 3. Motor function 4. Sensory function 5. vital signs LOC - CORRECT ANSWER -Sound and pain are the most common stimuli used to assess an individual's LOC. Sound- by speaking to the patient, are they responding? Pain to arouse the pt. Pupillary reaction - CORRECT ANSWER -1. We are gaining info. regarding the brain and also if there is an increase in ICP. 2. Pupils are assessed for size, shape and how they react to light. 3. The reactions to light can be described as brisk, sluggish or nonreactive/fixed. Motor function - CORRECT ANSWER -can pt squeeze your hand? follow commands? Unconscious? assess by observation
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Assess neurological status - CORRECT ANSWER - 1. LOC
strength of limbs? normal power, mild weakness, severe weakness etc.. bilateral or unilateral vital signs - CORRECT ANSWER - temperature, pulse, respirations, and blood pressure. ↑ systolic blood pressure with ↓ diastolic blood pressure is a threatening sign of ↑ ICP. place in isolation precautions - CORRECT ANSWER - droplet precautions, until pt has completed 24 hrs of antibiotic therapy. Remember that Meningitis is highly contagious. Administer antibiotics ASAP *priority - CORRECT ANSWER - Bacterial meningitis must be treated immediately with IV antibiotics. To reduce the risk of complications, such as brain swelling and seizures. Avoid stimulating pts. CNS - CORRECT ANSWER - Keep the environment quiet and dim lights. Stimulation of CNS can cause ICP. Assess for HA - CORRECT ANSWER - this could indicate swelling in the brain or inflammation of the meninges Assess for fever - CORRECT ANSWER - patient most likely already has a fever due to an infection, but keep the fever under control and prevent it from going up. If prescribed administer Tylenol. Assess light sensitivity - CORRECT ANSWER - because this one of the mnf. of meningitis Monitor resp. status - CORRECT ANSWER - 1. observe the respiratory rate
Assess for hearing loss - CORRECT ANSWER - Inflammation can damage the nerves that run between the ear and brain or if swelling spreads to the inner ear, it can damage the cochlea (inner ear)directly. Monitor ABG's and O2 sat. - CORRECT ANSWER - to check for hypoxia Elevate HOB 30 degrees - CORRECT ANSWER - Promote venous drainage from head Compensatory physiological changes in response to increased ICP - CORRECT ANSWER - 1. increased CSF absorption