- Bacterial meningitis.
- Encephalitis (also includes aseptic meningitis): inflammation of the brain and its coverings due to direct viral invasion, which usually results in a lengthy coma.
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Pathophysiology: brain tissue injury- release of enzymes that increase vascular dilation, capillary permeability-edema formation-increased intracranial pressure-depression of CNS function.
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Risk factors:
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Arboviruses.
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Enteroviruses (poliovirus, echovirus).
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Herpesvirus.
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Varicella-zoster (chickenpox).
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Postinfection complication (measles, mumps, smallpox).
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Assessment:
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Subjective data:
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Headache-severe.
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Fever-sudden.
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Nausea, vomiting.
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Sensitivity to light (photophobia).
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Difficulty concentrating.
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Objective data:
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Altered level of consciousness.
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Nuchal rigidity.
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Tremors; facial weakness.
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Nystagmus.
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Elevated temperature.
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Diagnostic test: lumbar puncture-fluid cloudy; increased neutrophils, protein.
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Lab data: blood-slight to moderate leukocytosis (about 14,000).
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Analysis/nursing diagnosis:
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Self-care deficit related to altered level of consciousness.
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Risk for injury related to coma.
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Sensory/perceptual alteration related to brain tissue injury.
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Altered thought processes related to increased intracranial pressure.
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Nursing care plan/implementation:
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Goal: support physical and emotional relaxation.
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Vital signs; neurological signs as ordered.
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Seizure precautions.
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Position: to maintain patent airway; prevent contractures; ROM.
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Medications as ordered:
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Analgesics for headache and neck pain.
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Antipyretics for fever.
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Antivirals.
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Anticonvulsants for seizures.
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Antibiotics for infection in aseptic meningitis.
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Osmotic diuretics to reduce cerebral edema.
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Corticosteroids for inflammation.
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No isolation.
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Goal: health teaching: self-care activities with residual motor and speech deficits; physical therapy.
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Evaluation/outcome criteria:
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Regains consciousness; is alert, oriented.
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Performs self-care activities with minimal assistance.