摘要:本文介绍了脑膜炎和肺炎两种病症,药物可用于治疗肺炎,但其他类型的肺炎可以通过简单地避免触发炎症的物质而被治疗。识别和及时治疗肺炎很重要,因为未经处理的肺炎可导致肺部结疤和呼吸永久困难。
igns – Establish baseline data. Assess for respiratory rate watch for manifestations of respiratory distress. Tachycardia as a result of fever. Thus increase metabolic rate and increases oxygen consumption.
Assess for color of skin – Watch for cyanosis of nail beds, ear lobes, mucous membrane and skin around the mouth is an indicative of systemic hypoxemia.
Maintain bed rest and provide comfort – Prevents over exhaustion and reduces oxygen consumption.
Monitor oxygen tubing set – Watch for displacement of any set prior to oxygen therapy
Dependent
Monitor ABGs, Pulse Oximetry – Follows progress of disease process and facilitates alterations in pulmonary therapy.
Prepare for critical care setting if indicated for Oxygen Therapy – Intubation and mechanical ventilation may be required in the event of severe respiratory insufficiency.
Evaluation
Goal is met. Patient demonstrates improved ventilation and oxygenation without symptoms of respiratory distress.
Subjective cues
No subjective cues noted
Objective cues
Glasgow Coma Scale of 6
• Eye opening – no response – 2
• Motor response – extends abnormally – 2
• Verbal response – no response – 2
(+) Brudzinki’s sign
(+) Kernig’s sign
On NGT feeding
On Intravenous Fluid at 60-70 microgtts/min
On 02 inhalation at 2-4 L/min
Nsg. Dx.
Ineffective Cerebral Tissue Perfusion r/t interruption of blood flow as manifested by changes in vital signs
Planning
After 8 hours of nursing care patient will demonstrate stable vital signs and absences of increase intracranial pressure.
Intervention
Independent
Monitor Vital Signs – Establish baseline data. Fluctuations in pressure may occur because of cerebral pressure. Irregularities can suggest location of increasing intracranial pressure and need for further intervention, including possible respiratory support.
Monitor and Document Neurological status –Assess trends of Level of consciousness and for increased intracranial pressure.
Assess for nuchal rigidity and onset of seizure activity – Seizures may reflect increased intracranial pressure, requiring evaluation and intervention.
DISCHARGE PLAN
Name of Patient: Miss Sleeping Beauty
Final Diagnosis: Bacterial pneumonitis, Bacterial Meningitis
Condition upon Discharge: Patient has fully recovered
Date of Discharge: July 23,2008
MEDICATIONS
Instructed patient and SO to take home medications on time.
Complete the duration of those take home medications
Instructed SO to give patient with Multi Vitamins
ENVIRONMENTAL CONCERNS
Maintain a clean and green environment
Provide proper disposal of waste
Encourage SO to remove or lessen any environmental hazards
TREATMENTS
Instructed SO to always keep the back of the patient dry.
Instructed SO to always keep the pati
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