nursing care plan for a patient with meningitis

you need to follow the steps of the nursing process when care planning:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
   • a physical assessment of the patient
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: http://allnurses.com/forums/f205/med...es-258109.html - medical disease information/treatment/procedures/test reference websites
2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
   
   • your instructors might have given it to you.
   • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
   • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
   • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
   • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
     
     • http://www1.us.elsevierhealth.com/ev...e/constructor/
     • http://www1.us.elsevierhealth.com/me...ctor/index.cfm
3. planning (write measurable goals/outcomes and nursing interventions)
   
   • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
     
     • improve the problem or remedy/cure it
     • stabilize it
     • support its deterioration
   • interventions are of four types
     
     • assess/monitor/evaluate/observe (to evaluate the patient's condition)
       
       • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
     • care/perform/provide/assist (performing actual patient care)
     • teach/educate/instruct/supervise (educating patient or caregiver)
     • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
4. implementation (initiate the care plan)
5. evaluation (determine if goals/outcomes have been met)

putting this into action based on the information you posted. . .

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - what was this patient's admitting medical diagnosis? what did the doctor write in the history and physical documentation? the physician's progress notes? what medications, tests and treatments were ordered? all that information needs to be known in order to help in determining the etiologies of the nursing diagnoses you will be choosing.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

• headache
• fever - need to state what the fever elevation is
• bp 148/86
• altered mental status - needs to be more descriptive

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

• decreased cardiac output r/t ??? aeb bp 148/86
• hyperthermia r/t ??? aeb fever (need to state what the fever elevation is)
• acute pain r/t ??? aeb headache
• risk for acute confusion r/t altered mental status
• risk for injury r/t altered mental status

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - your overall goal is always aimed to alter or change something about the problem

i am asking the moderators to move this thread to the nursing student assistance forum which is a more appropriate place for responses.

Moved to the nursing student assistance forum