ABCDE approach to Assessment Meningitis – Nursing Care Plan


Meningitis
Meningitis is a bacterial infection of the membranes covering the brain and spinal cord (meninges)
Signs of meningitis as follows:
  • fever
  • headache
  • stiff neck
  • photophobia and vomiting
  • confused (possible)
Assessment – Emergency Nursing Care Plan Meningitis
Always use the ABCDE approach to assessment
Airway
  • Make sure the airway clearance
  • Prepare tools to facilitate the airway if necessary
  • If there is a decrease in respiratory function immediately contact an anesthesiologist and treated in the ICU
Breathing
  • Assess respiratory rate – less than 8 or over 30 is a significant sign.
  • Assess oxygen saturation
  • Perform blood gas
  • Give oxygen via non re-breath mask
  • Chest auscultation
  • Make checks thoracic photo
Circulation
  • Assess heart rate – more than 100 or less than 40 x / min is a significant sign
  • Monitoring blood pressure
  • Check the capillary refill time
  • Attach infusion using a large cannula
  • Attach Catheterization
  • Check the lab for complete blood, urine, electrolyte
  • Perform blood cultures
  • Perform a throat swab for culture and sensitivity
  • Record the temperature
Disability
  • Assess level of consciousness
  • Observations of focal neurological signs
Exposure
  • Assess the ptechie
Sign of the threat to life:
If the patient shows signs of distress, showing patients should be brought immediately to the ICU as for the sign as follows :
  • Redness more
  • CRT more than 4 seconds
  • Oliguria
  • Breathing is less than 8, more than 30 per minute
  • Heart rate less than 40, more dari140 times per minute
  • Signs of impairment of consciousness
  • Focal neurology
  • Convulsions
  • Bradycardia and hypertension
  • Papiloedema
Emergency Nursing Care Plan – Meningitis

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