Nursing Diagnosis

Last week, I hinted on the concept of the “nursing diagnosis” in order to better understand the nursing interventions.  However, this week we are going to dive more deeply into the world of the nursing diagnosis.  The nursing diagnosis is the nurse’s clinical judgment about a client’s response to actual or potential health condition or needs (American Nursing Association, 2015).

For the condition of a patient with meningococcal meningitis, there can be many nursing diagnoses’ related to the condition they are in now, or what conditions they may develop.  Last week I listed some important nursing diagnoses, but now I am going to quickly summarize the 5 I think are most important to the care of meningococcal meningitis (Ackley, B., Ladwig, G. 2014).

1.  Risk for ineffective cerebral tissue perfusion

o   With the inflammation of the meninges, there is increased pressure on the brain.  This can decrease the availability for blood to reach the brain, which is crucial in the proper functioning of the brain. 

2.  Risk for infection transmission

o   A patient experiencing symptoms of this disease can put others around them as risk, including the doctors and nurses that care for this patient.

3.  Risk for delayed growth and development

o   With possible irreversible damage to the brain, or contaminated blood, there is a higher risk for debilitating effects down the road for the patient.

4.  Impaired mobility

o   Impaired mobility could be related to the damage that is done to the central nervous system, or the damage that is done to the neuromuscular system (loss of limbs).

5.  Risk for confusion

o   When there is an infection hindering the brain, patients are at an increased risk for confusion. 

The nursing diagnosis is the foundation for your nursing care.  However your care is based off of the condition of your patient.  With the basic nursing diagnosis you add what the diagnosis is related to and what evidence you have from your patient that is making you infer this diagnosis.  Then you think about what the plan is, what you want the outcome to be, and what nursing intervention you are going to implement in order to achieve this outcome.  It goes a little something like this…

Nursing Diagnosis: Risk for Infection Transmission

Is this an actual, or a potential nursing diagnosis? (Meaning, can this happen right now? Or will this happen in the future?)	Actual
Related to? (Meaning, why are they a risk for Infection transmission?)	Person to person transmission of the bacterium.
Plan?	Limit the transmission of the bacterium to healthy individuals.
Outcome?	No transmission of the bacterium to people in contact with the patient.
Nursing Interventions?	·      Show family members how to properly wear protective equipment when visiting the patient.  ·      Administer antibiotics at scheduled times. ·      Place mask on patient when moving them through the hospital.

(Nurse Labs, 2015)

Here is a website that discusses the nursing diagnosis and how it fits into the entire nursing process.  http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/Thenursingprocess.html

BIBLIOGRAPHY

Ackley, B., Ladwig, G., (2014) Nursing Diagnosis Handbook. Elseiver, 10^th edition.  Page 75.

American Nurses Association. (2015). The Nursing Process. Retrieved from http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing/Tools-You-Need/Thenursingprocess.html

Nurse Labs. (2015). Bacterial Meningitis. Retrieved from http://nurseslabs.com/bacterial-men

ingitis/

Nursing Care

In the hospital, the nurse works most closely with the patients.  It is up to them to be the eyes and ears for the physicians and act accordingly when a patient’s condition changes.  Nurses learn how to make their own interpretations of a patient’s condition without thinking in terms of actual diagnosis.  They think in terms of the “Nursing diagnosis.” These diagnoses are developed based on what they observe during their assessments.  We will discuss more next week on how nursing diagnosis are developed.  However I feel that the plan of care is best understood if you know why the nurse if performing that care.  The nursing care is determined based on these diagnoses.  With meningococcal meningitis, the care for one patient may be different than what another patient needs.  Also, there may be different protocols for nursing care in different hospitals.  That is why as a nurse, it is important to know the condition of your patient, as well as requirements for care.  Below I have created a chart of nursing diagnoses and the perspective care that will be done in order to treat/manage the diagnoses. 

http://staffingstream.wpengine.netdna-cdn.com/wp-content/uploads/2012/11/nursing.jpg

Nursing Diagnosis	Care for condition/ Why nurses do this
·  Risk for infection transmission related to contagious nature of organism	·  Institute Infection control precautions until 24 hours after initiation of antibiotic therapy o   This limits the risk of transmission of infection to health care providers and possibly other hospital patients ·  Reduce high fever to decrease load on heart and bran for oxygen demands o   Patients with infection experience fever.  Fever affects other body systems that we need to perform correctly in order for the patient to properly heal
·  Acute Pain related to headache, fever, neck pain secondary to meningeal irritation	·  Deliver pain medications as ordered and as needed pain medication if pain is not well controlled o   It is proven that if patients are in pain, their body will not heal appropriately, or take longer to heal.  We want pain to be constantly monitored and under control
·  Acute pain related to nuchal rigidity, muscle aches, immobility and increased sensitivity to external stimuli secondary to infectious process	·  Deliver pain medications as ordered and as needed pain medication if pain is not well controlled o   It is proven that if patients are in pain, their body will not heal appropriately, or take longer to heal.  We want pain to be constantly monitored and under control
·  Impaired physical mobility related to IV infusion	·  Perform range of motion exercises o   Range of motion exercises prevent muscle and joint stiffening.  We want the patient to be able to be mobile once they are able ·  Place a indwelling catheter o   Putting a catheter in place allows for the patient to stay in bed rather than getting up to use the restroom.  With this however, there is a risk of infection so we only put in place if highly needed
·  Activity intolerance related to fatigue and malise secondary to infection	·  Perform activity as tolerated o   We do not want to push our patients to perform activities if their body needs to rest ·  Cluster nursing care in order to increase length of uninterrupted periods o   Limiting the amount of times a nurse enters the room allows for more time for the patient to rest, which is critical in the healing process
·  Risk for impaired skin integrity related to immobility, dehydration, and sweating	·  Prevent complications associated with immobility such as pressure ulcers and pneumonia o   Turning the patient will allow for pressure on the skin to be alleviated.  We can also teach out patients how to deep breathe or use devices such as the incentive spirometer in order to keep the lungs open and active.  This will prevent other infections such as pneumonia ·  Change bed linens often if sweating in order to prevent constant moisture on skin o   Moisture increases the risk for ulcer development
·  Risk for injury related to restlessness and disorientation secondary to meningeal irritation	·  Protect the patient from injury secondary to seizure activity or altered level of consciousness o   Patients may experience seizures or disorientation.  As nurses we can provide extra padding on the beds to prevent further seizure related injury.  Also if the patient is a risk for getting out of bed without a health care provider present, we can place bed alarms or restraints as needed. ·  Keep bed rails raised and bed in low position o   Raised bed rails prevent the patient from falling out of bed.  If a patient does happen to fall out, having the bed low will minimize risk for injury ·  Assess neurologic status and vital signs o   This will determine if a patient is ready to get up and walk.  We want to reduce the risk of falls ·  Determine their oxygenation status with blood gas values and pulse oximetry
·  Interrupted family process related to critical nature of situation and uncertain prognosis	·  Inform family about patient’s condition and permit family to see patient at appropriate intervals o   As previously stated, rest is crucial in the healing process.  We want the patient’s family involved at appropriate times ·  Provide emotional support and teaching o   Families will often be stressed due to the new condition of their loved one.  It is important to listen to the family’s concerns and teach the family about how to appropriately care for their loved one
·  Anxiety related to treatment and risk of death	·  Explain to patient each medical intervention that is occurring o   If the patient is conscious, it is always important to explain the care they you are providing.  This gives them knowledge about their condition and also teaches them about their care ·  Provide emotional support o   The patient will be anxious or scared about their changing condition.  It is important to listen to the patient as they express their concerns and provide appropriate feedback

Clearly, this is not a comprehensive list of care that needs to be performed.  However I have highlighted some of the essential care needs for a meningitis patient.  Finding specific information related to the nursing care of theses patients is difficult since nurses are trained through their programs with expensive comprehensive textbooks.  However, here are 2 websites that explain some of the information that I have included in the table.  http://nurseslabs.com/bacterial-meningitis/ and http://www.nursingcenter.com/lnc/CEArticle?an=00152193-200711000-00035&Journal_ID=54016&Issue_ID=751243. 

Here is another link for a case study on a patient with meningococcal meningitis. http://wps.prenhall.com/wps/media/objects/737/755395/bacterial_meningitis.pdf

BIBLIOGRAPHY

Nurse Labs. (2015). Bacterial Meningitis. Retrieved from http://nurseslabs.com/bacterial-men

ingitis/ 

Matthews, C. Miller, L. Mott, M. (November, 2007). Getting Ahead of Acute Meningitis and Encephalitis. Retrieved fromhttp://www.nursingcenter.com/lnc/CEArticle?an=00152193-200711000-00035&Journal_ID=54016&Issue_ID=751243

Treatment and Vaccines

As we discussed previously, early diagnosis is imperative to receiving early treatment for meningococcal meningitis.  Once the condition is determined, the individual will be admitted to the hospital in order to receive the treatment.  Since meningococcal meningitis is caused by the bacterium Neisseria meningitidis, we are able to treat the condition with a number of effective antibiotics (WHO, 2015).  The delivery of antibiotics should happen immediately after diagnosis.  In some cases if the symptoms are severe and meningitis is highly suspected, then antibiotics may be delivered before a positive diagnosis (CDC, 2014).  

The most common antibiotics that are used to treat the infection include penicillin, ampicillin, chloramphenicol, and ceftriaxone (WHO 2015).  Antibiotics can act on a bacterium in one of two ways.   One way is to kill the bacterium itself (bactericidal), or slow their growth in order for the body to be able to take over (bacteriostatic).  For example, Penicillin is a drug that is bactericidal.  Penicillin kills the bacterium by targeting the building blocks that help make the walls of the bacterium.  This causes the bacterium to lose their integrity and break.  These medications should be delivered by parenteral route, which means any route outside of the GI tract (mainly intravenous, and intramuscular) (Meningitis Research Foundation, 2014).  If needed, the patient should be given supportive treatment such as airway management or basic fluids (Meningitis Research Foundation, 2014). Sometimes, individuals experience side effects to Penicillins.  Patients may have an immediate response known as anaphylaxis that develops within 30-60 minutes after delivery.  Patients may also develop a rash 1-72 hours after delivery.  Individuals that experience these side effects should then be labeled as "allergic" to penicillin.  Some individuals develop a rash over 72 hours later that cannot be explained.  This macropapilar rash is not considered to be an allergic response (Black, 2014).  Ceftriaxone elicits similar side effects including risk for anaphylaxis and rash, however it also includes risk for seizures, and GI dysfunction (Davis Drug Guide, 2014).  It is important for nurses to watch for these undesired reactions and respond appropriately (remove treatment immediately and deliver epinephrine for anaphylactic response).  Also, if the patient has experienced minimal reactions before, they should inform the nurse before delivery because a rash one time may lead to anaphylaxis the next.

Yes, there are treatments available for meningococcal meningitis.  However, patients do not always survive.  Even with antibiotic treatment, 10-15% of cases will die (CDC, 2014).  And out of the survivors, many suffer from long term disabilities such as loss of limbs from septicemia, deafness, nervous system problems, and brain damage (CDC, 2014).  This is why it is important to know about the vaccines that are available in order to prevent meningococcal meningitis.  Just like any vaccine, this one protects against most types of the disease.  There are two types of vaccines in the U.S. that specifically protect against the bacterium Neisseria meningitidis.  These vaccines include Menomune which is a polysaccharide vaccine, and Menactra, Menveo, and MenHibrix which are meningococcal conjugate vaccines (CDC, 2014).  It is recommended that all adolescents be vaccinated at 11-12 years old.  It is now known that the vaccine may only last 5 years, so it is important to receive boosters if you are still at high risk.  If you are an adult, you should still consider the vaccine.  You should receive the vaccine if you are a college student living in a residence hall, you are a military recruit, you have a damaged or removed spleen, you have a terminal complement deficiency, or if you are traveling to countries where the disease is common (CDC, 2014).  The best way to prevent disease is to vaccinate against it.  Here is the testimony of people who have experienced it first hand. 

  http://www.cbsnews.com/news/meningococcal-meningitis-could-derail-dreams-early-athletes-warn/


BIBLIOGRAPHY

Black, Douglas. (November, 2014). Lecture: Antibiotics and Antifungals. University of Washington, Seattle

Centers for Disease control and Prevention. (April, 2014). Meningococcal Disease: Diagnosis and Treatment. Retrieved from http://www.cdc.gov/meningococcal/about/diagnosis-treatment.html

Centers for Disease Control and Prevention. (April, 2014).  Meningococcal: Who Needs to be Vaccinated. Retrieved from http://www.cdc.gov/vaccines/vpd-vac/mening/who-vaccinate.htm

Davis Drug Guide. (2014). CefTRIAXone. Retrieved from http://www.drugguide.com/ddo/view/Davis-Drug-Guide/109029/all/cefTRIAXone

Meningitis Research Foundation. (2014). Meningococcal Meningitis and Septicaemia Guidance Notes. Retrieved from http://www.meningitis.org/assets/x/50631

World Health Organization. (February, 2015). Meningococcal Meningitis. Retrieved from http://www.who.int/mediacentre/factsheets/fs141/en/

PICTURES

Tangent Adhesives (2014). Adhesives for Needle and Syringe Assembly.  Retrieved From http://tangentindinc.com/applications/adhesives-for-needle-and-syringe-assembly.html

https://www.mims.com/SINGAPORE/drug/info/Penicillin%20G%20Sodium%20Sandoz/