Question

In room 910 is S.B., a 10-year-old female who presents with a 3-day history of fever and lethargy after returning home from a weeklong overnight camp. Mother states that patient vomited ×3 today, is irritable, and is now walking with an unsteady gait.

Subjective Data:

Complains of light sensitivity

Complains of severe headache

Complains of dizziness when standing up

Objective Data:

Vital signs: T 38.6, HR 112, R 32, BP 104/68

Cap refill 4-5 seconds

Purpural rash noted to trunk

Nuchal rigidity on exam

Pupils 4mm briskly reactive to light bilaterally

Positive Kernig sign

WBC 27.8

CSF- Protein 160, Glucose <15, cloudy fluid

Electrolytes within normal limits with glucose 105

What disease process would you surmise from the above data and why? Describe a positive Kernig sign.  What steps can be taken to reduce S.B.’s risk for complications from this disease process? What nursing actions should the nurse do in this clinical situation? Prioritize all actions. Outline the nursing interventions that focus on maintaining a stable ICP. S.B. suffers a tonic clonic seizure upon admission to the unit. Discuss the nurse’s role during the seizure.

Answer 1

●The disease process which could be surmised from the data is meningitis (fever,nuchal rigidity, + Kernig sign,light sensitivity,,severe headache, dizziness, tachycardia,tachypnea, vomiting,irritable ,skin rash) can occur in case of any infection to the brain or the meninges.

●A positive kernig sign refers to the experience of pain or inability to extend the flexed knee in lying down position .

●Some of the steps to reduce the risk of complications in the patient are

• Administer antibiotics as per order to treat infection
• Administer antipyretics to reduce body temperature
• Analgesics to relie e headache
• Steroid can help to reduce any inflammation
• Oxygenation to provided to prevent respiratory distress
• Monitor the patient vital signs hours with GCS reading
• Maintaining normal intracranial pressure

●The nursing actions are

• Monitoring vital signs
• Mental status examination or HCS
• Maintain hydration but preventing fluid overload
• Reduced increased ICP by positioning head of bed at 30°
• Infection control practices
• Meticulous handwashing
• Administration of appropriate medication
• Treat infection

●The nurses role during tonic clinic seizure are

• Provide a safe environment to prevent self injury
• Place patient in recovery position to prevent aspiration
• Administer oxygen to increase supply to brain and prevent damage
• Observe the duration of seizure, to help in diagnosis and treatment
• Do not restrain the patient as this can lead to fracture