- Hyperthermia related to Inflammatory process and Dehydration as evidenced by Tachycardia, Lethargy and Temperature reading of more than 100.4 F (38.0 C)
- Impaired Comfort related to Stress as evidenced by Expression of anxiety, overwhelm as evidenced by alterations in sleeping pattern and Feelings of irritability and restlessness
- Ineffective Protection related to Ineffective health self-management and weakened immune response as evidenced by Disorientation and Fever
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbalizes about high temperature Objective data: -Flushed skin -Hypotension -Tachycardia -Lethargy -Chills -Excessive sweating -Irritability -Skin warm to touch -Abnormal posturing | Hyperthermia related to Inflammatory process and Dehydration as evidenced by Tachycardia, Lethargy and Temperature reading of more than 100.4 F (38.0 C) | Patient will maintain a body temperature within the normal range for their age. Patient will remain free from any complications associated with hyperthermia, like seizures and dehydration. | 1. Provide a tepid sponge bath and other comfort measures. A tepid sponge bath is effective in lowering body temperature. Ice packs can be applied to the armpits or groin. Cool compresses can be applied to the forehead. 2. Provide oral or intravenous fluids as ordered. IV and oral fluids must be provided to ensure adequate hydration and prevent dehydration. 3. Administer medications as indicated. Antipyretics can help decrease the patient’s body temperature. Antibiotics, antivirals, or antifungals treat the underlying cause of hyperthermia in meningitis. 4. Instruct on signs of hyperthermia. Educate parents to monitor children at home for symptoms of hyperthermia that require prompt treatment, such as irritability, difficulty eating/feeding, and lethargy. | Patient maintained normal body temperature within the normal range for their age. Patient remained free from any complications associated with hyperthermia, like seizures and dehydration. |
| Subjective data: Verbalizes pain, exhaustion, or general unwellness Expresses feeling stressed or worried Expresses concern about their health or a procedure Objective data: -Signs of pain: grimacing, guarding, moaning, diaphoresis -Flat affect -Irritability or restlessness -State of panic or anxiety | Impaired Comfort related to Stress as evidenced by Expression of anxiety, overwhelm as evidenced by alterations in sleeping pattern and Feelings of irritability and restlessness | Patient will verbalize a sense of control over their situation. Patient will be able to rest/sleep quietly. | 1. Administer medications as needed. Analgesics, sedatives, antiemetics, and antipyretics manage the client’s pain, fever, nausea, and vomiting. 2. Provide periods of undisturbed rest. Overstimulation due to unconsolidated activities may worsen the patient’s hyperirritable state. They are highly sensitive to touch, light, and loud sounds. 3. Maintain a position of comfort. Nurses may elevate the head or turn patients to anticipate seizure or vomiting episodes. Patients with meningeal irritation and neck pain assume a position wherein the back is extended slightly and the body is curled. 4. Explain all procedures. Before implementing tests such as a CT scan or spinal tap, educate the patient on what to expect to prevent anxiety and increased stress. If possible, remain with the patient to provide comfort. 5. Encourage family support. When applicable, allow family visitation to provide emotional support to ease fear. | Patient verbalized a sense of control over their situation. Patient is able to rest/sleep quietly. |
| Subjective data: -Expresses concern about their health or a procedure Objective data: -Chilling -Disorientation -Fatigue -Fever -Restlessness | Ineffective Protection related to Ineffective health self-management and weakened immune response as evidenced by Disorientation and Fever | Patient will remain free from complications like seizures, focal neurologic deficits, and cognitive impairment. Patient will demonstrate or verbalize strategies to prevent contracting infectious diseases. | 1. Administer antibiotic therapy as indicated. Antibiotics, antifungals, or antivirals are administered depending on the underlying pathogen. 2. Administer IV fluids. Infants and young children are especially vulnerable to dehydration while ill. IV fluids may be necessary to prevent dehydration if the patient is refusing or unable to consume liquids. 3. Educate on immunization. The meningococcal conjugate vaccine is recommended for preteens age 11 and older. Some infants may receive the vaccine if they are at an increased risk for meningitis. 4. Instruct on strategies to prevent infectious diseases. Remind patients with a weakened immune system to avoid contact with sick people, avoid large crowds, and wear a mask in public places. Hand hygiene is the most important way to prevent transmitting infections, so infants and young children may need assistance with keeping their hands clean. | Patient remained free from complications like seizures, focal neurologic deficits, and cognitive impairment. Patient demonstrated and verbalized strategies to prevent contracting infectious diseases. |