Tb Meningitis

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Foundation University
COLLEGE OF NURSING
Dumaguete City

NURSING CARE ANALYSIS OF APATIENT WITH TB MENINGITIS

In partial fulfillment of the requirements in Nursing Care Management (NCM 3)
SUBMITTED TO:

Mrs. Ivy M. Cornelia, BS (Bio), RN, US-RP, MSN

SUBMITTED BY:

Flezle Dace S. Diao
Norman Tom JeorgeEdera

DATE SUBMITTED:
October 7, 2014

TABLE OF CONTENTS
Foundation University Mission and Vision
Acknowledgment
Central and Specific Objectives
Introduction
Demographic Data
Nursing History
a. Chief Complaints
b. Admitting Impression
c. History of Present Illness
d. Past Health History
e. Family History
f. Psychosocial History
g. Environmental History
h. Spiritual History
Genogram
Developmental Milestone
Review of Related System
Review of Related Literature
Pathophysiology
Intervention
a. Treatment and Rationale
b. Laboratory Exams
c. Drug Study
Nursing Theory

Nursing Management
a. Physical Assessment
b. Gordon’s Functional Health Pattern
c. NCP
Annotated Readings
Conclusion
Bibliography

Foundation University
COLLEGE OF NURSING
Dumaguete City

Life Purpose
To educate and develop individuals to become productive, creative, useful and responsible citizens of society

Vision
To be a dynamic, progressive school that cultivates effective learning, generates creative ideas, responds to societal needs and
offers equal opportunity for all.

Mission
In its quest for excellence in mind, body and character and the pursuit of truth and freedom, Foundation University commits itself
to:
1. Develop students of sound character and broad culture;
2. Prepare students for a definite career;

3. Imbue students with the spirit of universal brotherhood; and
4. Advocate truth, promote justice and advance knowledge

ACKNOWLEDGEMENT
This case study of our patient has greatly helped us in gaining more knowledge and skills in the field we have chosen. This
would not have been possible if not for the people who have been very kind enough to render their time, concern, and support.
We would like to express our gratitude to:
First to our almighty God who’s always been there to continually guide us and being the source of strength in all the things we
do.
To our dear parents, who never failed to give their whole-hearted support, helped us in every way they can, guided us to
become in the path that we should take and instilling to us the morals of a Christian individual, and gave us the opportunity of
education.
We would also like to thank, our Clinical instructor, Mrs. Ivy M. Cornelia, BS (Bio), RN, US-RP, MSN, who had been a good
facilitator, knowledgeable and a therapeutic nurse who helps us having the case for enrichment of our knowledge and for the
development of our skills as well as our attitudes.
For the brilliant authors of the books and articles who provided us significant information regarding our case.
Special thanks to the Negros Oriental Provincial Hospital to thepediastaff and personnel for aiding us and making our Pediatric
rotation full of learning, for their time and place that they have spared for us which enabled us to gain more knowledge and
skills and gave us the opportunity to meet our patient who become the subject of this case study.

Lastly, we would like to extend our heartfelt gratitude to our patient. We thank you for your time and cooperation and for
allowing us to make her our subject for this case study. If not for our patient, we would not have a case to study. Thank you for
opening up yourself to us, and for letting us learn from your case.

CENTRAL AND SPECIFIC OBJECTIVES
TOPIC DESCRIPTION:
This is to present the case of our patient, Aleafe Quialquial, who is diagnosed with TB Meningitis. This topic includes a
review of a normal Anatomy and Physiology of the Central Nervous system, the Pathophysiology of the mentioned disease
condition, the client’s Demographic data, his Developmental milestone as a school age, Genogram, Physical Examination results,
Functional Health Pattern, Nursing Care Plans, Diagnostic and Laboratory Examination findings, Medical and Nursing Management
and Related Readings.

CENTRAL OBJECTIVE:
At the end of the 1 hour presentation, the learners shall gain deeper knowledge, enhance existing skills as well as develop
beginning skills and manifest desirable attitudes and values towards the care of a patient diagnosed with TB Meningitis.

SPECIFIC OBJECTIVES:
At the end of the 1 hour case presentation, the learners shall:
1. orient themselves towards the psychosocial profile of the patient;
2. briefly review the anatomy and physiology of the system involved;
3. learn and be familiarize about the disease process and gain knowledge on the pathophysiology of the said disease condition;
4. enumerate possible ways to manage a patient having this type of condition;
5. critically analyze the significance of the different laboratory findings and correlate with the disease process;
6. enumerate and understand the different drugs prescribed by the physician and its effects;
7. formulate 15 nursing diagnosis appropriate for the client’s condition ;
8. identify appropriate dependent and independent nursing interventions relative to the patient’s case;
9. manifest positive values and attitudes through active participation in the discussion and asking related questions;
10. briefly discuss one journal reading and evaluate the case presentation objectively

Introduction
As we care for our patients in the pediatric ward, there should be an awareness of the complications that
we may encounter. It is best to prepare ourselves, as student nurses to provide the utmost and efficient care for
our patient. One of the conditions that are prevalent in our country is Tuberculosis and included in its
complications is Tuberculosis Meningitis which is common among children.
Tuberculous meningitis is also known as TB meningitis or tubercular meningitis. Tuberculous meningitis is
Mycobacterium tuberculosis infection of the meninges—the system of membranes which envelops the central
nervous system. It is the most common form of CNS tuberculosis.TBM is associated with a high frequency of
neurologic sequelae and mortality if not treated promptly. Children are among the subjects who most frequently
suffer from TBM due to their relative inability to contain primary Mycobacterium tuberculosis infection in the
lung.

Demographic Information
Name: Quialquial, Aleafe J.

Civil Status: Child

Address: Brgy. 4 Siaton, Negros Oriental

Religion: Roman Catholic

Room and Bed No.: ICU Doctor in charge: Dr. Ana Marie Yap

Nationality: Filipino

Date and Time Admission: 08/08/2014 @

8:43pm

Chief Complaints:Fever and seizures
Diagnosis: TB Meningitis
History of present illness: 2 days PTA had onset of fever. Given Paracetamol every relief of fever. PTA had stiffening of
extremities occurring several times.

General Impression: Received lying in bed, awake and unresponsive to verbal stimuli with D5NM 1L @KVO at the right
antecubital vein. Infusing well and no inflammation on the site. Skin is intact, warm to touch, good skin turgor and no presence of
lesion noted.

NURSING HISTORY
Chief Complaints: Fever and seizures
Admitting Impression: Received lying in bed, awake and unresponsive to verbal stimuli with D5NM 1L @KVO at the right
antecubital vein. Infusing well and no inflammation on the site. Skin is intact, warm to touch, good skin turgor and no presence of
lesion noted.

History of Present Illness: 2 days PTA had onset of fever. Given Paracetamol every relief of fever. PTA had stiffening of
extremities occurring several times.

Past Health History:
Family History:
Psychosocial History:
Environmental History: The family lives in uptown areas in siaton, negros oriental. They don't have their own
comfort room.
Spiritual History:

G
E

Amparo Jaos

Cristutu Jaos

63

Cancer

Felisa Quialquial Goiter

Felix Quialquial

Goiter

N
O

Mamiria Quialquial 28 yrs.
old

Ferian Quialquial
30 yrs old

LEGEND

G

FEMALE

R
A
M

MALE
Aleafe Quialquial - 7 yrs
old

Alea Quialquial -5 yrs old

Alfred Quialquial
- 2yrs old

DECEASED

Developmental task
6 TO 12 YEARS
Ego Developmental Task: Industry vs. Inferiority
Child develops a sense of self-worth by refining skills
Basic Strengths: Method and Competence
During this stage, often called the Latency stage, the child becomes capable of more complex
learning, creating and accomplishing numerous new skills and knowledge, building a personal
sense of industry. And, as your child’s world expands into the realm of school expectations and
increasing opportunities for peer relationships, feelings of inadequacy or inferiority can emerge.
Your compassion and listening ear will support her in developing competence and self-esteem as
she negotiates through these early school years.
As the world expands outside of the home environment, your child’s most significant
relationships expand into the school and community. You, as the parent, are no longer the sole
authority you once were. Authority figures such as teachers, school administrators, and coaches now influence your child. You, as
the parent, will remain crucial throughout the lifetime.

Anatomy and Physiology of the Central Nervous System
Head
The human nervous system consists of the central nervous system (CNS) and
peripheral nervous system (PNS). The former consists of the brain and spinal
cord, while the latter composes the nerves extending to and from the brain and spinal
cord. The primary functions of the nervous system are to monitor, integrate
(process) and respond to information inside and outside the body. The
brain consists of soft, delicate, non-replaceable neural tissue. It is
supported and protected by the surrounding skin, skull, meninges and
cerebrospinal fluid.

Skin
The skin constitutes a protective barrier against physical damage of
underlying
tissues,
invasion of hazardous chemical and bacterial substances and, through the
activity of its sweat glands
and blood vessels, it helps to maintain the body at a constant temperature.
Together with the sweat and oil glands, hairs and nails it forms a set of organs
called the integumentary system. The skin consists of an outer, protective layer, the epidermis and an inner layer, the dermis.
While the top layer of the epidermis, the stratum corneum, consists of dead cells, the dermis is composed of vascularised fibrous
connective tissue. The subcutaneous tissue, located underneath the skin, is primarily composed of adipose tissue (fat).

Skull
Depending on their shape, bones are classified as long, short, flat or irregular. Bones of different types contain different
proportions of the two types of osseous tissue: compact and spongy bone. While the former has a smooth structure, the latter is
composed of small needle-like or flat pieces of bone called trabeculae, which form a network filled with red or yellow bone marrow.
Most skull bones are flat and consist of two parallel compact bone surfaces, with a layer of spongy bone sandwiched between. The
spongy bone layer of flat bones (the diploë) predominantly contains red bone marrow and hence has a high concentration of blood.

The skull is a highly complex structure consisting of
22 bones altogether. These can be divided into two sets,
the cranial bones (or cranium) and the facial bones. While
the latterform the framework of the face, the cranial bones
form the cranial cavity that encloses and protects the
brain. All bones of the adult skull are firmly connected by
sutures. The frontal bone forms the forehead and contains
the frontal sinuses, which are air filled cells within the
bone. Most superior and lateral aspects of the skull are
formed by the parietal bones while the occipital bone
forms the posterior aspects. The base of the occipital bone
contains the foramen magnum, which is a large hole
allowing the inferior part of the brain to connect to the
spinal cord. The remaining bones of the cranium are the
temporal, sphenoid and ethmoid bones.

Meninges

The meninges are three connective tissue membranes enclosing the brain and the spinal cord. Their functions are to protect
the CNS and blood vessels, enclose the venous sinuses, retain the cerebrospinal fluid, and form partitions within the skull. The
outermost meninx is the dura mater, which encloses the arachnoid mater and the innermost pia mater.

Cerebrospinal fluid
Cerebrospinal fluid (CSF) is a watery liquid similar in composition to blood plasma. It isformed in the choroid plexuses and
circulates through the ventricles into the subarachnoid space, where it is returned to the dural venous sinuses by the arachnoid
villi. The prime purpose of the CSF is to support and cushion the brain and help nourish it.

Major regions of the brain and their functions
The major regions of the brain are the cerebral hemispheres, diencephalon, brain stem
and cerebellum.

Cerebral hemispheres
The cerebral hemispheres, located on the most superior part of the brain,
are separated by the longitudinal fissure. They make up approximately 83% of total
brain mass, and are collectively referred to as the cerebrum. The cerebral cortex constitutes a
mm thick grey matter surface layer and, because of its many convolutions, accounts for
total brain mass. It is responsible for conscious behaviour and contains three
functional areas: the motor areas, sensory areas and association areas.

2-4
about 40% of
different
Located internally are

the white matter, responsible for communication between cerebral areas and between the cerebral cortex and lower regions of the
CNS, as well as the basal nuclei (or basal ganglia), involved in controlling muscular movement.

Diencephalon
The diencephalon is located centrally within the forebrain. It consists of the thalamus, hypothalamus and epithalamus, which
together enclose the third ventricle. The thalamus acts as a grouping and relay station for sensory inputs ascending to the sensory
cortex and association areas. It also mediates motor activities, cortical arousal and memories. The hypothalamus, by controlling
the autonomic (involuntary) nervous system, is responsible for maintaining the body’s homeostatic balance. Moreover it forms a
part of the limbic system, the ‘emotional’ brain. The epithalamus consists of the pineal gland and the CSFproducingchoroid plexus.

Brain stem
The brain stem is similarly structured as the spinal cord: it consists of grey matter surrounded by white matter fibre tracts.
Its major regions are the midbrain, pons and medulla oblongata. The midbrain, which surrounds the cerebral aqueduct, provides
fibre pathways between higher and lower brain centres, contains visual and auditory reflex and subcortical motor centers. The
pons is mainly a conduction region, but its nuclei also contribute to the regulation of respiration and cranial nerves. The medulla
oblongata takes an important role as an autonomic reflex centre involved in maintaining body homeostasis. In particular, nuclei in
the medulla regulate respiratory rhythm, heart rate, blood pressure and several cranial nerves. Moreover, it provides conduction
pathways between the inferior spinal cord and higher brain centres.

Cerebellum

about 11% of
matter, and
impulses
order
to

The cerebellum, which is located dorsal to the pons and medulla, accounts for
total brain mass. Like the cerebrum, it has a thin outer cortex of grey matter, internal white
small, deeply situated, paired masses (nuclei) of grey matter. The cerebellum processes
received from the cerebral motor cortex, various brain stem nuclei and sensory receptors in
appropriately control skeletal muscle contraction, thus giving smooth,
coordinated movements.

The Cerebral Circulatory System
Blood is transported through the body via a continuous system of blood vessels.
Arteries carry oxygenated blood away from the heart into capillaries supplying
tissue cells. Veins collect the blood from the capillary bed and carry it back to
the heart. The main purpose of blood flow through body tissues is to deliver oxygen
and nutrients to and waste from the cells, exchange gas in the lungs, absorb
nutrients from the digestive tract, and help forming urine in the kidneys. All the
circulation besides the heart and the pulmonary circulation are called the
systemic circulation.

Blood supply to the brain
The major arteries are the vertebral and internal carotid arteries. The two posterior and single anterior communicating
arteries form the circle of Willis, which equalises blood pressures in the brain’s anterior and posterior regions, and protects the

brain from damage should one of the arteries become occluded. However, there is little communication between smaller arteries
on the brain’s surface. Hence occlusion of these arteries usually results in localised tissue damage.

Autoregulation
Panerai [1998] describes autoregulationof blood flow in the cerebral
mechanism by which cerebral blood flow (CBF) tends to remain relatively
cerebral perfusion pressure (CPP). With a constant metabolic demand,
pressure that would increase or reduce CBF are compensated by
resistance. This maintains a constant O2 supply and constant CBF.
cerebral autoregulation allows the blood supply to the brain to match
demand and also to protect cerebral vessels against excessive flow
arterial hypertension. Cerebral blood flow is autoregulated much
than in almost any other organ. Even for arterial pressure variations
and 150 mm Hg, CBF only changes by a few percent. This can be
accomplished because the arterial vessels are typically able to change
their diameter about 4-fold, corresponding to a 256-fold change in blood
is very active is there an exception to the close matching of blood flow to
up to 30-50% in the affected areas. It is an aim of PET, functional MRI,
near infrared spectroscopy (NIRS), and, possibly, near infrared imaging,
detect or image such localized changes in cortical activity and associated

vascular
bed
as
the
constant despite changes in
changes in CPP or arterial blood
adjusting the vascular
Therefore
its
metabolic
due
to
better
between 50

flow. Only when the brain
metabolism, which can rise by
to
blood flow.

REVIEW OF RELATED
LITERATURE
Meningitis is an acute or subacute inflammation of the meninges (lining of the brain and spinal cord). The bacterial or viral pathogens
responsible for meningitis usually come from another site, such as those that lead to an upper respiratory infection, sinusitis, or mumps. The
organisms can also enter the meninges through open wounds. Bacterial meningitis is considered a medical emergency because the outcome
depends on the interval between the onset of disease and the initiation of antimicrobial therapy. In contrast, the viral form of meningitis is
sometimes called aseptic or serous meningitis. It is usually self-limiting and, in contrast to the bacterial form, is often described as benign. In
the bacterial form, bacteria enter the meningeal space and elicit an inflammatory response. This process includes the release of a purulent
exudates that is spread to other areas of the brain by the cerebrospinal fluid (CSF). If it is left untreated, the CFS becomes thick and blocks the
normal circulation of the CFS, which may lead to increased intracranial pressure (ICP) and hydrocephalus. Long-term effects of the illness are
predominantly caused by a decreased cerebral blood flow because of increased ICP or toxins related to the infectious exudate. If the infection
invades the brain tissue itself, the disease is then classified as encephalitis. Other complications include visual impairment, cranial nerve
palsies, deafness, chronic headaches, paralysis, and even coma. Of the bacteria that cause meningitis, pneumococcal meningitis has the
highest rates of mortality at 21%. If severe neurological impairment is seen at the time of initial assessment or very early in the clinical
course, the mortality rate is 50% to 90% even when therapy is instituted immediately.

CAUSES
Meningitis is most frequently caused by bacterial or viral agents. In newborns, Streptococcus pneumoniae is the most frequent bacterial
organism; in other age groups, it is S. pneumoniae and Neisseria meningitidis. Haemophilus influenzae is the most common organism in
unvaccinated children and adults who contract meningitis. Viral meningitis is caused by many viruses. Depending on the cause, isolation
precautions may be indicated early in treatment. There has been a decrease in viral meningitis in locations where immunizations have become
routine.

GENETIC CONSIDERATIONS
Heritable immune responses could be protective or increase susceptibility.

GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS
Meningitis occurs most frequently in young children, elderly people, and persons in a debilitated state. Infants and the very old are at the most
risk for pneumococcal meningitis, whereas children from 2 months to 3 years most frequently have haemophilus meningitis. Prognosis is
poorest for patients at the extremes of age: the very young and the very old of both sexes. In the United States, African Americans are at
greater risk than other races and ethnicities, although at this time there is no explanation for those differences in risk.

Abnormality with Test Normal Result Condition Explanation Diagnostic Highlights
Lumbar puncture for cerebrospinal fluid (CSF) analysis
Red blood cells: 0–10/µL; white blood cells: 0–10/µL; routine culture: no growth; fungal culture: no growth; mycobacteria culture: no growth;
color: clear; protein: 15–50 mg/dL; glucose: 40–80 mg/dL; pressure: 5–13 mm Hg; gram stain: no positive cultures with invading
microorganism; sensitivities identify antibiotics that will kill bacteria; cells: 200/µL; protein: elevated 50 mg/dL (viral) and 500 mg/dL
(bacterial); glucose: 45 mg/dL; color: may be cloudy or hazy; pressure: elevated; gram stain: bacteria stain either gram positive (blue) or
gram negative (red) identifies invading microorganisms. Increased protein occurs as the result of the presence of viruses or bacteria; glucose
is decreased as microorganisms use glucose for metabolism. Lumbar puncture is not done in the presence of known increased intracranial
pressure.
Other Tests: Brain scan, computed tomography (CT) scan, magnetic resonance imaging (MRI), cultures and sensitivities (blood, nasal swab,
urine), C-reactive protein, complete blood count, counter immunoelectrophoresis (to determine presence of viruses or protozoa in CSF), chest
x-ray
Rehabilitation begins with the acute phase of the illness but becomes increasingly important as the infection subsides. If residual neurological
dysfunction is present as a result of irritation, pressure, or brain and nerve damage, an individualized rehabilitation program with a
multidisciplinary team is required. Vision and auditory testing should be done at discharge and at intervals during long-term recovery because
early interventions for these deficits are needed to prevent developmental delays.

Medication or Drug Class Dosage Description Rationale Pharmacologic Highlights
Antibiotics High-dose parenteral therapy IV for 2 wk
Choice of antibiotic depends on gram stain and culture and sensitivities; if no organisms are seen on gram stain, a third-generation
cephalosporin is often used while culture results are pending. Broad-spectrum coverage such as vancomycin and ceftazidime may be chosen
cause bacterial lysis and prevent continuation of infection; initial dosages are based on weight or body surface area and then are adjusted
according to peak and trough results to maintain therapeutic levels.
Independent Make sure that the patient has adequate airway, breathing, and circulation. In the acute phase, the primary goals are to preserve
neurological function and to provide comfort. The head of the bed should be elevated 30 degrees to relieve ICP. Keep the patient’s neck in
good alignment with the rest of the body and avoid hip flexion. Control environmental stimuli such as light and noise, and institute seizure
precautions. Soothing conversation and touch and encouraging the family’s participation are important; they are particularly calming with
children who need the familiar touch and voices of parents. Children are also reassured by the presence of a security object. Institute safety
precautions to prevent injury, which may result from either the seizure activity or the confusion that is associated with increasing ICP. Take into
account an increase in ICP if restraints are used and the patient fights them. Implement measures to limit the effects of immobility, such as
skin care, range-of-motion exercises, and a turning and positioning schedule. Note the effect of position changes on ICP, and space activities
as necessary. Explain the disease process and treatments. Alterations can occur in thought processes when ICP begins to increase and the
level of consciousness begins to decrease. Reorient the patient to time, place, and person as needed. Keep familiar objects or pictures around.
Allow visitation of significant others. Establish alternate means of communication if the patient is unable to maintain verbal contact (e.g., the
patient who needs intubation). As the patient moves into the rehabilitative phase, developmentally appropriate stimuli are needed to support
normal growth and development. Determine the child’s progress on developmental tasks. Make appropriate referrals if the child is not
progressing or if the child or family evidence signs of inability to cope.

DOCUMENTATION GUIDELINES
• Physiological response: Neurological examination; vital signs; presence of fever; adequacy of airway, breathing, and circulation
Other Drugs: Adjunct corticosteroid therapy has been reported to decrease the inflammatory process and decrease incidence of hearing loss
but is controversial. Vaccinations exist for meningococcal, pneumococcal, and hemophilic meningitis, and the prophylaxis for persons exposed
to meningococcal meningitis is rifampin.

• Fluid and electrolyte balance: Intake and output, body weight, skin turgor, abnormal serum electrolytes • Complications: Seizure activity,
decreased mental status, fever, increased ICP

DISCHARGE AND HOME HEALTHCARE GUIDELINES
Explain all medications and include the mechanism of action, dosage, route, and side effects. Explain any drug interactions or food
interactions. Instruct the patient to notify the primary healthcare provider for signs and symptoms of complications, such as fever, seizures,
develop- mental delays, or behavior changes. Provide referrals and teaching specific to the identified neurological deficits. Encourage the
parents to maintain appropriate activities to facilitate the growth and development of the child.

PATHOPHYSIOLOGY

TREATMENT AND RATIONALE

LABORATORY RESULTS
Laboratory test

Normal Value

Results

Hemoglobin

12-14 g %

11.7 g %

Hematocrit

37-44 vol %

34.4 vol %

White Blood cell

4.5 – 11T/cumm

41.4T/cumm

Correlation/Interpretation

CBC:
The iron-containing, hemoglobin is the main component of RBC that
transports oxygen from the lungs to the tissues of the body. It is increased in
polycythemia, dehydration and decreased in bleeding and anemia.

Hematocrit measures the percentsge of RBC per 100mL of blood. It is
increased in dehydration and polycythemia and decreased in anemias and
hemorrhage.
WBC (leukocytes) determines the fighting ability with bacteria. It usually
detects infection or inflammation whereby it increases, called leukocytosis
and decreases called leukopenia.

Differential count
Neutrophil

55-70 %

87.4 %
Neutrophils is the first to arrive at injured site (within 6 hours from injury) and
is essential for phagocytosis. It is increased with acute infections, trauma or
surgery, and decreased with viral infections and bone marrow suppression.

Lymphocyte

Monocytes

20-35 %

1-6 %

5.1 %

4.6 %

Lymphocytes are essential for cellular immunity and functions in the
formation of immunoglobulins (Igs). It usually elevates in viral and chronic
bacterial infection.
The monocyte functions in phagocytosis. It migrates to inflammatory

Eosinophil

Basophil

Platelet

1-4%

0-1 %

150-450 T/cumm

2.0 %

exudates to actively phagocytize bacteria and viruses. It is normally
increased in chronic inflammatory disease.

0.9 %

Eosinophils phagocytize antigen-antibody complexes and foreign particles
and appear to defend against parasitic infestations. It is increased in allergic
and parasitic infections.

401,000/cumm

Basophils cause the release of chemical mediators. It is increased during
allergic reactions.
Platelet plays a vital role in homeostasis and blood clotting. Its increase called
thrombocytosis may indicate malignancy and its decrease, thrombocytopenia
may occur during hemorrhage, leukemia.

Urinalysis:
Urine color

Straw to amber or
transparent

Yellow
To determine urine composition and possible abnormal components.

Transparency

Specific gravity

Clear

1.010-1.025

Slightly turbid

1.030

The color of urine is dependent on the state of the patient’s hydration, foods
eaten, drugs, etc. Dark amber indicates dehydration.
Cloudy and foamy may indicate increase in protein, thick and cloudy
indicates increase bacterial growth.
Specific gravity is an indicator of urine concentration, or the amount of
solutes present in the urine. As urine becomes more concentrated, its specific
gravity increases. Increase level may indicate dehydration, diarrhea,
excessive sweating, decrease level may indicate excessive fluid intake.

pH

4.6-8

6.0

Protein

Glucose

Negative

Negative

+

Urinary pH determines the relative acidity or alkalinity of urine and assesses
the client’s acid-base status. Urine normally is slightly acidic.

negative

Protein should not be present in urine because they are normally too large to
escape from glomerular capillaries into the filtrate however if the glomerular
membrane has been damaged, it can become “leaky” allowing proteins to
escape.
Urine is tested for glucose to screen client for diabetes mellitus and to assess
client during pregnancy for abnormal glucose tolerance. The amount of
glucose in the urine is normally negligible.

Microscopic:

Pus cells

Red cells

Epithelial cells

0-5/hpf

0-4/hpf

0-5

8-10/hpf

3-4/hpf

few

Mucous cells

Rare

Amorph. Cells

Rare

Its presence may indicate infection. If there are pus cells and bacteria, culture
must be done to rule out infection.
The appearance of RBC in urine depends largely on the concentration of the
specimen and the length of time the red cells have been exposed.
Epithelial cells in urine is of little specific diagnostic utility because cells lining
the urinary tract at any level may slough in to the urine.

Yeast cells

None

(-)

Presence may indicate infection.

Bacteria

None

Few

Presence may indicate infection.
Presence may indicate infection.

DRUG STUDY
Amikacin
CLASSIFICATION: Antibiotic – aminoglycoside
MOA: Interferes with protein with protein synthesis in bacterial cell by binding to ribosomal subunit, which causes misreading of
genetic code, inaccurate peptide sequence forms in protein chain, causing bacterial death
USES: severe systemic infection of CNS, respiratory, GI, Urinary tract, bone, skin, soft tissues
ADVERSE EFFECTS: seizures, neurotoxicity, hepatic necrosis, oliguria, hematuria, renal damage, renal failure, nephrotoxicity,
leukopenia, anemia, eosinophilia
NURSING RESPONSIBILITIES:














Assess patient for previous sensitivity reaction
Assess patient for signs and symptoms of infection, including characteristics of wounds, sputum, urine, stool,
WBC>10,00/mm3, earache, temp: obtain baseline information before and during treatment
Obtain C&S test before beginning drug therapy to identify if correct treatment has been initiated
Assess for allergic reactions; rash, urticaria, pruritus
Identify urine output; if decreasing, notify prescriber
Monitor blood studies: AST, ALT, CBC, Hct, bilirubin, LDH, alkaline phosphatase
Monitor electrolytes: potassium, sodium, chloride, magnesium monthly if patient is on long-term therapy
Assess bowel pattern daily; if severe diarrhea occurs, drug should be discontinued
Monitor for bleeding: ecchymosis, bleeding gums, hematuria, stool guaiac daily if on long term therapy
Monitor vital signs daily
Assess for growth of infection
Obtain weight daily
Teach patient to report sore throat, bruising, bleeding, joint pain; may indicate blood dyscrasias (rare)



Advise patient to report hypersensitivity: rash, itching, trouble breathing, facial edema and notify prescriber

Ceftiaxone
CLASSIFICATION: antibiotic – 3rd generation cephalosporin
MOA: inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable, leading to cell death
USES: serious lower respiratory tract, urinary tract, skin, intraabdominal infections; septicemia, meningitis; bone, joint infections;
PID caused by Neisseria gonorrhoeae
NURSING RESPONSIBILITIES:















Assess patient for previous sensitivity reaction to pencillins or other cephalosporins; cross-sensitivity between penicillins and
cephalosporins is common
Assess patient for signs and symptoms of infection including characteristics of wounds, sputum, urine, stool,
WBC>10,000/mm3, fever; obtain baseline information and during treatment
Obtain C&S before beginning drug therapy to identify if correct treatment has been initiated
Assess for anaphylaxis: rash, urticaria, pruritus, chills, fever, joint pain; angioedema may occur a few days after therapy
begins
Identify urine output; if decreasing, notify prescriber
Monitor blood studies: AST, ALT, CBC, Hct, bilirubin, LDH, alkaline phosphatase
Monitor electrolytes: potassium, sodium, chloride, magnesium monthly if patient is on long-term therapy
Assess bowel pattern daily; if severe diarrhea occurs, drug should be discontinued
Monitor for bleeding: ecchymosis, bleeding gums, hematuria, stool guaiac daily if on long term therapy
Monitor vital signs daily
Assess for growth of infection
Give for 10-14 days to ensure organism death, prevent superinfection
Teach patient to report sore throat, bruising, bleeding, joint pain; may indicate blood dyscrasias (rare)
Advise patient to contact prescriber if vaginal itching, loose foul-smelling stools, furry tongue occur; may indicate
superinfection



Advise patient to notify prescriber of diarrhea with blood or pus, may indicate pseudomembranous colitis

Cimetidine
CLASSIFICATION:H2 receptor antagonist
MOA: inhibits histamine at H2-receptor site in the gastric parietal cells, which inhibits gastric acid secretion
USES: short-term treatment of duodenal and gastric ulcers and maintenance; management of GERD and Zollinger-Ellison
syndrome
ADVERSE EFFECTS: seizure, dysrthymias, paralytic ileus, agranulocytosis, thrombocytopenia, neutropenia, aplastic anemia,
increase in protime, exfoliative dermatitis
NURSING RESPONSIBILITIES:









Assess patient with ulcers or suspected ulcers: epigastric or abdominal pain, hematemesis, occult blood in stools, blood in
gastric aspirate before and/or throughout treatment; monitor gastric pH
Monitor I&O ratio, BUN, creatinine, CBC with differential periodically
Give with meals for lengthened drug effect; antacid 1 hour before or 1 hour after cimetidine
Advise patient that may gynecomastia or impotence that develops is reversible after treatment is discontinued
Caution patient to avoid driving, other hazardous activities until stabilized on this medication; drowsiness or dizziness may
occur
Advise patient to avoid black pepper, caffeine, alcohol. Harsh spices, extremities of food; tell patient to avoid OTC
preparations; aspirin, cough, cold preparation; condition may worsen
Advise patient that smoking decreases the effectiveness of the drug; smoking cessation should be considered
Teach patient that drug must be continued for prescribed time to be effective and taken exactly as prescribed; doses are not
to be doubled; to take missed dose when remembered up to 1 hour before next dose




Instruct patient to report bruising, fatigue, malaise; blood dyscrasia may occur
Have patient report to prescriber immediately any diarrhea, black tarry stools, sore throat, dizziness, confusion, or delirium

Diazepam
CLASSIFICATION: antianxiety, anticonvulsant, skeletal muscle relaxant, central acting – Benzodiazepine
MOA: potentiates the actions of GABA, especially in limbic system, reticular formation; enhances presympathetic inhibition, inhibits
spinal polysynaptic afferent paths
USES: anxiety acute alcohol withdrawal, adjunct in seizure disorders; preoperative skeletal muscle relaxation; rectally for acute
repetitive seizures
ADVERSE EFFECT: ECG changes, tachycardia, neutropenia, respiratory depression, blurred vision, hypotension, dizziness,
hallucination, depression
NURSING RESPONSIBILITIES:







Assess degree of anxiety; what precipitates anxiety and whether drug control symptoms; other signs of anxiety:
dilated pupils, inability to sleep, restlessness, inability to focus
Assess for alcohol withdrawal symptoms, including hallucination, delirium, irritability, agitation, fine to coarse tremors
Monitor BP, pulse, respiratory rate; if systolic BP drop 20 mmHg, hold drug, notify the prescriber; monitor respirations q
5-15 minutes if given IV
Monitor blood studies: CBC during long-term therapy; blood dyscrasias have occurred (rarely)
Monitor for seizure control; type, duration, and intensity of seizure; what precipitates seizures
Monitor hepatic studies: AST, ALT, bilirubin, creatinine, LDH, alkaline phosphatase









Assess mental status: mood, sensorium, affect, sleeping pattern, drowsiness, suicidal tendencies, and ability of drug to
control these symptoms; check for tolerance, withdrawal symptoms; headache, nausea, vomiting, muscle pain,
weakness after long-term use
Advise patient that drug may be taken with food; that drug is not to be used for everyday stress or used longer than 4
months unless directed by prescriber; take no more than prescribed amount; may be habit forming
Caution patient to avoid OTC preparations unless approved by a prescriber; to avoid alcohol, other psychotropic
medications unless prescribed; that smoking may decrease diazepam effect by increasing diazepam metabolism; not
to discontinue medication abruptly after long-term use
Inform patient to avoid driving, activities that require alertness; drowsiness may occur; to rise slowly or fainting may
occur, especially in elderly
Advise patient not to become pregnant while using this drug

Isoniazid
CLASSIFICATION: antitubercular – isonicotinic acid hydrazide
MOA: inhibits RNA synthesis, decreases tubercle bacilli replication
USES: pulmonary TB as an adjunct; other infections caused by mycobacteria
ADVERSE EFFECT: hypersensitivity, peripheral neuropathy, dizziness, toxic encephalopathy, convulsions, seizures, jaundice, fatal
hepatitis, nausea, vomiting, agranulocytosis, hemolytic anemia, aplastic anemia, thrombocytopenia, eosinophilia,
methemoglobinemia
NURSING RESPONSIBILITIES:





Obtain C&S test, including sputum tests, before treatment; monitor every month to detect resistance
Monitor liver studies weekly: AST, ALT, bilirubin, increased results may indicate hepatitis; renal studies during treatment
and monthly: BUN, creatinine, output, sp gr, urinalysis, uric acid
Assess mental status often: affect mood, behavioral changes; psychosis may occur with hallucinations, confusion
Assess hepatic status: decreased appetite, jaundice, dark urine, fatigue






Assess for visual disturbance that may indicate optic neuritis: blurred vision, change in color perception; may lead to
blindness
Instruct patient that compliance with dosage schedule for duration is necessary, not to skip or double doses; that
scheduled appointments must be kept or relapse may occur
Caution patient to avoid alcohol while taking drug hepatoxicity may result; to avoid ingestion of aged cheeses, fish or
hypertensive crisis may result; give patient written directions on which foods to avoid while taking this medication
Tell patient to report peripheral neuritis: weakness, tingling/numbness of hands/feet, fatigue, hepatoxicity: loss of
appetite, nausea, vomiting, jaundice of skin or eyes

Pyrazinamide
CLASSIFICATION: antitubercular agent – pyrazinoic acid amine/nicoturmide analog
MOA: bactericidal interference with lipid; nucleic acid biosynthesis is possible
USES: tuberculosis, as an adjunct when other drugs are not feasible
ADVERSE EFFECT: hepatoxicity, headache, abnormal liver function tests, peptic ulcer, nausea, vomiting, hemolytic anemia,
photosensitivity, urticaria, urinary difficulty, increased uric acid
NURSING RESPONSIBILITIES:







C&S studies should be done before treatment begins, and periodically during treatment
Monitor serum uric acid, which may be elevated and cause gout symptoms
Monitor liver studies weekly: ALT, AST, bilirubin; hepatic status: decreased appetite, jaundice, dark urine, fatigue
Monitor renal status before treatment and monthly thereafter: BUN, creatinine, output, sp gr, urinalysis, uric acid
Monitor mental status often: affect, mood, behavioral changes: psychosis may occur
Instruct patient that compliance with dosage schedule, duration is necessary; that scheduled appointments must be kept
or relapse may occur

Advise diabetic patient to use blood glucose monitor to obtain correct result
Advise patient to report weakness, fatigue, loss of appetite, nausea, vomiting, yellowing of skin or eyes,
tingling/numbness of hands/feet
CORRELATION: It is essential part of the treatment of tuberculous meningitis.



Rifampin
CLASSIFICATION: antitubercular – rifamycin B derivative
MOA: inhibits DNA-dependent polymerase, decreases replication
USES: pulmonary TB, meningococcal carriers (prevention)
ADVERSE EFFECT: fatigue, drowsiness, confusion, nausea, vomiting anorexia, diarrhea, pseudomembranous colitis, heartburn,
pancreatitis, hematuria, acute renal failure, hemoglobinuria, hemolytic anemia, eosinophilia, thrombocytopenia, leucopenia, rash,
urticaria, weakness, ataxia
NURSING RESPONSIBILITIES:











Monitor renal status: before, qmo: BUN, creatinine, output, sp gravity urinalysis
Monitor mental status often: affect, mood behavioral changes; psychosis may occur
Monitor hepatic status: decreased appetite, jaundice, dark urine, fatigue
Assess for infection: sputum culture, lung sounds
C&S should be performed before beginning treatment, during, and after therapy is completed
Instruct patient that compliance with dosage schedule, duration is necessary
Instruct patient to notify prescriber if hepatitis, neutropenia, or thrombocytopenia occurs: sore throat, fever, bleeding,
bruising, yellow sclera, anorexia, nausea, vomiting, fatigue, weakness
Advise patient that urine, feces, saliva, sputum, sweat, tears may be colored red-orange; soft contact lens may be
permanently stained
Caution patient using oral contraceptives to use a nonhormonal method of birth control because rifabutin may decrease
the efficiency of oral contraceptives
Advise patient to avoid alcohol, hepatotoxicity may occur

CORRELATION: Rifampicin is typically used to treat Mycobacterium infections

PHYSICAL
ASSESSMENT

SYSTEM
INTEGUMENTARY SYSTEM

HEAD AND NECK

FINDINGS
Skin: Light brown, soft, even, flexible, warm, relatively dry with minimal perspiration and
oiliness, lifts easily and snaps back immediately to its resting position, no edema noted
Nails: nail bed is pinkish, nail plate is transparent, free edge is white with minimal dirt,
rounded, convex, 160 degrees, firm, rapidly returns to pink color (< 3 seconds)
Hair: black and evenly distributed
Head: upright and still, symmetrical to the rest of the body, smooth, round, no involuntary
movements, no edema, hydrocephalus noted head circumference is 46cm.
Eyebrows: symmetrical on appearance and movement, thin, no scaliness, equally
distributed, no lesions, no nodules, no tenderness, and no masses
Eyeball: sunset eyes noted and are drooping. Tenderness not noted for client is
unresponsive
Lacrimal and nasolacrimal ducts: no swelling and redness, no increased tearing and
tenderness
Visual acuity: unable to obtain data
Conjunctiva and Sclera: Palpebral is smooth, glistening, pale in color with minimal blood
vessels visible bulbar has globes which are clear with few underlying blood vessels and white
sclera visible, and sclera is China white
Cornea and Lens: cornea has no opacities or cloudiness, transparent, shiny and smooth, no
abrasions lens has no cloudiness
Iris: appears brown, flat and round with even color distribution
Pupils: black, round, equal in site in both eyes, eye receiving direct stimulus (light from
penlight) constricts briskly and opposite eye directly also constricts slowly. Rigidity seen upon
direct stimulus
Accommodation and Convergence: Convergence of eyes and constriction of pupil to
focus on a near object and dilation of pupil when looking at a far object cannot be obtained
Extraocular Movements: unable to obtain data
Ears: auricles are level with each other whose upright point of attachment is in straight line
with the lateral canthus on outer corner of eye, color is the same as that of the surrounding

CHEST/RESPIRATORY

CARDIOVASCULAR
BREASTS

skin (light brown), size is greater than 4 cm and smaller than 10 cm, symmetrical and almost
vertical without deformities, swelling, lesions, or nodules, auricles are soft and pliable and
nontender, canal is uniformly pink with tiny hair in its outer third with little serumen, appears
dry
Nose: proportion to other facial features and in the midline, shape is symmetrical and
consistent with age, gender, and race, symmetrical with other facial features, the same as
the surrounding skin, no deformities, nasal mucosa, septum, inferior and middle turbinates
are pink and moist with scant mucus, no exudates, bleeding and swelling; septum is close to
the midline, no tenderness and nodules. With nasogastric tube in place
Lips: Midline, symmetrical, skin slightly cracked, pale and dry, no unusual odor, soft,
nontender, no nodules, masses, and lumps
Oral mucosa and Gums: Mucosa is glistening, pink, soft, moist, smooth, and intact, no
bleeding or retraction, gums are pink, smooth, moist with a tight margin at each tooth no
edema, bleeding and lesions, tenderness, thickening or masses
Teeth: 20 teeth prominent, 10 on both upper and lower front teeth
Hard and Soft palate: unable to obtain data
Tongue: unable to obtain data
Oropharynx: unable to obtain data
Neck: Nuchal rigidity noted upon performing the technique and noted that it is positive
Posterior chest: unable to obtain data
Respiratory excursion: unable to obtain data
Anterior chest: rate = 34cpm, takes shallow breaths without use of accessory muscles
Respiratory excursion: unable to obtain data
Tactile fremitus: normal
S2 : rate = 120 bpm, rhythm: S1> S2 with no extra sounds S1: rate 10 bpm, rhythm S1< S2 with
no extra sounds upon auscultation
Breasts: color is the same as the surrounding skin (light brown), small with both breasts
equal in size, convex, no lesions, no discharge, no dimpling/retraction, nontender
Nipples and areola: pinkish, located on the 4th ICS, protruding and everted, no lesions and

no discharges
Axillae: light brown, no lesions, slight unusual odor
GASTROINTESTINAL/ABDOMEN

GENITOURINARY
MUSKULOSKELETAL

Hair distribution is equally and symmetrically distributed, skin intact, no lesions, no visible
striae. With Nasogastric tube in place Bowel sounds are audible with 7 clicks per minute,
tympany is heard in all quadrants and dullness is heard above organs upon percussion, no
masses and nontender upon deep and light palpation
No significant data noted on perineal area
unable to perform all the active ROM exercises from neck to toes, bedridden, and weak.
Positive for Brudzinski’s Sign and positive for Kernig’s sign

FUNCTIONAL HEALTH PATTERN

DEMOGRAPHIC DATA

Name: Quialquial, Aleafe J.

Civil Status: Child

Address: Brgy. 4 Siaton, Negros Oriental
Room and Bed No.:ICU

Religion: Roman Catholic

Doctor in charge: Dr. Ana Marie Yap

Nationality: Filipino
Date and Time Admission: 08/08/2014 @ 8:43pm

CC: Fever and seizures
Diagnosis: TB Meningitis
General Impression: Received lying in bed, awake and unresponsive to verbal stimuli with D5NM 1L @KVO at the right antecubital vein. Infusing
well and no inflammation on the site. Skin is intact, warm to touch, good skin turgor and no presence of lesion noted.

FUNCTIONAL HEALTH PATTERN

USUAL FUNCTIONAL PATTERNS
1.) Health perception – health management
pattern
 General health has been good
 Patient’s mother claimed that playing
and doing household chores is a form of
exercise
 Patient is not allergic to any food as
claimed by the mother
 Patient eats vegetables as claimed by

INITIAL APPRAISAL
DATE: September 3, 2014
 Experience fever for 2 days, seizure
episodes and vomited twice
 IVF D5NM @KVO
 Patient is unresponsive to verbal
stimuli
 Confined in the hospital for almost a
month now
 Vital signs:

ONGOING APPRAISAL
DATE: September 4, 2014
 Patient is unresponsive to verbal stimuli
 IVF D5NM @KVO
 Vital signs:
T = 37.4 °C
HR = 134 bpm
RR = 23 cpm
 PA of Chest:Thecolor of the chest is of
normal racial tone which is brown. Chest




the mother
Patient takes paracetamol every time
she has fever
Patient was able to complete her
vaccine as verbalized by the mother
Family has a history of hypertension,
goiter and cancer



T = 37.3°C
HR = 96 bpm
RR = 18 cpm
Medications:
INH 200mg/5ml 5ml OD 6a NGT
Rifampicin 200mg/5ml OD 6a NGT
PZA 500mg/5mL 2mL TID NGT
Cimetidine 85mg IVTT q6
Diazepam 4mg IVTT q6 PRN for
seizures
Paracetamol 200mg IVTT PRN for
T<38°C




2.) Nutritional-metabolic pattern
 Patient has no allergies on food as
verbalized by SO
 Patient eats 3 meals a day
 Patient started to eat solid foods at 6
months old as verbalized by SO
 Patient always eat vegetables and fish
as verbalized by SO
 Patient loves to eat toasted bread
dipped in milk or coffee
 No discomforts in eating/ diet
restrictions
 Drinks almost 10 glasses of water
everyday as verbalized by SO











Diet is through Nasogastric tube every
4 hours
D5NM 1L @KVO
Weight loss is evident
Appetite is not good due to illness and
not able to feed self
PA of the skin: The patent’s skin is
brown in color. Warm and good skin
turgor. No edema noted. The body hair
is evenly distributed.
Capillary refill is not good (>3sec.)
Observed to have dry nasal mucosa
Chest/Respiratory: takes shallow











wall are symmetrical, and the chest
expansion is symmetrical. Respiratory
rhythm is regular. The respiratory depth is
shallow. Respiratory pattern is normal.
The lung expansion is symmetrical. When
percussed the sound is resonance.
Respiratory rate is 23 cycles per minute
Medication
INH 200mg/5ml 5ml OD 6a NGT
Rifampicin 200mg/5ml OD 6a NGT
PZA 500mg/5mL 2mL TID NGT
Cimetidine 85mg IVTT q6
Diazepam 4mg IVTT q6 PRN for seizures
Paracetamol 200mg IVTT PRN for
T<38°C
No current laboratory results found
Diet is through Nasogastric tube 4 hours
D5NM 1L @KVO
No current weight scale reports
Not able to eat food by self and is still
weak
PA of the skin:The client’s skin is of
normal racial tone which is brown. It is dry
and warm. The skin turgor is good. The
body hair is evenly distributed. She
doesn’t have any edema.
Capillary refill is not good (>3sec.)
Observed to have dry nasal mucosa
Breathing with the use of accessory





Patient is in Formula-fed already.
Patients appetite is good before
hospitalization as verbalized by SO
Family member eat together as claimed
by the SO

3.) Elimination pattern
Bladder
 Patient usually urinates 6x per day as
verbalized by SO
 Urine is yellow in color
 No odor problems as claimed
 No pain in urination as claimed by SO
 Doesn’t use any assistive device as
claimed by SO
Bowel
 No difficulty and pain in defecating as
claimed
 Moves bowel once a day as claimed by
SO
 Stool is brown and well-formed as
verbalized by SO
 Patient is toilet trained as verbalized by
SO
Skin

breaths with use of accessory muscles.
 Clinical Laboratory report (08/09/2014
@1:58am)
WBC:
LYM: 5.1
LIC: 4.8
RBC:
HGB: 11.7 g/dL
HCT: 34.4%
MCV: 74
MCH: 25.3 pg
Bladder
 Pass on urine 2x/shift
 Urine color is yellow
Urinalysis
pH:6
Specific gravity: 1.030
Pus cells:8-10/hpf
 Patient does not use any diaper
because of rashes as verbalized by SO
Bowel
 Patient defecated once
 Stool is brownish
Skin
 Skin color is brown
 Temperature: 37.3°C
 No edema
 With lesions
 Slight perspiration noted on forehead

muscle

Bladder
 Pass on urine 2x/shift
Bowel
 Defecated once. Stool is yellowish and
watery.
 Patient does not use any diaper because
of rashes as verbalized by SO
 No urine analysis or fecalysis orders
asked for by her doctor
 PA of abdomen:Skin is of normal racial
tone which is brown, the contour is flat.
The bowel sound has no bruits. When
percussed the sound is tympany. The liver
is not palpable

 Skin color is brown
 Normal skin temperature
 No edema
4.) Activity-exercise pattern







Claimed to be physically strong
SO verbalized that client’s energy was
enough in completing his
desired/required activities.
Very active on play and is very
interactive
Spends time playing and taking naps
Perceived ability for self-care activity
with 0= independent, 1= assistive
device, 2= assistance from others, 3=
assistance from person and equipment,
4= totally dependent:
 FEEDING: Level 0
 BATHING: Level 0
 TOILETING: Level 0
 BED MOBILITY: Level 0
 DRESSING: Level 2
 GROOMING: Level 2
 GEN. MOBILITY: Level 2
 HOME MAINTENANCE: Level 2







Weak
Moved position every 2h as indicated
V/S:
Temp: T = 37.3°C
HR: 96 bpm regular in rhythm. PMI is
located at apical pulse
RR: 18cpm shallow and effortless
Perceived ability for self-care activity
with 0= independent, 1= assistive
device, 2= assistance from others, 3=
assistance from person and equipment,
4= totally dependent:
 FEEDING: Level 3
 BATHING: Level 2
 TOILETING: Level 2
 BED MOBILITY: Level 2
 DRESSING: Level 2
 GROOMING: Level 2
 GEN. MOBILITY: Level 2












Weak
Moved position every 2h as indicated
V/S:
Temp: 37.4°C
HR: 134 bpm regular in rhythm. PMI is
located at apical pulse
RR: 23cpm shallow
Positive Brudzinski’ sign
Postive for Kernig’s Sign
Positive for Nuchal Rigidity
Perceived ability for:
 FEEDING: Level 2
 BATHING: Level 2
 TOILETING: Level 2
 BED MOBILITY: Level 2
 DRESSING: Level 2
 GROOMING: Level 2
 GEN. MOBILITY: Level 2
PA of chest: The color of the chest is of
normal racial tone which is brown. Chest
wall are symmetrical, and the chest
expansion is symmetrical. Respiratory
rhythm is regular. The respiratory depth is
shallow. Respiratory pattern is normal.
The lung expansion is symmetrical. When
percussed the sound is resonance.

5.) Sleep – rest pattern
 Onset of sleep: 8 pm and sleeps 9
hours/day
 Awakening: 5:00 am. Is not restless at
night and does not experience having
difficulty in sleeping as verbalized by SO
 Is comfortable sleeping on a side-lying
and supine position with her father in
side
 Takes a nap if needed or upon after play
or felt tired
 No sleep-onset problems, and does not
use any sleep aids or devices
 Does not have any nightmares or early
awakenings
 Patient shares room with her parents as
verbalized

6.) Cognitive – perceptual pattern
 There is financial problems as
verbalized by SO
 Does not have any hearing difficulty.
 Very responsive and alert as stated by
SO
 Answers and talks very well to known














Sleeping patterns depends on hospital
activity
Onset of sleep: 10 pm
Found restless and SO stated sleeping
hours is about 10 hours per day with
short naps per day
Awakening: 10 am
Slept with light on
Appeared tired and has droopy eyes



Unresponsive to verbal stimuli
Glascow Coma Scale: 9
Behavior eye opening response:
spontaneously 4
Verbal response: No response 1
Motor response: Flexion withdrawal
from pain 4
Cerebellar function: Balance not intact,












Respiratory rate is 23 cycles per minute
Cerebellar function: Balance not intact,
bedridden Upper and lower extremities
are uncoordinated.
Sleeping patterns depends on hospital
activity
Onset of sleep: 9 pm
Found restless and SO stated sleeping
hours is about 6 hours per day with short
naps per day
Awakening: 6:00 am
Weak and appeared tired
Slept with lights on

Unresponsive to verbal stimuli
Weak
Glascow Coma Scale: 9
Behavior eye opening response:
spontaneously 4
Verbal response: No response 1
Motor response: Flexion withdrawal from
pain 4

SO
 Does not have any problems with vision
and does not wear any glasses/ contact
lenses
 Does not have any difficulty in learning
 Decision making is done by both
parents
 Stimulated through play
 Does speech in words
 With no pain problems
 Speaks and understands bisaya
 Educational attainment: Grade 1
7) Self-perception – self-concept pattern
 Describes herself as someone who is
understanding(parent)
 Child is active and competent as
claimed
 SO claimed that child’s personality is
friendly
 Mood Is usually altered depending on
what child is doing
 Ptient experienced temporary
separation from her parents for studying
 Patient is afraid when someone is
scaring her







cannot do heel and toe walk because
she is not responsive Upper and lower
extremities are uncoordinated. Stiffness
of the extremities seen



Cerebellar function: Balance not intact,
cannot do heel and toe walk because she
is not responsive Upper and lower
extremities are uncoordinated. Stiffness of
the extremities seen

Upon assessment client appears weak
and unresponsive
Face: slightly pale
No verbal interaction seen through
client and environment
Sudden exposure to nurses/doctors
creates fear to the patient
Mother directs patients attention
through soothing words and assurance



Upon assessment client appears weak
and unresponsive
No verbal interaction seen through client
and environment
Sudden exposure to nurses/doctors
creates fear to the patient
Mother directs patients attention through
soothing words and assurance





8.) Role – relationship pattern
 Lives with her family
 Family members is composed of 5
members
 Family and child interaction is good
 Interacts with people whom she knows
 Follow commands
 Has established close ties with her
neighbors and cousins
 Rate social activity as active and social
comfort as comfortable as stated by SO
 Parents are helping together in taking
care of their children
 Patient speaks bisaya as verbalized by
SO
 Decision made by both parents




9.) Sexuality – reproductive pattern
 genitals are fully developed
 No history of problems
 Has no problems with sexual
relationship and satisfied with sexual
functioning as evidenced by playing
dolls and any available toys at home as
verbalized by SO
 Patient wears appropriate clothing
 There are 5 in the family












Patient do not interact
Social activities are described as
limited due to disease condition and
somehow uncomfortable with social
situations in the hospital
Mother is very attentive to her needs
Her uncle is also there to attend her
needs
Decision making is done by both
parents
Finance is provided by both parents
and their relatives




Patient wears appropriate clothing
No problems aroused upon admission
related to genitalia
Vaginal bleeding not observed
Mother is very attentive to her needs











Patient is unresponsive
Social activities are described as limited
due to disease condition and somehow
uncomfortable with social situations in the
hospital
Both of her parents was there and was
very attentive to her needs
Decision making is done by both parents
Finance is provided by both parents and
their relatives

Patient wears appropriate clothing
Mother is very attentive to her needs
No problems aroused upon admission
related to genitalia
No further significant finding noted

10.) Coping stress tolerance pattern
 No tense all the time
 Child usually sleeps and play
 SO considers going out or playing with
palymates as an effective way of
handling/ resolving problems
 Usual handling of stress is good
 Satisfied with care receiving at home
 SO ask for support from her
husband/brother when she is feeling
stressed



11.) Value – belief pattern
 Goes to church every Sunday
 Religion: Roman Catholic
 Trust visayan practices
 Considers religion as an important thing
in their life
 SO Considers herself as someone who
is very religious
 SO doesn’t use herbal meds as
verbalized
 Prays when going to sleep
 Values health and family as verbalized












SO Feels a bit anxious about the
outcome of her child’s confinement but
is satisfied to care given to her
SO feels a bit bothered on her child’s
condition
SO observed to be quite tired



Considers fast recovery as something
of value during hospitalization as stated
by SO
Consider hospitalization as something
which will interfere with any religious
practices as stated by SO
SO claims that prayer helps him in
dealing with their problems
Thinks that admission interfere with his
plans in the future
Religion beliefs somehow helped deal
with problems as stated by SO










SO Feels a bit anxious about the outcome
of her confinement but is satisfied to care
given to her
SO feels so bothered on her child’s
condition

Considers fast recovery as something of
value during hospitalization as stated by
SO
Consider his hospitalization as something
which will interfere with any religious
practices as stated by SO
Claimed that they pray in the hospital
always
No further significant findings noted

NURSING
CARE PLANS

CUES AND
EVIDENCES
SUBJECTIVE:




Primary care
giver verbalized
“She is very
weak”
“Always sleeps”

OBJECTIVE:









V/S: T= 36.4°C
HR=120 bpm
RR=36 cpm
On O2 inhalation
via Nasal
cannula
regulated at 12L/min
Weak and
lethargic
Signs of
meningeal
irritation noted
through stiffness
of extremeties
Diet via NGT due

NURSING
DIAGNOSIS

OBJECTIVE

IMPLEMENTATION

Altered cerebral
perfusion related
to increased ICP

Within my 2-day
nursing care, client
will be able to
decrease signs of
increased ICP as
evidenced by:

1. Assess and
monitor
neurological
status of child
every 2-4 hours
and record,
weakness and
significant
changes



2. Monitor fluid
volume and
input and
output



Increase fluid
intake may
cause increase
in ICP

3. Monitor Vital
signs



4. Instruct SO for
Seizure
precautions,
proper
positioning of
child and



For baseline
purposes and
may indicate
any improving
complications
Prevent head
injuries and able
to stop further
complications

A. V/S within
normal range
T = 36.5-37.5
°C HR = 70100 bpm RR
= 20-35 cpm
B. Able to
respond on
the
environmental
stimuli
C. Weakness and
lethargy
unseen
D. Able to
participate and

RATIONALE

Identify signs of
improving
complications
and increase ICP

EVALUATION

Within my 2-day
nursing care,
client will be
able to decrease
signs of
increased ICP as
evidenced by:
A. Goal partially
met: V/S are
within normal
range
T = 37.4 °C
HR = 134 bpm
RR = 23 cpm
B. and C. Goal
not met:
Patient still
cannot move on
her own
D. Goal not met:
Patient still
cannot talk



to unable to
feed self by
mouth
Hematology
Hgb: 11.7
Hct: 34.4

complaint on
treatment and
interventions

prevention of
contractures
5. Note respiratory
status and
movements of
child



May need
resuscitation
and aspiration
precautions



Aide it
decreasing
muscle spasms
and convulsions



To prevent
further
complications to
arise

Collaborative:
6. Administer
anticonvulsants
and the like
7. Refer if
complications
persist and are
present

CUES AND
EVIDENCES
SUBJECTIVE:


Primary care
giver stated
“She is having
high fever every
night, her hands
and feet
stiffened”

OBJECTIVE:









HR= 134 bpm
RR=18 cpm
Turned and
positioned every
2h
Weak and
lethargic and is
unresponsive
Fed via
Nasogastric tube
Meningeal
irritation noted
via stiffness of
extremities

NURSING
DIAGNOSIS

OBJECTIVE

IMPLEMENTATION

RATIONALE

Infection: CNS
related to the
passage of
bacteria through
the Blood Brain
Barrier
secondary to TB
Meningitis

Within my 2-day
nursing care, client
will be able to
lessen infection as
evidenced by

1. Monitor for any
signs of infection



2. Monitor
laboratory
findings specially
on WBC, Hct, and
A. V/S within normal
Hgb
range of T =
36.5-37.5 °C HR
3. Monitor weight,
= 70-100 bpm
nutritional status
RR = 20-35cpm
and the like





B. Able to feed self
and seek comfort
C. Compliant in
treatment and
interventions

4. Teach SO to wear
mask or wear
any protective
D. Hematology
device to protect
reports normal
self from
value (Hgb: 11.5contamination of
15.5 g/dL, Hct:
the disease from
36-46%)
child
Collaborative:



May lead to
further
complications
Adequate way of
assessing for
systemic
infection
Assist in further
decline of
infection and
bring back
healthy state of
child
Mode of
transmission is
via nasal and
droplets

EVALUATION

Within my 2-day
nursing care, client
was able to lessen
infection as
evidenced by
A. Goal partially
met: V/S are
within normal
range
T = 37.4 °C
HR = 134 bpm
RR = 23 cpm
B. Goal not met:
Patient is still on
NGT feeding
C. Goal not met:
Patient still
cannot talk
D. Goal not met:
There are no
further lab test
ordered



Inhibit



Hematology
Hgb: 11.7
Hct: 34.4

5. Administer:
INH 200mg/5ml
3.0mL OD 6a
Rifampicin
200mg/s 3.0mL
OD 6a
PZA 500mg/5mL
1.0mL 3x a day
PO 8-4-6
6. Refer to physician
for further
complications
noted

production of
the bacteria and
kills forming
bacteria in the
circulation



Prevent further
complications

CUES AND
EVIDENCES
SUBJECTIVE:


Primary care
giver stated
“She always
sleep, cannot
move on her
own and her
hands and legs
stiffened”

OBJECTIVE:







Positioned every
2h
Fed via
Nasogastric tube
Stiffness of
upper and lower
extremities
maybe related
to meningeal
irritation
On seizure
precaution
On aspiration

NURSING
DIAGNOSIS

OBJECTIVE

Impaired Physical
Mobility related
to general
weakness and
neurologic deficit
secondary to TB
meningitis

Within my 2-day
nursing care, client
will be able to
mobilize as
evidenced by;
A. Maintain
optimal
mobilization on
extremities
B. Intact skin with
good skin
turgor, nontender and skin
breakdown not
noted
C. Decreased
atrophy of
muscles not
noted
D. Contractures
are lessened or
not noted

IMPLEMENTATION

1. Assess and
monitor for
ability to
mobilize

RATIONALE

EVALUATION



Hemiparesis
may occur to
this clients



Avoid skin
damage
promoting skin
and tissue
integrity

Within my 2-day
nursing care, client
was able to lessen
infection as
evidenced by:

2. Position client
every 2h

3. Perform
massage on
depressed parts
of body
4. Perform passive
ROM

5. Monitor for
complications,
constipation
and any bed
sores







Promote
circulation on
affected part
preventing
atrophy
Prevention of
contractures and
atrophy of
muscles
Complications of
immobility may
arise

A. Goal not met
B. Goal met: Good
skin turgor snaps
back less than 3
sec.
C. Goal not met:
Atrophy of
muscles still noted
on extremities
D. Goal not met
E. Goal met: S/O
able to fed
through NGT with
supervision

precaution
E. S/O
understands
and
demonstrate
proper NGT
feeding and the
rationale of
aspiration
precaution

Collaborative:
6. Refer to
physician if
further
complication
arise



Prevent further
complications

CUES AND
EVIDENCES
SUBJECTIVE:


Primary care
giver verbalized
“She cannot
speak and
cannot move on
her own”

OBJECTIVE:






Mouth forcedly
closed
Glasgow Coma
Scale: Verbal
response= No
response 1,
Motor
Response=
flexion
withdrawal from
pain 4
Weak and
lethargic
Signs of
meningeal

NURSING
DIAGNOSIS
Impaired verbal
communication
related to
neuromuscular
impairment

OBJECTIVE

IMPLEMENTATION

Within my 2-day
nursing care, client
will be able to
decrease signs of
aphasia

1. Assess and
monitor
neurological status
of child every 2-4
hours and record,
weakness and
significant changes



2. Monitor fluid
volume and input
and output



A. Able to open
mouth calmly
B. Able to make
small sound or nod
C. Able to flex or
extend extremities
without pain

3. Monitor Vital
signs

RATIONALE



D. Able to raise
hands for help
4. Instruct SO for
Seizure
precautions,
proper positioning
of child and
prevention of
contractures





Identify signs of
improving
complications

Increase fluid
intake may
cause increase
in ICP
For baseline
purposes and
may indicate
any improving
complications
Prevent head
injuries and able
to stop further
complications

May need
resuscitation

EVALUATION

Within my 2-day
nursing care, client
was able to lessen
infection as
evidenced by:
A. Goal not met:
Patient is still on
NGT feeding
B, C, and D. Goal
not met:
Patient still weak
and unresponsive
to verbal stimuli



irritation noted
through stiffness
of extremities
Diet via NGT due
to unable to
feed self by
mouth

8. Note respiratory
status and
movements of
child

and aspiration
precautions



Aide it
decreasing
muscle spasms
and convulsions



To prevent
further
complications to
arise

Collaborative:
9. Administer
anticonvulsants
and the like
10. Refer if
complications
persist and are
present

CUES AND
EVIDENCES
SUBJECTIVE:


Primary care
giver verbalized
“She is very
weak, she
cannot move on
her own”

OBJECTIVE:







Turned and
positioned every
2-4 hrs.
Weak and
lethargic
Signs of
meningeal
irritation noted
through stiffness
of extremities
Skin is dry

NURSING
DIAGNOSIS
Risk for
Impaired Skin
Integrity
related to
general
debilitation

OBJECTIVE

Within my 2-day
nursing care, client
will be able to
maintain intact skin
as evidenced by:
A. S/O
understands
and
demonstrate
proper postural
drainage
B. Absence of
weakness
C. Stiffness of
extremities
decreases
D. Skin is intact,
moist and skin
turgor is good
(<3sec)

IMPLEMENTATION

1. Monitor fluid
volume and input
and output
2.Monitor Vital
signs

RATIONALE

EVALUATION



Increase fluid
intake may
cause increase
in ICP



Within my 2-day
nursing care, client
was able to lessen
infection as
evidenced by:

For baseline
purposes and
may indicate
any improving
complications


3. Inspect skin,
tissues and mucous
membranes
routinely
4. Anticipate and
use preventive
measures in clients
who are at risk of
skin breakdown
5. Change positions
every 2-4hrs.



Provides
opportunity for
early
intervention



Decubitus ulcers
are difficult to
heal and
prevention is
best treatment



Improve
circulation,
muscle tone and
joint motion

A. Goal partially
met: S/O
reported
turned and
positioned
the client
every 2-4 hrs.
B. And C. Goal
not met:
Weakness still
noted
D. Goal partially
met: skin is
intact and skin
turgor is good
(<3sedc)

6. Use a rotation
schedule in turning
client.



Allows for longer
periods free of
pressure

CUES AND
EVIDENCES
SUBJECTIVE:


Primary care
giver verbalized
“She doesn’t
take any
vitamins”

OBJECTIVE:
 Weight: 17.2 kg
(7yrs ols= )
 Weak and
lethargic
 Poor muscle
tone
 Signs of
meningeal
irritation noted
through stiffness
of extremities
 Skin is dry
 Diet via NGT

NURSING
DIAGNOSIS

OBJECTIVE

IMPLEMENTATI
ON

Altered Nutrition:
Less than body
requirements
related to
insufficient
dietary intake

Within my 2-day
nursing care, client
will be able to
demonstrate
weight gain as
evidenced by:

1. Monitor fluid
volume and input
and output



Increase fluid
intake may cause
increase in ICP

2. Monitor Vital
signs



For baseline
purposes and may
indicate any
improving
complications

A. Weight
appropriate for her
age (7yrs. Old= )
B. Absence of
weakness
C. Skin is intact and
smooth
E. S/O able to
demonstrate and
understands the
rationale of NGT
feeding

RATIONALE


3. Assess weight,
age, body build,
strength,
activity/rest level.
4. Evaluate
energy
expenditure.

5. Recommend
monitoring
weight weekly

Baseline data

EVALUATION

Within my 2-day
nursing care, client
was able to lessen
infection as
evidenced by:
A. Goal not met:
Weight: 17.2 kg
B. Goal not met:
weakness still
noted and not able
to move in her bed
alone



Activity level
affects
nutritional needs

C. Goal partially
met: Skin is intact
and warm to touch



Provides
information
regarding
effectiveness of
dietary plan

D. SO verbalized
the rationale of
NGT feeding

CUES AND
EVIDENCES
SUBJECTIVE:


Primary care
giver verbalized
“She is very
weak, she has
fever and
vomited twice
prior to
admission”
“She avoids
noise or
someone who is
shouting”



OBJECTIVE:






T = 37.4 °C
HR = 134 bpm
Wrinkled
eyebrow
Weak and
lethargic
Droopy eyes

NURSING
DIAGNOSIS

OBJECTIVE

Acute headache
pain related to
increase cerebral
vascular pressure

Within my 2-day
nursing care, client
is able to relieved
discomfort as
evidenced by:
A. V/S within
normal range T =
36.5-37.5 °C HR =
70-100 bpm RR =
20-35 cpm
B. Able to smile
C. Able to move
simple movements
D. Able to move
head slowly
E. Absence of
droopy eyes

IMPLEMENTATIO
N

RATIONALE

1. Monitor fluid
volume and input
and output



Increase fluid
intake may cause
increase in ICP

2. Monitor Vital
signs



For baseline
purposes and may
indicate any
improving
complications

4. Encourage/
maintain bedrest
during acute
phase



Minimizes
stimulation/promo
tes relaxation



Activities that
increase
vasoconstriction
accentuate the
headache in the
presence of
increased cerebral
vascular pressure.

5. Eliminate/
minimize
vasoconstricting
activities that may
aggravate
headache

Collaborative:
6. Administer
Analgesic:



Exhibits analgesic
action by
peripheral

EVALUATION

Within my 2-day
nursing care, client
was able to lessen
infection as
evidenced by:
A. Goal partially
met: V/S are
within normal
range
T = 37.4 °C
HR = 134 bpm
RR = 23 cpm
B. Goal not met:
wrinkled
eyebrows still
noted
C. and D. Goal
not met:
Weakness
still noted
E. Goal not met:
Droopy eyes
still noted

Paracetamol
200mg IVTT
7. Refer if
complications
persist and are
present



blockage of pain
impulse
generation
To prevent further
complications to
arise

JOURNAL 1:Presentation and outcome of tuberculous meningitis in adults in the
province of Castellon, Spain: a retrospective study
The aim of this study was to describe the epidemiological and clinical features of tuberculous meningitis in the province of
Castellon, Spain. Retrospective analysis was done of all cases attended during the last 15 years. The following groups of variables
were assessed: sociodemographic data, medical antecedents, clinical presentation, imaging study results, analyses, cerebrospinal
fluid microbiology, treatment, and outcome. Twenty-nine cases were included. Median of age of patients was 34 years, and 17
(59%) were males. HIV infection was present in 15 cases (52%), fever, the most common symptom, occurred in 27 (93%), nuchal
rigidity was noted in only 16 (55%), and syndrome of inappropriate ADH secretion (SIADH) occurred in 13 cases (45%). Chest
radiograph was abnormal in 15 cases (52%). Anaemia was found in 22 subjects (76%), hypoalbuminaemia in 18 (62%) and
hyponatraemia in 15 (52%). Macroscopic aspect of cerebrospinal fluid was normal in 17 cases (65%). Acid-fast stain was positive in
only one case (4%). Two patients presented resistance to anti-tuberculous medications. Twelve patients (41%) died and eight
(28%) presented sequelae. An association was found between death as outcome and presence of SIADH and lower level of serum
cholesterol. Tuberculous meningitis is a rare and frequently difficult to recognize disease, which results in significant morbidity and
mortality. We found an association of mortality with SIADH and lower level of serum cholesterol.

Reaction:
Due to the characteristics of the present study, with a relatively small number of cases, and a retrospective design, the
researchers may have failed to identify other important prognostic factors. In brief, our study shows that TM is a rare and
frequently difficult to recognize disease, which results in significant morbidity and mortality.

JOURNAL 2:Dexamethasone for the Treatment of Tuberculous Meningitis in
Adolescents and Adults
The results of this study show that adjunctive treatment with dexamethasone improved survival in patients over 14 years of
age with tuberculous meningitis, but when the outcome measure was broadened to death or severe disability, there was no
significant benefit. Meta-analysis of previous data is difficult, given variable methods of outcome assessment, loss to follow-up,
and small numbers of survivors, but earlier studies suggested that corticosteroids reduced disability.We assessed disability by
means of two scores that have been well validated for the assessment of outcomes after stroke in the developed worldbut not for
other diseases in different settings. We sought to reduce intraobserver and interobserver variability by training four experienced
Vietnamese physicians to assess all survivors, and there was excellent agreement in the scores they assigned. However, the
scores may have lacked discriminative power in this setting, and we may have failed to detect a true effect. Data concerning focal
neurologic sequelae suggest this failure is unlikely — dexamethasone did not affect the incidence or resolution of hemiparesis,
paraparesis, or quadriparesis, which are the most common causes of severe disability due to tuberculous meningitis. Previous
smaller studies have reported similar findings; the authors hypothesized that corticosteroids exert an effect by reducing basal
meningeal inflammation and brain-stem encephalopathy but do not modify infarct-causing periarteritis.
Reaction:
Dexamethasone may improve outcomes by reducing the frequency of adverse events that necessitate a change in the
antituberculosis-drug dose or regimen (such change was an independent risk factor for death in our study) — severe clinical
hepatitis, in particular. Studies of pulmonary tuberculosis showed that corticosteroids reduced the incidence of severe drughypersensitivity reactions, but this effect has not been documented for other forms of tuberculosis and is not widely recognized.
No increase in corticosteroid-related adverse events was observed in our study.

JOURNAL 3:Corticosteroids for managing tuberculous meningitis
Tuberculous meningitis usually presents with headache, fever, vomiting, altered sensorium, and sometimes convulsions. It is
diagnosed clinically with confirmation by microscopy, culture of cerebral spinal fluid, or the polymerase chain reaction test.
Disability in tuberculous meningitis is multifactorial. Some of the important causes of disability are persistent or progressive
hydrocephalus, involvement of the optic nerves or optic chiasm in the supracellar region, vasculitis leading to cerebral infarcts and
stroke, multiple cranial neuropathies, and arachnoiditis.Disability related to antituberculous treatment most often occurs as
ethambutol-induced toxic optic neuritis, which may be irreversible, or isoniazidrelated peripheral neuropathy. Tuberculous
meningitis can be classified according to its severity. The British Medical Research Council (MRC) use three stages (MRC 1948):
stage I (mild cases) is for those without altered consciousness or focal neurological signs; stage II (moderately advanced cases) is
for those with altered consciousness who are not comatose and those with moderate neurological deficits (eg single cranial nerve
palsies, paraparesis, and hemiparesis); and stage
III (severe cases) is for comatose patients and those with multiple cranial nerve palsies, and hemiplegia or paraplegia, or both.

Reaction:
Corticosteroids should be routinely used in HIV-negative people with tuberculous meningitis to reduce death and disabling
residual neurological deficit amongst survivors. However, there is not enough evidence to support or refute a similar conclusion for
those who are HIV positive.

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