Physical Assessment

In this essay, case of Sophia is discussed. Sophia is nine year old girl admitted to emergency department with complains like lethargy, less eating and drinking and headache. She was diagnosed with Haemophilus influenzae type b meningitis. Physical assessment was performed in Sophia. Based on the physical assessment potential problems were identified in Sophia. Assessment and management for these problems is discussed. Step wise procedure for management of Haemophilus influenzae type b meningitis is discussed. Aspects to be considered in provision of family centered care are also discussed.

Physical assessment of the patient provides information about the complete health status. Nurse can apply different techniques for physical assessment like observation, inspection, palpation, percussion and auscultation. Nurse performed physical assessment in Sophia.  Her heart beats were 70 beats per minute. These heart beats were in the lower range for children of Sophia’s age. In her age group, heart beat should be in the range of 70-110 heart beats. Her blood pressure was 120/60 mmHg. Her diastolic blood pressure was normal however systolic blood pressure was towards slightly higher side. Her respiratory rate is 11 breaths per minute and it was normal. There was no abnormality in her breathing and she needs not to put extra efforts for breathing. Her oxygen saturation level is also normal. This cardiopulmonary assessment is important in case of Sophia because due to infection there may be occurrence of sepsis. Sepsis is a systemic inflammatory response syndrome (Ahmed et al., 2013).  Meningitis In A Nine Year Old Girl Case Study

Due to occurrence of sepsis there is possibility of reduced blood pressure, rapid heart rate, abnormal temperature and increased breathing rate. Blood clotting in meningitis patients is also responsible for pulmonary complications. Blood clotting leads to insufficient blood supply to organs and consequent hypoxia. This hypoxia increases demand of oxygen and lung starts breathing at faster rate. Purpuric rash over trunk was observed in Sophia. This rash may be due to purpulish discoloration of the skin due to small bleeding vessels. This purpuric rash occurs due to infection. Lips pink with dry mouth was observed in Sophia. Pink lips may occur in Sophia due to anemia. In the literature it is mentioned that anemia in H influenzae meningitis is predominantly higher as compared to other types of meningitis. Tacky mucous membrane observed in Sophia. This tacky mucous membrane generally occurs due to the anemia. Gastrointestinal observations in Sophia were normal. Her abdomen was soft without tenderness and distension. Her bowel sounds were normal. There were no scars on her abdomen. Skin assessment for color, turgor, lesions, bruising and wound is important component of the physical assessment (Ronit et al., 2013).

In Sophia, tenting skin turgor was observed. Skin turgor is generally used for evaluating dehydration in the patient. If skin turgor remains for more than few seconds, it is considered as tenting skin turgor. Her skin was pale. Inflammation of the brain and blood vessels along with clot formation in the veins lead to the overall weakness, loss of sensation and inability in movement in extremities. Movement of most of the extremities was also reduced in Sophia. Meningitis causes acquired brain injury. As a result, there was behavioural changes in Sophia. These behavioural changes include irritability, trouble in concentrating and sleep disorders. Menigitis patients are generally intolerant to voice and respond to it aggressively. Sophia was also responding to voice. Due aches and weakness of muscles in meningitis patients, there can be occurrence of sluggishness in these patients. Sophia was also experiencing sluggishness. Neck become stiff and painful. Hence, it is difficult to move it. Eating and drinking decreased in Sophia due to meningitis. Her bowel opening was normal, however her urine output was completely diminished. Physical assessment of Sophia indicated that she was suffering through different physical, behavioral, psychological and social problems. Physical support can be provided to her by assisting her in daily activities. Due to movement problem and fatigue, she would not be able to perform her daily activities. Sophia was exhibiting irritable behavior. This irritable behavior can be managed with the help of social worker or psychiatric. Emotional support should be provided to Sophia and her family members. This emotional support would also be helpful in relieving stress on Sophia and her family members. Sophia may fill fear of social isolation due to diseased condition. Confidence should be given to her that society would support her in recovering from this disease (Ball et al., 2014).

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Problems

Two problems identified in Sophia are kidney problem and chronic fatigue. In physical assessment also these two problems were predominantly evident. Due to kidney problem, there is less urine output in Sophia. Prioritization of the kidney problem in Sophia is very important because urinary retention is rare but very prominent manifestation of the meningitis. Use of urethral catheter on immediate basis and intermittent clean catheter is very important because urinary retention has good prognosis. In the initial phase of the meningitis, it is difficult to observe typical meningitis symptoms and neurological signs. In such scenario, urinary obstruction can be considered as important clue for meningitis. Urinary retention generally occurs in meningitis patients due to urinary bladder obstruction and impaired detrusor muscle contractibility. Urinary retention cannot be considered as the symptom of meningitis.  This occurrence of urinary retention along with meningitis is generally termed as meningitis-retention syndrome. This urinary retention occurs in the young people generally after 8-9 days of meningitis. Urethral catheterization is the first choice for the treatment of urinary retention. In urinary retention, there is atonic or hypotonic neurogenic bladder and intact bladder sensation at the time of bladder filling phase. This lead to impaired bladder contractibility. As a result, there is difficulty in voiding and it lead to urine retention (Roberton and  South, 2007).

Urinary obstruction occurs due to neurogenic bladder. There is alteration in the neurogenic bladder due to infection and inflammatory demyelination in the peripheral or central nervous system. These patients are mainly associated with the severe suprapubic pain. Lower abdominal distention is one of the features of these patients, however in Sophia lower abdominal distension was not observed. Nurse should plan for tests to understand reasons behind urinary retention in Sophia. Nurse should order for tests like blood cell count, erythrocyte sedimentation rate, C-reactive protein, and urinalysis. Nurse should order for blood and urine culture examinations. Nurse should evaluate Sophia’s medical history for urine retention, structure of urethra, hematuria, diabetes and history for urethral surgery. Nurse should perform digital rectal examination. This digital rectal examination gives idea about the size and shape of prostate. Nurse should evaluate hardens and tenderness by palpitation. Fluid management is the prominent intervention to be provided to the Sophia. Oliguria mainly occurs due to intravascular hypovolemia. In such patients on time and sufficient resuscitation is required. It includes isotonic ringer solution for 30 mniutes. With the administration of isotonic ringer solution, urine output should be increased in approximately 5-6 hours. If oliguria continues after 6 hours also, nurse should undertake central nervous monitoring for further evaluation. At 6 hours, oliguria should be monitored using urethral catheter. Nurse should keep daily records of input and output, daily weight, physical examination and sodium levels (Avner et al., 2004).

Hyperkalemia can be managed with restricting potassium intake and improving utilization of potassium by cells. This utilization of potassium by cells can improved by administering sodium bicarbonate. This sodium bicarbonate can be useful in treating mild acidosis. Hypertension patients with urine retention can be treated with oral or sublingual calcium channel blockers and intravenous hydralazine. In severe case dialysis should be performed. This dialysis is useful in removing toxins and maintaining optimum acid-base balance. Obstruction of the urinary bladder neck should be removed by slight insertion of urethral catheter. Obstruction of urinary bladder can also be managed by endoscopic ablation of urethral valves (Menkes et al.,2006).

Fatigue in meningitis patients is generally of benign type. After recovery of patient from meningitis also, there is possibility of abnormal fatigue in the patient. In the previous studies it was established that fatigue and headache can arrive after three months of meningitis recovery and can sustain upto 1 year. Fatigue problem in meningitis is a long term problem. Even though in the initial phase severity of this problem is not evident, its consequences would be more in long term. Hence, attention should be given to the management of fatigue in the initial phase. Management of fatigue is very important because it can affect quality of life of Sophia. Fatigue would definitely affect daily activities of Sophia. Nurse should identify, fatigue score in Sophia. This quantitative score of fatigue would be helpful in deciding type of intervention and management to be provided to Sophia. Nurse should identify reason behind fatigue in Sophia. In case of Sophia, fatigue may be due to less food intake and anemia. Due to infection, there would be less red blood cells (RBC) production and destruction of existing RBCs in Sophia. Red blood cells carry hemoglobin which contains iron. Hemoglobin helps red blood cells to carry oxygen from lung to blood and carbon dioxide from blood to lungs. Due to less oxygen to muscles there is less production of ATP (McGregor et al.,2000).

There is also less supply of oxygen to brain, heart, muscles and other organs. As a result these less energy is available with these organs. Due to this person feels fatigued. Fatigue can also be developed in Sophia due to central mechanisms. Due to infection and inflammation there raised levels of cytokines in Sophia. Due to these cytokines, there may be alteration in the neuroimmune interaction which may lead to the neural plasticity and altered circuity. Another factor responsible for fatigue in Sophia is cachexia. Cachexia is a condition in which there is malnutrition, body weight loss and muscle wasting (Wang, 2008).

Hence, nurse should ask her to increase her food intake. Nurse should administer her medicine for anemia. Nurse should implement collaborative plan to Sophia for management of fatigue. Nurse should evaluate her activities of daily living and accordingly assist in her activities. Nurse should evaluate blood glucose level, hemoglobin, blood urea nitrogen (BUN) and oxygen saturation. In case of abnormality in these parameters nurse should take corrective measures for thes particular parameter.  Nurse should evaluate sleeping pattern of Sophia and remove external stimuli during her sleep. Sophia should perform her activities based on the fatigue level. Sophia should incorporate compulsory rest period during her activities. Sophia should set her priorities for performing activities. Sophia should have balanced nutrition comprising of fats, carbohydrate, proteins, vitamins and minerals. Nurse should provide massage and cool showers for Sophia. Nurse should teach Sophia and her family members about signs and symptoms of fatigue. Studies have shown that consumption of polyunsaturated fats and adenosine triphopspahte (ATP), are helpful in improving fatigue condition (Scheld et al., 2014; Manno, 2012).

Management of meningitis should incorporate both primary care and emergency medicine. Physician should incorporate experts from different fields like infectious disease specialist, neurologist and neurosurgeons for management of meningitis. By virtue of this physician can provide care to infection and nervous pathology in meningitis. Initial management of meningitis depends on the early recognition of disease, rapid diagnostic assessment and emergence of antimicrobial and adjuvant therapy.  Initial diagnosis should be initiated with the blood culture. Lumbar puncture should also be performed to confirm infection in the cerebrospinal fluid (CSF). In some patients due to difficulty in obtaining CSF, physician prefers to perform CT scan prior to analysis of CSF. This CT scan would be helpful in detecting nervous system lesions. In case, there is delay in CSF analysis or CT scan, physician should initiate antimicrobial therapy. This would be helpful in prevention of spread of infection. Along with antimicrobial therapy appropriate adjuvant therapy also should be initiated. Delay in initiating of therapy could also lead to morbidity and mortality, if patient has severe infection. Antimicrobial therapy should be planned according to the age of the patient. Initiation of treatment prior to CSF analysis may some time lead to undetectable levels of microorganisms in the CSF. In such cases, specific diagnostic tests should be performed for CSF samples. After the detection of the microorganisms, treatment should be modified based on the requirement (Tunkel et al., 2004).

Family centered care is important component of children’s nursing intervention because children don’t have much understanding about health and diseases. Nurse should enquire about Sophia’s health issues, food habits and psychological issues from her family members. Nurse should plan nursing intervention for Sophia based on this information. By virtue of this nurse can provide holistic care to Sophia. Nurse should promote family members of Sophia to give her morale support and emotional stability. This support from family members would help Sophia to face social consequences. Nurse should give confidence to family members of Sophia that with proper medication and other allied care, her condition could be definitely improved (Chalmers, 2017).

Nurse should incorporate family members in planning nursing care for Sophia. Nurse should provide education to the family members for improving urine output and managing anaemia. Nurse should also provide education to family members about management of fatigue. Nurse should prepare activity and sleep patterns for Sophia with the help of family members. Nurse should advise family members to maintain proper hygienic condition because, infection can exaggerate her diseased condition. Nurse should advise her family members to administer plenty of fluid to Sophia. It would be helpful in improving urine output in her. This understanding of the disease condition by family members would definitely be helpful in relieving stress on the family members (Barnsteiner et al., 2014).

Nurse should know strengths and weaknesses of Sophia and her family members. Nurse should provide correct health information of Sophia to her family members. Nurse should consider cultural and socioeconomic factors while providing nursing intervention to Sophia. Nurse should promote Sophia for hospitalization with the help of her parents because children generally would not prefer to join hospital for treatment. Nurse should maintain confidentiality of her diseased condition and hospitalization, so that Sophia would not face social consequences (Shaul, 2014; Watson and Rodwell, 2014).

Conclusion:

 Sophia is diagnosed with Haemophilus influenzae type b meningitis. Few of her physical symptoms supports occurrence of Haemophilus influenzae type b meningitis in Sophia. These symptoms include irritability, inability for movement, purpuric rash, pink lips, dry mouth, tacky mucous membranes, pale skin, reduced eating and drinking, sluggishness and reduced urinary output. From this fatigue development and kidney dysfunction are the two problems identified in Sophia. With stepwise approach for assessment and management, best practice can be provided for Sophia. Family centered care is very important aspect for children like Sophia. It can be concluded that implementation of evidence based care and follow up would definitely be helpful in improving condition of patient with Haemophilus influenzae type b meningitis.

References:

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