Ineffective breathing pattern related to the emphasis on the central respiratory regulation
Goal :
1. Long-term goal
Effective breathing pattern.
2. Short-term goals
Breathing pattern gradually improved
Outcomes:
- Frequency breath : normal 16-20x/menit
- Breath rhythm : regular
1. Assess and monitor the frequency of the pattern and rhythm of the breath.
rational :
Ineffective breathing pattern changes a sign of an increase in intracranial pressure weight that presses the medulla oblongata.
2. Maintain effective airway by performing airway clearance such as suctioning and oral hygiene.
rational :
Excessive mucus will accumulate and lead to airway obstruction.
3. Give oxygenation appropriate order and monitor the effectiveness of oxygen administration.
rational :
To meet the need of oxygen in the blood and tissues.
4. Maintain airway patency with neck and neutral position.
rational :
Position neck extension / bending resulted obstructed airway.
Nursing Diagnosis II
Hyperthermia related to inflammation of the meninges
Goal :
1. Long-term goal
Body temperature within normal limits
2. Short-term goals
Body temperature gradually improved
Outcomes:
- The client is able to mobilize .
- The body temperature of 36-37 ° C, reduced perspiration.
1. Give cold compress on the area's many blood vessels until the temperature returns to normal.
rational :
Cold compresses can cause conduction process where there is heat transfer from one object to another by physical contact between the two objects.
2. Instruct the client to wear thin and absorbs sweat.
rational :
With thin clothing facilitate the absorption of sweat and gives a sense of comfort.
3. Observation vital signs : temperature, blood pressure, respiration and pulse.
rational :
To find out more action to be done.
4. Collaboration of antipyretic therapy.
rational :
Antipyretics inhibit heat on hypothalamic function.
Nursing Diagnosis III
Risk for impaired skin integrity related to prolonged bed rest
Goal :
1. Long-term goal
Impaired skin integrity is not happening
2. Short-term goals
Signs of impaired skin integrity is not happening
Outcomes:
- No signs of impaired skin integrity such as : redness and blisters on the skin.
1. Set and change the position of the patient's sleep , every 2 hours.
rational :
Can reduce the pressure that causes continuous optimal circulation in the area of emphasis.
2. Give bearing on areas of the body and are prominent on the surface of the bed.
rational :
With a bearing on area of emphasis is given to reduce the pressure of circulation effects which are not smooth.
3. Do a massage every day.
rational :
Massage action as a stimulus for vasodilatation to vascular kontriksi on the surface so that the experience will help the circulation in the area.
4. Observation sign decubitus like blisters , redness on elbows , heels and back area every day.
rational :
If found signs of decubitus immediately take action to anticipate the occurrence of excessive tissue damage.
Nursing Diagnosis IV
Self - care deficit related to changes in the central nervous system , physical weakness
Goal :
1. Long-term goal
Self-care are met
2. Short-term goals
Less care is gradually being met.
Outcomes:
- Daily activities can be conducted of patients, while pain and can be performed after discharge from the hospital.
- Body weight did not decrease.
- Intact skin.
- Normal bowel and bladder.
1 . Observation of the patient's level of function.
rational :
Determine the patient's level of need.
2. Instruct the patient to express his feelings about his inability to perform self-care.
rational :
Assist patients in getting a better level of functioning.
3. Provide assistance and support as needed such as bathing, defecation and urination, hygiene , dressing and eating.
rational :
Will increase the feeling of independent (standalone).
4. Give all measurements / tools and food hygiene.
rational :
To save energy.
5. Maintain indwelling catheter if necessary.
rational :
To empty the bladder in a patient unconscious.
