NCPASSESEMENTDIAGNOSISBACKGROUND KNOWLEDGEPLAN OF CAREINTERVENTIONRATIONALEEVALUATION

SUBJECTIVE:

OBJECTIVE:

Ineffectivebreathingpatternrelated to the emphasis on the central respiratory regulation*Assess and monitor the frequency ofthe patternand rhythm of the breath.

*Maintain effective airway by performing airway clearance such as suctioning and oral hygiene.

*Give oxygenation appropriate order and monitor the effectiveness of oxygen administration.

* Maintain airway patency with neck and neutral position.rational :

*Ineffectivebreathingpattern changes a sign of an increase in intracranial pressure weight that presses the medulla oblongata.

* Excessive mucus will accumulate and lead to airwayobstruction

* To meet the need of oxygen in the blood and tissues.

*Position neck extension / bending resulted obstructed airway.

ASSESEMENTDIAGNOSISBACKGROUND KNOWLEDGEPLAN OF CAREINTERVENTIONRATIONALEEVALUATION

OBJECTIVE:

Hyperthermiarelated to inflammation of the meninges *Give cold compress on the area's manyblood vesselsuntil the temperature returns to normal.

*Instruct the client to wear thin and absorbs sweat.

*Observation vital signs : temperature, blood pressure, respiration and pulse.

*Collaboration of antipyretic therapy.

* Cold compresses can cause conduction process where there is heat transfer from one object to another by physical contact between the two objects.

* With thin clothing facilitate the absorption of sweat and gives a sense of comfort.

* To find out more action to be done.

*Antipyretics inhibit heat on hypothalamic function

ASSESEMENTDIAGNOSISBACKGROUND KNOWLEDGEPLAN OF CAREINTERVENTIONRATIONALEEVALUATION

OBJECTIVE: