No.

1.

Nursing Diagnoses
Risk for ineffective cerebral
tissue perfusion. (Domain 4.
Activity/Rest, Class. 4
Cardiovascular/Pulmonary
Responses, Code 00201).
Possibly evidenced by:
a. Embolism
b. Cerebral aneurysm
c. Hypertension

NOC (Nursing
Outcomes
Classufication)
Tissue Perfussion:
Cerebral 0406
1. Intracranial
pressure (5)
2. Headache (5)
3. Restlessness (5)
4. Decreased level of
consciousness (5)
Tissue Perfusion:
Cellular 0416
1. Systolic blood
pressure (5)
2. Diastolic blood
pressure (5)
3. Oxygen saturation
(5)
4. Fluid balance (5)
5. Apical heart rate
(5)
6. Heart rhythm (5)
7. Pain (5)
8. Decreased level of
consciousness (5)
Neurological Status
0909
1. Central motor
control (5)
2. Cranal sensory and
motor function (5)
3. Spinal sensory and
motor function (5)
4. Intracranial
pressure (5)
5. Pupil size (5)
6. Pupil reactivity (5)
7. Eye movement
pattern (5)
8. Breating pattern

NIC (Nursing
Interventions
Classification)

Implementation

Embolus Precautions 4110

Embolus Precautions 4

1. Elicit a detailed patient

health history to
determine risk level of
patient (e.g., recent
surgery, bone fractures,
current cancer
treatment, pregnancy,
postpartum, immobility,
paralysis, edematous
extremities, COPD,
stroke, CVAD, history
of previous DVT or PE,
or obesity put patients at
high risk)
2. Evaluate for the
presence of Virchows
triad: venous stasis,
hypercoagulability, and
trauma resulting in
intimal damage
3. Perform a
comprehensive
appraisal of pulmonary
status
4. Administer prophylactic
low-dose anticoagulant
and/or antiplatelet
medication (e.g.,
heparin, clopidogrel,
warfarin, aspirin,
dipyridamole, dextran),
per organizational
policy and protocol
5. Assist patient with
passive or active range
of motion, as
appropriate

1. Obtain the clien

health history i
detail to determ
the risk level by
means of physi
examination,
support
examination, E
2. Evaluate the
existence of th
sign triad Virch
venous stasis,
hypercoagulability
trauma resulting in
intimal damage
3. Conduct a
comprehensive
assessment usi
variety of ways
a variety of too
assess the
competence or
ability of the
patient's pulmo
status
4. Provide prophyla
low-dose anticoagu
and/or antiplatelet
medication (e.g.,
heparin, clopidogre
warfarin, aspirin,
dipyridamole, dext
per organizational
and protocol
5. Helping patient w
passive or active ra
of motion, as appro

(5)
9. Hyperthermia (5)
10. Apical heart rate
(5)
11. Radial pulse rate
(5)

6. Change patient position

every 2 hours,
encourage early
mobilization or
ambulate as tolerated
7. Prevent injury to vessel
lumen by preventing
local pressure, trauma,
infection, or sepsis
Neurologic monitoring 2620

6. Change the patient

position every 2 ho
encourage early
mobilization or am
as tolerated
7. Prevent injury to v
lumen by preventin
local pressure, trau
infection, or sepsis
Neurologic monitoring

1. Monitor pupillary size,

shape, symmetry, and
reactivity
2. Monitor level of
consciousness
3. Monitor level of
orientation Monitor
recent memory, attention
span, past memory,
mood, affect, and
behaviors
4. Monitor vital signs:
temperature, blood
pressure, pulse, and
respirations
5. Monitor respiratory
status: ABG levels, pulse
oximetry, depth, pattern,
rate, and effort
6. Monitor for tremor
7. Monitor facial symmetry
8. Monitor speech
characteristics: fluency,
presence of aphasias, or
word-finding difficulty
Vital signs monitoring 6680

1. Monitoring pupilla
size, shape, symme
and reactivity
2. Monitoring level of
consciousness
3. Monitoring the leve
orientation Monitor
recent memory, atte
span, past memory,
mood, affect, and
behaviors
4. Monitoring vital sig
temperature, blood
pressure, pulse, and
respirations
5. Monitoring respirat
status: ABG levels,
oximetry, depth, pa
rate, and effort
6. Monitoring for trem
7. Monitoring facial
symmetry
8. Monitoring speech
characteristics: flue
presence of aphasia
word-finding diffic
Vital sign monitoring

1. Monitor blood pressure,

pulse, temperature, and
respiratory status, as
appropriate
2. Monitor blood pressure
while patient is lying,
sitting, and standing
before and after position
change, as appropriate
3. Monitor blood pressure,
pulse, and respirations
before, during, and after
activity, as appropriate

1. Monitoring blood
pressure, pulse,
temperature, and
respiratory status, a
appropriate
2. Monitoring blood
pressure while pati
lying, sitting, and
standing before and
position change, as
appropriate
3. Monitoring blood

4. Identify possible causes

of changes in vital signs

2.

Impaired verbal communication.

(Domain5. Perception/Cognition,
Class 5. Communication, Code
00051).
May be related to:
a. Central nervous system
impairment
b. Physiological condition
(decreased circulation to
brain)
Possibly evidenced by:
a. Does not speak
b. Difficulty verbalizing
c. Difficulty forming
sentences or words
d. Difficulty expressing
thoughts verbally
(aphasia)
e. Slurred speech

Communication 0902
Communication
1. Use o written
Enhancement: Speech
language (5)
Deficit 4976
2. Use of spoken
language (5)
1. Monitor speech speed,
3. Use of pictures and
pressure, pace, quantity,
drawings (5)
volume, and diction
4. Use of non-verbal 2. Monitor cognitive,
language (5)
anatomical, and
Tissue Perfussion:
physiological processes
associated with speech
Cerebral 0406
capabilities (e.g.,
1. Intracranial
memory, hearing, and
pressure (5)
language)
2. Headache (5)
3.
Monitor patient for
3. Restlessness (5)
frustration, anger,
4. Decreased level of
depression, or other
consciousness (5)
responses to impaired
speech capabilities
Sensory Function:
4.
Provide alternative
Hearing 2401
methods of speech
1. Auditory acuity
communication (e.g.,
(left) (5)
writing tablet, flash
2. Auditory acuity
cards, eye blinking,
(right) (5)
communication board
3. Air conduction of
with pictures and letters,
sound (left) (5)
hand signals or other
4. Air conduction of
gestures, and computer)
sound (right) (5)
5. Adjust communication
5. Bone conduction
style to meet needs of
of sound (left) (5)
client (i.e., stand in front
of patient when
speaking, listen
attentively, present one
idea or thought at a time,
speak slowly while
avoiding shouting, use
written communication,
or solicit familys
assistance in
understanding patients
speech)
Communication
Enhancement: Hearing

pressure, pulse, and

respirations before,
during, and after ac
as appropriate
4. Identify possible ca
of changes in vital
Communication
Enhancement: Speech
Deficit 4976

1. Monitoring speech
speed, pressure, pa
quantity, volume, a
diction
2. Monitoring cogniti
anatomical, and
physiological proce
associated with spe
capabilities (e.g.,
memory, hearing, a
language)
3. Monitoring patient
frustration, anger,
depression, or othe
responses to impair
speech capabilities
4. Provide alternative
methods of speech
communication (e.
writing tablet, flash
cards, eye blinking
communication bo
with pictures and le
hand signals or oth
gestures, and comp
5. Adjust communica
style to meet needs
client (i.e., stand in
of patient when
speaking, listen
attentively, present
idea or thought at a
speak slowly while
avoiding shouting,
written communica
or solicit familys
assistance in
understanding patie
speech)
Communication

Deficit 4974

Enhancement: Hearing
Deficit 4974

1. Perform or arrange for

routine hearing
assessments and
screenings
2. Monitor for excessive
accumulation of
cerumen
3. Instruct patient not to
use foreign objects
smaller than patients
fingertip (e.g., cottontipped applicators, bobby
pins, toothpicks, and
other sharp objects) for
cerumen removal
4. Note and document
patients preferred
method of
communication (e.g.,
verbal, written, lip
reading, or American
Sign Language) in plan
of care
5. Gain patients attention
prior to speaking (i.e.,
obtain attention through
touch)
6. Avoid noisy
backgrounds while
communicating
7. Avoid communicating
more than 2-3 feet from
patient
8. Avoid smoking, chewing
food or gum, and
covering mouth when
speaking
Communication
Enhancement: Visual Deficit
4978

1. Perform or arrange
routine hearing
assessments and
screenings
2. Monitor for excess
accumulation of ce
3. Instruct patient not
foreign objects sma
than patients finge
(e.g., cotton-tipped
applicators, bobby
toothpicks, and oth
sharp objects) for
cerumen removal
4. Make a note and
document patients
preferred method o
communication (e.g
verbal, written, lip
reading, or America
Sign Language) in
of care
5. Get patients attent
prior to speaking (i
obtain attention thr
touch)
6. Avoid noisy backgr
while communicati
7. Avoid communicat
more than 2-3 feet
patient
8. Avoid smoking, ch
food or gum, and
covering mouth wh
speaking
Communication
Enhancement: Visual D
4978

1. Monitor functional
implications of
diminished vision (e.g.,
risk of injury,
depression, anxiety, and
ability to perform
activities of daily living

1. Monitor functional
implications of
diminished vision (
risk of injury, depre
anxiety, and ability
perform activities o
daily living and val
activities)

and valued activities)

2. Assist patient in
enhancing stimulation of
other senses (e.g.,
savoring aroma, taste,
and texture of food)
3. Provide adequate room
lighting
4. Minimize glare (i.e.,
offer sunglasses or draw
window covering)
5. Provide literature with
large print
6. Instruct parents, family,
educators, and caretakers
to recognize and respond
to nontraditional
expressive forms of
communication (e.g.,
movements and facial
expressions)
7. Provide referral for the
patient in need of
surgical or other medical
treatment
Memory Training 4760

2. Help the patient in

enhancing stimulat
other senses (e.g.,
savoring aroma, tas
and texture of food
3. Provide adequate ro
lighting
4. Minimize glare (i.e
offer sunglasses or
window covering)
5. Provide literature w
large print
6. Give instructionfor
parents, family,
educators, and care
to recognize and re
to nontraditional
expressive forms o
communication (e.g
movements and fac
expressions)
7. Provide referral for
patient in need of
surgical or other m
treatment
Memory Training 4760

1. Stimulate memory by
repeating patients last
expressed thought, as
appropriate
2. Reminisce about past
experiences with patient,
as appropriate
3. Implement appropriate
memory techniques,
such as visual imagery,
mnemonic devices,
memory games, memory
cues, association
techniques, making lists,
using computers, using
name tags, or rehearsing
information
4. Assist in associatelearning tasks, such as
practice learning and
recalling verbal and
pictorial information
presented, as appropriate
5. Provide opportunity to

1. Stimulating memor
repeating patients
expressed thought,
appropriate
2. help the patien
recall about past
experiences with pa
as appropriate
3. teaching appropriat
memory techniques
as visual imagery,
mnemonic devices,
memory games, me
cues, association
techniques, making
using computers, u
name tags, or rehea
information
4. help patients to do
associate-learning t
such as practice lea
and recalling verba
pictorial informatio
presented, as appro

3.

Impaired physical mobility.

(Domain 4. Activity/Rest, Class
2. Activity/Exercise, Code
00085).
May be related to:
a. Decrease in muscle
control, mass, strength
b. Neuromuscular
impairment
c. Pain
d. Sensoriperceptual
impairment
Possibly evidences by:
a. Slowed movement
b. Decrease in fine or gross
motor skills
c. Decrease in range of
motion
d. Discomfort

Ambulation 0200
1. Walks with
effective gait (5)
2. Walks at moderate
pace (5)
3. Walks at fast pace
(5)
4. Walks up steps (5)
5. Walks down steps
(5)
Mobility 0208
1. Balance (5)
2. Gait (5)
3. Body positioning
performance (5)
4. Running (5)
5. Moves with ease
(5)
Balance 0202
1. Maintains balance
while sitting
without back
support (5)
2. Maintains balance
while standing (5)
3. Maintains balance
while walking (5)
4. Maintains balance
while standing on
one foot (5)
Gait 0222
1. Balance while
walking (5)
2. Speed appropriate
for activity (5)
3. Hesitancy (5)
4. Limping (5)

use memory for recent

5. Provide opportunit
events, such as
use memory for rec
questioning patient about
events, such as
a recent outing, as
questioning patient
appropriate
a recent outing, as
6. Monitor changes in
appropriate
memory with training
6. Monitoring change
memory with traini
Exercise Promotion:
Exercise Promotion:
Strength Training 0201
Strength Training 0201
1. Provide information
about muscle function,
exercise physiology,
and consequences of
disuse
2. Determine muscle
fitness levels using
exercise field or
laboratory tests (e.g.,
maximum lift, number
of list per unit of time)
3. Provide information
about types of muscle
resistance that can be
used (e.g., free weights,
weight machines,
rubberized stretch
bands, weighted objects,
aquatic)
4. Demonstrate proper
body alignment
(posture) and lift form
for exercising each
major muscle group
Pain Management 1400
1. Perform a
comprehensive
assessment of pain to
include location,
characteristics,
onset/duration,
frequency, quality,
intensity or severity of
pain, and precipitating
factors
2. Use therapeutic
communication
strategies to
acknowledge the pain

1. Provide informatio
about muscle funct
exercise physiology
consequences of di
2. Determine muscle
levels using exercis
field or laboratory t
(e.g., maximum lift
number of list per u
time)
3. Provide informatio
about types of mus
resistance that can
used (e.g., free wei
weight machines,
rubberized stretch b
weighted objects,
aquatic)
4. apply proper body
alignment (posture)
lift form for exercis
each major muscle
Pain Management 140

1. assessing the pain a

comprehensive
assessment of pain
include location,
characteristics,
onset/duration,
frequency, quality,
intensity or severity
pain, and precipitat
factors
2. Using therapeutic
communication
strategies to
acknowledge the pa
experience and con
acceptance of the

3.

4.

5.
6.

experience and convey

acceptance of the
patients response to
pain
Determine the impact of
the pain experience on
quality of life (e.g.,
sleep, appetite, activity,
cognition, mood,
relationships,
performance of job, and
role responsibilities)
Evaluate past
experiences with pain to
include individual or
family history of
chronic pain or resulting
disability, as appropriate
Teach principles of pain
management
Encourage patient to
monitor own pain and to
intervene appropriately

patients response t
3. Determine the impa
the pain experience
quality of life (e.g.,
sleep, appetite, acti
cognition, mood,
relationships,
performance of job
role responsibilities
4. Evaluate past
experiences with pa
include individual o
family history of ch
pain or resulting
disability, as approp
5. Teaching principles
pain management
6. Ask the patient to
monitor own pain a
intervene appropria

Neurologic monitoring

1. Monitoring pupilla
size, shape, symme
and reactivity
1. Monitor pupillary size,
2. Monitoring level of
shape, symmetry, and
consciousness
reactivity
3. Monitoring level of
2. Monitor level of
orientation Monitor
consciousness
recent memory, atte
3. Monitor level of
span, past memory,
orientation Monitor
mood, affect, and
recent memory, attention
behaviors
span, past memory,
4. Monitoring vital sig
mood, affect, and
temperature, blood
behaviors
pressure, pulse, and
4. Monitor vital signs:
respirations
temperature, blood
5. Monitoring respirat
pressure, pulse, and
status: ABG levels,
respirations
oximetry, depth, pa
5. Monitor respiratory
rate, and effort
status: ABG levels, pulse 6. Monitoring for trem
oximetry, depth, pattern, 7. Monitoring facial
rate, and effort
symmetry
6. Monitor for tremor
8. Monitoring speech
7. Monitor facial symmetry
characteristics: flue
8. Monitor speech
presence of aphasia
characteristics: fluency,
Neurologic monitoring 2620

presence of aphasias, or
word-finding difficulty

word-finding diffic