NURSING CARE PLAN

CUES NURSIN INFEREN GOAL/PL NURSING RATIONA EVALUATI

G CE AN INTERVENTI LE ON
DIAGNO ON
SIS
No Ineffective Hypoxia is Following  Assessed  Provide At the end of
Subjectiv airway a an 8-hr respiratory s a basis the shift, the
e Cues clearance pathologic nursing rate. for client was
related to al interventio evaluati able to
Objective hypoxia. condition n, the ng display
: in which client will adequac patency of
 Dyspn the body be able to:  Noted chest y of airway as
ea; use as a whole  Normal movement; ventilati manifested
of (generalize breathin use of on. by:
access d hypoxia) g accessory  Client’s
ory or a region pattern: muscles  Use of respirator
muscle of the RR = during accessor y rate is
s for body 12-20 respiration. y within
respira (tissue cpm muscles normal
tion: hyoxia) is of range:
elevate deprived  Auscultated respirati RR-18
d of breath on may bpm.
should adequate sounds; occur in
ers. oxygen noted areas respons
 Increa supply. with e to
se in presence of ineffecti
respira adventitiou ve
tory s sounds. ventilati
rate: on.
RR-25
cpm  Crackle
s
indicate
accumul
ation of
secretio
ns and
inability
to clear
airways.

CUES NURSING INFERENC GOAL/PL NURSING RATION EVALUAT

DIAGNOSI E AN INTERVEN ALE ION
 S TION
No Ineffective Increased After 4 > Monitored > To > After 4
Subjective cerebral cardiac hours of blood know the hours of
Cues tissue output that nursing pressure base line nursing
perfusion injures the interventio every 4hours. of BP > intervention
related to endothelial n the pt > Instructed Sodium the
Objective: increased cells of the blood to have tends to be patient’s
PR = 85 intracranial arteries and pressure enough rest excreted at blood
bpm pressure the action of will on semi a faster pressure
RR = 30 and prostaglandi decrease fowlers rate. was
bpm vasoconstri ns. from 160/ position. > decreased
160/100m ction of Vasoconstri 100mmHg Instructed to > To from
mHg blood ction occurs to eat low fat reduce 160/100mm
vessels and blood 120/80mm and low salt edema that Hg to
pressure Hg. diet. > may 140/90mm
increases. Administered activate Hg.
anti- renin
hypertensive angiotensi
drug as n-
ordered. aldosteron
e system.
> To
control the
BP and to
avoid
other
complicati
ons.

CUES NURSING INFEREN GOAL/PL NURSING RATIONA EVALUATI

DIAGNO CE AN INTERVENTI LE ON
SIS ON
No Risk for Brain After 3 Monitor •To assess After 3 hours
Subjecti injury damage or hours of peripheral baseline of nursing
ve Cues related to "brain nursing pulses and data intervention,
brain injury" interventio vital signs, •To assist the client
damage. (BI); n, the client especially the client to verbalized
Objectiv means the will be able heart rate reduce or understandin
e: destruction to verbalize every hour to correct g of
T: 36.7 or understandi every four individual individual
PR: 65 degenerati ng of hours risk factor. factors that
bpmRR: on of brain individual depending on contribute to
18 cells, often factors that the client’s possibility of
cpmBP: with an contribute condition. injury and
120/70 implication to • take steps to
mmHg that the possibility Provide correct
loss is of injury information situations.Go
significant and take regarding al was met
in terms of steps to disease/conditi
functionin correct on that may
g or situations result in
conscious increased risk
experience of injury.
. It is a
common
and very
broad in
scope,
such that
in
medicine a
vast range
of specific
diagnoses
exist.
Brain
injuries
occur due
to a wide
range of
internal
and
external
factors. A
common
category
with the
greatest
number of
injuries is
traumatic
brain
injury
(TBI)
following
physical
trauma or
head injury
from an
outside
source, and
the term
acquired
brain
injury
(ABI) is
used in
appropriate
circles, to
differentiat
e brain
injuries
occurring
after birth
from
injury due
to a
disorder or
congential
malady.