Vous êtes sur la page 1sur 5


Diagnosis Planning(NOC) Intervention(NIC) Rationale

Ineffective After giving the 1. Monitoring 1. Irregulars in these
Cerebral intervent vital sign every are indication of
Tissue ion for 1 30 minutes, problems /
Perfusio x 24 noting : complications of
n hours, hypertension the brain function
the or 2. Assesses trends
patient hypotension, in LOC, potential
will : heart rate, for increased ICP
pupillary and that is useful
1. Exhibit reaction and in determining
growing respirations location, extent,
tolerance to 2. Assessed LOC and progression
activity : GCS or resolution of
2. Engage in 3. Monitoring CNS damage.
behaviors or intake ( IV line, 3. To show the
action to medicine, and status of
improve Food ) and circulating
tissue output ( Urine volume, fluid
perfusion and drains) transfer /
3. Verbalize or 4. Promoted of improvement and
demonstrate high back rest response to
normal position therapy.
sensation 5. Gave the 4. Reduce arterial
and medicine by pressure by
movement as doctor’s promoting venous
appropriate order….. drainage and may
4. State when improve cerebral
to contact circulation and
physician or perfusion

Ineffective After giving the 1. Monitoring 1. A normal

Airway intervent respiratory respiratory status
Clearanc ion for 1 status, pattern, rate for an adult
e x 30 including rate, without dyspnea is
minutes depth, and 12 to 16. With
(short effort secretions in the
term) 2. Promoted high airway, the
and 1 x back rest and respiratory rate
24 hours semi-fowler’ will increase.
(long position 2. An upright
term), 3. Maintained on position allows for
patient suction and maximal air
will : nebulizing as exchange and
needed lung expansion
1. Maintain 4. Deep 3. Suctioning may
clear, open breathing stimulate
airways as exercise coughing and help
evidenced to remove
by normal secretions
breath 4. This technique
sounds, can help increase
normal rate sputum clearance
and depth of
and ability to
cough up
and deep
2. demonstrate
increased air

Impaired skin After giving the 1. Monitoring for 1. Systematic

integrity intervent color inspection can
r.b ion for 1 changes, identify impending
surgery x 24 redness, problems early
hours, swelling, 2. To reduces the
patient warmth and risk for infection
will : pain 3. Wound infections
2. Dressing for may be managed
1. report any wound care well and more
altered 3. Medicine by efficiently with
sensation or doctor’s order topical agents,
pain at site 4. Checking although
of tissue every 2 hours intravenous
impairment antibiotics may be
2. manifest indicated
wound 4. Mechanical
healing damage to skin
manifested and tissues is
by often associated
decreasing with external
size of the devices
wound and

Risk For Injury After giving the 1. Assessed 1. To determine the

intervent GCS, pupil, etc patient’s condition
ion for 1 2. Avoid use of that may cause
x 24 restraints as injury
hours, needed 2. If patient is
patient restrained, the
will : patient has an
increased risk of
developing an
injury associated
1. Remains
with mechanical
free of
2. Explains
methods to

Risk for Infection After giving the 1. Observed and 1. With the onset of
intervent report signs infection the
ion for 1 and symptoms immune system is
x 24 of infection activated and
hours, such as signs of infection
patient redness, appear
will : warmth, 2. Laboratory values
1. Remains discharge, and are correlated with
free of increased body client’s history and
infection, as temperature physical
evidenced 2. Monitoring examination to
by normal vital sign every provide a global
vital signs 30 minutes view of the client’s
and absence 3. Noted and immune function
pf signs and reporting and nutritional
symptoms of laboratory status and
infection values ( e.g., develop an
white blood appropriate plan
cell count and of care for the
differential, diagnosis
serum protein, 3. Intact skin is
serum nature’s first line
albumin, and of defense against
cultures) microorganisms
4. Assessed skin entering the body
of color, 4. Use of sterile
moisture, technique
texture, and prevents infection
turgor in at risk clients
5. Maintained
technique as
6. Using clothes,
gloves as