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NURSING CARE PLAN

CUES NURSIN INFEREN GOAL/PL NURSING RATIONA EVALUATI


G CE AN LE ON
INTERVENTI
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 client was
related to al interventio rate. for able to
hypoxia. condition n, the evaluati display
Objective in which client will ng patency of
: the body be able to: airway as
adequac
as a whole manifested
 Dyspn (generalize  Normal y of by:
ea; use d hypoxia) breathin ♦ Noted chest ventilati
 Client’s
or a region g movement;
of on.
of the respirator
access pattern: use of
body y rate is
ory (tissue RR = accessory
♦ Use of within
hyoxia) is 12-20 muscles
muscle accessor normal
deprived
s for cpm during
of y range:
respira adequate respiration.
muscles RR-18
oxygen
tion: of bpm.
supply.
elevate respirati
d ♦ Auscultated on may
should breath occur in
ers. sounds; respons
noted areas e to
 Increa
with ineffecti
se in
presence of ve
respira
adventitiou ventilati
tory
s sounds. on.
rate:
RR-25
cpm ♦ Crackle
s
indicate
accumul
ation of
secretio
ns and
inability
to clear
airways.

CUES NURSING INFERENC GOAL/PL NURSING RATION EVALUAT


E AN ALE ION
DIAGNOSI INTERVEN
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
increased cells of the blood to have tends to bepatient’s
intracranial arteries and pressure enough rest excreted atblood
Objective: pressure the action of will on semi a faster pressure
and prostaglandi decrease fowlers rate. was
PR = 85 vasoconstri ns. from 160/ position. > decreased
bpm ction of Vasoconstri 100mmHg Instructed to from
RR = 30 blood ction occurs to eat low fat > To 160/100mm
bpm vessels and blood 120/80mm and low salt reduce Hg to
pressure Hg. diet. > edema that 140/90mm
160/100m increases. Administered may Hg.
mHg anti- activate
hypertensive renin
drug as angiotensi
ordered. n-
aldosteron
e system.
> To
control the
BP and to
avoid
other
complicati
ons.

CUES NURSING INFEREN GOAL/PL NURSING RATIONA EVALUATI


CE AN LE ON
DIAGNO INTERVENTI
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, the client
damage. (BI); n, the client especially the •To assist verbalized
means the will be able heart rate client to understandin
destruction to verbalize every hour to reduce or g of
Objectiv or understandi every four correct individual
e: degenerati ng of hours individual factors that
on of brain individual depending on risk factor. contribute to
T: 36.7 cells, often factors that the client’s possibility of
PR: 65 with an contribute condition. injury and
bpmRR: implication to take steps to
that the possibility • correct
18
cpmBP: loss is of injury Provide situations.Go
120/70 significant and take information al was met
mmHg in terms of steps to regarding
functionin correct disease/conditi
g or situations on that may
conscious result in
experience increased risk
. It is a of injury.
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.