Cues Nursing Diagnosis Goal/ Plan Nursing Intervention Rationale Evaluation
Acute pain related to post After 1 hour of INDEPENDENT: After 1 hour of nursing
operative procedure nursing intervention intervention the patient’s pain
Determine pain characteristics through Establishes baseline for assesing
(craniotomy) as evidenced by the patient’s pain will improvement/change is under control as evidenced
client’s gestures and response to
guarding behavior be controlled as interventions by less guarding behavior ,
evidenced by less decreased bp, and less
guarding behavior, withdraws to pain
decrease in BP, and Monitor vital signs High Bp indicates pain; to check
less withdraws to pain patient’s reponding well to
interventions
Objective: INTERFERENCE:
Positioning of client Avoids direct pressure(intra cranial
Guarding behavior Behavior response to avoid pain pressure) to area of post op wound
which could result in vasoconstriction/
Restlessness Expressing behavior for pain increased pain.
DEPENDENT:
Irritability Expressing behavior for pain Appropriate pain killers to provide
Administer specific pain management
drugs as prescribed by the physician relief of discomfort when unrelieved by
other measures (e.g. acitaminophen, and
Change in BP Elevation of blood pressure anti-inflammatory drugs)
promotes vasoconstriction which
makes pain increased
Provide rest periods to facilitate comfort, The patient’s experiences of pain may
sleep, and relaxation
become exaggerated as the result of
fatigue
COLLABORATIVE:
To have a close monitor of the client’s
Collaborate with the people from the
laboratory progress regarding its wound and
properties biological properties related
to her post-op condition
Collaborate with the nuerologist To update patients prognosis after
craniotomy
Cues Nursing Diagnosis Planning Nursing Intervention Rationale evaluation
After 30 minutes of nursing After 30 minutes of nursing
Ineffective breathing pattern intervention the patient will be INDEPENDENT: intervention the patient
related to neuromuscular able to establish effective Monitor Mechanical ventilator To obatain baseline for assesing established effective
dysfunction secondary to Post respiratory pattern as evidenced especially the manual RR improvement /change in client’s
operative surgery by normal respiratory rate, breathing
absence of tachypnea .
Assess for pain May limit respiratory effort
Objective: INTERFERENCE:
Suction airway as needed To clear out secretions
With oxygen ventilator The patient needs oxygen to be Place head 30 degrees elevated Semi-fowler’s provide good
saturated and assist in breathing breathing pattern
Tachypnea The client experiences RR of 30- DEPENDENT:
40
1:1 lung expansion Normal is 1:2 ratio To suffice needed oxygen
Adjust oxygen at lowest
concentration indicated and requirement of the patient
Low hemoglobin Low concentration of prescribed respiratory
hemoglobin makes poor medications
transport of oxygen
Give combivent nebule q 6 hrs To provide normal breathing if
Low potassium Low potassium weakens muscle as prescribed by the phycisian other measures are ineffective
strength an neuron function;
affects breathing
COLLABORATIVE:
Pain Pain makes breathing difficult
Referal to the laboratory For the CT scan and montioring
of patient’s prognosis
Cues Diagnosis Planning Intervention Rationale Evaluation
Impaired skin integrity After 4 days of nursing INDEPENDENT: After 4 days of nursing
related to presence of suture intervention the patient will intervention the patient displayed
Monitor vital signs To obtain baseline data
over the head display timely wound timely wound repair/healing
repair/healing Note changes in color, texture, To assess extent of injury
and turgor
INTERFERENCE: Provide wound care To assist client in
Objective: correcting/minimizing condition
and to promote optimal healing
Emphasize aseptic technique A first line defense against
With intact suture on right side closed site of wound from the nosocomial infections and cross
of the head post -operation (craniotomy) conatmination
Swelling of suture site Swelling always occurs after Keep the patients position and To avoid pressure on the wound
surgery and may stay for 5 days; ensure the suture is intact and to keep it from accidental re-
indication risk for infection opening
DEPENDENT:
Hyperthermia Incision induce elvated Provide optimum nutrion, To aid in healing and for tissue
temperature increased protien and Vit. C repair
COLLABORATIVE: The physician knows the time
intervals, right frequency of
Assist physician to wound care tending the surgical wound and
regimens
remving of suture.
Cues Nursing Diagnosis Goal/ Plan Nursing Intervention Rationale Evaluation
Risk for infection related to After
increased WBC count
secondary to post-op surgery
INDEPENDENT:
Objective data: INTERFERENCE:
Post-op surgery Invasive procedure increases risk
for invading pathogenic
organisms
DEPENDENT:
Inadequate secondary defense Decreased hemoglobin count
COLLABORATIVE:
WBC count slightly increased
Signs of potential infection
proliferation
Swelling of incision site
Cues Nursing Diagnosis Goal/ Plan Nursing Intervention Rationale Evaluation
Subjective Data: Afte
INTERFERENCE:
INDEPENDENT:
Objective data:
DEPENDENT:
COLLABORATIVE:
