NCP #1

Assessment Nursing Scientific Planning Implementation Rationale Evaluation

Diagnosis Explaination
 Cyanotic Ineffective Due to After 8 hours of INDEPENDENT: After 8 hours of
lips Peripheral decreased nursing  Note current  Affecting systemic nursing
 Pale Tissue cardiac output, interventions, situation or presence circulation/ interventions,
conjunctiva Perfusion there is patient (guided of conditions that can perfusion patient was able
and nail related to decreased by the wife) will affect perfusion to all to demonstrate
beds decreased preload and be able to body systems behaviors to
 Weak cardiac stroke volume demonstrate  Identify presence of  To identify client at improve
peripheral output as thus there is behaviors to high risk factors higher risk for circulation, as
pulses evidenced by decreased improve venous stasis, evidence by:
 Cold pale nail blood pumped circulation, as vessel wall injury  Engage foot-
clammy beds and out from the evidenced by: and ankle
skin conjunctiva blood. Decrease  Engage foot- hypercoagulability. exercises
 Dry, scaly instroke volume ankle  Measure capillary  To determine  Use of
skin decreases exercises refill adequacy of pressure
 Decreased perfusion  Use of systemic relieving
skin turgor throughout the pressure circulation devices
>4 seconds body. relieving  Inspect lower  That often (foam
 Decrease devices (foam extremities for skin accompany padding)
capillary padding) texture diminished  Changes
refill  Changes peripheral position at
position at DEPENDENT circulation timed
timed  Administer KCL and intervals
intervals. Ferrous Sulfate

COLLABORATIVE:
 Collaborate  To promote
intreatment of optimal blood
underlying conditions flow, organ
 Refer to dietician perfusion, and
function
 To maximize
systemic
circulation and
organ perfusion
 For well-balanced,
low saturated-fat,
low cholesterol
diet and other
modifications as
indicated.
NCP #2

Assessment Nursing Scientific Planning Implementation Rationale Evaluation

Diagnosis Explaination
Ineffective Irritant(inhalation) After 8 hours of INDEPENDENT After 8 hours of
Airway nursing nursing
Clearance Inflammatory intervention,  Monitor  It is an indication of intervention, the
related to response the patient will respiratory rate respiratory distress short term goal
accumulation be ableto and accumulation of was fully met as
of secretions Increase expectorate secretions evidenced by:
as evidenced production of secretions as  Position in a semi-  To open or maintain  Effective
by crackles secretions evidenced by: fowler’s position airway and it also coughing
on bilateral enhances drainage to clearing the
lung fields Accumulation of  Effective different lung retained
and secretions coughing segments secretions
productive and clearing  Keep environment  Physical or chemical  Enhanced
cough Blocks the airway of retained allergen free such allergen serves as airway
(airway secretions as cleaning to irritants patency
constriction)  Enhanced remove dusts.  Normal
airway  Increase fluid  Hydration can help respiratory
Changes in the patency intake liquefy viscous rate
respiratory  Normal secretion and improve
pattern respiratory secretion clearance
rate (12-  Monitor for  It may compromise
Dyspnea 20bpm), feeding airway
depth and intolerance,
Work of breathing rhythm abdominal
increases to distention and
compensate for emotional
the blockage. stressors.
 Auscultate breath  To ascertain status
sounds and assess and note progress
air movement
 Give chest  To remove bronchial
physiotherapy secretions and
improve ventilation
 Encourage deep  To promote proper
breathing lung expansion
exercises

DEPENDENT
 Administer  Act as a
salbutamol bronchodilator
nebulization as
ordered
NCP #3

Assessment Nursing Scientific Planning Implementation Rationale Evaluation

Diagnosis Explaination
Impaired Skin Surgical
Integrity Intervention
related to (Craniotomy)
surgical
incision on Incision on the
Right Parietal Right posterior
area as parietal surgical
evidenced by hole to remove
Surgical the tumor tissue
dressing on
the right Surgery involves
parietal area cutting/
of the head penetration of
skin surface and