3.

Nursing Intervention
No Nursing Diagnosis Objective (NOC)
Perfusion of cerebral Goal (NOC):
tissue is not effective Impaired tissue perfusion can be
r.o O2 brain decreases achieved optimally
Criteria results:
● Able to maintain awareness level of
● sensory function and improved
1
motoric
Nutritional imbalance: Purpose (NOC):
less than the body's 1. Nutritional status
needs r.o inability to 2. Food intake
absorb nutrients 3. Liquid and nutrients
Evaluation criteria:
1. Describe diet closeness 1. Determine the client's motivation to
2
components
2. Laboratory values
(eg, transferinine, albumin, and 3. Refer the doctor to determine the causes
electrolyte)
3. Reportlevel of giji
4. Laboratory values (eg trasferin,
Intervention (NIC) Rational
intervention (NIC)
1. Systemic blood pressure elevations
1. Monitor TTV every hour and record the followed by decreased
results. diastolic blood pressure are a sign
of increased ICT. Irregular breath
indicates an increase in ICT
2. Able to know the level of motor
response of patients
2. Assess motor responses to simple 3. Prevent / reduce atelectasis
commands. 4. Reduce venous static
3. Monitor neurological status regularly. 5. Reduce the risk of complications
4. Push active / passive leg exercises.
5. Collaboration of drugs according to
indications.
Intervention (NIC):
1. Management of food disorders
2. Nutritional awareness
3. Assistance increases BB
Nursing activities:
change eating habits 1. Client motivation affects in
2. Know the client's favorite foods nutritional changes
of changes in nutrition 2. Client's favorite foods to facilitate
nutrition
3. Refer doctors to know changes in
 albomen and eletrolit the client and for the healing
on nutrient5. Recommended 4. Help eat according to client needs process
tolerance to nutrition. 4. Help eat to know changes in
5. Create a pleasant environment to eat nutrition and for assessment
5. Create an environment for the
comfort of client breaks and for
indoor / room calm .

Physical mobility Objective (NOC): Intervention (NIC):

▪ Activity therapy, ambulation
barriers or decrease Clients are asked to indicate the level of
r.o muscle strength ▪ Activity therapy, joint mobility.
mobility, indicated by the following
indicators (specify value 1 - 5: ▪ Change of position of
dependency (not participating) requires
Nursing Activity:
1. Teach clients about and monitor the use
help from others or tools need help from
others, independent with help tools help
of 1. Teach clients about and monitor the
or fully independent). use of client mobility tools more
Evaluation Criteria: mobility aids. easily.
3
1. Demonstrate the correct use of 2. Teach and help clients in the transfer 2. Helping clients in the transfer process
assistive devices with supervision.
process. will help clients practice this way.
3. Give positive reinforcement during 3. Giving positive reinforcement during
2. Request assistance for mobilization
activities if needed. activities. the activity will help the client's
3. Supporting BAB enthusiasm in training.
4. Support ROM training techniques
4. Using an wheelchair effectively. 4. Accelerate clients in mobilizing and
loosening muscles
5. Collaboration with the medical team 5. Knowing the development of client
about client mobility mobilization after ROM exercises
Risk of damage to Purpose (NOC): 1) Instruct the patient to use loose 1. skin can be moist and may feel
4
skin integrity r.o risk Tissue Integrity: Skin and Mucous clothing unable to rest or need to move
 factors: dampness Membranes 2. M reduce the risk of infection in
Result Criteria: Good 2) Avoid wrinkles in bed the skin
● skin integrity can be maintained 3) Keep skin to keep it clean and dry 3. The first way to prevent the
(sensation, elasticity, 4) Mobilize the patient (change the occurrence of infection
temperature, hydration, patient's position) every two hours 4. Prevent the occurrence of further
pigmentation) 5) Monitor the skin for redness complications
● No wound / skin lesions 6) Apply lotion or oil / baby oil in a 5. Know the progress of the
● Demonstrate an understanding in depressed area occurrence of skin infections
the repair process of the skin and 7) Collaboration of antibiotics 6. Reduce exposure to germs
prevent sedera repeatedly according to indications The infection on the skin
● able to protect the skin and retain 7. Reduce the risk of infection
moisture and natural treatments
Disorders of verbal Purpose (NOC): Intervention (NIC):
communication r.o 1. Make communication fairly, 1. Check client communication
neuromuscular Communication can work well language is clear, simple and if whether really unable to
damage, damage to necessary repeated communicate
central speech Criteria results: 2. Listen diligently if the patient starts 2. Know how client's
talking communication ability
a. Clients can express feelings 3. Know the degree / level of client
3. Stand in the patient's field of view communication skills
5 b. Understand the intent and when talking 4. Reduce the occurrence of
conversation of others 4. Train muscles speak optimally advanced complications The
5. Involve the family in practicing 5. family knows & is able to
c. Patient talk can be understood verbal communication on patient demonstrate how to train verbal
6. Collaboration with speech therapist communication on clients
without the help of nurses
6. Knowing the development of
communication verbal client