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