NURSING GOALS NURSING ACTION RATIONALE EXPECTED

DIAGNOSES OUTCOME
Ineffective airway To maintain a Elevate the head of To prevent Maintains clear
clearance related patent airway and the bed 30 aspiration. airway and
to altered LOC ensure ventilation degrees. demonstrates
appropriate breath
Position the patient To promote sounds.
in a lateral or semi drainage of
prone position. secretions.

Suctioning should
also be done. To remove
secretions.
Chest
physiotherapy and
postural drainage To promote
may be initiated. pulmonary hygiene.

Auscultate the
chest every 8 To detect
hours. adventitious breath
sounds or absence
of breath sounds.
Risk of injury To protect the Ensure that side To prevent Experiences no
related to patient from injury rails are padded occurrence of injury injuries.
decreased LOC and kept in raised due to fall.
position for the day
and three nights

Provide privacy, To ensure patient’s

and inform the dignity.
patient to every
nursing care to be
 done.
Deficient fluid To maintain fluid Hydration status To know the status Attains or maintains
volume related to balance and should be of the patient. adequate fluid
inability to take managing assessed. balance
fluids by mouth nutritional needs To meet fluid a. Has no clinical
Administering the needs. signs or
required IV fluid. symptoms of
dehydration
For patient with To minimize the b. Demonstrates
intracranial possibility of normal range
conditions, the IV increased ICP. of serum
solutions must be electrolytes
administered slowly c. Has no clinical
To administer fluid signs or
If the patient does and enteral symptoms of
not recover quickly, feedings. overhydration
gastrotomy tube
will be inserted.
Impaired oral To provide mouth Mouth should be To remove Achieves healthy
mucous membrane care. cleansed and secretions and oral mucous
related to mouth rinsed crust. membranes
breathing, absence To keep it moist.
of pharyngeal
reflex and altered Put a thin coating TO prevent drying,
fluid intake of petrolanum cracking, and
encrustations.

For patient with ET To prevent

tube, the tube ulceration.
should be moved to
opposite side of the
mouth daily
Risk for impaired To maintain skin Regular turn the To avoid pressure. Maintains normal
skin integrity and joint integrity. patient side by skin integrity
related to side.
prolonged To prevent
immobility After turning, the ischemic necrosis
patient should be over the pressure
repositioned areas.
carefully.
To prevent
Dragging or pulling shearing force and
the patient should friction on the skin
be avoided. surface.

Maintain correct To prevent

body position and contractures.
passive exercise.

Use of splints or
foam boots. To help prevent
foot drop and
eliminates the
pressure of bedding
Use of trochanter on the toes.
rolls.
To support the hip
joints and keep the
legs in proper
Fluidized or low-air- alignment.
loss beds may be
use. To decrease
pressure on bony
prominences.
Impaired tissue To preserve corneal Eyes should be To remove debris Has no corneal
integrity of cornea integrity. cleansed with and discharges. irritation
related to cotton balls with
diminished or sterile normal
absent corneal saline To prevent dryness.
reflex
Instill artificial tears
every 2 hours if
prescribed. To avoid contact
with the cornea.
If cold compress is
prescribed, care
must be exerted.
Ineffective To maintain body Environment can To promote a Attains or maintains
thermoregulation temperature be adjusted, normal body thermoregulation
related to damage depending on the temperature.
to hypothalamic patient’s condition.
center
Remove all bedding To lessen the heat.
over the patient.

Administer To reduce fever.

acetaminophen as
prescribed.

Give cool sponge To increase surface

baths and allow an cooling.
electric fan to blow
over the patient.

Using a To help reduce

hypothermia heat.
blanket.

Frequent To assess the

 temperature patient’s response
monitoring. to therapy
To prevent an
excessive decrease
in temperature.
Impaired urinary If the patient is not To drain urine. Has no urinary
elimination related voiding, an To monitor urine retention
to impairment in indwelling urinary output.
neurologic sensing catheter is inserted
and control and connected.
To assess urinary
The patient is tract infection.
observed for fever
and cloudy urine.
To ensure complete
An intermittent emptying of the
catheterization bladder at
program may be intervals.
initiated.
Bowel incontinence Monitor the number To detect fecal Has no diarrhea or
related to and consistency of impaction. fecal impaction.
impairment in bowel movements
neurologic sensing and perform a
and control and rectal examination.
also related to
changes in Administer glycerin To soften stool.
nutritional delivery suppository if
methods indicated.
To empty the lower
Enema the patient colon.
every other day.