C.

Nursing Interventions
1. Chronic pain (00133) is associated with tumor permeation: increased intracranial
pressure.
Domain 12: Comfort
Class 1. Physical Comfort

NOC NIC
Aim : after nursing action for 1 x 24 Pain Management (1400)
hours the perceived pain is reduced 1 or 1) Reducing / eliminating factors that cause
can be adapted by the client with the / enhance the experience of pain
results criteria: 2) Select and implement one type of action
a. Clients reveal pain that is felt to be (pharmacology, non-pharmacology,
reduced or can be adapted to be interpersonal) to facilitate pain relief
shown to decrease the scale of 3) Consider the type and source of pain
pain.Scale = 2 when choosing a pain relief strategy
b. Clients do not feel pain. 4) Encourage clients to use adequate pain
c. The client is not nervous treatment
Domain-Health Knowledge & Behavior 5) Instruct patient / family to report pain
(IV) immediately if pain arises.
Pain Control (1605) 6) Teach relaxation techniques and
The client can recognize the onset i distraction methods
Clients can describe the causal factors 7) Observation of signs of non-verbal pain
Clients recognize symptoms related to such as facial expressions, anxiety, crying
pain (160509) / grimacing, changes in vital signs.
Report pain control (160511) Collaboration: Analgesic Administration
Pain: Disruptive Effects (2101) (2210)
H Interpersonal relationships are not 1) Determine location, characteristics,
interrupted quality, and severity of pain before client
T indakan role as before treatment
Can do daily activities 2) Check medical demand for medication,
Physical activity is not disturbed dosage, and frequency of prescribed
analgesics (prescription)

2. The ineffectiveness of the breath pattern (00032) is associated with suppression of the
medulla oblongata.
Domain 4: Activity / Rest
Class 4. Cardiovascular / Pulmonary Responses
NOC NIC
Objective: after nursing action for 1 x 24 hours the Airway Management (3140)
breathing pattern returns to normal with the results
criteria:
 a. Effective breathing pattern 1) Monitor respiration and
b. Normal GDA oxygenation status, which is
appropriate
c. Cyanosis does not occur
Domain-Physiologic Health (II) Respiratory Management (3350)
Cardiopulmonary Class (E) 1) Monitor speed, rhythm, depth
Respiratory Status (0415) and breathing effort.
Normal Respiraroty Rate
2) Monitor breathing patterns
Respiraory Normal Rhythm
Normal inspiration depth 3) Monitor the level of oxygen
Normal oxygen saturation saturation in a quiet client
There is no cyanosis 4) Auscultation of breath sounds,
recording areas of decreased
ventilation and the presence of
additional sounds

3. The risk of ineffective cerebral tissue perfusion (00200) is associated with increased
intracranial pressure, tumor surgery, cerebral edema.
Domain 4: Activity / Rest
Class 4. Cardiovascular / Pulmonary Responses
NOC NIC
Objective: after 1x24 hours of Intracranial Pressure (ICP) Monitoring (2590)
nursing action the client's 1) Monitor the quality and characteristics of ICT
tissue perfusion improves waveforms
marked by stable vital signs 2) Monitor cerebral perfusion pressure
with the results criteria: 3) Neurological status monitor
a. Cerebral perfusion 4) Monitor client ICTs and neurological responses to
pressure > 60mmHg, treat environmental activities and stimuli
intracranial pressure 5) Monitor the amount, speed, and characteristics of
<15mmHg, mean cerebrospinal fluid flow (CSF)
arterial pressure 80- 6) Give pharmacological agents to keep ICTs to a certain
100mmHg extent
7) Gives the time of nursing intervention to minimize
b. Showing normal level
PTIK
of awareness
8) Periodically monitor for signs and symptoms of
c. Good patient increased ICT
orientation a. Assess changes in level of consciousness,
d. RR 16-20x / minute orientation, memory, check GCS values

e. Headache decreases or b. Assess vital signs and compare with previous

does not occur conditions
Domain-Physiologic Health c. Assess autonomic function: number and pattern of
(II) breathing, pupil size and reaction, muscle
Cardiopulmonary Class (E) movement
Perfusion Tissue: Cerebral
(0406)
Normal intracranial pressure d. Assess for headache, nausea, vomiting, papilla
Systolic blood edema, diplopia, seizures
pressure normal e. Measure, prevent and reduce ICT
Diastolic blood
1. Maintain the position by raising the
pressurenormal
head 15-30 0 , avoiding the prone position or
Normal Mean Blood Pressure
excessive flexing of the legs
Missing headache
Not experiencing a decrease in 2. Monitor blood gas analysis, maintain
level of consciousness PaCO2 35-45 mmHg, PaO2> 80mmHg
There is no neurologic reflex 3. Collaboration in giving oxygen
disorder
4. Avoid factors that can increase ICT
9) Rest the patient, avoid nursing actions that can
interfere with the patient's sleep
10) Give sedative or analgesic collaboratively.

4. The risk of injury (00035) is associated with vertigo secondary to orthostatic

hypotension.
Domain 11: Safety / Protection
Class 2. Physical Injury
NOC
Objective: after nursing actions for 1x24 Fall Prevention (6490)
hours diagnosis is not the actual problem
with the results criteria:
a. The patient can identify the
conditions that cause vertigo
b. Patients can explain the method
ofpreventing a sudden decrease in
blood flow in the brain associated
with orthostatics.
c. Patients can carry out movements
to change positions and prevent
sudden drops of pressure in the
brain.
d. Explain several episodes of vertigo
or dizziness.
Domain-Health Knowledge & Behavior
(IV)
Class-Risk Control & Safety (T)
Falls Occurrence (1912)
No falls occur when
standing , walking ,sitting and sleeping
NIC
1) Identification of behavior and factors that
influence the risk of falling
2) Give a sign to remind the client to ask for
help when going out of bed,right
3) Use appropriate techniques to deliver
clients to and from wheelchairs, beds,
toilets and more
4) Assess the patient's blood pressure when
the patient changes body position.
5) Discuss with clients about the physiology
of orthostatic hypotension.
6) Teach techniques to reduce orthostatic
hypotension
a. To
find out whether the patient has
orthostatic hypotension or not.
b. To
increase client knowledge about
orthostatic hypotension.
Domain-Health Knowledge & Behavior c. Train
(IV) client abilities and provide comfort when
Class-Risk Control & Safety (T) experiencing orthostatic hypotension.
Physical Injury Severity (1913)
No surgery head injury
There is no mobility disorder
Decreased level of consciousness does not
occur
Bleeding does not occur

5. Nutritional disorders: less than body requirements (00002) associated with the effects
of chemotherapy and radiotherapy.
Domain 2: Nutrition
Class 1. Ingestion
NOC NIC
Objective: after 1x24 hours of nursing action the client's Nutrition Monitoring (1160)
nutritional needs can be adequately fulfilled with the 1) Assess for signs and
results criteria: symptoms of nutritional
a. Anthropometry: weight does not go down deficiencies: weight loss,
(stable) signs of anemia, vital signs
b. Biochemistry: normal adult albumin (3,5-5,0) g / 2) Monitor patient nutritional
dl intake
3) Give food in small portions
c. Normal hemoglobin (male 13.5-18 g / dl, female
but often.
12-16 g / dl)
4) Weigh every 3 days
1) Clinis: do not look thin, there are fat folds,
5) Monitor laboratory results:
hair is not rare and red
HB, albumin
2) Diet: the client consumes his portion of food
6) Collaboration in the
and appetite increases
administration
Nutritional Status (1004)
of antiemeticdrugs
Adequate nutrition intake
Adequate food intake
Adequate fluid intake
Hydration

6. Impaired physical mobility (00085) is associated with sensory and motor disorders
Domain 4: Activity / Rest
Class 2. Activity / Exercise
NOC NIC
Objective: after nursing measures for 1 x 24
hours, mobility disorders can be minimized 1) Periodically assess motor function
by the results criteria:
 1. Maintain the function position as
evidenced by the absence of
contractures. Foodtrop
2. Increase strength not affected /
compensated for body parts
3. Showing behavioral techniques that
allow the resumption of activities
Mobility (0208)
Balance is maintained
Awake coordination
Move easily
7. Comfort feeling (00214) is associated with pain due to not being able to move the neck.
Domain 12: Comfort
Class 1. Physical Comfort
NOC
Objective: after 1x24 hours of nursing
action, it provides comfort for neck
motion to the client with the results
criteria:
a. Clients can move the neck
normally
b. Clients can act normally
2) Keep your ankles 90 degrees with the
foot board. Use trochanter rolls along
the thigh while in bed
3) Measure and monitor blood pressure in
the acute phase or until stable.Change
position slowly
4) Daily skin inspection. Assess the
stressed area and provide careful skin
care
5) Helps encourage pulmonary hygiene
such as deep breath, coughing, suction
6) Assess for redness, swelling / tension in
the calf tissue muscles
NIC
1) Assess the range of motion of the client's
neck
2) Give helth education to patients
regarding decreased neck movement
function
3) Collaburation with physiotherapy
4) Knowing the neck's mobility
5) Helping patients to be able to accept the
conditions experienced
6) Therapy can help restore the neck motion
of the client normally
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