CUES NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Ineffective airway Short term: Independent: At the end of nursing
clearance related to interventions, the patient
“ga ubo siya usahay pero decrease energy, fatigue At the end of 30mins. Of >position head >to open or maintain was able to have patent
walay gagawas na nursing interventions, the appropriate for age. open airway at rest or airway, adequate
plemas,” as verbalized patient will be able to: compromised ventilation, and absence
by the mother. >have a patent airway individuals. of adventitious breath
>have adequate >monitor respirations >indicate of respiratory sounds.
Objective: ventilation; and and breath sounds noting distress and
>have absence of rate and sounds. accumulation of
>ineffective cough adventitious breath secretions.
>abnormal breath sounds.
sounds(crackles) Collaborative:
>lethargy Long term:
>teach SO to provide >to enable SO to
At the end of 1 week of proper positioning of the participate in patient’s
nursing interventions, the patient to promote care.
patient will be able to optimum airway
maintain patent airway, clearance.
adequate ventilation, and
absence of breath
sounds.
 CUES NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Impaired skin integrity Short term: Independent: Short term:
related to attained
“ning niwang akong nutritional status. At the end of 8 hrs. of >monitor patient’s >to act as baseline date At the end of 8 hrs. of
anak,” as verbalized by nursing intervention: weight. for evaluation. nursing intervention:
the mother. Patient’s will increase >allow child to eat solid >to assess desired food >patient increased
nutritional status. foods as tolerated. to eat. nutritional intake.
Objective:
Long term: Dependent: Long term:
>Emaciation
>Underweight At the end of 16 hrs. of >offer IV fluids as >to promote nutritional At the end of 16 hrs. of
>Inappropriate height for nursing intervention: ordered. status. nursing intervention:
age >patient will maintain >patient maintained skin
skin integrity. Collaborative: integrity.
>demonstrate >demonstrated
behaviors/techniques to >instruct SO on proper >to promote optimum behaviors/techniques to
prevent skin breakdown. breast feeding. suction of breast milk. prevent skin breakdown.
 CUES NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Hyperthermia related to Short term: Independent: Short term:
dehydration
“gapanginit ang bata,” as After 8 hrs. of nursing >monitor body temp >to evaluate After 8 hrs. of nursing
verbalized by the mother intervention: every 4 hrs. effectiveness of intervention:
>temp will reach normal interventions >temp reached normal
Objetive: >fluid balance will be >increase fluid intake >to replace fluid loss >fluid balance is stable
stable (intake >patient stated increased
>patient has temp. of approximately equals Dependent: comfort
37.8 º C output)
>skin turgor is slow >patient will state >administer antipyretic >to stabilize temp. Long term:
increased comfort as ordered.
>administer IV fluids as >to replace fluid loss After 16 hrs. of nursing
Long term: ordered. intervention:
>temp remained normal
After 816 hrs. of nursing Collaborative: >fluid balance
intervention: maintained stable.
>temp will remain >instruct SO to perform >to enable SO to
normal TSB participate in patient care
>fluid balance will
maintain stable.