DATE & NURSING

CUES NEED OBJECTIVE/GOAL NURSING INTERVENTIONS EVALUATION

TIME DIAGNOSIS
August Subjective cues E Constipation At the end of 2 1. Identified factors (e.g., GOAL MET
9, 2010 “Naglisod ko og L related to days of nursing medications, bed rest, diet) that August 11, 2010 @
12:00 libang sulod sa tulo I insufficient care, the patient may cause or contribute to 12:00 AM
AM ka adlaw,” as M fiber/fluid intake will be able to: constipation. At the end of 2
verbalized by the I R: Constipation is Regain normal ® Assessing causative factors is days of nursing
patient. N defined as having a pattern of bowel an essential first step in teaching care, the patient
“Gamay lang jud A bowel movement functioning and planning for improved bowel was able to:
ang mugawas na T fewer than three as evidenced by: elimination. Regain normal
tae kung malibang I times per week. 2. Evaluated usual dietary habits, pattern of bowel
ko,” as verbalized by O With constipation • Change in eating habits, eating schedule, functioning
the patient. N stools are usually bowel pattern and liquid intake. as evidenced by:
Objective cues hard, dry, small in • Change in ® Change in mealtime, type of • Change in
• Abdominal P size, and difficult to character of food, disruption of usual bowel pattern:
distention A eliminate. Some stool schedule, and anxiety can lead • Patient was
• Abdominal girth: T people who are • Comfort in to constipation. able to
45 cm T constipated find it passage of stool 3. Assessed activity level. defecate
• Hypoactive E painful to have a ® Prolonged bed rest, lack of once each
bowel sounds R bowel movement exercise, and inactivity day.
upon N and often contribute to constipation. • Change in
auscultation experience 4. Evaluated current medication character of
• Nonproductive straining, bloating, usage that may contribute to stool:
desire to and the sensation constipation. • Patient
 defecate of a full bowel. ® Drugs that can cause verbalized
• Decreased oral People who eat a constipation include the stool was
intake high-fiber diet are following: narcotics, antacids soft in
• Hard, formed less likely to with calcium or aluminum base, consistency
stool become antidepressants, • Comfort in
constipated. The anticholinergics, passage of
most common antihypertensives, and iron and stool:
causes of calcium supplements. • Patient
constipation are a 5. Assessed degree to which verbalized
diet low in fiber or a patient’s procrastination ease of
diet high in fats, contributes to constipation. defecation.
such as cheese, ® Ignoring the defecation urge
eggs, and meats. eventually leads to chronic
constipation, because the
rectum no longer senses, or
responds to, the presence of
stool. The longer the stool
remains in the rectum, the drier
and harder (and more difficult to
pass) it becomes.
6. Encouraged daily fluid intake of
2,000 to 3,000 ml/day, if not
contraindicated medically.
® Sufficient fluid intake is
 necessary for the bowel to
absorb sufficient amounts of
liquid to promote proper stool
consistency.
7. Encouraged increased fiber in
diet (e.g. raw fruits, fresh
vegetables); a minimum of 20 g
of dietary fiber is recommended.
® Fiber absorbs water, which
adds bulk and softness to the
stool and speeds up passage
through the intestines.
8. Encouraged activity within limits
of individual ability.
® To stimulate contraction s of
the intestines.
9. Encouraged a regular time for
elimination.
® Many persons defecate
following first daily meal, as a
result of the gastrocolic reflex;
depending on the person’s
usual schedule, any time, as
long as it is regular, is fine.
10. Suggested drinking warm,
stimulating fluids, such as hot
water. ® To promote
moist/soft stool and facilitate
passage of stool.
DATE & NURSING
CUES NEED OBJECTIVE/GOAL NURSING INTERVENTIONS EVALUATION
TIME DIAGNOSIS

August Objective cues H Risk for infection At the end of 1. Note risk factors for occurrence GOAL MET
10, 2010 related to rendering 2 hours of of infection.
@ 12:00 • Chest tube E inadequate nursing care, the ® Risk factors should be August 10, 2010
AM located at right primary defenses patient will be able identified to assess causative @ 2:00 AM
A
upper quadrant secondary to to: factors/contributing factors. At the end of
• Wound dressing L presence of chest 2. Observe for localized signs of rendering 2
at right upper tube. • Gain knowledge in infection at chest tube site. hours of nursing
quadrant T infection control as ® Assessing the site of possible
R: Bacteria can care, the patient
• No secretions evidenced by source of infection will give a
H enter around the was able to:
from wound discussing the clue for prompt intervention.
tube and cause an wound care as
dressing - 3. Assess and document skin • Gain
infection around
• Wound dressing evidenced by: conditions around site.
the lung. The knowledge in
not changed for P longer the chest - Clean and dry ® Assessment gives a general infection
2 days tube stays in the wound dressing overview of the possible control as
E chest, the greater - Understanding
• Dirt present on source of problem. evidenced by
the risk for and demonstration 4. Stress proper hand hygiene by all
borders of R discussing
infection. The risk of proper hand
plaster caregivers between the wound
of infection hygiene
• Medications: C therapies/clients. care as
is decreased by
Cefuroxime 1.5 special care in ® This measure will help evidenced
E
gms IVTT bandaging the skin prevent contamination. by:
• WBC Count: 7.2 P at the point where 5. Maintained asepsis for dressing
x 10^3/uL the tube goes into changes and wound care. - Newly
T the chest. A break ® To prevent cross- changed
• Neutrophils: 75%
in the body’s first contamination. dressing
• Lymphocytes: I line of defense 6. Administer prophylactic
25% - Clean and
places a person at antibiotics as indicated.
• Monocytes: 4% O dry wound
risk for infection. ® Prophylactic antibiotics will
• Eosinophils: 3% dressing
N help prevent infections.
7. Encourage taking the - Patient
- medications as prescribed and understandin
directed. g and
H
® Premature discontinuation of demonstratio
E treatment may result in drug- n of proper
resistant strains of bacteria. hand hygiene
A 8. Observe and report any signs of
infection such as fever, redness
L
and inflammation.
T ® Reporting any signs of
infection will help in applying
H
DATE & NURSING
CUES NEED OBJECTIVE/GOAL NURSING INTERVENTIONS EVALUATION
TIME DIAGNOSIS
August Objective cues A Risk for activity At the end of 2 hours 1. Evaluated client’s actual GOAL MET
11, 2010 intolerance of nursing care, the and perceived limitations
@ 1:00 • Presence of C patient will be able ® Evaluation provides August 11, 2010
related to limited @ 3:00 AM
AM respiratory to: information about needed
T
mobility and intervention.
problem At the end of 2
I physical 2. Assessed emotional and hours of nursing
• Presence of • Understand psychological factors
limitations care, the patient
chest tube and V potential loss of affecting the client. was able to:
secondary to ability in relation ® Stressors may increase
chest drainage I existing condition effects of post-operative pain
presence of chest • Understand
bottle • Perform activities or illness and may force
T tube potential loss
• Shows some of daily living inactivity. of ability in
 reluctance in Y R: Immobility, within physical 3. Monitored vital signs. relation
performing stress, and limitations and ® Inactivity or forced activity existing
- weakness are without reluctance may alter client’s vital signs condition
activities
some factors which status.
E
• Deconditioned affects client’s 4. Minimized environmental • Perform
X tolerance to activity and noise. activities of
status; middle-
activity. Insufficient ® To promote rest and daily living
age E within
physiological and conserve energy.
psychological 5. Organized nursing care to physical
R limitations
energy may hinder allow for periods of
C client’s ability to uninterrupted rest. and without
engage in ®To promote rest and reluctance.
I necessary conserve energy.
activities. 6. Assisted client with self-
S
care activities as needed.
E ®To promote rest and
conserve energy.
P 7. Kept supplies and
personal articles within
A
easy reach.
T ®To promote rest and
conserve energy.
T 8. Instructed patient to report
a decreased tolerance for
E activity and to stop any
activity that causes chest
R pain, shortness of breath,
dizziness, or extreme
N fatigue or weakness.
® To provide for timely
intervention.
DATE & NURSING
CUES NEED OBJECTIVE/GOAL NURSING INTERVENTIONS EVALUATION
TIME DIAGNOSIS

June 16, Objective cues H Risk for infection At the end of GOAL MET
2010 @ related to rendering 2 hours of 1. Note risk factors for
4:00 pm • Stoma draining E presence of nursing care, the occurrence of infection. July 16, 2010 @
to colostomy stoma secondary patient will be able ® Risk factors should be 6:00pm
52 hours A
bag to Hirschsprung’s to: identified to assess
and 30 At the end of
L disease. causative
minutes 1. Maintain vital rendering 2 hours
• Lymphocytes: factors/contributing factors.
POSTOP R: Hirschsprung’s signs within of nursing care,
H 41% (20-35) T 2. Observe for localized signs
disease is normal range the patient was
of infection at stoma site.
H characterized by no able to:
® Assessing the site of
• Medications: peristalsis Temp = 36 –
- possible source of infection 1. Maintain
Cefoxitin occurring in the 37.5
will give a clue for prompt vital signs
P affected portion of intervention.
RR = 16-20 within
intestine. Thus, 3. Assess and document skin
• VS: cpm normal
E colostomy is
BP = 90/60 conditions around site. range
indicated. PR = 60-100 ® Assessment gives a general
Temp = 36.2 R
Colostomy refers to bpm overview of the possible Temp =
PR = 93 bpm a surgical
C source of problem. 36.7
RR = 22 cpm procedure where a 2. Manifest
4. Stress proper hand hygiene
E portion of the large absence of RR = 19
by all caregivers between
intestine is brought redness or cpm
P therapies/clients.
through the inflammation
® This measure will help PR = 90
abdominal wall to on stoma site.
T prevent contamination. bpm
carry stool out of 5. Use gloves when cleaning
I the body. A break the colostomy bag. 2. Manifest
in the body’s first ® Use of gloves help prevent absence of
O line of defense cross-contamination. redness or
N places a person at 6. Administer prophylactic inflammati
risk for infection antibiotics as indicated. on on
- ® Prophylactic antibiotics will stoma site.
Source:
help prevent infections.
H
- 2001. The 7. Encourage taking the
E Lippincott medications as prescribed and
Manual of directed.
A Nursing ® Premature discontinuation
Practice 7th of treatment may result in
L
Edition drug-resistant strains of
T Philadelphia bacteria.
: Lippincott 8. Observe and report any signs
H
 5. Risk for impaired skin integrity related to presence of stoma secondary to Hirschsprung’s disease

DATE & NURSING

CUES NEED OBJECTIVE/GOAL NURSING INTERVENTIONS EVALUATION
TIME DIAGNOSIS

July 14, Objective cues N Risk for impaired At the end of GOAL MET
2010 @ skin integrity rendering 2 hours of 1. Monitor vital signs
1:30 pm • Presence of U related to nursing care, the ® Monitoring vital signs will July 14, 2010 @ 2:30
stoma on presence of patient will be able establish the patient’s pm
2 hours T
abdomen stoma secondary to: baseline data.
POSTOP At the end of
• Pinkish R to Hirschsprung’s 2. Note presence of
1. Identify rendering 2 hours of
peristomal area disease conditions/situations that
individual risk nursing care, the
T may impair skin integrity.
factors such patient was able to:
• S/P colostomy ® Many factors and
I as: conditions contribute 1. Identify
R: Hirschsprung’s - Dirty
O impaired skin integrity. individual risk
disease is colostomy bag 3. Assess the general factors such
characterized by no - Retention of
N condition of the skin. as:
peristalsis wastes in bag ® Assessing the skin and
A occurring in the 2. Verbalize noting any problems will - Dirty
affected portion of understanding provide information colostomy bag
L intestine. Thus, of about possible - Retention of
colostomy is treatment/thera
- complications that will wastes in bag
indicated. py regimen. occur in the skin. 2. Verbalize
M Colostomy refers to 3. Demonstrate 4. Encourage regular understanding
a surgical behaviors/tech cleaning of the colostomy of treatment /
E procedure where a niques to bag. therapy
portion of the large prevent skin
T ® Cleaning the colostomy regimen. “Oo
intestine is brought breakdown bag will prevent wastes ma’am
A through the such as from retaining for a long kasabot mi sa
abdominal wall to cleaning of the period of time on the skin imong
B carry stool out of colostomy bag which will help in gipangsulti.
the body. The and the maintaining the skin Importante jud
O contents that pass peristomal integrity. nah siya.” As
through the stoma skin. 5. Encourage cleaning the verbalized by
from the transverse skin after every drainage SO.
colon may contain of the bag using a damp 3. Demonstrate
L
enzymes or irritants cloth. behaviours /
I that could disrupt ® Regular cleaning will techniques to
skin surface. prevent bacteria from prevent skin
C accumulating on the breakdown
skin. such as
Source: 6. Encourage ambulation and cleaning of
P exercise. the colostomy
- 2001. The
® These kinds of activities bag and the
Lippincott
A will help in promoting peristomal
Manual of
blood circulation. skin.
T Nursing
7. Emphasize importance of
Practice 7th
T adequate nutritional/fluid
Edition
intake.
Philadelphia
E ® These measures will
: Lippincott
help maintain general
R Williams
good health and skin
and Wilkins
N turgor.
8. Instruct patient and SO to
report significant changes in
the skin such as redness
and inflammation.
® Such changes indicate
possible skin breakdown
and infection.