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CUES NURSING SCIENTIFIC RATIONALE GOAL INTERVENTION RATIONALE EVALUATION

DIAGNOSIS PLAN

SUBJECTIVE Risk for A state in which an After 1 day of 1. Assess to rule out After 1 day of
CUES: aspiration individual is at risk for nursing gastrointesti hypoactive peristalsis nursing
related to entry of gastric interventions, nal function and abdominal interventions,
nakukurian Neuromuscular secretions, oropharyngeal the patient will distension. the patient was
na hiya dysfunction secretions, or exogenous be able to have: 2. Position able to have:
pagtutulon food or fluids into patient with to prevent gastric
asya naka tracheobronchial Normal head of bed reflux through Normal
NGT hiya as passages because of breath elevated 30 gravity. If head breath
verbalized by dysfunction of normal sounds or degrees elevation is sounds or
the patients protective mechanisms. no change contraindicated, no change
watcher. in patients position patients in in
Aspiration(the baseline 3. Maintain right lateral decubitus patients
misdirection breath patency and position to facilitate baseline
OBJECTIVE of oropharyngeal sounds functioning passage of gastric breath
CUES: secretions or gastric of contents accross the sounds
contents into the larynx ABG values pylorus.
nasogastric
with NGT for and lower respiratory remain ABG
suction
feeding tract) is common in older within values
apparatus
history of adults with dysphagia and patients remain
to prevent
CVA can lead to aspiration baseline 4. Provide within
accumulation of
(January pneumonia. frequent and patients
No gastric contents.
2017) scrupulous baseline
The older adult with one evidence of mouth care
minimize gag
of these conditions is at gastric No
reflex
even greater risk for contents in 5. Ensure that to prevent evidence
Aspiration because The lung endotrachea colonization of the of gastric
dysphagia is secretions l/tracheosto oropharynx with contents
superimposed my cuff is bacteria and in lung
properly noculation of the secretions
inflated lower airways.
Goals met
6. Treat nausea
promptly;
collaborate to limit aspiration of
with oropharyngeal
physician on secretions.
an order for
antiemetic
to prevent vomiting
Additional and resultant
interventions for aspiration.
patients receiving
continuous or
intermittent enteral
tube feedings

1. Position
patients with
head of bed
elevated 45
degrees

2. Check to prevent gastric


placement of reflux. If a head-down
feeding tube position becomes
either by necessary at any
auscultation time, interrupt the
or feeding 30 minutes
radiographic before the position
ally at change.
regular
intervals
(e.g., before
to ensure proper
administerin
placement of the
g
tube.
intermittent
feedings and
after
position
changes,
suctioning,
coughing
episodes or
vomiting

3. Instill blue
food coloring
to feeding
solutions

4. Monitor to assist with


patients for identification of
signs of gastric contents in
CUES NURSING SCIENTIFIC GOALS INTERVENTION RATIONALE EVALUATION
DIAGNOSIS RATIONALE S
delayed pulmonary
SUBJECTIVE: IMPARIED Alteration in Short Term: Independent:
gastric secretions.
maluya hiya PHYSICAL mobility may be a emptying 1. Strength or
1. Assessed to decrease potential
ngan MOBILITY temporary or more deficiencies and
for vomiting and
functional ability/
After 8 hour(s) of aspiration
kailangan hiya related to permanent may provide
extent of
hin bulig kay decreased problem. Most nursing information
impairment
naghihinigdau muscle strength disease and intervention regarding recovery.
initially and on a
ursing
n Diagnosis/
nala hiya as andAnalysis
control rehabilitative client and Nursing Intervention
Goal & Objectives Rationale
Assists in choice of Evaluation
Cues regular basis.
verbalized by states involve significant others interventions.
Risk for Impaired Skin is the primary will be able to: Response
his wife.
Skin Integrity
some degree
defense of the body; it s to
protects the body ofagainst Short Term: Independent:
immobility(e.g., interventi
r/ t to prolonged infections and diseases 2. Allows the nurse GOAL MET
After 6-8 hrs of Assess between folds
2. Assessed Pressure ons/
immobility and brought about by astheseen instrokes,
nursing interventions of skin, remove anti to identified
ulcers under teaching
unrelieved pressure invasion of microbes in the of nursing 1.Assume proper embolic
legfracture, clients usual
stockings or medical plans and
body. A normal skin is positioning such devices previous activities actions
interventions, the & use
activities ona devices are
trauma, morbid
moist and intact; dryness performe
client will: mirror to see the initiating plan of
commonly
Subjective : of the skin is moreobesity,
prone and as moderate affected and d.
heels. Also assess overlooked.
to friction that may result high back rest under oxygen sides.
tubing
care regarding
The relative multiple unaffected
to impairment of the skin sclerosis). especially on the ears
Attainmen
mentioned Haveand reduced
turning the things to do in t/progress
OBJECTIVE: integrity as compared with & the cheek, beneath
maiha na hiya a moist skin. risk of further order for the client toward
siget client side-side
impairment of splints and under
> LIMITED desired
paghinigda. Brunner
Pressure on soft tissues skin integrity medical devices. to perform the said
every two hours. outcome(
ROM between bony s)
and Suddarth, Patients Note objective data Reassessmen
activities. Maybe
> WEAKNESS prominences t of ulcer is
of pressure ulcer
Objective: Medical-Surgical caregivers will (stage, length, width,
reducedcompleted
but still Modificati
ON demonstrate ons of
Nursing 11 vth
understanding depth, wound bed each
promotes time
client
Prolong bed
EXTREMITIES Compresses capillaries & appearance, drainage dressing are plan of
ridden edition & skill in care self-esteem andor care.
occludes blood flow & condition of changed
of wound
Long-term: 3. Scheduled
periulcer tissue) sooner if
>Inability
Prolongedto easy rehabilitation.
activity or ulcer shows
immobility
make a fist Pressure not relieved manifestation
After 2 days of procedures with s of
>Assistance 3. Activity and rest
deterioration.
Long Term: nursing rest periods.
Analyses of
with ADLs. Microthrombi formation intervention
After 3-4 days of the Encourage enhances healing
the trends in
nursing interventions,
client will report healing
and build are
muscle
participation in
increased ADLs within strength and
strength and individual endurance. Client
+ occlusion in capillaries & the client will: important
blood flow step in
assessment.

Experience
Formation of blister healing of
Increase the
ulcer/regain
frequency of turning
skin integrity
(turning q2). Position To disperse
Rupture of blister (reduce size of
ulcer) the client to stay off pressure over
the ulcer. If there is time or
Reduce risk no turning surface decreasing
+ open wound for infection without a pressure the tissue
ulcer, use a pressure load
redistribution bed &
continue turning the
client

Elevate heels off the Heel covers


bed by using pillows do not relieve
or heel elevation pressure, but
botts. they can
reduce
friction.
Maintain head of bed
@ the lowest
elevation, if client To prevent
must have the head further
elevated to prevent occurrence of
aspiration, reposition pressure
to 30 degree lateral ulcer.
position. Use seat
cushions & assess
sacral ulcers daily.
To reduce risk
Follow body of infection
substance isolation
precautions; use
clean gloves & clean
dressing for wound
care.

Practicing proper hand


washing before & after
wound care.

Dependent/Collaborative:
To prevent
malnutrition
& delayed
Ensure adequate
healing
dietary intake.
Review dieticians
recommendations.
To prevent
Prevent the ulcer contaminatio
from being exposed n/spread of
to urine & feces. Use infection
indwelling catheters,
bowel containment To promote
systems, & topical wound
creams or dressings. healing on
clients who
Supplement the diet do not have
with vitamins & adequate
minerals. Vitamins C calories.
and zinc are
commonly
prescribed.
Pressure
ulcers cannot
heal in clients
Provide oral with severe
supplementations, malnutrition.
tube-feedings or
hyperalimentation to
achieve positive
nitrogen balance.
To promote
Remove devitalized
faster healing
tissue from the
& reduce
wound bed, except in
infection
the avascular tissue
or on the heels.
Began by cleansing
the ulcer bed with
normal saline, then
use appropriate
technique for
debridement. Once
the ulcer is free of
devitalized tissue,
apply dressing the
keep the wound bed
moist & the
surrounding skin dry.
Do not use occlusive
dressings on ulcer.