CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE CUES: Ineffective Short term goals: Independent: Short term
“permikogihangakm breathing At the end of 30 goals:
aam” as verbalized pattern minutes of thorough Allow client bed rest To conserve
by the patient. related to nursing care, the in between energy and Goals met.
shortness of patient will be able to. activities. to avoid After 15
oxygen overexertion minutes of
supply Demonstrate different Encourage slower thorough
OBJECTIVE CUES: kinds of relief respirations use of To assess nursing
Abnormal increase restlessness and pursed lip client in intervention,
of RR of 28cpm. feeling of breathless technique. taking the client was
control of the able to
Restlessness Appears restful situation and establish
Assist client on to reduce normal
Shortness of breath Establish normal semi-fowlers anxiety level. breathing
breathing pattern from position pattern from
23cpm to 20c.p.m To promote 28cpm to
expansion of 24cpm and
Long term goals: Monitor pulse lungs and demonstrated
After 8 hours of oximetry provide different kinds
thorough nursing comfort. of relief
intervention, the client restlessness
will able to: To and feeling of
verify/mainte breathless.
Maintain breathing Dependent: nance
pattern within the Provide oxygen improvement
normal range (12- therapy in oxygen
16cpm) saturation Long term
goals:
Goals met.
To maintain After nursing
an interventions,
acceptable the client was
level of able to
oxygen at maintain
tissue level. breathing
pattern within
the normal
range

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE CUES: Impaired Short term goals: Independent: Short term
Subjective cues: swallowing After15 minutes of Assist with To identify cause goals:
“maglisodkogtulonm related to thorough nursing diagnostic testing of swallowing
aam” as verbalized by abnormal intervention, the client of swallowing disorder Goals met.
the patient. function of will able to: activity. After 15
swallowing minutes of
mechanism Verbalize Encourage a rest thorough
understanding of period before nursing
OBJECTIVE: action of properly meals To minimize intervention,
intake of food and fatigue the client was
Coughing, choking, or water. able to
gagging before a Provide understand
swallow consistency of the action on
Lack of chewing Long term goals: food and fluid that For choking or how to intake
Delayed swallow After 8 hours of is most easily to aspiration can be properly the
thorough nursing swallowed. reduced food and
intervention, the client water
will able to: Dependent:

Able to demonstrate Long term

effective swallowing Refer to surgeon, goals:
without getting a gastroenterologist
problem. or neurologist Goals met.
Consider tube After nursing
feedings or For treat to interventions,
parenteral improved the client was
solutions, as swallowing able to
indicated demonstrate
For the client effective
who unable to wallowing
achieve without
adequate getting a
nutritional problem.
intake.

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE CUES: Decreased Short term goals: Independent: Short
Heart palpitation cardiac After15 minutes of Administer fluids, To support termgoals:
Fatigue output thorough nursing diuretics, inotropic systemic and Goalsmet.Aft
Dyspnea;feeling related to intervention, the drugs, cardiac er15minuteso
breathless altered client will able to: antidysrhythmics, circulation and fthoroughnur
Anxiety heart rate steroids, determine singinterventi
or rhythm. Verbalize knowledge vasopressors and/or therapeutic, on,theclientw
OBJECTIVE: of the disease dilators, as indicated adverse, or toxic asableto
tachycardia process, individual amd evaluate effects of Verbalizekno
EKG [ECG] changes risk factors, and response. therapy. wledgeofnthe
( arrhythmia) treatment plan Provide adequate To promote diseaseproce
abnormal skin color including relaxation rest patient ss,individualri
alterations in blood techniques. relaxation skfactors,and
pressure readings Provide treatmentpla
cough Long term goals: psychological Honesty can be nincludingrel
After 8 hours of support. Maintain a reassuring when axationtechni
thorough nursing calm attitude, but so much activity ques.
intervention, the admit concerns if and worry are
client will able to: questioned by the apparent to the Longtermgoal
client. patient. s:
Display Elevate legs when This limits Goalsmet.Aft
hemodynamic sitting(if heart venous stasis, ernursinginte
stability (e.g. blood failure present or improves venous rventions,the
pressure, cardiac extremities are return and clientwasable
output, renal edematous). Apply systemic to
perfusion/ urinary antiembolic hose or circulation, and Report/Demo
output, peripheral sequential reduces the risk nstratedecrea
pulses). compression of sedepisodeso
devices when thrombophlebitis fdyspnea,angi
Report/ indicated, being . na,anddysrhy
Demonstrate sure they are thmias
decreased episodes individually fitted
of dyspnea, angina, and appropriately To reduce
and dysrhythmias. applied. anxiety and
Encourage conserve energy
relaxation
techniques.

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVECUES: Impaired After 8 hours of Monitor vital signs It serves as a
Dyspnea gas nursing and cardiac baseline for data. All After8hoursof
Visual Disturbance exchange intervention, the rhythm. vital signs are nursinginterv
related to patient will be impacted by changes ention, the
OBJECTIVE: ventilation- able to maintain in oxygenation. patient was
Abnormal arterial perfusion optimal gas Elevate the head of able to
blood gases (ABGs)/ imbalance exchange and the bed and Elevation or upright maintain
arterial pH participate in position the client position facilitates optimal gas
Abnormal breathing treatment appropriately. respiratory function exchange as
pattern regimen (e.g. by gravity; however, evidenced by
Tachycardia breathing a patient in severe normal ABGs
excercises, Note the character distress will seek a and alert
effective and effectiveness position of comfort. responsive
coughing, use of of the coughing This affects the mentation or
oxygen) within mechanism. ability to clear no further
level of ability or airways of secretion. reduction in
situation. Assess level of mental status
consciousness and A decreases level of
mentation consciousness can be
changes. an indirect
 measurement of
impaired
oxygenation, but it
Encourage also impairs one's
frequent position ability to protect
changes and deep- airway, potentially
breathing and further and adversely
coughing affecting
excercises. Use oxygenation.
incentive This promotes
spirometer, chest optimal chest
physiotherapy, expansion,
intermittent mobilization of
positive-pressure secretions, and
breathing, as oxygen diffusion.
indicated.

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Impaired After 8 hours, the Monitor vital signs It serves as a After8hoursof
Exposure to oral mucous patient will be and cardiac baseline for data. All nursinginterv
pathogen membrane able to rhythm. vital signs are ention;
Oral pain or related to Verbalize impacted by changes Responses to
discomfort allergy understanding of in oxygenation. interventions
Difficulty in eating or causitive or risk Elevate the head of and actions
swallowing factor. the bed and Elevation or upright are
Identify specific position the client position facilitates performed.
OBJECTIVE: interventions to appropriately. respiratory function The patient
Geographic tongue promote healthy by gravity; however, was able to
Oral edema oral mucosa a patient in severe demonstrate
Difficulty speaking distress will seek a techniques to
Mucosal pallor Demonstrate Note the character position of comfort. restore
techniques to and effectiveness /maintain
restore/maintain of the coughing This affects the integrity of
integrity of oral mechanism. ability to clear oral mucosa.
mucosa airways of secretion.
Assess level of A decreases level of
consciousness and consciousness can be
mentation an indirect
changes. measurement of
impaired
oxygenation, but it
Encourage also impairs one's
frequent position ability to protect
changes and deep- airway, potentially
breathing and further and adversely
coughing affecting
excercises. Use oxygenation.
incentive
spirometer, chest The patient
physiotherapy, maintains optimal
intermittent gas exchange as
positive-pressure evidenced by normal
breathing, as ABGs and alert
indicated. responsive
mentation or no
further reduction in
mental status