NURSING

CUES SCIENTIFIC BASIS OBJECTIVES IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Ineffective tissue While a male fetus is in Short Term: INDEPENDENT: INDEPENDENT: Short Term:
“My child develops perfusion related to the womb, the testes After 1-2 hours of 1. Assess for signs of After 1-2 hours of
a sizeable lump in protrusion of the are formed in the nursing decreased tissue perfusion nursing interventions,
his left groin area intestinal portions abdomen and before interventions, the such as decreased or the patient was able to
and the swollen site birth, they descend patient will be able absence of bowel sounds, identify changes in

is more apparent into the scrotum via to: nausea and abdominal lifestyle that are needed to

when my son cries”, the inguinal canal. The  Identify changes in distention/pain. 2.Early detection of cause increase tissue perfusion
weakness that occurs lifestyle that are 2. Assess for possible causative facilitates prompt, effective and the significant other
as verbalized by the
in the abdominal wall needed to was able to verbalize
mother. factors related to temporarily treatment.
may be present at birth increase tissue knowledge of treatment
impaired arterial blood flow. 3. Assessment is needed for
or may develop later perfusion regimen, including
OBJECTIVE: 3. Monitor quality of all pulses. ongoing comparisons; loss of
on in life resulting in appropriate exercise and
 Painless lump decrease in oxygen the significant other peripheral pulses must be
medications and their
like appearance resulting in failure to will be able to: reported or treated
actions and possible side
in the left groin nourish tissues at the  Verbalize immediately.
effects.
area capillary level. knowledge of 4. Maintain optimal cardiac 4.This ensures adequate
treatment output. perfusion of vital organs.
Short term goal met.
Reference: regimen, including Support may be required to
Pathophysiology by appropriate facilitate peripheral circulation
MacCance 8 Edition
th
exercise and (e.g., elevation of the limb,
page 1280 medications and antiembolism devices.
their actions and
5. Doppler flow studies or
 possible side 5. Assist with diagnostic testing angiograms may be required Long Term:
effects as indicated. for accurate diagnosis. The patient maintains
6. These facilitate perfusion optimal tissue perfusion
6. Anticipate need for possible when obstruction to blood flow to vital organs as
embolectomy, heparinization, exists or when perfusion has evidenced by strong
Long Term:
vasodilator therapy, dropped to such a dangerous peripheral pulses,
The patient will be
thrombolytic therapy, and level that ischemic damage normal ABGs, alert LOC
able to maintain
fluid rescue. would be inevitable without and absence of pain;
optimal tissue
treatment. warm and dry skin and
perfusion to vital
7. This promotes optimal lung vital signs within
organs, warm and
ventilation and perfusion. The acceptable range.
dry skin and vital 7. Position patient in upright.
patient will experience optimal
signs within
lung expansion in upright Long term goal met.
acceptable range.
position.

DEPENDENT:
DEPENDENT: 1. This maintains maximal
1. Report change in ABGs (e.g., oxygenation and ion
hypoxemia, metabolic balance and reduces
acidosis, hypercapnia). systemic effects of poor
Titrate medications to treat perfusion.
acidosis, administer oxygen
 as needed. 2. This maintains adequate
2. Institute continuous pulse oxygen saturation of
oximetry and titrate oxygen arterial blood.
administered.
COLLABORATIVE:
 NURSING
CUES SCIENTIFIC RATIONALE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective cues: Impaired bowel Short Term Goals: Independent: Independent: Short Term Goals:
elimination related
to protrusion of
Objective cues: Long Term Goals: Dependent: Long Term Goals:
intestinal portion
 Lump like Collaboration:
appearance in
the left groin Dependent:
area

Collaboration:
 NURSING
CUES SCIENTIFIC RATIONALE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective cues: Imbalanced Short Term Goals: Independent: Independent: Short Term Goals:
nutrition less than Biologic, psychologic,
1. Document actual weight using 1. Patients may be unaware of their
body requirements economic factors weighing scale; do not estimate actual weight or weight loss due
Objective cues: ↓ Long Term Goals: to estimating weight Long Term Goals:
related to inability to
Impair a person’s ability 2. Obtain nutritional history; 2. Patient's perception of actual
 Lump like ingest or digest to ingest or digest food/ include family, significant intake may differ.
appearance in food or to absorb absorb nutrients others, or caregiver in
nutrients because ↓ assessment.
the left groin
of biologic, Imbalanced Nutrition 3. Determine etiologic factors for 3. With proper assessment you
area psychologic, or (less than body reduced nutritional intake may be able to plan appropriate
requirements) interventions (i.e., patients with
economic factors
dentation problems may require
referral to a dentist)
4. Monitor or explore attitudes 4. Many psychological,
toward eating and food. psychosocial, and cultural factors
determine the type, amount, and
appropriateness of food
consumed.
5. Encourage patient participation 5. Determination of type, amount,
in recording food intake using a and pattern of food or fluid intake
daily log. as facilitated by accurate
documentation by patient or
caregiver as the intake occurs;
memory is insufficient.
6. Monitor patient daily or weekly 6. During aggressive nutritional
support, patient can gain up to
0.5 lbs per day.
7. Provide companionship during 7. Attention to the social aspects of
mealtime. eating is important in both the
hospital and home setting.
8. Build up and persuade a 8. Pleasing milieu helps in lowering
pleasing milieu for meals. Dish stress and is more favorable to
up foods in well-ventilated, eating. It also encourages
pleasing environment, with socialization and maximizes
unhurried ambiance, friendly patient comfort when eating
company. difficulty cause discomfiture.
9. Give frequent mouth care, 9. Lowers discomfort related with
noting secretion precautions. nausea or vomiting, oral lesions,
Prevent us of alcohol- mucosal dryness, and halitosis.
containing mouthwashes Clean mouth may improve
appetite
10. Encourage exercise as 10. Metabolism and utilization of
nutrients are enhanced by
indicated
activity.