CUES Nursing Diagnosis Analysis Goal and Interventions Rationale

Objectives

After 2days of Dependent

Subjective: nursing interventions:
“Buhat nyo ako intervention the
pataas” Impaired physical Mobility and client will be able Administer
mobility related activity tolerance to increased medication prior
Objective: decreased muscle are affected by physical activity to activity as
strength any disorder that needed for pain
Cannot move on impairs the ability relief.
her own of the nervous
system, Independent
Fixed position in a musculoskeletal Interventions:
longer period of system,
time. cardiovascular Securing the A sagging
system, mattress is firm mattress, a
Limited position respiratory and level yet has mattress that is
system, vestibular enough give to fill too soft or an
apparatus. and support underfilled
Fundamental’s of natural body waterbed used
Nursing 8th edt. curvature over a prolonged
VOl. 2 Kozier pg. period can
1119 contribute to the
development of
hip flexion
contractures and
low back strain
and pain.

Fundamentals of
Nursing 8th edt,
Vol2 Kozier pg
1131.
After 20 minutes Teach the client Labels that Does the client
of nursing range of motion pertain to was able to
intervention the exercises. providing range of perform ROM
client will be able motion exercises, exercises?
to perform range ambulating clients
of motion with or without Yes___ No___
exercises mechanical aids
and strategies to
prevent
complication of
immobility,
Fundamentals of
Nursing 8th edt,
Vol2 Kozier pg
1131.

After 30 mins of Teach the family People who are Does the client
nursing member weak, in frail, In family member
intervention the significance of pain, paralyzed or was able to know
client family avoid placing one unconscious rely the significance of
member will know body part on nurses to avoid placing one
the significance of particularly one provide or assist body part
avoid placing one with bony with position particularly one
body part prominences changes. with bony
particularly one directly on the top Fundamentals of prominences
with bony of another body Nursing 8th edt, directly on the top
prominences part. Vol2 Kozier pg of another body
directly on the top 1131. part?
of another body
part.
Yes___ No___
After 30 mins of Teach the family Excessive pressure client family
nursing members the use can damage veins member will know
intervention the of support devices and predispose the significance of
client family for the client. the client to avoid placing one
member will know thrombus body part
the significance of formation. particularly one
the use of support Fundamentals of with bony
devices for the Nursing 8th edt, prominences
client. Vol2 Kozier pg directly on the top
1131. of another body
part.

After 30 mins of Discuss to the Use only those Does the client
nursing family members support devices the client family
intervention the the importance of needed to member was able
client family having a bed that maintain the to know the
member will know is clean and dry alignment and to significance of the
the significance for the client. prevent stress on use of support
of having a bed the client muscles devices for the
that is clean and and joints. client?.
dry for the client. Fundamentals of
Nursing 8th edt, Yes__ No___
Vol2 Kozier pg
1131.

Wrinkled or damp Was the client

sheets increase family member
the risk of able to know the
pressure ulcer significance
formation. of having a bed
Fundamentals of that is clean and
Nursing 8th edt, dry for the client?
Vol2 Kozier pg
1131.