Cues Nursing Diagnosis Scientific Rationale Objectives Nursing Interventions Rationale Evaluation

Subjective: Acute Pain related Abdominal pain can be Within 4-6 hours of Independent: Independent: After 4 to 6 hours of
- “Naul-ol akon to tissue induced by stimulation nursing intervention, 1. Encourage client to 1. Pain is perceived, nursing intervention,
tiyan kada gabi inflammation of visceral nociceptors. client will be able to: report type, manifested, and client was able to
pero diri pirmi” Activation of location, and tolerated individually. verbalize relief or
as verbalized Source: Marilynn nociceptors usually • Verbalize relief or intensity of pain, It is important for client absence of pain and
by the patient E. Doenges, Mary requires previous absence of pain. rating it on a scale. to differentiate demonstrate relaxed
- “Diri ito hiya Moorhouse and sensitization by • Demonstrate Note associated incisional pain from body posture and
nahingaturog Alice Murr (2014). pathological events, relaxed body symptoms. other types of chest ability to rest and sleep
danay kun Nursing Care such as inflammation, posture and ability Ascertain how this pain, such as angina appropriately.
naatakar it kaul- Plans: Guidelines ischemia or acidosis. to rest and sleep compares with or discomfort from
ol hit tiyan” as for Individualizing The bacteria that cause appropriately. preoperative chest chest tubes. Goals were
verbalized by Client Care a UTI can invade the pain. completely met.
the significant Across the Life lining of the urinary tract
other Span. which in turn leads to 2. Monitor vital signs. 2. Heart rate usually
Philadelphia, inflammation and increases with acute
Objective: Pennsylvania: irritation. pain, although a
- Difficulty in F.A. Davis bradycardic response
sleeping Company. Page Source: Curatolo M. can occur in a
- Restlessness 104. Pathophysiologie der severely diseased
- Had a rating of abdominalen heart.
6 in the numeric Schmerzen
pain rating [Pathophysiology of 3. Provide comfort 3. May promote
scale. abdominal pain]. Ther measures, such as relaxation, redirect
Umsch. 2011 back rubs and attention, and reduce
Aug;68(8):415-9. position changes, analgesic dosage or
German. doi: assist with self-care frequency.
10.1024/0040- activities, and
5930/a000187. PMID: encourage
21796591 diversional
activities, as
indicated.

4. Identify and 4. Relaxation techniques

encourage use of aid in management of
behaviors such as stress, promote sense
guided imagery, of well-being, may
distractions, reduce analgesic
 visualizations, and needs, and promote
deep breathing. healing.

5. Tell client that it is 5. Presence of pain

acceptable, even causes muscle
preferable, to tension, which can
request analgesics impair circulation, slow
as soon as healing process, and
discomfort intensify pain.
becomes
noticeable.

Collaborative: Collaborative:
1. Administer 1. Provides for control of
analgesics pain and inflammation
medications— and reduces muscle
(e.g., opioids, tension, which
nonsteroidal anti- improves client
inflammatory drugs comfort and promotes
[NSAIDs]) by healing.
appropriate route
(e.g., IV, patch, by
mouth) as indicated

Source: Marilynn E.
Doenges, Mary
Moorhouse and Alice
Murr (2014). Nursing
Care Plans:
Guidelines for
Individualizing Client
Care Across the Life
Span. Philadelphia,
Pennsylvania: F.A.
Davis Company.
Pages 104 - 105.
 Nursing Nursing
Cues Scientific Rationale Objectives Rationale Evaluation
Diagnosis Interventions
Subjective: Impaired Urinary Frequency of normal Within 1-2 days of Independent: Independent: After 1-2 days of
- “Danay maihi ihi Elimination related urination may vary nursing 1. Assess voiding 1. Voiding pattern nursing interventions,
pero talagudti la to urinary tract considerably from intervention, pattern, including identifies the client was able to
man an ihi” as infection individual to individual client will be able frequency and characteristics of maintain balanced
verbalized by depending on to: amount. Compare bladder function, intake and output and
the patient Source: Marilynn personality traits, urine output with including verbalize or
- “Ha usa E. Doenges, Mary bladder capacity, or • Maintain fluid intake. Note effectiveness of demonstrate behaviors
kaadlaw, Moorhouse and drinking habits. Because balanced specific gravity. bladder emptying, and techniques to
nakakadamo Alice Murr (2014). of this fact, a history of intake and renal function, and prevent retention.
hiya pagbalik Nursing Care frequency is sometimes output fluid balance.
balik ha cr” as Plans: Guidelines difficult to obtain. • Verbalize or Goals were
verbalized by for Individualizing Changes in the pattern demonstrate 2. Palpate for 2. Bladder dysfunction completely met.
the significant Client Care of frequency or a history behaviors and bladder distention is variable but may
other Across the Life of voiding more than techniques to and observe for include loss of
Span. once at night after prevent overflow. bladder contraction
Objective: Philadelphia, retiring, however, are retention. and inability to relax
- Record of 24- Pennsylvania: clues to urinary urinary sphincter,
hour urine F.A. Davis pathology. Urgency may resulting in urine
output states Company. Page occur with or without retention and reflux
that patient 260. voiding and frequently incontinence.
urinates more culminates in
than 10 times a incontinence. With 3. Encourage fluid 3. Adequate fluid intake
day. severe lower urinary intake of 1500 to helps maintain renal
tract inflammation, the 2000 mL/day. function. It is thought
desire to urinate may be that fluids can reduce
constant with only a few risk of infection by
milliliters of urine decreasing ability of
eliminated with each bacteria to adhere to
voiding. Urgency also bladder wall.
more commonly
accompanies the dysuria 4. Observe for 4. Changes in urine
associated with urinary changes in urine characteristics may
tract infections. Urinary characteristics— indicate UTI and
urgency implies cloudy, bloody, increased risk of
inflammation, often foul odor, and so sepsis.
involving the trigone and forth.
posterior urethra. Stretch
receptors in the bladder Collaborative: Collaborative:
and posterior urethra
 subserve reflexes 1. Monitor blood urea 1. These laboratory
responsible for the urge nitrogen/creatinine tests reflect renal
to void. The urge to (BUN/Cr), white function and identify
urinate usually occurs blood cell (WBC) complications.
when the bladder count, and
approaches maximum urinalysis (UA)
capacity. Either
inflammatory or Source: Marilynn E.
neuropathic processes Doenges, Mary
can lead to increased Moorhouse and
sensitivity of these Alice Murr (2014).
receptors. Nursing Care Plans:
Guidelines for
Source: Wrenn K. Individualizing Client
Dysuria, Frequency, Care Across the Life
and Urgency. In: Span. Philadelphia,
Walker HK, Hall WD, Pennsylvania: F.A.
Hurst JW, editors. Davis Company.
Clinical Methods: The Pages 260 - 261.
History, Physical, and
Laboratory
Examinations. 3rd
edition. Boston:
Butterworths; 1990.
Chapter 181. Available
from:
https://www.ncbi.
nlm.nih.gov/books
/NBK291/

Nursing
Cues Nursing Diagnosis Scientific Rationale Objectives Rationale Evaluation
Interventions
Subjective: Risk for Deficient Fluid imbalances arise Within 1-2 days of Independent: Independent: After 1 to 2 days of
- “Sige ako hin Fluid Volume as either deficits or nursing 1. Measure I&O 1. Helps estimate fluid nursing intervention,
balik balik ha cr excesses. It greatly intervention, accurately. replacement needs. the client was able to
ky sige gihap Source: Marilynn affects body function client will be able display near balanced
tak ihi” as E. Doenges, Mary and, when severe, can to: 2. Encourage fluid 2. Diuretic phase of AKI input and output, have
verbalized by Moorhouse and lead to death. An intake. Provide may revert to oliguric moist mucous
the patient Alice Murr (2019). inadequate intake of • Display I&O allowed fluids phase if fluid intake is membranes and good
Nursing Care fluid in a healthy near balance not maintained or skin turgor, and
- “Talagudti la it Plans: Guidelines individual is a relatively • Have moist throughout 24- nocturnal dehydration displayed electrolytes
iya paginom hin for Individualizing uncommon mucous hour period. occurs within normal range.
tubig ky di man Client Care cause of dehydration. membranes
hiya mahilig Across the Life When fluid deficit • Electrolytes 3. Orthostatic Goals were
uminom” as Span. occurs, the individual will within normal 3. Monitor BP, noting hypotension and completely met.
verbalized by Philadelphia, require fluid volume range postural changes, tachycardia suggest
the significant Pennsylvania: replacement. and heart rate hypovolemia.
other F.A. Davis
- “Bagan mamara Company. Page Source: 4. In diuretic or post
akon but-ol 604. Shane Bullock and 4. Note signs and obstructive phase of
ngan baba” as Majella Hales (2013). symptoms of renal failure, urine
verbalized by Principles of dehydration, such output can exceed 3
the client Pathophysiology. as dry mucous L/d. Extracellular fluid
Pearson Australia. membranes, thirst, (ECF) volume
Objective: Pages 720 - 721 dulled sensorium, depletion activates
- Potassium is and peripheral the thirst center, and
2.66mmol/L in vasoconstriction. sodium depletion
blood chemistry causes per sis tent
test thirst, unrelieved by
drinking water.
Continued fluid
losses and
inadequate
replacement may
lead to hypovolemic
state

Collaborative:
Collaborative: 1. In nonoliguric AKI or
1. Monitor laboratory in diuretic phase of
studies, such as AKI, large urine
sodium. losses may result in
sodium wasting,
while elevated
urinary sodium acts
osmotically to
increase fluid losses.
Restriction of sodium
may be indicated to
break the cycle.
Source: Marilynn E.
Doenges, Mary
Moorhouse and
Alice Murr (2019).
Nursing Care Plans:
Guidelines for
Individualizing Client
Care Across the Life
Span. Philadelphia,
Pennsylvania: F.A.
Davis Company.
Pages 604 - 605.