Nursing Nursing

Cues Scientific Rationale Objectives Rationale Evaluation

Diagnosis Interventions
Subjective: Unstable Blood Gestational diabetes is Within 4 to 6 Independent: Independent: After 4 to 6 hours
- “Diri na ak Glucose Level caused when there are hours of nursing 1. Perform 1. All available of nursing
sugad related to excessive counter- intervention, fingerstick glucose interventions, the
kakusog adherence to insulin hormones of client will be able glucose monitors will client was able to
kumaon kesa diabetes pregnancy. This leads to: testing. provide maintain glucose
han una ky management to a state of insulin satisfactory in satisfactory
bagan waray plan as resistance and high • Maintain readings if range with
ko na gana” evidenced by blood sugar in the glucose in properly used glucose level of
as reported lack ofmother. There may be satisfactory and 89, acknowledge
verbalized. interest in food
defective insulin range maintained factors that lead
- “Gutiay la an receptors. Hormones • Acknowledge and routinely to unstable
ginkaon han Source: that raise blood sugar factors that calibrated. glucose and
akon asawa Marilynn E. include the glucagon, lead to verbalize
kaninan aga” Doenges, epinephrine and unstable 2. Review 2. Identifies understanding of
as verbalized Mary norepinephrine, glucose. client’s dietary deficits and body and energy
by the Moorhouse cortisol, growth • Verbalize program and deviations needs.
significant and Alice hormone, etc. these understanding usual pattern; from
other Murr (2019). hormones are released of body and compare with therapeutic Goals were
- “Skyflakes Nursing Care due to stress. Thus, energy needs. recent intake. plan, which completely met.
nala akon Plans: during phases of stress may
ginkakaon Guidelines for like pregnancy precipitate
para la Individualizing diabetes control unstable
mamay sulod Client Care worsens and blood glucose and
ak tiyan ky Across the sugar rises. uncontrolled
waray ako Life Span. hyperglycemia.
ganahi” as Philadelphia, Source: Mandal,
verbalized Pennsylvania: Ananya. (2019, 3. Identify food 3. Incorporating
F.A. Davis February 26). preferences, as many of the
Objective: Company. Diabetes including client’s food
- Glucose Page 383. Pathophysiology. ethnic and preferences
monitoring News-Medical. cultural needs. into the meal
results: 104 Retrieved on plan as
mg/dL at September 21, 2021 possible
5pm and 79 from increases
mg/dL at https://www.news- cooperation
5am medical.net/ with dietary
- Diagnosis of health/Diabetes- guidelines
gestational Pathophysiology after
diabetes. .aspx. discharge.
- Patient has 4. Observe for 4. Once
not fully signs of carbohydrate
consumed hypoglycemia metabolism
her meal. – changes in resumes,
LOC, cool and blood glucose
clammy skin, level will fall,
rapid pulse, and as insulin
hunger, is being
irritability, adjusted,
anxiety, hypoglycemia
headache, may occur.
light-
headedness,
and
shakiness.

Collaborative: Collaborative:
1. Monitor 1. Blood glucose
laboratory will decrease
studies, such slowly with
as serum controlled fluid
glucose, replacement
acetone, pH, and insulin
and HCO3. therapy. With
the
administration
of optimal
insulin
dosages,
glucose can
then enter the
cells and be
used for
energy. When
this happens,
acetone levels
decrease and
acidosis is
corrected.

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
383-385.

Nursing Nursing
Cues Scientific Rationale Objectives Rationale Evaluation
Diagnosis Interventions
Subjective: Mild Anxiety Fear is an automatic Within 4 to 6 Independent: Independent: After 4 to 6 hours
- “Makulba kun related to neurophysiological hours of nursing 1. Evaluate 1. Apprehension of nursing
narounds na change in state of alarm intervention, anxiety level, may be interventions, the
an doctor ky health status characterized by a fight client will be able noting client’s escalated by client was able to
bangin may evidenced by or flight response to a to: perception of severe pain, verbalize
diri maupay expressed cognitive appraisal of situation and severity of awareness of
na nakita ha concerns. present or imminent • Verbalize verbal and illness, feelings and
ak lab result” danger. Anxiety is awareness of nonverbal urgency of healthy ways to
as Source: linked to fear and feelings and responses. diagnostic deal with them,
verbalized. Marilynn E. manifests as a future- healthy ways Encourage free procedures, report anxiety is
- “Tak asawa Doenges, oriented mood state to deal with expression of and possibility reduced and
sige lat Mary that consists of a them. emotions. of surgery. appears relaxed.
paghuna Moorhouse complex cognitive, • Report
huna na and Alice affective, physiological, anxiety is Goals were
bangin kuno Murr (2019). and behavioral reduced to a completely met.
diri ihatag hit Nursing Care response system manageable 2. Review 2. These factors
Ginoo it na Plans: associated with level. physiological are present in
amon twins” Guidelines for preparation for the • Appears factors present, seriously ill
as verbalized Individualizing anticipated events or relaxed. such as sepsis client and can
by the Client Care circumstances or toxins cause or
significant Across the perceived as related to contribute to
other Life Span. threatening. infection, anxiety.
Philadelphia, medications,
Objective: Pennsylvania:
- Difficulty in F.A. Davis Source: Chand SP, and metabolic
sleeping Company. Marwaha R. Anxiety. imbalances.
- Loss of Page 398. In: StatPearls
appetite [Internet]. Treasure 3. Provide 3. Knowing what
Island (FL): ongoing to expect can
StatPearls information reduce
Publishing; 2021 regarding anxiety for
January. Available disease both client
from: process and and significant
https://www.ncbi. anticipated other (SO).
nlm.nih.gov/books/ treatment.
NBK470361

4. Provide 4. Affirms client’s

presence. value as a
Acknowledge human being
anxiety and in need of
fear. Be assistance in
accurate and dealing with a
factual in serious health
providing threat and
information. helps client
Correct and SO
misconceptions identify and
about disease deal with
process and reality.
possible
treatments.

5. Provide 5. Promotes
comfort relaxation and
measures: enhances
family ability to deal
presence, quiet with situation.
environment,
soft music,
back rub, and
therapeutic
touch.

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
398.

Nursing Nursing
Cues Scientific Rationale Objectives Rationale Evaluation
Diagnosis Interventions
Subjective: Risk for Microbial colonization Within 4 to 6 Independent: Independent: After 4 to 6 hours
- “Ginoperahan Infection as of wounds is inevitable, hours of nursing 1. Examine 1. Identifies of nursing
ako han evidenced by and in most situations intervention, wound; presence of interventions, the
September 10 invasive endogenous bacteria client will be able document and granulation client was able to
ha akon procedures predominate, many of to: report tissue identify individual
pantog” as which are potentially changes in indicating risk factors and
verbalized Source: pathogenic in the • Identify appearance, healing and interventions to
- “Pira na ak Marilynn E. wound environment. individual risk odor, or provides for reduce potential
kaadlaw Doenges, The risk of wound factors and quantity of early for infection,
waray karigo Mary infection increases as interventions drainage. detection of maintain safe
ky waray man Moorhouse local conditions favor to reduce burn-wound aseptic
ako and Alice bacterial growth rather potential for infection. environment and
makagdara Murr (2019). than host defense. infection. achieve timely
hin bado ugsa Nursing Care Consequently, a • Maintain safe 2. Emphasize 2. Prevents wound healing
makanhi pero Plans: primary aseptic and model cross- free of purulent
ginlilimpyohan Guidelines for objective in wound environment. good contamination exudate and be
man an ak Individualizing management is to • Achieve handwashing from one afebrile.
tahi” as Client Care redress the host- timely wound technique for wound area to
verbalized Across the bacterial balance, and healing free all individuals another and Goals were
Life Span. this is most effectively of purulent coming in reduces risk completely met.
Objective: Philadelphia, achieved by ensuring exudate and contact with of healthcare-
- Post- Pennsylvania: that the wound is be afebrile. client. acquired
operative F.A. Davis cleared of devitalized infection.
bilateral tissue and foreign
 wound on Company. bodies, the bacteria 3. Use gowns, 3. Prevents
abdomen Page 751. bacterial load and gloves, exposure to
- Wound is dry inflammation are masks, and infectious
and intact controlled, and that strict aseptic organisms.
adequate tissue technique
perfusion is during direct
maintained. wound care
and provide
Source: Philip G. sterile or
Bowler (2002) Wound freshly
pathophysiology, laundered bed
infection and linens and
therapeutic options, gowns.
Annals of Medicine,
34:6, 419-427, DOI: 4. Monitor vital 4. Indicators of
10.1080/07853890 signs for fever sepsis
2321012360 and increased requiring
respiratory prompt
rate and depth evaluation
in association and
with changes intervention.
in sensorium,
presence of
diarrhea,
decreased
platelet count,
and
hyperglycemia
with
glycosuria.

Collaborative: Collaborative:
1. Administer 1. Topical
topical antimicrobial
antimicrobial agents help
agents, as control
indicated bacterial
growth and
prevent drying
of wound,
which can
 cause further
tissue
destruction.

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
751-753.