Assessment Nursing Diagnosis Goals and Intervention Rationale Evaluation

and Intervention Objectives

Subjective Cues: Nursing Goal: Facilitate the Independent: After 8 hours of
Diagnosis: Altered maintenance of nursing intervention,
Objective Cues: Renal Perfusion RT electrolyte balance. 1.Establish rapport 1. To get the Goal met the patient
 Increase in Lab Glomerular cooperation of the was able to.
results (BUN, Malfunction Objectives: patient and SO.  Demonstrate
Creatinine) After 8hours of nursing participation in
 Edema intervention the patient 2. Monitor and 2. To obtain his/her
Inference: will be able to. record vital signs baseline data. recommended
 Hematuria
and assess treatment
loss of kidney  Patient will patient’s general program.
T excretory functions demonstrate condition.
 Demonstrate
Vital signs: participation in behaviour/lifest
3. Determine 3. To assess
BP: 150/70 mmhg his/her yle changes to
Impaired excretion factors related to causative and
Temp:36.4 C recommended prevent
of nitrogenous individual situation contributing factors
RR: 21 cpm treatment complications
waste product program. and note situation
PR: 88bpm
 Patient will that can affect all
demonstrate body system.
behaviour/lifest 4. To assess for
Increase in 4. Note
yle changes to hematuria
Laboratory result of characteristic of
prevent and proteinuria an
BUN, Creatinine, urine: measure
complications d renal
Uric Acid Level. urine specific
gravity. impairment.

5. Ascertain usual 5. To compare with

Altered Renal voiding pattern and current situation
Perfusion Note presence, and May indicate
location intensity pain on affected
duration of pain. organ.
6. Monitor for 6. To note degree
dependent of impairment of
generalized renal function.
edema.

7. Measure urine 7. To assess renal

output on a regular perfusion and
schedule and function.
weigh daily.

8. Identify 8. To promote
necessary changes wellness and
in lifestyle and prevent further
assist client to progression of
incorporate disease complication.
management to
ADLs.

Dependent
1.Administer 1. For faster
medication as recovery. It is used
ordered. to treat the client’s
disease condition.
2. Monitor patients 2. To monitor any
lab result and unusual
chemistry abnormalities in
patient condition.
3. Refer to 3. Diet is one of
physician about the the factors that can
prescribe diet that help in patients’
is appropriate to recovery and avoid
the client any complications

Collaborative:
 1.Coordinate with 1.Good nutrition
the nutritionist can aid in patients’
about the recovery.
prescribed diet for
the patient.

Assessment Nursing diagnosis Goals and Intervention Rationale Evaluation

and inference Objectives
Subjective: patient Acute abdominal Goals: To facilitate Independent: After 4 hours of
describe pain as pain r/t optimal activity: 1.Observe and 1.Assists in nursing intervention,
crushing and obstruction/ductal exercise, rest and document differentiating cause goal met; the patient
intermittent lasting for spasm sleep. location, severity of pain, and provides was able to.
30 minutes, with Objectives: After 4 (0–10 scale), and information about -Report pain is
radiation to the back. Inference: hours of nursing character of pain disease progression relieved/controlled.
Cholangitisis the intervention the (steady, and resolution, -Pain is reduce from
Objectives: most serious patient will be able to. intermittent, development of 6/10 to 2/10.
 Guarding complication of -Report pain is colicky). complications, and -Demonstrate use of
Behaviour gallstones and more relieved/controlled. effectiveness of relaxation skills and
 Facial mask of difficult to diagnose. -Pain is reduce from interventions. diversional activities
pain Itis caused by 6/10 to 2/10. as indicated for
 Pain scale was impacted stone in -Demonstrate use of 2.Note response 2.Severe pain not individual situation
6/10 the common bowel relaxation skills and to medication, and relieved by routine
 (+) Generalize duct, resulting in diversional activities report to physician measures may
weakness bile stasis, as indicated for if pain is not being indicate developing
bacteremia and individual situation. relieved. complications or need
Vital signs: septicemia if left for further
BP: 150/70 mmhg untreated. It is more 3.Promote intervention.
Temp:36.4 C likely to occur when bedrest, allowing 3.Bedrest in low-
RR: 21 cpm an already infected patient to assume Fowler’s position
PR: 88bpm position of reduces intra-
comfort. abdominal pressure.
4.Encourage use
of relaxation 4.Promotes rest,
techniques. redirects attention,
Provide may enhance coping.
diversional
activities.
5.Control 5.Cool surroundings
environmental aid in minimizing
temperature. dermal discomfort.

6.Make time to 6.Helpful in

 listen to and alleviating anxiety an
maintain frequent d refocusing attention,
contact with which can relieve
patient. pain.

Dependent:
1.Maintain NPO 1.. Removes gastric
status, insert secretions that
and/or maintain stimulate release of
NG suction as cholecystokinin and
indicated. gallbladder
2. Administer contractions.
medication as 2. For faster recovery.
ordered. It is used to treat the
client’s disease
condition.

Assessment Nursing Diagnosis Goals and Objectives Intervention Rationale Evaluation

and Inference
Subjective Cues: Decreased Cardiac Goals: To facilitate the Independent: After 4 hours of
Output rt Alteration maintenance of 1.For patients 1.Fluid restriction nursing intervention,
Objective Cues: in heart rate, regulatory mechanism with increased decreases the Goal met;the patient
 Noted atrial extracellular fluid
 fibrillation rhythm, and and functions. preload, limit volume and reduces was be able to;
(11/30); ECG conduction Objectives: fluids and sodium demands on the 1.Patient
(12/1): After 4 hours of as ordered. heart. demonstrates
 left atrial Inference: nuraing intervention 2. In patients with adequate cardiac
enlargement Decrease the patient will be able 2.  Closely decreased cardiac output as evidenced
 leftward Contractability to; monitor fluid output, poorly by blood pressure and
deviation 1.Patient demonstrates intake, including functioning ventricles pulse rate and rhythm
BP:150/70 (at adequate cardiac IV lines. Maintain may not tolerate within normal
the ER) output as evidenced by fluid restriction if increased fluid parameters.
Ventricle dilates to blood pressure and ordered. volumes. 2.Patient exhibits
increase pulse rate and rhythm 3. These actions can warm, dry skin,
Vital signs: contractability from within normal 3. If chest pain is increase oxygen eupnea with absence
BP: 150/70 mmhg stretched muscle parameters. present, have the delivery to the of pulmonary
Temp:36.4 C fibers 2.Patient exhibits patient lie down, coronary arteries and crackles.
RR: 21 cpm warm, dry skin, monitor cardiac improve patient 3.Patient remains free
PR: 88bpm eupnea with absence rhythm, give prognosis. Symptoms of side effects from
Increase ventricular of pulmonary crackles. oxygen, run a can also be the medications used
radius results in 3.Patient remains free strip, medicate for manifestations of to achieve adequate
increase wall of side effects from the pain, and notify myocardial ischemia cardiac output.
tension medications used to the physician. and should be 4.Patient explains
achieve adequate reported immediately. actions and
cardiac output. 4. Atrial fibrillation is precautions to take for
Increase oxygen 4.Patient explains 4.  Place on a common in heart cardiac disease
consumption and actions and cardiac monitor; failure and can cause
increase cardiac precautions to take for monitor for a thromboembolic
workload cardiac disease dysrhythmias, event.
especially atrial
fibrillation.
5. Observe 5. This promotes the
Cardiac output falls patient for cooperation of the
understanding patient in their own
and compliance medical situation.
 with medical
Increase regimen,
sympathetic outflow including
to increase heart medications,
rate and systemic activity level, and
vascular resistance diet.
6. Upright position is
6. Position patient recommended to
in semi- reduce preload and
Stroke volume falls Fowler’s to high- ventricular filling
Fowler’s when fluid overload is
the cause.
Decrease cardiac
output Dependent: 1. The failing heart
1.Administer may not be able to
oxygen therapy respond to increased
as prescribed. oxygen demands.
Oxygen saturation
needs to be greater
than 90%.
2. Depending on
2. Administer
etiological factors,
medications as
common medications
prescribed, noting
include digitalis
side effects and
therapy, diuretics,
toxicity.
vasodilator therapy,
antidysrhythmics,
angiotensin-
converting enzyme
inhibitors, and
inotropic agents.