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.
Lab results excretory functions demonstrate condition.
 Demonstrate
BUN: 111mg/dl participation in behaviour/lifest
3. Determine 3. To assess
Creatinine: 16.83mg/dl his/her yle changes to
Impaired excretion factors related to causative and
recommended prevent
of nitrogenous individual situation contributing factors
treatment complications
Vital Signs waste product program. and note situation
 Patient will that can affect all
Temp: 36.8 c demonstrate body system.
RR: 33 behaviour/lifest 4. To assess for
PR:76 Increase in 4. Note
yle changes to hematuria
BP:180/100 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: Independent: After 4 hours of
describe pain as pain r/t Objectives: After 4 1.Observe and 1.Assists in nursing intervention,
crushing and obstruction/ductal hours of nursing document differentiating cause goal met; the patient
intermittent lasting for spasm intervention the location, severity of pain, and provides was able to.
30 minutes, with patient will be able to. (0–10 scale), and information about -Report pain is
radiation to the back. Inference: -Report pain is character of pain disease progression relieved/controlled.
Cholangitisis the relieved/controlled. (steady, and resolution, -Pain is reduce from
Objectives: most serious -Pain is reduce from intermittent, development of 6/10 to 2/10.
 Guarding complication of 6/10 to 2/10. colicky). complications, and -Demonstrate use of
Behaviour gallstones and more -Demonstrate use of effectiveness of relaxation skills and
 Facial mask of difficult to diagnose. relaxation skills and interventions. diversional activities
pain Itis caused by diversional activities as indicated for
 Pain scale was impacted stone in as indicated for 2.Note response 2.Severe pain not individual situation
6/10 the common bowel individual situation. to medication, and relieved by routine
 (+) Generalize duct, resulting in report to physician measures may
weakness bile stasis, if pain is not being indicate developing
bacteremia and relieved. complications or need
septicemia if left for further
untreated. It is more 3.Promote intervention.
likely to occur when bedrest, allowing 3.Bedrest in low-
an already infected patient to assume Fowler’s position
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:

Objective Cues: