Cues Nursing Background Goals And Objectives Nursing Interventions & Rationale Evaluation

Diagnosis Knowledge

Subjective: Anxiety related Vague uneasy feeling NOC: Anxiety Level NIC: Anxiety Reduction
 “Okay naman to disease of discomfort or dread
daw, pero process accompanied by an Goal:
natatakot ako evidenced by autonomic response After effective nursing interventions,
para sa health expressed (the source is often the client will be able to appear
ko. Di ko concerns nonspecific or relaxed and report that anxiety is
alam regarding unknown to the reduced to a manageable level.
gagawin ko changes in life individual); a feeling
minsan” events of apprehension Objectives:
 Expressions caused by anticipation After 8 hours of nursing The nurse will: The client was able
of fear and of danger. It is an interventions, the client will be able to:
distress alerting sign that to:
 Weakness warns of impending  Encourage client to share thoughts and 1. Display
 Reports of danger and enables the 1. Display appropriate range of feelings. appropriate
uncertainty individual to take feelings and lessened fear Rationale: Provides opportunity to examine range of
measures to deal with realistic fears and misconceptions about feelings and
Objectives: that threat. diagnosis. lessened fear
 Fidgeting  Permit expressions of anger, fear, and
 Restlessness despair without confrontation. Give
 Overexcitem information that feelings are normal and
ent are to be appropriately expressed
 Increase in Rationale: Acceptance of feelings allows client
wariness to begin to deal with situation.
 Facial
tension  Assist client and SO in recognizing and
clarifying fears to begin developing coping

2. Demonstrate use of effective
coping mechanisms and active
participation in treatment regimen
strategies for dealing with these fears. 2. Demonstrate use
Rationale: Coping skills are often stressed of effective
after diagnosis and during different phases of coping
treatment. Support and counseling are often mechanisms and
necessary to enable individual to recognize active
and deal with fear and to realize that control participation in
and coping strategies are available. treatment
 Provide calm, quiet environment. regimen
Rationale: Facilitates rest, conserves energy,
and may enhance coping abilities.

Cues Nursing Background Goals And Objectives Nursing Interventions & Rationale Evaluation
Diagnosis Knowledge

Subjective: Imbalanced Intake of nutrients NOC: Adherence Behavior: Healthy NIC: Nutrition Therapy
 “Di Nutrition: less insufficient to meet Diet
ako
masyadong than body metabolic needs.
nakakakain dahil requirements Goal:
wala akong gana related to After effective nursing interventions,
madalas. Naka insufficient the client will be able to participate in
dietary
soft diet lang din intake specific interventions to stimulate
evidenced
kasi ako, di tulad by appetite and increase dietary intake
nung dati na lack of interest
pwede in food.
ako Objectives: The nurse will: The client was able
kumain ng kahit After 8 hours of nursing to:
ano” interventions, the client will be able
 2 weeks of poor to:
appetite PTA  Monitor daily food intake
1. Demonstrate behaviors and Rationale: Identifies nutritional strengths and
Objectives: lifestyle changes to regain deficiencies
 Weight loss with and/or maintain appropriate
adequate food weight.  Assess skin and mucous membranes for
intake pallor, delayed wound healing
 Food intake less Rationale: Helps in identification of protein-
than calorie malnutrition, especially when weight
recommended and anthropometric measurements are less
daily allowances than normal.

 Create pleasant dining atmosphere;

encourage client to share meals with family
and friends.
Rationale: Makes mealtime more enjoyable,
which may enhance intake.
Cues Nursing Background Goals And Objectives Nursing Interventions & Rationale Evaluation
Diagnosis Knowledge
Subjective: Risk for Susceptible to a NOC: Bowel Elimination NIC: Nutrition Therapy
 “I cannot constipation decrease in frequency
remember the related to of defecation, Goal:
term used by the change in eating accompanied by After effective nursing interventions,
doctor, pero patterns and difficulty passing the client will be able to Establish or
parang change in usual stool, which may regain normal pattern of bowel
constipated daw foods compromise health. functioning.
si dad., as
verbalized by the Objectives:
patient’s S/O After 8 hours of nursing The nurse will:
interventions, the client will be able
Objectives: to:
 Frequent  Ascertain usual elimination habits.
belching 1. Maintain usual bowel Rationale: Data required as baseline for future
 Excessive flatus consistency and pattern evaluation of therapeutic needs and
 Hyperactive effectiveness.
bowel sounds
 Monitor I&O and weight.
Rationale: Dehydration, weight loss, and
electrolyte imbalance are complications of
diarrhea. Inadequate fluid intake may
potentiate constipation.

 Encourage adequate fluid intake, increased

fiber in diet, and regular exercise
Rationale: May reduce potential for
constipation by improving stool consistency
and stimulating peristalsis; can prevent
dehydration associated with diarrhea.
  Adjust diet as appropriate—avoid foods
high in fat, such as butter, fried foods, and
nuts; foods with high-fiber content and
those known to cause diarrhea or gas,
including cabbage, baked beans, and chili;
food or fluids high in caffeine; or extremely
hot or cold food and fluids.
Rationale: GI stimulants that may increase
gastric motility and frequency of stools.

 Monitor laboratory studies, such as

electrolytes, as indicated.
Rationale: Electrolyte imbalances may be the
result of, or contribute to, altered GI function.

Cues Nursing Background Goals And Objectives Nursing Interventions & Rationale Evaluation
Diagnosis Knowledge

Subjective: Imbalanced Intake of nutrients NOC: Adherence Behavior: Healthy NIC: Nutrition Therapy
“Di ako masyadong Nutrition: less insufficient to meet Diet
nakakakain dahil than body metabolic needs.
wala akong gana requirements Goal:
madalas. Naka soft related to After effective nursing interventions,
diet lang din kasi insufficient the client will be able to participate in
ako, di tulad nung dietary intake specific interventions to stimulate
dati na pwede ako evidenced by appetite and increase dietary intake
kumain ng kahit lack of interest
ano” in food. Objectives: The nurse will: The client was able
After 8 hours of nursing to:
Objectives: interventions, the client will be able
 Sudden weight to:
loss of 9kg 3  Monitor daily food intake
weeks PTA 1. Demonstrate behaviors and Rationale: Identifies nutritional strengths and
 Food intake less lifestyle changes to regain deficiencies
than and/or maintain appropriate
recommended weight.  Assess skin and mucous membranes for
daily allowances pallor, delayed wound healing
 Hyperactive Rationale: Helps in identification of protein-
bowel sounds calorie malnutrition, especially when weight
and anthropometric measurements are less
than normal.

 Create pleasant dining atmosphere;

encourage client to share meals with family
and friends.
Rationale: Makes mealtime more enjoyable,
which may enhance intake.