Cues Nursing Diagnosis Scientific Reason Planning Intervention Rationale Evaluation

Objective:
-weight loss (from
69kg-58kg)

-pale in overall
appearance
Weakness

-decrease RBC
(4.40x1058kg)

-pale in overall
appearance
Weakness

-decrease RBC
(4.40x10
13
/L)

-no rice for the past
6 months during
dinner.

-loose biceps and
triceps skin folds.







Imbalance
Nutrition: Less
than Body Weight
related to self-
imposed dietary
restrictions, lack
of information
and poor choice
of kind of foods as
manifested by
weight loss. Pale
in overall
appearance.

Intake of nutrients
insufficient to
meet metabolic
needs.

Source:
Nurse’s Pocket
Guide by M.
Doenges

Short Term:
After 6 hours of
nursing
intervention, the
patient will be
able to verbalize
understanding of
causative factors
when known and
the necessary
interventions.

Long Term:
The patient will be
able to
demonstrate
behaviours,
lifestyle changes
to maintain health
and appropriate
weight.

1.Established NPI

2.Assess weight,
BMI.

3.Encourage
several small
nutritious meals.

4.Evaluate total
daily food intake.

5.Emphasize
importance of
well-balanced,
nutritious intake.
Provide
information
regarding
individual
nutritional needs
and ways to meet
these needs
within financial
constraints.

1.To gain client’s
confidence.
2.To establish
baseline
parameters.
3.To meet
nutritional needs.
4.To reveal
possible cause of
imbalance and
changes that
could be made in
client’s intake.
5.Compliance to
realistic diet
modifications.

Short Term:
Served foods are
tolerated and
verbalized
understanding of
other
interventions to
attain balance
nutrition.

Long Term:
Lifestyle changes
are demonstrated
and actualized to
maintain healthy
balance.

Cues Nursing Diagnosis Scientific Reason Planning Intervention Rationale Evaluation

Objective:
-weight loss (from 69kg-
58kg)

-pale in overall appearance
Weakness

-decrease RBC
(4.40x1058kg)

-pale in overall appearance
Weakness

-decrease RBC
(4.40x10
13
/L)

-no rice for the past 6
months during dinner.

-loose biceps and triceps
skin folds.







Imbalance Nutrition: Less
than Body Weight related
to self-imposed dietary
restrictions, lack of
information and poor
choice of kind of foods as
manifested by weight loss.
Pale in overall appearance.

Intake of nutrients
insufficient to meet
metabolic needs.

Source:
Nurse’s Pocket Guide by M.
Doenges

Short Term:
After 6 hours of nursing
intervention, the patient
will be able to verbalize
understanding of causative
factors when known and
the necessary
interventions.

Long Term:
The patient will be able to
demonstrate behaviours,
lifestyle changes to
maintain health and
appropriate weight.

1.Established NPI

2.Assess weight, BMI.

3.Encourage several small
nutritious meals.

4.Evaluate total daily food
intake.





5.Emphasize importance of
well-balanced, nutritious
intake. Provide information
regarding individual
nutritional needs and ways
to meet these needs within
financial constraints.

1.To gain client’s
confidence.
2.To establish baseline
parameters.
3.To meet nutritional
needs.

4.To reveal possible cause
of imbalance and changes
that could be made in
client’s intake.



5.Compliance to realistic
diet modifications.

Short Term:
Served foods are tolerated
and verbalized
understanding of other
interventions to attain
balance nutrition.

Long Term:
Lifestyle changes are
demonstrated and
actualized to maintain
healthy balance.

Cues Nursing Diagnosis Scientific Reason Planning Intervention Rationale Evaluation

Subjective:
-insomia

-restlessness

-too much talking

-coo extremities

-sweating

-expresses financial
concerns

-increase BP: 150/100
mmHg

-increase RR: 21cpm

Anxiety (severe) related to
situational crisis and stress
AMB too much talking;
restlessness secondary to
upcoming surgery.

Vague uneasy feeling of
discomfort of dread
accompanied by an
autonomic response (the
source of ten non- specific
or unknown to the
individual) a feeling of
apprehension caused by
anticipation of danger. It is
an altering signal that
warms of impending danger
and enables the individual
to take measures to deal
with threat.

Source: Nurses pocket guide
by M. Doenges

Short Term:
after shift, the patient will
appear relaxed and report
anxiety is reduced to a
manageable level.

Long Term:
Identify healthy ways to
deal with and express
anxiety.

1.Established NPI

2.Monitor VS

3.Observe Behaviours

4.Notes reports of
insomnia.

5.Reviewed Coping skills in
post.

6.Established therapeutic
relationship, conveying
empathy and unconditional
positive regard. Note SN
needs to be aware of own
feelings of anxiety or
uneasiness exercising core.

7.Provided accurate
information about the
situation .

8.Provided comfort
measures (e.g calm and
quiet environment, warm
bath or backrub.

1.To alleviate fear and to
gain confidence.

2.To identify physical
responses associated with
both medical and emotional
conditions.

3.Which can point to the
client level of anxiety.

4.Which may be
behavioural indicator of use
of withdrawal to deal with
problems.

5.To determine those that
might be helpful in current
circumstances.

6.To avoid the contagious
effect of transmission of
anxiety.
7.Helps client identify what
is reality based.

8.To promote relaxation.



Short Term:
Goal met
The patient appeared
relaxed and verbalized
decreased of anxiety.


Long Term:
The patient verbalized and
actualizes healthy ways to
deal with and express
anxiety.
Assessment Problem/Diagnosis Scientific Reason Planning/ Goal Intervention Rationale Evaluation

-(+)epigastric tenderness
upon admission

-facial grimace

-irritable

-guarding behaviour

-BP 150/100 mmHg


Alteration in comfort; Pain
related to inflammation of
the gallbladder
Due to the presence of
stones in the gallbladder
that causes some
obstruction in the cystic
duct which in turn causes a
sharp pain on the right part
of the abdomen that causes
discomfort to patient.

Referrence:
Afdhal NH. Diseases of the
Gallbladder and Bile Ducts.
In: Goldman L, Ausiello D.
(eds.). Cecil Textbook of
Medicine. 23rd ed.
Philadelphia, Pa: Saunders
Elsevier; 2007.

Short term goal:

After 6 hours of nursing
intervention Patient will be
able to verbalize relief from
pain and there is less
autonomic responses to
pain.


Long term goal:

Patient will be able to
identify ways on how to
relieve discomfort during
reoccurrence of pain.
1. Observed and
documented the location,
severity ( 0-10) and
character of pain.
2. Response to medication
noted and physician
informed when pain is not
relieved.
3. Bed rest promoted and
allows client to assumed
position of comfort.
4. Environmental
temperature controlled.
6. Encouraged use of
relaxation techniques (
guided imagery,
visualization, deep breathing
exercise. To Provide
diversional activities.
7. Made time to listen and
maintained frequent contact
with client.


1. Assist in differentiating
cause of pain and provides
information about disease
progression/ resolution,
development of
complication and
effectiveness of
intervention.
2.severe pain by routine
measures may indicate
developing complications/
need for further intervention
3. bed rest in fowlers
position reduces intra-
abdominal pressure,
however, client will naturally
assume least painful
position.
4.cool surroundings aid in
minimizing dermal
discomfort
6. Promotes rest, redirects
attention, may enhance
coping.
7. Helpful in alleviating
anxiety and refocusing
attention which can relieve
discomfort.


Short term:
Goal met: After 6 hours of
nursing intervention
patient was able to
verbalize relief from pain,
there’s relaxation and
demonstrated negative
guarding behaviour on the
abdominal site.

Long term:
Goal met: On patient’s
continuation of care she
was able to identify ways to
relieve pain by proper
positioning to reduce
pressure on the abdomen
and to promote comfort.
Cues Nursing Diagnosis Scientific Reason Planning Intervention Rationale Evaluation
Subjective:
“pwede bang maulit ang
sakit ko?” as verbalized by
the patient

Objective:

-Frequently asking
question about his
condition ,treatment and
diet
-With worried gaze
Knowledge deficit regarding
condition prognosis,
treatment, self-care and
discharge needs.
There is this presence of
knowledge deficit due to
some unfamiliar
information that causes
some confusion to the
client that needs to be
discussed.



Source: Psychiatric Clinical
Pathways : An
Interdisciplinary Approach
By: Patricia C. Dykes





Short term goal:
After 6 hour of nurse-
patient interaction the
patient will Verbalize
understanding of disease
process, prognosis, and
potential complications.

Long term goal:
On the process of long
term intervention, client
will be able to cope up
with her condition by
understanding the
necessary adjustment for
her lifestyle, importance of
therapeutic regimen
prescribed, and give
cooperation on the
procedures and test being
done.
1. Provided explanations of
/reasons for test procedures
and preparation needed.

2. Reviewed disease
process/prognosis. Discuss
hospitalization and
prospective treatment as
indicated. Encouraged
questions, expression of
concern.

3. Reviewed drug regimen
and possible side effects.


4. Instructed patient to
avoid food/fluids high in fats
(e.g., whole milk, ice cream,
butter, fried foods, nuts,
gravies, pork), gas producers
(e.g., cabbage, beans,
onions, carbonated
beverages), or gastric
irritants(e.g., spicy foods,
caffeine, citrus).


5. Suggest patient limit gum
chewing, sucking on
straw/hard candy, or
smoking.
1. Information can decrease
anxiety, thereby reducing
sympathetic stimulation.

2. Provides knowledge base
from which patient can make
informed choices. Effective
communication and support
at this time can diminish
anxiety and promote healing.


3. Gallstones often recur,
necessitating long-term
therapy.

4. Prevents/limits recurrence
of gallbladder attacks










5. Promotes gas formation,
which can increase gastric
distension/discomfort.




Short term:
After 6 hours of nursing
intervention the patient
can

Long term:
Goal was met as
evidenced by:
Client was able to
-Participate in learning
process.
-Knowledge: Treatment
Regimen
-Verbalize understanding
of therapeutic regimen.
-Correctly perform
necessary procedures and
explain reasons for the
actions.
-Initiate necessary
lifestyle changes.

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