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CUES/ DATA NURSING RATIONALE GOALS AND INTERVENTION RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES S
Subjective: Involuntar Decreased After 8 hours (1 1. Monitor 1. Harmful After 8
“Bigla nalang y muscle shift) of nursing patient for incident s hours (1
siya nahulog at movement endurance, can shift) of
nauntog sa intervention, the self-harm
s of the strength, contribute nursing
pader tapos client should be (sleeping, and give
left control, or intervention,
napansin ng able to : home possible
teacher niya na extremities mass related the client
related to to
safety) recurrences
partially met
magalaw na 2. Keep of the
daw yung impaired Neuromuscul impairment and
katawan niya”, mobility. ar impairment patient achieved
 maintain to the
as verbalized by specifically away from client. the
functional sharp
the father. the 2. Involuntary following:
ability
premature objects. movements
Objective: death of cells  prevent of the client >maintaine
3. Feed
 Jerky in the basal additional might lead d functional
moveme impairme patient
ganglia, her to harm ability
nts of nt of slowly herself.
particularly with few >prevented
the physical 3. Patient
the additional
hands activity but might be at
and feet cerebellum, risk of impairment
the area that  ensure a frequent of physical
 Fingers aspiration
coordinates safe 4. Encourage 4. Can help activity
are
snapping voluntary environm independe regain >ensured a
 Head muscle ent. nt mobility safe
turns activity, as  Perform ambulatio and can do environment
fast from evidenced by activities n as long activities of >performed
one side the of daily daily living activities of
as without
to involuntary living with possible. daily living
another minimal assistance
jerky 5. Perform 5. Necessary
without
 movements assistanc discomfort
FUNCTIONAL e Range of to regain
of the head, normal and with
LEVEL
Perform Motion
CLASSIFICATION hands fingers  reflexes to minimal
and feet. health exercises speed assistance.
Level 2-
Requires help teachings recovery. >Acquired
from another and
person for practiced
assistance, health
supervision, or teachings.
teaching

CUES/ DATA NURSING RATIONALE GOALS AND INTERVENTIO RATIONALE EVALUATION


DIAGNOSIS OBJECTIVES NS
Risk for At risk for After 4 hours of 1.Monitor level 1.A decreased level After 4
Subjective: aspiration entry of nursing of of consciousness is hours of
related to gastrointestin consciousness a prime risk factor nursing
intervention, the for aspiration
impaired al secretions, intervention,
client should be 2.Monitor for
stabilizatio oropharyngea the client
n of the l secretions, able to : choking during 2.Choking indicates
partially met
eating or aspiration.
body. or solids or and
>experience no drinking.
fluids into 3.This will help achieved
Objective: tracheobronc aspiration as the
3.Supervise or detect
Cyanotic hial passages evidenced by abnormalities early. following:
assist patient
PR:112 due to noiseless with oral
RR:28 dysfunction or respirations, intake. 4.Semisolid foods >absence of
absence of clear breath like pudding and aspirations
normal sounds, clear 4.Offer foods hot cereal are most as
protective with easily swallowed. evidenced
and odorless Liquids and thin
mechanisms. consistency by good PR,
secretions that patient foods like creamed RR.
can swallow. soups are most
>Identify Cut foods into difficult for patients
with dysphagia
>Identified
causative/ risk small pieces. causative/ris
factors 5.Proper positioning k factors
5.Position
patient at 90- of patients with
>Demonstrate swallowing >Demonstra
degree angle,
techniques to whether in bed difficulties is of ted
prevent or in a chair or primary importance techniques
wheelchair. during feeding or to prevent
aspiration.
Use cushions or eating. aspiration
>acquire and 6.This removes
practice health pillows to residuals and >Acquired
maintain reduces pocketing and
teachings of food that can be
position. practiced
later aspirated.
teachings.
6.Provide oral
care after
meals.

CUES/ DATA NURSING RATIONALE GOALS AND INTERVENTION RATIONALE EVALUATION


DIAGNOSI OBJECTIVES S
S
Subjective: Delayed Developmental After 5 hours of 1. Assess 1.To determine After 5 hours
“ Sinusubuan growth delay occurs when present level of where to focus of nursing
children have not nursing
ko siya parati and personal, social, more your intervention,
at inaalalayan reached the intervention, the client
developm developmental cognitive and interventions.
ko maligo at the client partially met
ent related milestones by the motor
maglakad- expected time should be able and achieved
lakad. Kulang to the development. 2.To have a basis the following:
effects of period. to : on what to
na din tulog Developmental
niya. Madalas physical delays can occur in 2.Assess render to the >Demonstrat
disability/ >Demonstrate an client.
siya pagising all five areas of etiological ed increase in
gising sa impaired development or increase in factors for personal,
medaling- physical may just happen in personal, social, alteration in 3.To have a basis social,
araw. Madali one or more of language,
mobility. language, growth and if the client is
those areas.
din siya cognition, or motor development having nearly cognitive or
mapagot at >growth in each normal weight motor
hingalin”, as activities activities
area of 3.Evaluate and height to
verbalized by development is appropriate to age
height and appropriate
the father.
appropriate age for age.
related to growth in group. weight before
the other areas. So and if there are
and after
Objective: if there is a improvements >Performed
>Perform self-care intervention.
Assisted in difficulty in one self-care and
area (e.g., speech and self- control
doing self-care 4.To help client self-control
and mobility), it is activities 4.Assist client to
and likely to influence prevent, regain activities
ambulation appropriate for age. appropriate appropriate
development in minimize, or
other areas (e.g., growth and for age.
>Demonstrate overcome delay/
Father social, physical and
answers my emotional). weight/ growth development. >Demonstrat
questions. stabilization or regressed ed
Client cannot Environmental risk weight/growt
also includes a progress toward development. 5.for the client to
speak clearly be active by h stabilization
child's life age- appropriate
and with a soft or progress
experiences. For 5.Encourage in participating in toward age.
voice. example, children
size.
meeting her daily
who are having educational,
Client was difficulty in >Perform health activities of life. >Acquired and
physical, practiced
absent in performing teaching psychological health
school for activities of daily
needs of the teachings.
almost 3 living, poor
nutrition, or lack of patient.
weeks.
care are at
increased risk for
developmental
delays.