Cues/Data Nursin G Diagno SIS Rationale Goal/Pla Nning Interventions Rationale Evaluation

Mark Joseph Pallera Austria BSN IV – A06/Group 21/RLE MDH 3C:Espinosa December 01, 2010
NURSIN
G GOAL/PLA
CUES/DATA RATIONALE INTERVENTIONS RATIONALE EVALUATION
DIAGNO NNING
SIS
SUBJECTIVE: N/A Chronic A state in which After 8 hour 1.Assess and document 1.the absence of behaviors After 8 hors of
Pain an individual of nursing behaviors that might be thought to be indicative of nursing
OBJECTIVE: related to experiences pain interventions indicative of pain(e.g. pain does not necessarily intervention the
-constantly disease that is persistent the client will change in activity, loss of mean that pain is absent. client was able to
complains of pain: process or intermittent relate/demon appetite, guarding, Certain behaviors have demonstrate an
5/10 on the pain (cancer) and last for strate grimacing, moaning, been shown to be alleviation from
scale greater than 6 improvement/ etc..) indicative of pain and can pain, as evidence
-client shows signs months. alleviation of be used to assess pain who by:
of pain during Unpleasant pain, as cannot use a self report
bowel movements sensory and evidence by: pain rating tool (1)reports of pain
-during episodes of emotional 2.for persistent cancer alleviation
experience of pain, experience (1)report pain, obtain a 2.opioid analgesic such as (2)negative for
the client shows arising from improvement/ prescription to administer morphine is used to relieve facial grimacing,
facial grimacing, actual/potential alleviation of opioid analgesic the client of persistent crying, etc…
guarding, crying tissue damage. pain to cancer pain for comfort (3) vital signs with
and strokes Due to the tolerable purposes in normal limits: RR
affected area destruction/disea levels = 18; PR = 100
-loss of appetite se process of (2)negative 3.if opioid dose is 3.client receiving long-term
-increased cancer, the client for grimacing, increased, monitor opioid therapy generally
respiratory experiences crying, sedation and respiratory develop tolerance; and can
rate/pulse rate discomfort and guarding status cause respiratory
pain. (3)vital signs depression.
with in
normal limits: 4.handle the client’s body 4.this action lessens the
RR = 12-20; gently. discomfort/pain
PR = 60-100 experienced by the client
NURSIN
G GOAL/
DIAGNO PLANNING
SIS
SUBJECTIVE: N/A Deficient The state in After 8 hours 1.Monitor intake; ensure 1.the adequate intake After 8 hours of
Fluid which an of nursing at least 1500ml of oral should be provided for nursing
Volume individual intervention fluids is taken every adequate hydration intervention the
OBJECTIVE: related to experiences or is the client will 24hrs client was able to
-insufficient oral decreased at risk of increase increase fluid
fluid intake fluid experiencing intake of 2.mintor output; ensure 3.more output than intake intake as specified
-negative balance reserve dehydration. fluids to a an output of at least 1000 will play apart in the amount according
of intake and and specified to 1500 ml every 24 hrs. development of to age and
output decreased amount dehydration and increased metabolic needs
-weight loss sensation according to fluid volume deficit.
-dry skin/mucous of thirst age and 3.watch for early signs of
membrane metabolic hypovolemia, including 3.assessing early sign can
-poor skin tugor needs, as restlessness, weakness, prevent complication, thus
-decreased blood evidence by: muscle cramps, etc… provide proper
pressure intervention and planning
(1)demonstra 4.check/assess vital signs
te no signs q1-4 hrs; observe for
and tachycardia, increased 4.these signs and
symptoms of breathing. symptoms can result in
dehydration decreased tissue
5.Initiate a fluid challenge oxygenation
of crystalloids (lactated
ringers/0.9 normal saline) 5.can help the client regain
for replacement of intravascular volume
intravascular volume. quickly.
NURSIN
G GOAL/
DIAGNO PLANNING
SIS
SUBJECTIVE: N/A Hyperther Due to After 1 hour 1.Provide TSB as 1.froviding tepid sponge After 1 hours of
mia related infection the of nursing indicated bath can help decrease nursing
to inflammatory intervention temperature through the intervention the
OBJECTIVE: inflammato response is the client will process of client was was
-Temp = 38.5*C ry triggered causing maintain a evaporation/conduction able to demostrate
-skin is warm to response the body temperature temperature
touch secondary temperature to with in the 2.provide a cool/well 2.with the use of reading of 37.5*C.
to disease rise to defend normal range, ventilated room for the convection, and movement
process against infections as evidence client; also provide the of air currents the client’s
by: client with loose clothing temperature will decrease
(1) Temp 3.administer antipyretic 3.the use of pharmacologic

=36.5-37.5 medication as ordered by means will help decrease
physician the client’s temperature
NURSIN
G GOAL/PLA
DIAGNO NNING
SIS
SUBJECTIVE: N/A Imbalanced Intake of After 8 hours 1.determine daily caloric 1.the need to determine After 8 hours of
Nutrition: nutrients of nursing requirements that are the nutritional needs can nursing
less than insufficient to intervention realistic and adequate. greatly help with future intervention the
OBJECTIVE: body meet metabolic the client will Refer /consult with a interventions and plan of client was able to
-cachexic requiremen needs. The ingest/receive dietitian. care based on the needs of receive the
appearance ts related client’s lack of daily the patient. adequate
-observed to anorexia appetite and nutritional 2.maintain/provide good nutritional
dramatic weight and fatigue decreased ability requirements oral hygiene for the 2.although the client requirements in
loss secondary to intake in accordance patient cannot ingest food orally it accordance with
-observed anorexia to disease sufficient with is still important to keep metabolic needs
-fatigue/lack of process nutrients needed metabolic good oral hygiene for the
energy (cancer) to sustain proper needs. 3.provide the client with client
-pale conjunctival body function . nasogastric feedings q 6
and mucous hours as ordered by 3.keeping the client to
membranes physician of 1500 kcal receive the correct amount
-poor muscle tone diet per day. of nutrition to help with
and muscle cell/tissue regeneration
weakness and to fight of disease, in
-mental irritability the hope to recover.
and confusion 4.consider to provide TPN
for the client for 4.due to the clients current
continuous and on-going nutritional state the client
nutritional intake needs to receive proper
and adequate nutrition.
NURSIN
G GOAL/PLA
DIAGNO NNING
SIS
SUBJECTIVE: N/A Impaired Invasion of the After 16 hours 1.Monitor site of skin 1.systemic inspection and After 8 hours of
Skin body structure; of nursing impairment at least once assessments can identify nursing
Integrity destruction of intervention a day for color changes, impending intervention the
OBJECTIVE: related to skin layers the client will redness, swelling, problems/complications client was able to
-thin, dry, flakey physical (dermis); demonstrate warmth, pain, and other early demonstrate
skin immobility disruption of skin progressive signs of infection improvement of
-poor skin tugor surface healing/impro skin integrity of
-erythematic (epidermis). Due vement of 2.Minimize exposure of 2.these substances are affected sites, as
located on the to the clients integrity of skin impairment and irritating and can cause evidence by:
buttocks and immobility, the the affected other areas to moisture skin breakdown and
shoulders client is confined areas, as from incontinence, destruction, and can cause (1)decrease in
-stage I pressure in the bed with evidence by: perspiration. infection or irritation redness of affected
ulcer present on little or no area
the sacral region activity; pressure (1)decrease 3.create/implement a 3.turning the client relieves (2) sacral pressure
-IV site @ right on bony in the redness schedule for turning the pressure and allows the sore shows
dorsal side of the prominences of affect client to relieve pressure skin to “breath” preventing improvements
hand cause irritation areas from site that are most the skin from breaking
and breakdown (2)stage I affected: turn and down
in the integrity of pressure ulcer reposition the client q 2
the skin and on sacral hrs.
surrounding region will 4.decreases the exposure
structures halt its 4.provide bed baths and to irritating agents to the
progress and adequate/proper hygiene skin, promoting skin
show for the client: sponge integrity
improvement bath, diaper change,
perianal care, etc…
5.early assessment and
5.teach skin and wound intervention help prevent
assessment and ways to serious problems from
monitor signs and developing
symptoms of infection,
complications, and
healing. 6.this allows the members
and other care givers to
6.teach how to properly turn and reposition the
turn and reposition the client properly, preventing
client atleast every 2 hrs the worsening and
development of pressure
ulcers
NURSIN
G GOAL/PLA
DIAGNO NNING
SIS
SUBJECTIVE: N/A Ineffective Inability to clear After 8 hours 1.auscultate breath sounds q4 1.the presence of course crackles After 8 hours of
hrs. indicates fluid in the airway;
Airway secretions or of nursing nursing
wheezing indicates an airway
clearance obstructions from intervention obstruction intervention the
OBJECTIVE: related to the respiratory the client will client was able to
-presence of thick immobility, tract to maintain maintain a 2.monitor respiratory pattern, 2.with secretions in the airway, maintain a patent
including rate, depth, and effort. the respiratory rate will increase
purulent sputum stasis of a clear airway. patent airway airway, as
-ineffective cough secretions, Due to being at all times, 3.observe sputum, noting color, 3.normal sputum is clear or gray evidence by:
-presence of and confined only to as evidence odor, and volume and minimal; abnormal sputum is
nasogastric tube ineffective the bed, not by: green, yellow, or bloody; (1)absence of
malodorous and often copious
-experienced DOB cough being able to crackles
if HOB is less than move and (1)absence of 4.position the client to optimize 4.an upright position allows for (2)stable
30 degrees ambulate, the crackles respirations with head of bed maximal lung expansion, as well respiratory rate
-capillary refill 3-4 clients secretions during elevated 45 degrees and as, decrease the chance of and rhythm
reposition at least every 2 aspiration pneumonia
secs easily pools and auscultation hours.
(3)capillary refill
-changes in cause an airway of the lung 5.due to the client’s less than 3
respiratory rate obstruction. The fields 5.provide the client suctioning ineffective/decreased cough seconds
and rhythm pooled secretions (2)stabilize to clear secretions, and clear reflex, the client needs assistance
the airway passage in the removal of excessive
-slightly audible becomes thick respiratory secretions that can block the
crackles and becomes rate and airway
auscultated even harder to rhythm 6.provide oral care every 4 hrs
expel due to the (3)capillary 6.oral care freshens the mouth
after respiratory secretions have
clients reduced refill less than been removed/expectorated;
ability to cough. or equal to 3 7.administer oxygen as ordered which reduces the risk for
sec. by the physician pneumonia
8.administer medications such 7.oxygen correct hypoxemia,

as bronchodilator as ordered by which can be caused by retained
the physician respiratory secretions
9.Provide postural drainage, 8.bronchodilators decrease airway

percussion. resistance and liquefies thick
secretions
9.thios action helps to clearer and

loosen secretions, thereby making
it easier to expel through
coughing and suctioning.
NURSIN
G GOAL/
DIAGNO PLANNING
SIS
SUBJECTIVE: N/A Ineffective The state in After 8 hours 1.assess the client vital 1.assessment can hinder After 8 hours of
breathing which an of nursing sings q2-4 hrs further complication and nursing
pattern individual intervention assist in planning and intervention the
OBJECTIVE: related to experiences an the client will management client was
-RR = 25 decreased actual or demonstrate 2.Auscultate breath Able to
-PR= 110 energy/fati potential loss of an effective sounds, noting decrease 2.abnormal lung sounds demonstrate
-Capillary Refill = 4 gue and adequate respiratory or absent sounds, can indicate a respiratory effective
seconds excessive, ventilation rate, as crackles, or wheezes.\ pathology associated with respiratory
-irregular breathing thick related to an evidence by: an altered breathing rate/rhythm, as
pattern secretions altered breathing 3.note abdominal pattern evidence by:
-constant coughing pattern. (1) RR = 12- breathing, use of
-observed difficulty 20 accessory muscle, nasal 3.signals increasing (1) RR = 20
of breathing. (2) PR = 60- flaring, retractions, respiratory difficulty and (2)PR = 98
-thick purulent 100 irritability, confusion, or increasing hypoxia (3) CAP REFILL =
sputum (3) cap. Refill lethargy <3 sec
= <3 seconds
4.position the client in an
upright or semi-fowler’s 4.an upright position
position facilitates lung expansion
5.Administer oxygen as 5.O2 can decrease

ordered by physician dyspnea and hypoxemia
6.provide suctioning for 6. Suctioning can alleviate

the client secretions that bloock the
airway and improve
breathing pattern
NURSIN
G GOAL/PLA
DIAGNO NNING
SIS
SUBJECTIVE: N/A Risk for The state in After 8 hour 1.monitor respiratory 1.signs of aspiration should After 8 hors of
Aspiration which a person is of nursing rate, depth, and effort. be detected as soon as nursing
OBJECTIVE: related to at risk for entry interventions Note any signs of possible to prevent further intervention the
-receiving feedings depressed of secretions, the client will aspiration such as aspiration and to initiate client was free
via nasogastric laryngeal solids, or fluids be free of/not dyspnea, cough, treatment that can be of/not experience
route q8h and glottic into the experience cyanosis, wheezing, or lifesaving aspiration, as
-decreased level of reflexes tracheobroncial aspiration, as fever. evidence by:
conciousness: secondary passages. Due evidence by: 2.the action helps to make
lethargic to naso- to the weakness sure that the client is free (1) clear lung fields
-bedridden client gastric and the inability (1)clear lung 2.ausculate lung sounds from aspiration. (2)patent airway
-decreased tube to adequately fields frequently and before and (3)able to receive
strength feedings. swallow; the (2)maintain after feedings: note any 3.maintaining a sitting nasogastric feeding
-depressed cough client had a patent airway new onset of crackles or position after meals may without aspiration
and gag reflexes nasogastric tube (3)administer/ wheezing help decrease aspiration
inserted for receive pneumonia, especial in the
nasogastric nasogastric 3.keep head of bed elderly
feedings. If not feeding elevated 30-40 degrees
maintained the without when feeding; for atleast 4.this assess and confirms
nasogastric tube aspiration 30 - 60 mins after the correct placement of
may become feeding. the feeding tube, thereby
dislodged or decreasing the
maybe placed in chances/occurrence of
the bronchial 4.determine placement of aspiration during the
tree, rather than the feeding tube before nasogastric feeding
the stomach; each feeding; by
causing the aspirating gastric content 5.increased intragastric
content to enter and using the pressure from retained
the lungs. auscultatory air feeding can cause/result in
insufflation method regurgitation and
aspiration.
5.Check for gastric
residuals before feedings; 6.to allow proper action in
if residual is greater than the case aspiration occurs;
100 ml, hold the feeding also precautions can
decrease the
6.teach the family signs chances/occurrences of
of aspiration and aspiration if proper
precautions to prevent knowledge and skills are
aspiration taught.
7.family members should

7.teach the family how to be knowledgeable in
safely administer tube administering feedings, in
feeding. the case that there would
be no one else available to
administer the feeding to
the client. Proper feeding
technique can greatly
prevent aspiration.
CUES/DATA NURSIN RATIONALE GOAL/ INTERVENTIONS RATIONALE EVALUATION

G PLANNING
DIAGNO
SIS
SUBJECTIVE: N/A Risk for The state in After 1 hours 1.watch for signs of 1.care giving might After 8 hours of
Care Giver which an of nursing depression in the weaken the immune nursing
Role Strain individual is at intervention caregiver. Intervene to system and predispose the intervention the
OBJECTIVE: related to high risk to the caregiver help the caregiver cope individual to illness; client was able to
Caregiver--- multiple experience will maintain depression in family have the
-present and care needs physical, and have the caregiver is estimated to knowledge to
provides care for and emotional, and knowledge to be 40-50% maintain physical
the patient around concern social burdens in maintain 2.arrange for a home and psychological
the clock about the process of physical and health nurse to provide 2.can decrease the burden health
-complex activities; ability to giving care to psychological nursing care and case of care giving in caregiver
amount of manage another health management following
activities; home care discharge
unpredictability of 3.practicing personal well-
health situation 3.Help the caregiver find being measures can
personal time to meet increase stamina energy,
his/her own needs and and self esteem and
learn stress management enhance the quality of care
techniques given
4.teach the caregiver how 4.will allow the caregiver

to provide the physical the knowledge to take care
care needed or give care to the client.
NURSIN
G GOAL/
DIAGNO PLANNING
SIS
SUBJECTIVE: N/A Readiness Ability to After 8 hours 1.Be present for the client 1.the care giver will be a After 8 hours of
for experience and of nursing and an active listener source of comfort and nursing
enhanced integrate intervention support for the client intervention the
OBJECTIVE: Spiritual meaning and the client will 2.Encourage the client to client was
-client expresses well-being purpose in life express pray, setting the example 2.prayer is considered an Able to express
hope related to through peace, by praying with and for adjunct therapy in critical peace, serenity,
-tells stories of desire for connectedness serenity, the client care/end-of-life care; acceptance,
past events harmony with self and acceptance, shared prayer can be one surrender, and joy
-laughs with family with self, others, and a surrender, of the deepest form of
-requests prayers others, power greater and joy 3.encourage increased communication
-interacts with higher than oneself: God quality of life through
family and friends power/God social support 3.connectedness was
-prays, participates when faced defined as an important
in religious with element that enhances
activities: prayer, serious 4.offer to read to the spirituality
etc.. illness client and encourage
engagement in regular 4.reading to a client is an
bibliotheca act of care because time is
being spent with them;
reading spiritually uplifting
materials, including sacred
5.Help the client writings, enhances
participate in religious wellbeing
rites or obtain spiritual
guidance 5.helps the client to adapt
and accept the situation; it
also serves as an outlet
and comfort for the client
Client Info/Brief Health History:

General Data
Name: EA
Address: Muntinlupa City
Age: 89 y/o
Sex: Female
Date of Birth: September 28, 1920
Civil Status: Widowed
Occupation: N/A
The client is suffering from what the doctors have said to be colon cancer; however, the client was not able to be official diagnosed due to the procedures required to
confirm the diagnosis. The doctor’s opted not to pursue colonoscopy and other invasive procedures due to the client’s past medical history and age.
6 months prior, the client exhibited weight loss and decrease in appetite, as well as, profound bowel pattern changes. The client was then taken to the hospital for a
medical checkup. The doctors considered the diagnosis of colon cancer; however due to the client’s past medical history and age, the doctors opted from doing
invasive procedures on the client. After a few days in the hospital, the client showed improvement toward heath and then was discharged. The client, however,
continued to have bowel pattern changes: bowel urgency, and alternating episodes of constipation and diarrhea. The client was “in-and out” for the hospital for six
months, with her health condition growing worse. About 3 months prior, the client was confined to bed rest due to extreme fatigue. The fatigue was due to the
decrease in appetite and energy to intake food; until the client was too weak to feed on her own, doctors inserted a nasogastric tube for the purpose of feeding. The
client’s health continued to deteriorated until she passed away.

Cues/Data Nursin G Diagno SIS Rationale Goal/Pla Nning Interventions Rationale Evaluation

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Mark Joseph Pallera Austria BSN IV – A06/Group 21/RLE MDH 3C:Espinosa December 01, 2010

(1) Temp 3.administer antipyretic 3.the use of pharmacologic

8.administer medications such 7.oxygen correct hypoxemia,

9.Provide postural drainage, 8.bronchodilators decrease airway

9.thios action helps to clearer and

5.Administer oxygen as 5.O2 can decrease

6.provide suctioning for 6. Suctioning can alleviate

7.family members should

CUES/DATA NURSIN RATIONALE GOAL/ INTERVENTIONS RATIONALE EVALUATION

4.teach the caregiver how 4.will allow the caregiver

Client Info/Brief Health History:

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