Cues/clues Nursing

Diagnosis

Plan Nursing Interventions Rationale Evaluation

S> “masakit ang

likod ko” as

verbalized

O> with facial

grimace

Irritable at times

Slightly weak in

appearance

With guarding

behavior

Pain scale=8/10

BP=110/80

Alteration in

comfort; flank pain

secondary to

disease condition

At the end of nursing

intervention the

patient will be able

to demonstrate ways

and technique on

how to reduce pain

to a tolerable level

Assessed severity of pain using pain

scale

Monitor VS esp. BP

Provided comfort measures such as

positioning

Provided diversional activities such as

listening to music or talking to S.O.

Instructed S.O. not to leave the patient

alone

Provided therapeutic touch

Demonstrated and encouraged to do

deep breathing exercise

Encouraged back tapping

Avoid abrupt movements

Provided adequate rest and sleep

periods

Administered analgesics as ordered

For baseline data

For baseline data

To promote comfort and

relaxation

To divert focus of attention

to pain

To prevent pain stimulation

To promote comfort and

relaxation

For pharmacologic

intervention

“Medyo nawala na ung sakit

ng likod ko”as verbalized

Pain scale= 6/10

BP=90/60

Cues/clues Nursing Nursing Plan Nursing Interventions Rationale Evaluation

Diagnosis

O>BP =

150/90mmHg

>PR = 89bpm

>episodes of

dizziness

>slightly pale nail

beds; capillary refill

time of 2-3 seconds

Decrease cardiac

output related to

increase peripheral

vasoconstriction as

evidenced by

elevated blood

pressure

At the end of

nursing

interventions, patient

with the help of SO

will be able to

demonstrate ways

and techniques on

how to normalize

cardiac output and

maintain blood

pressure within

normal range

assess contributing factors

assess general appearance

monitor v/s esp. blood pressure

instruct to move gradually and have a

gradual increase in activities

encourage to avoid strenuous activities

assist in moderate high back rest

encourage to limit intake of salty and

fatty foods

instruct the SO not to leave the patient

alone

PRN meds given

serves as baseline data

serves as baseline

data

serves as baseline data

to prevent dizziness

to prevent dizziness

to promote relaxation and

comfort

to prevent water retention

to prevent injury through

proper supervision

for pharmacological

purposes

Seen pt in semi-fowler’s

position

Seen SO always on bedside

Seen pt moving gradually

BP=130/90

Cues/ Clues Nursing Plan/Goal Nursing Interventions Rationale Evaluation

Diagnosis

O

Weak in

appearance

With assistance

in doin activities

With dry

slightly skin

With easy

fatigability

With long nails

Self-care deficit

related to decrease

strength and

endurance

secondary to

disease condition

At the end of the

nursing interventions

the patient with the

help of the S.O, will

be able to identify

ways on how to

enhance proper

hygiene

Assess capability to do activities

Discuss the importance of hygiene

Instruct SO to clean and cut long

fingernails

Instruct SO to do sponge bath

Encourage the patient to take a bath

Encourage to do oral hygiene

Encourage SO to be involve in giving

patient proper hygiene

Instruct SO to provide non-constricting

clothes

Encourage patient to splash a little

baby cologne after bath

To identify the patient’s

status

To educate the patient

about the importance of

hygiene

For proper personal

hygiene

For proper personal

hygiene

For proper personal

hygiene

For proper personal

hygiene

For the SO will be able to

apply the procedures at

home

To make the patient feel

comfortable

For the patient to feel

fresh

Seen S.O. wiping patients

extremities

Seen S.O. assisting patient

in changing of clothes and

doing some activities

Cues/ Clues Nursing

Diagnosis

Plan/Goal Nursing Interventions Rationale Evaluation

O

With edema on

the feet +1

Fluid volume

excess related to

compromised

regulatory

mechanism

secondary to

disease condition

At the end of the

nursing intervention

the patient will be

able to identify ways

on how to lessen

fluid volume excess

Assess general condition

Assess contributing factors

Assess the characteristic of edema

Monitor VS esp. BP

Instructed to limit fluid intake to less

than 1L a day

Put pillows under both legs

Instructed to turn side to side at least

every 2 hours

Advised to eat foods rich in albumin

such as egg white

Regulate IVF properly

Emphasized the importance of

furosemide treatment

Encouraged to have adequate rest and

sleep

Emphasized the importance of strict

adherence to treatment regimen

For baseline data

For baseline data

For baseline data

For baseline data

To avoid fluid

accumulation in the body

To increase venous return

To help in fluid shift

To help in lessen the

edema

For rehydration

To help in the disease

condition

To regain body strength

For faster prognosis

Seen with pillows under the

legs

Seen drinking ample

amount of water

Cues/ Clues Nursing Plan/Goal Nursing Interventions Rationale Evaluation

Diagnosis

S> “Wala kaming

pera, naghahanap

ng pa kami ng

pagkukunan para

makabili ng

pangsalin ng dugo”

O> still for blood

transfusion

>without any

contraptions

Noncompliance to

treatment regimen

r/t lack of

involvement

financial problems

At the end of

nursing intervention

the S.O. with the

patient will be able

to realize the

importance of

compliance to

treatment regimen

Identified strategies most effective for

S.O.

Encouraged S.O. on verbalization of

feelings

Helped S.O. in understanding the need

for the following treatment and

consequences of non-compliance

Emphasized the importance of

adherence to treatment regimen

Provided emotional support to S.O.

For S.O. to easily complete

with the treatment

To asses emotional

response that interfere

with compliance

For the S.O. to realize the

importance of the

treatment

For the S.O. to understand

the need for the following

the prescribed treatment

To help S.O. cope up with

the problem

Tranfused 1 “U” of FWB

Cues/ Clues Nursing Plan/Goal Nursing Interventions Rationale Evaluation

Diagnosis

O

Hgb=9gm/dl

Hct= 29.6

Poor skin turgor

Pale

conjusctivae

With Pale and

slightly dry lips

Pale nailbeds,

2-3upon

blanching

Slightly pale in

appearance

For BT

Altered tissue

perfusion related

to decreased O2

carrying capacity

of the blood as

revealed in the

laboratory results

At the end of

nursing intervention

the patient will

demonstrate ways

and technique on

how to improve

arterial circulation

Assessed causative factors such as

bleeding

Monitored V/S esp. PR

Assessed capillary refill time

Monitored and reviewed findings

Encouraged to eat Iron-rich foods like

green leafy vegetables like malunggay

Encouraged to increase intake of Vit. C

Regulated IVF properly

Encouraged to turn from side to side

Instructed to increase fluid intake

Encouraged to do O2 conservation

techniques such as sitting and sleeping

Watched out for any sign of bleeding

Provided safety measures

Advised to avoid strenuous activities

Provided bed exercises with proper

instruction to S.O.

To see cause of decreased

in Hgb in the blood

To identify any alteration

To assess for tissue

perfusion

To identify progression of

dse.

To facilitate adequate

tissue perfusion

For better absorption and

increase resistance of

body to infection

To maintain hydration

To improve circulation

To support circulating

volume and tissue

perfusion

To conserve O2 of body

To prevent further damage

Hgb=11.3

Hct=35%

With pinkish nailbeds

With pinkish conjunctiva

FWB transfused

To prevent further injury

To promote wellness,

provide optimum health

and improve blood count

levels

Too improve circulation

Cues/ Clues Nursing

Diagnosis

Plan/Goal Nursing Interventions Rationale Evaluation

O>with yellow to

brownish colored urine

No crystals or blood

observed

Goes to comfort room

twice per shift

Impaired urinary

elimination related

to decreased renal

perfusion

secondary to

disease condition;

nephrolithiasis

At the end of the

nursing intervention

the patient will vid

in normal amounts

and usual pattern

Monitored Intake and output and

characteristic of urine

Encourage oral fluid intake

Investigate reports of bladder fullness

or palpate suprapubic distention

Document any stone expelled and send

laboratory for analysis

For baseline data

To lessen concentration of

the urine

For hydration

To eliminate bladder

distention

With slightly colored urine

Cues/ Clues Nursing

Diagnosis

Plan/Goal Nursing Interventions Rationale Evaluation

S “Ano bang nagyayari

kapag nagkakabato” as

verbalized.

O>asking questions

about his health

problem

>Asks regarding the

food he can eat

>Unfamiliar with the

things that contributes

to his health problem

like eating salty foods

Knowledge deficit

related to lack of

information

regarding current

health condition

At the end of the

shift the patient will

be able to verbalize

understanding of his

disease process and

potential

complications

Reviewed disease process and potential

complications

Stressed the importance of increased

fluid intake (3-4 L/day)

Encouraged to notice dry mouth and

excessive diaphoresis and to increase fluid

intake whether or not feeling thirsty

Encourage to eat low salt low fat foods

Discussed medication regimen

For baseline data

To impart knowledge

To help avoid foods that

may complicate condition

To avoid dehydration

Seen drinking plenty of

water. Seen eating citrus foods

Cues/ Clues Nursing

Diagnosis

Plan/Goal Nursing Interventions Rationale Evaluation

S> “hindi ako

madumi”as verbalized.

O>hypoactive bowel

sounds upon

auscultation, 3bpm

>with negative bowel

movement for 1 week

Constipation

related to

insufficient

physical activity

At the end of the

nursing intervention

the patient will

demonstrate

behaviors to relieve

constipation

Monitored input and output

Auscultated for bowel sounds

Instructed to increase oral fluid intake

at least 6-8 glasses per day

Instructed to eat high in fiber foods

such as oranges.

Encourage to increase mobility or

exercise such as walking

For baseline data

to help stimulate bowel

movement and for hydration

to help stimulate bowel

movement

still with negative bowel

movement