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CUES NURSING SCIENTIFIC GOAL & NURSING RATIONALE EVALUATION

DIAGNOSIS BASIS OUTCOME ACTIONS &


CRITERIA NURSING
ORDERS
Subjective Impaired Fractures occur After 8 hours of After 8 hours of
cues: physical when the bone is rendering appropriate rendering
mobility, subjected to stress nursing interventions appropriate
-“ sakit akong inability to stand greater that it can the patient will be nursing
luyo ug wala alone related to absorb. When the able to: interventions the
nga tiil” as skeletal bone is broken, patient was able:
verbalized by impairment to adjacent structures
the patient. facture of the left are also affected, 1. Demonstrate
femoral neck resulting in soft increasing Independent 1.Demonstrate
tissue edema, function of increasing function
Objective hemorrhage into the - assist patient to -to improve of the extremities.
cues: the muscles and extremities. do active ROM muscle
joints, joints exercises on the strength and
-received dislocations, lower extremities. joint mobility.
patient lying ruptured ten-dons, 2.Regain or
on bed, awake, (GULANICK maintain mobility
severed nerves, and
coherent, & & MYERS: at the highest
damaged blood
responsive. 2007, p. 127) possible level.
vessels. Body
organs maybe
injured by the
-IVF of 1 L # Dependent -in order for 3. Verbalize
force that caused
21 PLR with the fracture -administer the muscle to understanding of
remaining 270 fragments. After a analgesics such as be more relax the situation /risk
mL @ 30 fracture, the Tramadol (Tramal) and relieves factors, individual
gtts/min. extremities cannot as prescribed by the pain therapeutic
infusing well function properly the physician. regimen and
(GULANICK
@ right arm. because normal & MYERS: safety.
functions of 2007, p. 127)
muscle depend on
- grimace face the integrity of the -Goal was met
noted bones which they -to develop
are attached. Collaborative individual
(Gulanick & - consult with exercise or
- limited ROM Myers: 2007, p. physical or mobility
126) occupational program and
therapist as identify
indicated. appropriate
adjunctive
devices.

-v/s (GULANICK
& MYERS:
• BP: 2007, p. 129)
130/80
mmHg
• T: -patient may
38.2°C be restricted
• P : 75 by self-view
bpm or self-
• R : 20 perception out
cpm Independent
of proportion
-assess degree of with actual
2. Regain or mobility produced physical
maintain by injury or limitations
mobility at treatment and note requiring
the highest patient’s interventions
possible perception of to promote
level. immobility. progress
toward
wellness.

(GULANICK
& MYERS:
2007, p. 127)

3. Verbalize
understanding
of the
situation /risk
factors,
individual
therapeutic
regimen and
safety
measures.
NURSING SCIENTIFIC BASIS GOAL & NURSING
OUTCOME ACTIONS &
CUES DIAGNOSIS CRITERIA NURSING RATIONALE EVALUATION
ORDERS

Subjective Alteration in Pain is a typical sensory After 8 hours of After 8 hours of


cues: comfort : Acute experience that may be rendering rendering
Pain related to described as the appropriate nursing appropriate
-“ sakit akong tissue trauma 2° unpleasant awareness of intervention, the nursing
luyo ug wala a noxious stimulus or patient will be able intervention, the
to MVA bodily harm. to reduced pain patient was able
nga tiil” as
Individuals experience from 8 to 4 with 10 to have reduction
verbalized by
pain by various daily as the most painful. of pain from 8 to
the patient. hurts and aches, and 4 with 10 as the
occasionally through 1. The patient most painful.
more serious injuries or will verbalize
Objective illnesses. Pain is reduction of 1. The patient
defined scientifically as pain from a will verbalize
cues: unpleasant sensory and pain scale of 4 reduction of
emotional experience in a 0-10 scale pain from a
-received
associated with actual with 10 as the Independent pain scale of
patient lying or potential tissue most painful. 4 in a 0-10
on bed, damage, or described in - perform proper - appropriate scale with 10
awake, terms of such damage. nursing measures will as the most
coherent, & Pain of any type is the interventions and be painful.
responsive. most frequent reason appropriate 2. Patient will
implemented
why people tend to seek procedures to demonstrate
medical consultation. It alleviate pain. to prevent ways to
is a major symptom in infections and reduce pain.
- diaphoresis many medical complications.
conditions, significantly -use non- 3. The patient
interfering with a pharmacologic - use of non- will
person’s quality of life interventions for pharmacologic appreciate the
- pain scale of and general functioning. relieving pain methods will care rendered.
8/10, as of 0 Diagnosis is based on (eg. Relaxation) embrace the
is no pian and characterizing pain in results of pain - Goal was met
10 is the most various ways, according reliever. Gate
painful to duration, intensity, control theory
type (dull, burning or states that
stabbing), source, or cutaneous
location in body. stimulation
-guarding Usually, pain stops closes the pain
behavior without treatment or pathways.
responds to simple (BARE &
measures such as SMELTZER,
resting or taking an 2004: 1140)
- T : 38.2°C analgesic, and it is then
called acute pain. But it
may become intractable -in order for
and develop into a the muscle to
condition called chronic be more relax
pain, in which pain is and relieves
no longer considered a
the pain
symptom but an illness
by itself. The study of Dependent (GULANICK
pain has it recent years
O – occurs --administer & MYERS:
attracted many different
fields such as analgesics such as 2007, p. 127)
when moving
pharmacology, Tramadol
L – on his left neurobiology, nursing (Tramal) as
sciences, dentistry, prescribed by the
leg physician.
physiotherapy, and
D– psychology. Pain
medicine is a separate
approximately
subspecialty figuring -diverts
1 min. under some medical attention and
specialties like may enhance
C – gnawing anesthesiology,
pain coping
physiatry, neurology, abilities.
and psychiatry. Pain is (DOENGES,
A – frequent Independent
part of the body’s 2002:368)
moving - instruct patient
defense system, 2. Patient will to use relaxation
triggering a reflex demonstrate
R – rest exercises such as
reaction to retract from ways to reduce focused
T – Tramadol a painful stimulus, and pain. breathing, -promotes
(Tramal) helps adjust behavior to commercial or active, not
increase avoidance of individualized passive role.
that particular harmful tapes. (DOENGES,
stimulation in the 2002: 369)
future. Given its Dependent
significance, physical -provide
pain is also linked to individualized
various cultural, physical therapy
religious, philosophical, or exercise
or social issues. program that can -bed rests
(http://en.wikipedia.org) be continued by decreases
the client when body
discharged. metabolism
and thus
Collaborative reduces
-encourage muscle
patient to have tension.
adequate bed rest (BARE &
periods. SMELTZER,
2004: 1140)

- Establish a
trusting
relationship
that
Independent encompasses
-establish a patient’s
specific time to physiological,
talk with patient emotional,
about pain and its social, sexual,
psychological and and financial
emotional effects. concerns.
(SPARKS &
TAYLOR,
2005: 227)
- Pain is a
subjective
experience
and cannot be
felt by others.
(DOENGES,
2002: 367)

- to achieve
Dependent pain
management
-accept client’s
goals and
description of maximize
pain. patient’s
3. The patient cooperation.
(SPARKS &
will appreciate
TAYLOR,
the care
2005: 227)
rendered.

Collaborative

-work closely
with staff and
patient’s family.

NURSING SCIENTIFIC BASIS GOAL & NURSING


OUTCOME ACTIONS &
CUES DIAGNOSIS CRITERIA NURSING RATIONALE EVALUATION
ORDERS

Subjective
cues:

-“lisod man
ilihok akong
lawas” as
verbalized by
the patient.