Subjective Data

Di ganahan mu
kaonas
V. Care Maps/Care
Pathways: Part I and II
verbalized

Objective Data
Throat ulcer and
esophagus

Part I. Nursing Diagnostic Reasoning: Analysis of Data

Weight loss

sakit kaayo

Step 1: Identify
abnormal findings and client strengths
akong tutunlan
Pain
as verbalized

Restless

Luya kayo as
verbalized

Irritable

Step 2. Identify cue clusters

-

Dilignhan
mu kaon
as
verbalized
Weight
loss

sakit
kaayo
tutunlan
as
verbalized
Swelling of
oral cavity
and
esophagus

naa koy luas

as verbalized

throat ulcer
Restless
irritable

Step 3 Draw insights and Inference

Weight loss it is
caused by inability to
ingest food due to
loss of appetite and
can be a symptom of
an underlying
medical disorder.

Pain is caused by
inflammatory
response by a
localized infection.

Risk for infection

caused by
opportunistic fungal
infection.

Step 4 List possible nursing diagnosis

Imbalanced
Nutrition : Less than
body requirements
related to inability
to ingest foods s/t
pain swallowing

Pain r/t swelling

of oral cavity

Risk for infection

related opportunistic
fungal infection as
evidenced by throat
ulcer

Step 5 Check for defining characteristics: Major and Minor

Major:
Swelling
of oral cavity and
esophagus is
present.

Major: Patient is
unable to swallow
solid foods.

Minor: NONE
Minor: NONE

Major: swelling of oral

cavity and esophagus.
Skin is warm to touch.
Patient is
experiencing chills.
Minor: NONE

Nursing Actions:

Nursing Actions:

Nursing Actions:

INDEPENDENT

INDEPENDENT

INDEPENDENT

Step 6 Confirm or rule out diagnosis

Assess and
Monitor or record
monitor
clients
the
This
diagnosis
meets the
Accept diagnosis
throat
and
characteristics of
defining characteristics
because it meets the
mouth. Note for
the pain, noted
defining
the presence of
the report verbal,
give
the child tobut
characteristics
characteristics.
of mouth and
nonverbal cues,
eat
small
mealsmore
need
to collect
throat ulcer .
and the
but
often. information.
additional
Encourage
hemodynamic
Assess causative
patient to
response
factors
increase fluid
(grimacing,
contributing to
intake.
crying, anxiety,
imbalanced

Educate the
sweating,
nutrition
patient the
clutching his
Educate the
importance of
chest, rapid
Steppatient
7 Document Conclusion:
Key
Nursing
Diagnosis/
safe sex.
breathing, blood
Adjust and
Problem
pressure / heart
importance of
monitor
frequency
eating healthy
Part II. Clinical Care Pathways
environmental
change).
food.
factors.
Instruct patient
Step 1: Key Nursing Diagnoses (Wellness, Risk, Actual, and Collaborative Nursing
S.O to report
COLLABORATIVE
COLLABORATIVE
Problems)
pain immediately.
Risk for infection
Imbalanced
Monitor
Pain
Provide
a quiet,
r/t
Administer
related
slowSwelling
activity, and
Nutrition
less values
than
laboratory
antibiotic
opportunistic
body
thatrequirements
indicate
of comfortable
oral cavity
fungal
asinfection
action ( bed
r/tnutritional
inability towelland
as evidenced
by
prescribed
linen, dry / not
swallow
food
being/deteriorati
throatby
ulcer
the
crossed, rubbing
on
physician
his back).

Evaluation of
nutritional
status
Confirm because
it
and
weight
loss.
meets the one are of
Tell
the mother to
defining

COLLABORATIVE
Administer
analgesics

Provide oral
care to the
patient

CLIENT OUTCOMES
After 3 weeks of
nursing intervention,
the patient S.O will
verbalize and
demonstrate selection
of foods or meals that
will achieve a
cessation of weight

CLIENT
OUTCOMES

CLIENT
OUTCOMES

Within 3 weeks of
providing nursing
interventions, the
patient will be
report reduced
pain to a tolerable

After 3 weeks of
giving nursing
interventions, the
patient will be
report
improvement of
oral care and