CUES NURSING RATIONALE NSG.

NSG RATIONALE EVALUATION

DIAGNOSIS OBJECTIVE INTERVENTION

SUBJECTIVE: PROBLEM: SHORT TERM INDEPENDENT SHORT TERM

Pathogens GOAL: 1. Establish and Helps in fluid GOAL:
Fluid Volume cause tissue After 30 encourage needs replacement from
Nung bago kami Deficit damage and minutes – 1 such as frequent active loss of After 30
ma-admit dito inflammation hour of nursing oral needs like fluids minutes of
sa hospital, ETIOLOGY: by releasing care, the water, juices, and rendered care,
sumusuka siya endotoxins patient will be Gatorade. the patient had
ng 3 beses at Active fluid that stimulate able to restore restored his
dumudumi ng volume loss the mucosal its normal 2. May restrict To allow bowel body’s
madami. Pero lining of the circulating diet for age rest and reduced circulating
ngayon hindi na SIGNS AND intestine body fluids except oily foods intestinal fluids.
siya sumusuka. SYMPTOMS: resulting in the workload
Nagtatae greater (goal met)
naman siya ng As manifested secretion of 3. provide To prevent stress
basa tapos by 6-7 water and LONG TERM comfort and anxiety that LONG TERM
makalat, episodes of electrolytes GOAL: measures may induced GOAL:
madaming loose watery into the After 1 day of peristalsis
beses na, with particles intestinal rendering After 1 day of
nakaka 6-7 na stool, lumen. The nursing care, 4. Increase oral To replace loss of rendered
siyang dumi, moderate in active the patient will fluid intake water and for nursing care,
minsan konti, amount and secretions of able to rehydration the patient had
minsan madami. scanty. Bulging chloride and reestablish maintained
Lagi niya when supine bicarbonate and maintain 5. Proper Maintain optimum normal
sinasabi na secondary to ions are the body fluids as regulation of IVF hydration and circulating body
masakit daw intestinal colic, small bowel will be electrolyte fluids as
tiyan niya tapos hyperactive leads to the manifested by balance evidence by
ang tigas ng bowel sounds is inhibition of decrease BM negative BM
tiyan niya heard, dry lips sodium re- per shift, lips DEPENDENT: per shift, lips
parang ang and eyes are absorption. To are no longer 1. Administer It helps to are no longer
daming kabag. slightly sunken balance the dry, no food supplement strengthen the dry, no
and teary as excess sodium, intestinal colic drugs immune system. tenderness of
verbalized by large amounts and no (prozinc,5ml/OD) It helps to stomach,
OBJECTIVE: the mother of protein rich tenderness of maintain balance intestinal colic
“Nung bago foods fluids the stomach, of WBC and RBC is decrease and
>6-7 episodes kami ma-admit are secreted in and eye is not in the blood. eye is no longer
of loose watery dito sa the bowel’s sunken. Because, the sunken
with particles hospital, ability to client has
stool, moderate sumusuka siya reabsorb the infection (goal met)
in amount and ng 3 beses at fluid and therefore the
scanty. dumudumi ng leading to WBC is increased.
madami. Pero diarrhea.
>Bulging when ngayon hindi na 2. Administer Bacillus clausii is
supine siya sumusuka. anti-diarrheal a good bacteria in
secondary to Nagtatae medications our body. These
intestinal colic naman siya ng drug contains of
and tenderness basa tapos (Erceflora 1 billions of good
of the stomach makalat, bottlet, BID) bacteria, it helps
madaming to populate our
>hyperactive beses na, GIT of good
bowel sounds is nakaka 6-7 na bacteria and
heard siyang dumi, outnumbering
minsan konti, those pathogenic
>dry lips minsan madami. or disease causing
 Lagi niya microorganisms
> eyes are sinasabi na such as amoeba,
slightly sunken masakit daw bacteria
and teary tiyan niya
tapos ang tigas
ng tiyan niya
parang ang
daming kabag.