CUES/ EVIDENCES NURSING SCIENTIFIC BASIS OUTCOME CRITERIA NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

Subjective: Risk for infection Infection After 8 hours of 1. Note risk factors for - This will determine
related to impaired nursing intervention occurrence of infection the probable
no verbal cues primary defense the patient will be free such as environmental contributing factors
mechanism secondary from any signs of exposure and skin that could cause
Objective: to surgical incision infection as evidenced integrity.
- received patient, infection on the
by:
lying in bed, sleeping incision site and these
with IVF of D5LR i L - incision site is dry, will serve as a guide
infusing well on left clean and intact 2. Observe for for preventive
arm regulated at 30 localized signs of measures.
gtts/min with the -no fever as evidenced infection at incision
following vital signs: by Temp. 37.0-37.5 C. site. - For early
identification of onset
T – 36.4 C - The patient and her 3. Assess and of infection for prompt
S.O will display document skin
intervention
PR – 88 bpm positive attitudes to conditions noting
prevent infection such inflammation,
RR – 20 cpm - Informs the nurse for
as handwashing and secretions and
the occurrence of
disinfection prior to drainage.
BP – 140/100 mmHg touching the wound. infection and the
4. Note signs and appropriate
− with symptoms like fever, interventions to
transverse chills and excessive manage the infected
incision at sweating. site.
lower
epigastrium at 5. Maintain sterile -Identifies for the
approximately technique in
13 cm in proper treatment.
performing wound
length dressing. Use gloves
upon caring for open
− dry and intact lesions.
dressing -Reduces risk for
noted. 6. Stress proper acquiring infection on
handwashing site.
− the color of techniques by all
the caregivers between
surrounding therapies.
area of the -Lessens possibility of
 incision is pink 6. Cleanse incision site contracting nosocomial
daily and whenever infections towards the
Laboratory result: necessary with client.
povidone-iodine
WBC: 19.28 k/uL solution or other Ensures prevention of
appropriate solution. infection and promotes
healing.
7. Change dressings
that are dry and clean
and ensure it is
properly done.
Clean wound dressing
protects the incision
site or wound from
8. Review individual exposure to bacteria.
nutritional needs.
Encourage intake of
protein rich foods to
promote healing and
repair of cells and
9. Instruct client or high-caloric diet for
significant others to energy.
protect the integrity of
the skin, care for
lesions and prevention
of spread of infection Promotes cooperation
(WAYS). and increases
effectiveness in
10. Monitor laboratory preventing infection.
tests like WBC count.

For early and/ or

11. Administer
antibiotics as accurate
indicated. determination for
possible occurrence of
Health Teaching to infection
prevent infection Such
as Handwashing.
Increasing intake of This may be used to
foods rich in Vitamin treat infections in
ETC. ETC. cases that it has
persisted.
 GOALS AND NURSING
NURSING SCIENTIFIC
CUES OUTCOME INTERVENTION RATIONALE EVALUATION
DIAGNOSIS BASIS
CRITERIA S
Subjective: Activity Most activity After 8 hours of Independent: Goal partially
“Di man ko intolerance intolerance is nursing met.
kalihok-lihok related to related to interventions the 1. Assess the 1. The stated
dai oi. Kapoy generalized generalized patient will be patient’s parameters After 8 hours of
jud akong weakness. weakness and able to reduce response to are helpful nursing
lawas.”as debilitation the effects of activity, in assessing interventions
verbalized by secondary to inactivity, marked physiologica patient was able
the client acute or chronic promote optimal increase BP l responses to regain her
illness and physical activity. during or to stress of strength
Objective: disease. This is after activity and, and reduce the
-patient is not especially Specifically the activity; if present, effects of
able to stand apparent in patient will be chest pain are inactivity.
or sit by his older patients able to: or dyspnea; indicators of
seslf with a history of • maintain excessive over Specifically, the
-stressful cardiopulmonary activity fatigue and exertion patient was able
appearance related level within weakness; to:
-BP is elevated problems. Since capabilities diaphoresis
with the range there is as ; dizziness • maintain
of 140/90- insufficient evidenced or syncope. activity
150/90 mmHg supply of blood by the level within
-he ask for to the body, absence of 2. Monitor capabilities
sometime to generalized weakness blood 2. Comparison as
rest weakness is and fatigue pressure. of pressures evidenced
noted which can Measure in provides a by the
alter the ADLs of • recognize both arms more absence of
the patient. and and thigh complete weakness
appreciate three picture of and fatigue
the times, vascular
importance three to involvement • recognize
of the five or scope of and
intervention minutes problem. appreciate
s apart while the
patient is at importance
rest then of the
sitting, the intervention
standing s
for initial
evaluation. 3. Helps
reduce
3. Provide sympathetic
calm, stimulation;
restful promotes
surroundin relaxation
gs;
minimize
environmen
tal activity
or noise.
Limit the
number of 4. Reduces
visitors and physical
length of stress and
stay. tension that
affect blood
4. Schedule pressure
 periods of and the
uninterrupt course of
ed rest; hypertensio
assist n.
patient with
self care 5. Can reduce
activities as stressful
needed stimuli,
produce
5. Instruct calming
patient in effect,
relaxation thereby
techniques, reducing
guided blood
imagery, pressure.
distractions
.

1. To assess
the need for
Collaborative: the family or
significant
1. Refer to others to
physical bring in and
therapist. an
ambulation
aid from
home
 GOALS AND
NURSING SCIENTIFIC NURSING
CUES OUTCOME RATIONALE
DIAGNOSIS BASIS INTERVENTIONS
CRITERIA
PROBLEM
PRIORITY # 1 Acute Because of poor After 8 hours of Independent:
Subjective: headache tissue perfusion, nursing 1. Determine 1. Facilitates
“Maglabad akong related to the heart tries interventions, the specifics of diagnosis of
ulo, ari dapit sa increased to compensate patient will be able pain, e.g., problem and
tangkogo unya cerebral thus pumping to report pain is location, initiation of
mura kog vascular double to meet relieved or characteristics, appropriate
malipong”. pressure the demands of controlled. intensity (0- therapy.
the body. Since 10scale), Helpful in
Objective : there is Specifically, the onset/duration. evaluating
 reports of compensatory patient will be able Note nonverbal effectiveness
throbbing mechanism, to: cues. of therapy.
pain located there is increase 2. Encourage/ 2. Minimizes
in in blood  verbalize maintain bed stimulation/
suboccipital pressure which methods that rest during promotes
region leads to acute provide relief acute phase. relaxation.
which headache.  display 3. Provide/
occurs relaxed face recommend 3. Measures
during  feel rested nonpharmacolo that reduce
waking  demonstrate gical measures cerebral
 hours and use of for relief of vascular
disappears relaxation headache, e.g., pressure and
spontaneou skills and quiet, dimly lit that
sly divertional room and slow/block
 reluctance activities diversional sympathetic
to move activities. response are
head, effective in
 avoidance relieving
of bright 4. Eliminate/ headache
lights and minimize and
noise, vasoconstrictin associated
 wrinkled g activities that complications
brow, may aggravate .
clenched headache,e.g., 4. Activities that
fists straining at increase
 reports of stool, vasoconstrict
stiffness of prolonged ion
neck, coughing, accentuate
dizziness, bending over. the headache
blurred 5. Assist patient in the
vision, with presence of
nausea and ambulation as increased
vomiting needed. cerebral
vascular
pressure.
5. Dizziness and
Dependent: blurred vision
frequently
1. Administer are
 medications associated
as with vascular
indicated: headache.
Dependent:
Analgesics 1. Reduce/
control
pain and
decrease
stimulatio
n of the
sympathet
ic nervous
system
CUES/ NURSING SCIENTIFIC OUTCOME NURSING RATIONALE
EVIDENCES DIAGNOSIS BASIS CRITERIA INTERVENTION
Subjective: Risk for injury Injury After 8 hours of 1. Assess the Certain age
No verbal cues related weak nursing muscle strength groups are at
Objective: muscle intervention, the of the patient higher risks.
- received strength patient will be able 2. Assess the One's level in
patient, lying in secondary to to verbalize degree of cognitive ability
bed, conscious post exposure understanding of dependence of greatly affects
with IVF of to spinal individual factors the patient. decisions and
D5LR i L anesthesia that contribute to abilities of
infusing well on possibility of 3. Assess for patient.
left arm injury and take any signs of Certain abilities
regulated at 30 steps to correct lightheadednes and styles can
gtts/min with situations s and feeling of influence
the following Specifically the faintness carelessness
vital signs: patient will be able 4. Encourage and increased
T – 36.4 C to achieved and or patient to do risk-taking
PR – 88 bpm increase the isometric without
RR – 20 cpm distance of exercise . consideration of
BP – 140/100 ambulation from 5. Assist the consequences.
mmHg the bed to the client in doing Apathy may
-edema noted nurse station active ROM enhance
on upper and 6. Institute disregard for
lower safety own or other's
extremities precaution such safety.
-muscle as Dangling the Patient may feel
strength score feet before lightheadedness
of 3/5 ambulation if one abruptly
-dizziness and 7. Encourage stands and walk
lightheadednes Deep breathing after lying in
s on ambulation and coughing bed.
-needs exercises Prevent possible
assistance on 8. Encourage respiratory
task and and assist the complications.
ambulation client in doing Increasing the
and increasing distance of
the distance of ambulation
ambulation. further aids in
9. Instructed patient's healing
the S.O to assist by promoting
in ambulation increased
and to provide circulation and
rest whenever providing
lightheadednes positive attitude
s occurs. towards cure.
Cues Nursing Scientific Basis Goal and Outcome Nursing Rationale Evaluation
Diagnosis Criteria Intervention
Subjective: Impaired Many After 8 hours of INDEPENDENT: Goal met.
physical postsurgical appropriate After 8 hours
“Isaka sa ko bi, mobility related patients are nursing 1. Assess 1. Influences of appropriate
alsaha ko,” as to presence of unable to intervention the activity choice of nursing
verbalized by surgical assume a patient will be able limitation, intervention. intervention,
the patient incision comfortable to display noting presence the patient
addressing her secondary to position increased muscle or degree of displayed
need of because of strength. restriction increase
assistance to limitation in 2. Change in strength and
her husband. independent Specifically the 2. Monitor vital vital signs may normal range
 purposeful patient will be able signs every four indicate of motion and
Objective: physical to: hours. discomfort. appreciated
movement of the
-weakness the body or of -appreciate the importance of
noted one or more importance of optimal
-needs full extremities optimal mobility or 3. Keep skin 3. Prevent skin mobility or
assistance and secondary ambulation clean and dry. irritation. ambulation as
ambulation incisional pain, evidenced by
-poor muscle activity - perform normal 4. Keep linens 4. To promote patient able to
strength restrictions, range of motion dry and wrinkle comfort and to sit on bed and
(grade 4) immobilization free. prevent dangle legs
devices, or an - gain knowledge irritation. over the edge.
array of tubes to choose the right
and monitoring kinds of foods in 5. Taught deep
lines. order to gain breathing 5. Relieves
muscle strength exercise and muscle and
encourage emotional
frequent change tension;
of position decreases
when on bed discomfort,
rest. maintains
muscle strength
and joint
mobility,
enhances
(Ascani, Mary circulation and
Ann.et prevent skin
al.Mastering 6. Instruct breakdown.
Medical-Surgical patient and
Nursing: assist with
Disorders and active or 6. Maintains
Treatments,Nur passive ROM joint flexibility,
sing Tips and exercises. prevents
Guidelines,Patie contractures,
nt Teaching and and aids in
Outcome) reducing muscle
7.Encourage tension.
ambulation to
the level of 7. To reduce
tolerance of the postoperative
patient. abdominal
distention by
increasing
gastrointestinal
tract and
abdominal wall
tone and
stimulating
peristalsis.
8. Encourage
adequate 8. Adequate
nutritional intake of
intake. protein, Vit.C
rich foods to
strengthen
muscle and
boost immune
system.
 (Doenges,
Marilynn E. et
al.Nurse’s (Doenges,
Pocket Marilynn E. et
Guide:Diagnosis al.Nurse’s
, Prioritized Pocket
interventions, Guide:Diagnosis
and , Prioritized
Rationales.10th interventions,
edition.p.509) and
Rationales.10th
edition.p.509)

Cues Nursing Scientific Basis Goal and Outcome Nursing Rationale Evaluation
Diagnosis Criteria Intervention
Subjective: Acute Pain Pain is a highly Within 8 hours of INDEPENDENT: Goal met.
“Ang sakit kay related to subjective state nursing 1. Assess the 1. Helps Within 8 hours
mag-ulyap- surgical in which a intervention the location and evaluate degree of nursing
ulyap niya incision site variety of patient will to severity of pain of discomfort interventions
mada raman. secondary to unpleasant verbalize a through pain and the patient
Para nako 4/10 sensations and reduction of pain. scale of 1-10. effectiveness of verbalized a
ra ang sakit.” wild range of analgesia or decrease of
as verbalized by distressing may reveal pain, from
the patient. factors may be Specifically, the developing 4/10 to 1/10.
experienced by patient will be able 2. Monitor the complications.
Objective: the sufferer. to: vital signs.
-guarding Pain may be 2. Change in
behavior noted acute, a - report that pain is vital signs may
on the incision symptom of relieved indicate acute
site injury or illness 3. Encourage pain and
-grimaced face such as - verbalize deep breathing discomfort.
noted surgical incision. methods that exercise.
Pain may also provide relief of 3. Relieves
arise from pain muscle and
emotional, emotional
psychological, -demonstrate use tension,
cultural, or of relaxation skills enhances sense
spiritual and diversional 4. Encourage of control and
distress. Pain activities as verbalization of may improve
can be very indicated for feelings of pain. coping abilities.
difficult to individual situation
explain, 4. Reduction of
because is - follow prescribed anxiety/fear can
unique to pharmacological promote
individual; pain regimen 5. Provide relaxation/comf
should be comfort ort.
accepted as measures like
described by change in
the sufferer. position.
5. May relieve
(Gulanick , 6. Encourage pain and
Meg.et diversional enhance
al.Nursing Care activities like circulation.
Plans) listening to
music. 6. Refocuses
attention,
DEPENDENT: thereby
reducing pain
1. Administer and discomfort.
analgesic like
Revalan 500 mg
1 tab every 6
hours P.O. RTC 1. Relieves pain,
as prescribed enhances
by the comfort and
physician. promotes rest.

(Doenges,
Marilynn E. et
al.Nurse’s
Pocket (Doenges,
Guide:Diagnosis Marilynn E. et
, Prioritized al.Nurse’s
interventions, Pocket
and Guide:Diagnosis
Rationales.10th , Prioritized
edition.p.388) interventions,
and
Rationales.10th
edition.p.388)