CUES NSG.

DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

EXPLANATION
SUBJECTIVE: Risk for infection r/t After 2hour of - Observe for signs - patient may be GOAL MET
- high glucose level, high glucose level NSG. Intervention of infection and admitted with
Decreased in blood the client will able inflammation. infection, which After NSG.
OBJECTIVE: leukocyte function. to; could have Intervention the
-flushed skin viscosity of blood - Identify precipitated the client is
-excessive thirst intervention to ketoacidic stage.
-dry mouth and decreased prevent risk for Be free from risk
skin leukocyte function infection. - Promote hand - Reduce for the for infection.
-itching skin - Verbalize ways in washing by nurse risk of
Decreased preventing and patient. contamination
reaction to infection.
microorganism.
- instruct the - to prevent
Risk for infection. After 1day of NSG. patient and SO to transmission of
Intervention the maintain organism.
client will able to; cleanliness.

- Reduce or be free - maintain aseptic - high glucose in

from risk for technique in any the blood creates
infection. invasive an excellent
procedure. medium for
bacterial growth.

- provide - to prevent
continuous care to decubitus ulcer
the skin such and skin break
maintaining the down.
skin dry, wrinkle
free.

- facilitate - it will decrease

adequate susceptibility to
hydration. infection
CUES NURSING SCIENTIFIC PLANNING NUSING RATIONALE EVALUATION
DIAGNOSIS EXPLANATION INTERVENTION
Subjective: Ineffective After 4hours of - Monitor Vital - to serve as base GOAL MET
breathing pattern NSG. Intervention signs. line data and ·
“Nahihirapan ako r/t disease process the client will able determine the After Of
huminga” to; severity of nursing
verbalized by the problem. interventions,
client - Verbalize the client
understanding of - assess the airway - any obstruction or was able to:
Objective: causative factors for patency. secretion may
affect the airway Demonstrate
- body malaise - demonstrate pattern. effective breathing
- RR-28 changes to pattern.
- use of accessory improve - Position -Promote
muscle. oxygenation. patient in semi or gravitational full to
- pale color of nail high Fowler’s diaphragm.
and lips After 1day of NSG. position.
- decreased skin Intervention the
turgor. client will able to; - encourage the - to promote
- lethargic patient to deep oxygenation.
- Demonstrate breathing exercise.
effective breathing
pattern. - avoid vigorous - to conserve
activities or energy that may
maintain bed rest. lower oxygen
demand.

- encourage for - smoking can

smoking cessation. promote
vasoconstriction.

- demonstrate use - to decrease

of relaxation tension
technique.

-Discuss - it can promote

preventing vasoconstrictions.
exposure to cold
and dressing
warmly.

- administer - to provide
oxygen as ordered. adequate oxygen
in blood.