Nursing Problem with Cues Nursing Diagnosis with Objectives (SMART) Nursing Interventions Nursing Interventions Rationale Evaluation

Rationale

1. Abdominal pain Chronic Pain r/t physical Short-term: Independent: 1. Pain is not always present, but if Short-term:
response to disease After 2 hours of nursing 1. Noted reports of pain including location, duration, present should be compared with Partially met. There’s minimal
Subjective Data: interventions, patient will intensity and reviewed factors that alleviate or patient’s previous pain symptoms. This facial grimace, though abdominal
“I experience pain every 15-30 minutes for 10 seconds Rationale: verbalized decrease of pain aggravate pain. comparison may assist in diagnosis of guarding is still present patient
with a pain scale of 10/10.” as verbalized by the from 10 to 7, absence of facial etiology of bleeding and development of verbalized decrease of pain from
patient Pain is highly subjective state in grimace, will demonstrate complications. 10/10 to 8/10.
which a variety of unpleasant relapse body posture and be 2. Note nonverbal pain cues, e.g., restlessness,
Objective Data: sensations and a wide range of able to rest appropriately. reluctance to move, abdominal guarding, tachycardia, 2. Nonverbal cues may be both
 Vital signs: T – 38.7 °C, RR – 22 bpm, HR – 110 distressing factors may be diaphoresis. Investigate discrepancies between verbal physiologic and psychological and may
bpm experienced by the sufferer. Long-term: and nonverbal cues. be used in conjunction with verbal cues
 Facial grimace Pain may be symptom of injury After the 8-hour shift, patient to evaluate extent/severity of the
 Abdominal guarding or illness. will verbalized tolerance to 3. Provide frequent oral care and comfort measures, problem.
 Body rigidity pain as evidenced by improved e.g., back rub, position change. Long-term:
Ref: (Doenges, Moorhouse, & sleeping pattern, relapse body 3. Halitosis from stagnant oral secretions Goal met. After an 8-hour
Murr, 2013) posture, normal vital signs, and is unappetizing and can aggravate intervention patient verbalized
absence of facial grimace. 4. Provided and implemented prescribed dietary nausea. Gingivitis and dental problems improved sleeping pattern, vital
modifications. may arise. signs in normal range, and absence
of facial grimace
5. Administer medications, as indicated, e.g.: 4. Patient may be NPO initially. When
 Antacids; oral intake is allowed, food choices will
depend on the diagnosis and the etiology
HEALTH TEACHING of the bleeding.
- Provide anticipatory guidance to client with
condition in which pain is common and educate about 5. Decreases gastric acidity by absorption
when, where, and how to seek intervention or or by chemical neutralization. Evaluation
treatments. type of antacid in regard to total health
-Assist client and SO(s) to learn how to heal by picture, e.g., sodium restriction
developing sense of internal control, by being
responsible for own treatment, and by obtaining the Ref: (Doenges, Moorhouse, & Murr,
information and tools to accomplish this. 2013)

Discuss potential for developmental delays in child

with chronic pain. Identify current level of function
and review appropriate expectations for individual
child.

Ref: (Doenges, Moorhouse, & Murr, 2013)

 Nursing Problem with Cues Nursing Diagnosis with
Rationale
2. Weight loss
Impaired Balance Nutrition
Subjective Data: less than Body
“I think, I lost half of my weight” as verbalized Requirements r/t change in
by the patient digestive
process/absorption of
nutrients
Objective Data:
 Weight: Rationale:
 Prior to admission – 60 kg Adequate nutrition is
 April 30, 2018 – 30 kg necessary to meet the
 Prominent bones body’s demands. Nutritional
 BMI: 14, underweight status can be affected by
 Decreased creatinine 33 umol\L disease.
(4-7-19)
Ref: (Doenges, Moorhouse,
& Murr, 2013)
Objectives (SMART)
Short-term:
Within 5 hours of nursing
interventions, patient will
verbalize understanding of
functional changes.
Long-term:
After 1 week of nursing
interventions, patient will
be able to demonstrate 3. Monitor tolerance to fluid and food intake,
progressive weight gain of 2 noting abdominal distension, reports of
kl per week. increased pain/ cramping, nausea/ vomiting.
Nursing Interventions
Independent:
1. Maintain patency of jejunostomy tube.
2. Note character and amount of gastric
drainage.
Collaborative:
4. Administer IV fluids, TPN, and lipids as
indicated.
5. Progress diet as tolerated, advancing from
clear liquid to bland diet with several small
feedings.
HEALTH TEACHING
- Emphasizes importance of well-balanced,
nutritious intake. Provide information regarding intake is advanced gradually to
individual nutritional needs and ways to meet
these needs within financial constraints.
-Provide positive regard, love, and acknowledge Ref: (Doenges, Moorhouse, & Murr,
of “voice within” guiding client with eating
disorder.
-Develop consistent, realistic weight goal with
client.
(Doenges, Moorhouse, & Murr, 2013)
Nursing Interventions Rationale Evaluation
1. Provides rest for GI tract during Short-term:
acute postoperative phase until Goal met. Patient verbalized
return of normal function. understanding of functional
changes.
2. Will be bloody for first 12 hours,
and then should clear/ turn greenish.
Continued recurrent bleeding
suggests complications. Decline in
output may reflect progression of Long-term:
fluid through the GI tract, suggesting Goal not met. The patient
return of function. maintained her weight.
3. Complications of paralytic ileus,
obstruction, delayed gastric
emptying, and gastric dilation may
occur, possibly requiring reinsertion
of NG tube.
4. Meets fluid/nutritional needs
until oral intake can be resumed.
5. Usually NG tube is clamped for
specified periods of time when
peristalsis returns, to determine
tolerance. After NG tube is removed,
prevent gastric irritation/distension.
2013)
 Nursing Problem with Cues Nursing Diagnosis with Objectives (SMART) Nursing Interventions Nursing Interventions Rationale Evaluation
Rationale

3. Presence of Jejunostomy tube (Jtube)
Subjective cues:
“I feel shy and less confident now that I have a
tube in my stomach.” as verbalized by the
patient
Objective cues:
 Presence of Jejunostomy tube (Jtube)
Disturbed body image Short-term: Independent: 1. Provides information about Short-term:
related to insertion of After 2 hours of nursing 1. Ascertain whether counselling was initiated patient’s / SO’s level of knowledge Goal met. After 2 hour of
Jejunostomy tube intervention, patient will when the possibility and/ or necessity of ostomy about individual situation and nursing intervention, patient
verbalize feeling about the was first discussed. process of acceptance. verbalized feelings about the
Rationale: stoma and will demonstrate incision and demonstrated
A disturbance or alternation beginning acceptance by 2. Encourage patient/ SO to verbalize feelings 2. Helps the patient to realize that acceptance by participating in
in the attitude of person has viewing stoma and regarding the ostomy. Acknowledge normality of feelings are not unusual and that self-care and viewing stoma
about the actual or participating in self-care. feelings of anger, depression, and grief over loss. feeling guilty about them is not
perceived structure or Discuss daily “ups and downs” that can occur. necessary/ helpful. Patient needs to
functions of all part of the recognize feelings before they can
body. This attitude is Long-term: be dealt with effectively.
dynamic and altered After 5 hours of nursing 3. Provide opportunity for patient to deal with
through interaction with intervention, patient will ostomy through participation in self-care. 3. Independence in self-care helps to Long-term: Goal met. After 5
other persons and situations Verbalize acceptance of the improve self-confidence and hours of intervention, patient
and is influenced by age and situation, incorporating acceptance of situation. verbalized acceptance to
developmental level. change into self-concept situation.
without negative self- 4. Maintain positive approach during care 4. Assists patients/ SO to accept
Ref: (Doenges, Moorhouse, esteem. activities, avoiding expressions of disdain or body changes and feel all right about
& Murr, 2013) revulsion. Do not take angry expressions self. Anger is most often directed at
personal the situation and lack of control
individual has over what has
happened (powerlessness), not with
the individual caregiver.

5. Note behaviours of withdrawal, increased 5. Suggestive of problems in

dependency, manipulation, or non-involvement adjustment that may require
in care. further evaluation and more
Health Teaching extensive therapy.
Ref: (Doenges, Moorhouse, & Murr, 2013)
Ref: (Doenges, Moorhouse, & Murr,
2013)
 Nursing Problem with Cues Nursing Diagnosis with Objectives (SMART) Nursing Interventions Nursing Interventions Rationale Evaluation
Rationale
4. Anxiety Anxiety related to change in Short-term: Independent: 1. May indicative of the degree of Short term:
health status After 1 hour of nursing 1. Monitor physiologic responses, e.g., fear patient is experiencing but may Goal met
Subjective Data: intervention, patient will headache, dizziness, tingling sensations. also be related to physical After an hour of intervention,
”I’m scared of what will happen to me in the Rationale: verbalize appropriate range condition/shock state. patient verbalized appropriate
future.” as verbalized by the patient A vague uneasy feeling of of feelings. She will appear range of feeling. She was
discomfort or dread relaxed and report anxiety 2. Establishes a therapeutic relaxed and reported reduced
accompanied by an is reduced to manageable 2. Encourage verbalization of concerns. Assist relationship. Assists the patient in anxiety.
Objective Data: automatic response; the level. patient in expressing feelings by active listening. dealing with feelings and provides
 Restlessness source often non-specific or opportunity to clarify
 Irritability unknown to the individual; Long-tern: misconceptions.
 HR – 110 bpm a feeling of apprehension After 8-hour shift, patient
 Diaphoresis caused by anticipation of will discussed 3. When patient is expressing own Long term:
 Increased tension danger. It is an altering fears/concerns recognizing 3. Acknowledge that this is a fearful situation fear, the validation that these Goal met.
signal that warns of healthy vs. unhealthy fears. and that others have expressed similar fears. feelings are normal can help patient After the nursing
impending danger and Patient will demonstrate to feel less isolated. Intervention
enables the individual to problem-solving and demonstrated problem
take measures to deal with effective use of resources. 4. Helps reduce fear of going, solving and effective
threat. through a frightening experience and effective use of
4. Encourage SO to stay with patient as able. alone. resources.
Ref: (Doenges, Moorhouse, Respond to call signal promptly. Use touch and
& Murr, 2013) eye contact as appropriate. 5. Removing patient from
outside stressors promotes
5. Provide a calm, restful environment. relaxation, may enhance
coping skills.
Ref: (Doenges, Moorhouse, & Murr, 2013)
Ref: (Doenges, Moorhouse, & Murr,
2013)
 Nursing Problem with Cues Nursing Diagnosis with
Rationale
5. Knowledge deficit Risk for infection
transmission r/t lack of
Subjective Data: knowledge reducing the
“My daughter does not know she has HIV” as risk of transmitting HIV
verbalized by the patient’s mother.
Rationale:
Objective Data: HIV can be transmitted via
the exchange of body fluids
from one infected
individuals to a healthy
person, ignorance to how
HIV is transmitted and
acquired s detrimental to
HIV prevention efforts.
Ref: (Hong, Daria, […] and will comply to the
Mwamburi, Knowledge of therapies ordered by the 3. Discuss the mode of transmission of the
HIV transmission and
associated factors, Journal
of AIDS & Clinical research,
Objectives (SMART) Nursing Interventions Nursing Interventions Rationale Evaluation
Short-term: Independent: Short-term:
After an hour of 1. Educate the mother of the patient about Goal met. Mother of the
intervention to the mother the importance of letting the patient patient understood that the
of the patient, she will know about HIV. patient has to know he
understand the importance condition but asked for more
of letting the patient know 2. Identify susceptible Individuals 2. Contested susceptible time and wants to do it alone
of her condition. individuals to be tested for HIV,
- Homosexual practices Some high risk behaviours can be
Long-term: - Bisexual practices eliminated. A professional in high- Long-term:
After 5 hours of nursing - IV/Intranasal/ Intradermal drug users risk situations must practice Goal not met. Patient’s
intervention, the patient - Health care workers universal precaution. mother did not tell the
will know her condition - First responders (police, rescue workers, patient her condition.
and will begin to accept it ambulance, fire-fighters).
by verbalizing her
understanding to HIV and
3. HIV is transmitted by sexual
physician virus. contact, by contact with infected
- Unprotected vaginal, anal, or oral sex with blood, body fluid and blood
infected hosts or infected sex paraphernalia. products, and prenatally.
- Unprotected sex with infected person.
- Breastfeeding, perinatal transmission.

4. Reduce the risk of transmission of HIV. 4. The risk of developing sexually

Explain low-risk sexual m behaviours :
- Mutual masturbation
- Massage
Vaginal intercourse with condom.
transmitted infections is prevented
with abstinence. Activities that do
not include penile, vaginal, anal, or
oral contact carry low or no risk.
Transmission is reduced by condom
we and limiting having multiple
partners.
Nursing Problem with Cues Nursing Diagnosis with Objectives (SMART) Nursing Interventions Nursing Interventions Rationale Evaluation
Rationale

5. Provide Facts to dispel myths regarding 5. Dispelling myths and correcting

HIV transmission. misinformation can reduce
- The AIDS virus is not transmitted by anxiety and allow others to
mosquitoes, swimming pools, clothes, eating interact more normally with the
utensils, telephones, toilet seats, or close client.
contact.
- Saliva, sweat, tears, urine, and feces do not
transmit HIV.

6. Initiate Health Teaching and Referrals as 6. Protocols for exposure to body

Indicated
-Emphasize the need to be careful when
choosing sex partners (past sexual partners,
experimentation with drugs).
-Provide the community and the schools
with facts regarding AIDS transmission, and
dispels myths.
fluids possibly contaminated with
HIV are available in all health care
facilities.
Ref: (Doenges, Moorhouse, &
Murr, 2013)

Health Teaching
Promote wellness
(teaching/Discharge Consideration)
- Review individual nutritional needs,
appropriate exercise program, and need for
rest
-Discuss the role of smoking in respiratory
infections.
-Provide information and involve in
appropriate community and national
education programs to increase awareness
of and prevention of communicable
diseases.

(Doenges, Moorhouse, & Murr, 2013)