CUES

NURSING
DIAGNOSIS

SCIENTIFIC
EXPLANATION


OBJECTIVE

INTERVENTION

RATIONALE

EVALUATION

Subjective:
Objective:
>Patient is
conscious and
coherent
>with ongoing
IV of D5 0.3
NaCl 500cc X
KVO
>Vital signs:
BP: 110/80
PR: 79
RR: 20
Temp: 37.2
>patient is
oliguric average
of 10mL/hour
>Hgb: 73
Hct: 0.20
(Normal Values:
Hgb is 125-
175g/L and Hct
I 0.40-0.52 for
male)
>patient is
restless



>Excess fluid
volume
related to
inability of the
kidney to excrete
waste products

>Kidneys are
responsible for
the elimination
of waste
products in our
body. If there is
an alteration
on the normal
functioning of
the kidney,
there would be
a problem in
the excretion of
waste
products.
Making the
waste to stay
in the
circulation and
excessive fluid
may be the
result because
there are only
intake but a
limited amount
of output
because of the
damaged of

>After four
hours of
nursing
interventions;
*there would
be a stabilized
fluid volume
by increasing
the urine
output of the
patient
*the client
verbalize an
understanding
of individual
dietary/fluid
restriction

>Establish
rapport



>Monitor vital
signs





>Monitor I and O



>Assess appetite
and note for
nausea or
vomiting


>Restrict Na and
fluid intake as
indicated

>Administer
medications such

>to facilitate
client and
student nurse
interaction

>to be able to
monitor the
changes in the
condition of
the client

>to monitor
the normality
of urine
output

>to be able to
know other
reason which
contributes to
his condition

>to avoid
further excess
fluid
accumulation

>to promote

>After four
hours, goal
met as
evidenced by:
*an increase
in urine
output from
10mL to
30mL/hour
*the client
verbalized
understanding
of fluid
restriction in
his diet and
began to
implement it
*patient is
awake
*patient
always stay on
bed
malfunctioning
kidney.
as diuretics as
ordered


>Evaluate
edematous
extremities,
change position
frequently

>Discuss
importance of
fluid restriction
and hidden
sources of intake
such as foods
high in water
content

>Identify danger
signs requiring
notification of
healthcare
provider.

elimination of
waste
products

>to reduce
tissue
pressure and
risk of skin
breakdown

>for better
understanding
on why the
client needs t
restrict his
fluid
consumption


>to ensure
timely
evaluation









ASSESSMEN
T


NURSING
DIAGNOSIS

SCIENTIFIC
EXPLANATIO
N


OBJECTIVE

NURSING
INTERVENTIO
N

RATIONALE

EVALUATIO
N

Subjective:
Objective:
>Patient is
conscious and
coherent
>with
ongoing IV of
D5 0.3 NaCl
500cc X KVO
>Vital signs:
BP: 110/80
PR: 79
RR: 20
Temp: 37.2
= poor
sanitation
= unable to
meet
patients
demands
for
personal
care
= poor
hygiene
= presence

>Risks for
infection
related to
environment
al condition

>Risk for
infection is the
state in which
an individual is
at risks for
being invaded
by pathogenic
organisms /
microorganism
s due to poor
environmental
sanitation to its
surroundings

>After 5
hours of
patient and
student
nurse
interaction
the patient
will verbalize
understandin
g and identify
intervention
to reduce
risk for
infection

>Establish
rapport




>Encourage the
pt. and the S.O
to practice
proper hand
washing
techniques

>Encourage the
patient and the
SO to practice
environmental
sanitation

>Encourage the
patient to throw
the garbage or
trash properly




> To gain the
cooperation of
the patient
during the
interaction

> To reduce or
minimize the
transfer of
microorganism
s


> To prevent
the spread of
microorganism
s in the
surroundings

> To avoid
insects and
other
microorganism
s that carries
viruses


>Goal met
because the
patient as
well as the SO
practicing the
interventions
given
of insects
in the
surroundin
gs


>Instruct the
patient to eat
foods rich in Vit.
C like guava,
oranges,
calamansi etc

>Encourage
compliance to
drug regimen

> To increase
body
resistance





> For
protection
against
infection