Cues Explanation of Objectives Nursing Rationale Evaluation

the problem intervention

Prioritization
Problem
1. IMBALANCE NUTRITION: LESS THAN
BODY REQUIREMENT related to weight
loss
2. ACUTE PAIN related to ongoing disease
process 2° gastric cancer with
adenocarcinoma
3. ANXIETY related to cancer diagnosis
4. Impaired physical mobility related to
weakness
Justification
This problem does not affect airway, breathing
and circulation, but affects the physiologic needs
of human. Wherein in maslow’s hierarchy of
need physiological needs the
most important as all the
other needs become secondary until these
needs are met.
It is not life threatening but important because
the effects of this problem may disturb other
function eventually.
This was prioritized first because the pain is
already tolerated.
In order to achieve the Maslow’s hierarchy of
needs, an individual must be capable of doing
things without alteration or pain.
This is an actual problem because pain causes
changes to the client’s homeostasis and can
affect the treatment and cooperation of the
patient. This must be addressed first before
proceeding to other problems.
Pain is considered as sixth vital sign and needs an
immediate intervention.
Problem anxiety interferes with the sufferer's
ability to function. Anxiety may occur without a
cause, or it may occur based on areal situation
but may be out of proportion to what would
normally be expected.
Impairment is a problem in body function or
structure; an activity limitation is a difficulty
encountered by an individual in executing at ask
or action; while a participation restriction is a
problem experienced by an individual
in involvement in life situations. Thus disability is
a complex phenomenon, reflecting an interaction
between features of a person’s body and features
of the society in which he or she lives."
(Kozier et al. Fundamentals of Nursing. 9Th
edition. 2002. p. 916)
5. READINESS FOR ENHANCED SUPPORT
SYSTEM related to sufficient family
functioning.
It is considered as a last priority because it is not
a problem while the strength of the child can be
used to resolved existing problems, the existing
condition of the client requires more support
from the health care team.