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Cues Nursing Diagnosis Scientific Reason Planning Intervention Rationale Evaluation

Objective: Imbalance Intake of nutrients Short Term: 1.Established NPI 1.To gain client’s Short Term:
-weight loss (from Nutrition: Less insufficient to After 6 hours of confidence. Served foods are
69kg-58kg) than Body Weight meet metabolic nursing 2.Assess weight, 2.To establish tolerated and
related to self- needs. intervention, the BMI. baseline verbalized
-pale in overall imposed dietary patient will be parameters. understanding of
appearance restrictions, lack Source: able to verbalize 3.Encourage 3.To meet other
Weakness
of information Nurse’s Pocket understanding of several small nutritional needs. interventions to
and poor choice Guide by M. causative factors nutritious meals. 4.To reveal attain balance
-decrease RBC
(4.40x1058kg)
of kind of foods as Doenges when known and possible cause of nutrition.
manifested by the necessary 4.Evaluate total imbalance and
-pale in overall weight loss. Pale interventions. daily food intake. changes that Long Term:
appearance in overall could be made in Lifestyle changes
Weakness appearance. Long Term: 5.Emphasize client’s intake. are demonstrated
The patient will be importance of 5.Compliance to and actualized to
-decrease RBC able to well-balanced, realistic diet maintain healthy
(4.40x1013/L) demonstrate nutritious intake. modifications. balance.
behaviours, Provide
-no rice for the past
lifestyle changes information
6 months during
to maintain health regarding
dinner.
and appropriate individual
-loose biceps and weight. nutritional needs
triceps skin folds. and ways to meet
these needs
within financial
constraints.
Cues Nursing Diagnosis Scientific Reason Planning Intervention Rationale Evaluation

Objective: Imbalance Nutrition: Less Intake of nutrients Short Term: 1.Established NPI 1.To gain client’s Short Term:
-weight loss (from 69kg- than Body Weight related insufficient to meet After 6 hours of nursing confidence. Served foods are tolerated
58kg) to self-imposed dietary metabolic needs. intervention, the patient 2.Assess weight, BMI. 2.To establish baseline and verbalized
restrictions, lack of will be able to verbalize parameters. understanding of other
-pale in overall appearance information and poor Source: understanding of causative 3.Encourage several small 3.To meet nutritional interventions to attain
Weakness choice of kind of foods as Nurse’s Pocket Guide by M. factors when known and nutritious meals. needs. balance nutrition.
manifested by weight loss. Doenges the necessary
-decrease RBC Pale in overall appearance. interventions. 4.Evaluate total daily food 4.To reveal possible cause Long Term:
(4.40x1058kg) intake. of imbalance and changes Lifestyle changes are
Long Term: that could be made in demonstrated and
-pale in overall appearance The patient will be able to client’s intake. actualized to maintain
Weakness demonstrate behaviours, healthy balance.
lifestyle changes to
-decrease RBC maintain health and
(4.40x1013/L) appropriate weight. 5.Emphasize importance of 5.Compliance to realistic
well-balanced, nutritious diet modifications.
-no rice for the past 6 intake. Provide information
months during dinner. regarding individual
nutritional needs and ways
-loose biceps and triceps to meet these needs within
skin folds. financial constraints.
Cues Nursing Diagnosis Scientific Reason Planning Intervention Rationale Evaluation

Subjective: Anxiety (severe) related to Vague uneasy feeling of Short Term: 1.Established NPI 1.To alleviate fear and to Short Term:
-insomia situational crisis and stress discomfort of dread after shift, the patient will gain confidence. Goal met
AMB too much talking; accompanied by an appear relaxed and report 2.Monitor VS The patient appeared
-restlessness restlessness secondary to autonomic response (the anxiety is reduced to a 2.To identify physical relaxed and verbalized
upcoming surgery. source of ten non- specific manageable level. 3.Observe Behaviours responses associated with decreased of anxiety.
-too much talking or unknown to the both medical and emotional
individual) a feeling of Long Term: 4.Notes reports of conditions.
-coo extremities apprehension caused by Identify healthy ways to insomnia. Long Term:
anticipation of danger. It is deal with and express 3.Which can point to the The patient verbalized and
-sweating an altering signal that anxiety. 5.Reviewed Coping skills in client level of anxiety. actualizes healthy ways to
warms of impending danger post. deal with and express
-expresses financial and enables the individual 4.Which may be anxiety.
concerns to take measures to deal 6.Established therapeutic behavioural indicator of use
with threat. relationship, conveying of withdrawal to deal with
-increase BP: 150/100 empathy and unconditional problems.
mmHg Source: Nurses pocket guide positive regard. Note SN
by M. Doenges needs to be aware of own 5.To determine those that
-increase RR: 21cpm feelings of anxiety or might be helpful in current
uneasiness exercising core. circumstances.

7.Provided accurate 6.To avoid the contagious


information about the effect of transmission of
situation . anxiety.
7.Helps client identify what
8.Provided comfort is reality based.
measures (e.g calm and
quiet environment, warm 8.To promote relaxation.
bath or backrub.
Assessment Problem/Diagnosis Scientific Reason Planning/ Goal Intervention Rationale Evaluation
Alteration in comfort; Pain Due to the presence of Short term goal: 1. Observed and 1. Assist in differentiating Short term:
-(+)epigastric tenderness related to inflammation of stones in the gallbladder documented the location, cause of pain and provides Goal met: After 6 hours of
upon admission the gallbladder that causes some After 6 hours of nursing severity ( 0-10) and information about disease nursing intervention
obstruction in the cystic intervention Patient will be character of pain. progression/ resolution, patient was able to
-facial grimace duct which in turn causes a able to verbalize relief from 2. Response to medication development of verbalize relief from pain,
sharp pain on the right part pain and there is less noted and physician complication and there’s relaxation and
-irritable of the abdomen that causes autonomic responses to informed when pain is not effectiveness of demonstrated negative
discomfort to patient. pain. relieved. intervention. guarding behaviour on the
-guarding behaviour 3. Bed rest promoted and 2.severe pain by routine abdominal site.
Referrence: allows client to assumed measures may indicate
-BP 150/100 mmHg Afdhal NH. Diseases of the Long term goal: position of comfort. developing complications/ Long term:
Gallbladder and Bile Ducts. 4. Environmental need for further intervention Goal met: On patient’s
In: Goldman L, Ausiello D. Patient will be able to temperature controlled. 3. bed rest in fowlers continuation of care she
(eds.). Cecil Textbook of identify ways on how to 6. Encouraged use of position reduces intra- was able to identify ways to
Medicine. 23rd ed. relieve discomfort during relaxation techniques ( abdominal pressure, relieve pain by proper
Philadelphia, Pa: Saunders reoccurrence of pain. guided imagery, however, client will naturally positioning to reduce
Elsevier; 2007. visualization, deep breathing assume least painful pressure on the abdomen
exercise. To Provide position. and to promote comfort.
diversional activities. 4.cool surroundings aid in
7. Made time to listen and minimizing dermal
maintained frequent contact discomfort
with client. 6. Promotes rest, redirects
attention, may enhance
coping.
7. Helpful in alleviating
anxiety and refocusing
attention which can relieve
discomfort.
Cues Nursing Diagnosis Scientific Reason Planning Intervention Rationale Evaluation
Subjective: Knowledge deficit regarding There is this presence of Short term goal: 1. Provided explanations of 1. Information can decrease Short term:
“pwede bang maulit ang condition prognosis, knowledge deficit due to After 6 hour of nurse- /reasons for test procedures anxiety, thereby reducing After 6 hours of nursing
sakit ko?” as verbalized by treatment, self-care and some unfamiliar patient interaction the and preparation needed. sympathetic stimulation. intervention the patient
the patient discharge needs. information that causes patient will Verbalize can
some confusion to the understanding of disease 2. Reviewed disease 2. Provides knowledge base
Objective: client that needs to be process, prognosis, and process/prognosis. Discuss from which patient can make Long term:
discussed. potential complications. hospitalization and informed choices. Effective Goal was met as
-Frequently asking prospective treatment as communication and support evidenced by:
question about his Long term goal: indicated. Encouraged at this time can diminish Client was able to
condition ,treatment and On the process of long questions, expression of anxiety and promote healing. -Participate in learning
diet Source: Psychiatric Clinical term intervention, client concern. process.
-With worried gaze Pathways : An will be able to cope up -Knowledge: Treatment
Interdisciplinary Approach with her condition by 3. Reviewed drug regimen 3. Gallstones often recur, Regimen
By: Patricia C. Dykes understanding the and possible side effects. necessitating long-term -Verbalize understanding
necessary adjustment for therapy. of therapeutic regimen.
her lifestyle, importance of -Correctly perform
therapeutic regimen 4. Instructed patient to 4. Prevents/limits recurrence necessary procedures and
prescribed, and give avoid food/fluids high in fats of gallbladder attacks explain reasons for the
cooperation on the (e.g., whole milk, ice cream, actions.
procedures and test being butter, fried foods, nuts, -Initiate necessary
done. gravies, pork), gas producers lifestyle changes.
(e.g., cabbage, beans,
onions, carbonated
beverages), or gastric
irritants(e.g., spicy foods,
caffeine, citrus).

5. Suggest patient limit gum 5. Promotes gas formation,


chewing, sucking on which can increase gastric
straw/hard candy, or distension/discomfort.
smoking.

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