Dat

e Cues Need Nursing Objectives of Care Nursing Intervention Evaluation

and Diagnosis
time
A Subjective Ineffective Within 8 hours span of 1.) Establish rapport August 14, 2010
U "ubo pa, cge ubo pa, A airway care, patient will be ®To promote a good @ 11pm
G e gawas jud ang C clearance able to manifest a working and trusting
U plema sa imong T related to patent airway as relationship. “GOAL PARTIALLY MET”
S tutunlan pra dli mu I increased evidenced by:
T bara sa imong pag V sputum 2.) Assess respiratory Within 8 hours span of care,
hinga.", as I production a. respiratory rate movements and use of patient was able to manifest
1 verbalized by his T secondary to within normal range of accessory muscle. a patent airway as evidenced
4 sister. Y Pulmonary 16-20cpm; ® Use of accessory by:
, & Tuberculosis muscles to breath indicates
Objective E b. absence of an abnormal increase in a. respiratory rate within
2 • restless X adventitious sound like work of breathing. normal range of 16-20cpm;
0 • wheezing E ®The signs and wheezing and crackles; RR:
1 R symptoms of 3.) Assess cough for
0 • crackles C pulmonary TB c. demonstration of effectiveness and b. absence of adventitious
• ineffective I are insidious. deep breathing and productivity. sound like wheezing and
@ cough S Most patients coughing exercises; ® Patients may have crackles;
• moderate E have a low- and ineffective cough due to -
3p high back grade fever, fatigue or thick tenacious c. demonstration of deep
m P cough, night d. expectoration of secretions. breathing and coughing
rest
A sweats, fatigue, secretions readily. exercises; and
• fever T and weight loss. 4.) Auscultate lung sounds,
Vital Signs of: T The cough may noting areas of decreased d. expectoration of minimal
• T: 37.2 E be ventilation and presence of amount of secretions
• PR: 84 R nonproductive, adventitious sounds. approximately 10cc.
• CR: 85 N or ® Bronchial lung sounds
• RR: 24 mucopurulent are commonly heard over -
• Blood sputum may be areas of lung density or
Pressure: expectorated. consolidation.
120/80 Copious
• Chest x-ray secretions 5.) Monitor chest x-ray
obstruct the results.
result: +
airways in many ® These determine
patients with TB progression of disease
Medications:
and interfere process (e.g clearing of
with adequate infiltrates.)
• Rifampicin-
gas exchange.
 450 mg 1 tab 6.) Position head midline
OD Bibliography: with flexion appropriate for
• Isoniazid – Smeltzer, et.al. age/condition
300 mg 1 tab (2010). Brunner ® To open or maintain open
OD. and Suddarth’s airway in at-rest or
Textbook of compromised individual
Medical- 7.) Elevate head of the bed/
Surgical turn to sides every two
Nursing. hours
Lippincott ® To take advantage of
Williams and gravity decreasing pressure
Wilkins: 530 on the diaphragm and
Walnut Street, enhancing drainage
Philadelphia, of/ventilation to different
PA 19106. pp. lung segments.
569-571
8.) Assist patient with
coughing, deep breathing
exercise and splinting as
necessary.
® This improves
productivity of cough.

9.) Maintain adequate

hydration. Increase oral
fluid intake at least 2oo ml
per day in level of cardiac
tolerance.
® To aid in the mobilization
of secretions.
10.) Use humidity
(humidified oxygen or
humidifier at bedside) as
ordered.
® Increasing the humidity of
inspired air will loosen
secretions.

11.) Consult the respiratory

therapist for nebulizer
treatments, as appropriate
and ordered.
® A nebulizer may be used
to humidify the airway to
thin secretions to facilitate
their removal.

12.) Administer medications

such as cough suppressant
and mucolytics as
prescribed.
® To treat nonproductive
cough, loosen and mobilize
secretions.

Bibliography:
Doenges, Marilynn, et al.
(2005). Nursning Care
Plans Guidelines for
individualizing Patient Care.
6th Edition. Philadelphia:
F.A. Davis Company. Page
69-72

Gulanick, Meg,et.al. (2007).

Nursing Care Plans. 6th ed.
Mosby, Inc.: Elsevier
(Singapore) Pte.Ltd, 3
Killney Road #08-01,
Winsland house 1,
Singapore, pp. 479-491
Dat Cues Ne Nursing Objectives of Care Nursing Intervention Evaluation
e ed Diagnosis
and
time
A Objective: A Ineffective At the end of 8 hours 11 Assess for signs of August 14, 2010
U C
tissue perfusion span of care, our decreased tissue
G T
U - status post CVA I related to patient will be able to perfusion @
S V
- Lack of energy interruption of gain optimal tissue ® Baseline data is attained
T I
- hemoglobin count T bood flow – perfusion to vital so that further assessment 11: 00 PM
1 Y
> 115 g/dL arterial organs as evidenced will have a comparison on
4 &
, - Chest pain; not E membrane due by: whether there is “Goal Met “
X
noted to improvement or not
2 E
0 - Quantitative Trop – R Atherosclerosis 1) Remain negative 11 Monitor international After the 8 hours span of
1 C
I ordered secondary to signs of bleeding normalized ratio (INR) care, my patient was able to
0 I
- Fecal Occult blood S Myocardial and prothrombin gain an increase in the tissue
@ E
test ordered result: Infarction 2) Maintain absence of time/partial perfusion (not yet optimal) as
3p Negative P chest pain thromboplastin time evidenced by:
m A
® Decrease in (PT/PTT) if
T
- BP monitored T tissue perfusion 3) Decrease Cardiac anticoagulants are used 1) Signs of bleeding not
E
every 4 hours results in the Rate and maintain for treatment noted throughout span of
R
N failure to values of other Vital ® Blood clotting studies care
- Vital signs: nourish the signs within normal are used to determine or
Cardiac Rate: 85 tissues at the range such as ensure that clotting factors
bpm arterial level. remain within therapeutic 2) Chest pain not noted
Pulse Rate: 84 Reduced blood Cardiac Rate: 60 – 100 levels. throughout span of care
Blood Pressure: flow causes bpm 11 Monitor quality of all
120/80 mmHg decreased Blood Pressure: pulses 3) Maintained Normal Vital
Respiratory Rate: nutrition and 90/60 – 120/80 mmHg ® Assessment is needed Signs
24 cpm oxygenation at Respiratory Rate: for ongoing comparisons;
Temperature: the cellular 16–20 cycles per loss of peripheral pulses Cardiac Rate: 86 bpm
37.2 o C level. minute Temperature: must be reported or Pulse Rate: 84
36.5–37.2°C treated immediately. Blood Pressure:
Bibliography: 11 Maintain optimal 100/60 mmHg
cardiac output Respiratory Rate:
Doenges, ® This ensures adequate 20 cycles per minute
Marilynn. perfusion of vital organs. Temperature:
Nurse’s Support may be required 36.9 °C
Pocket to facilitate peripheral
Guide. 10th circulation.
edition. 11 Do passive range-
Philadelphia: of-motion (ROM)
F.A. Davis exercises to unaffected
Co. © 2006 extremity every 2 to 4
p. 254 hours
® Exercise prevents
® Tissue venous stasis.
perfusion is the 11 Anticipate or
amount of blood continue
that actually anticoagulation as
flows through ordered
the capillaries ® Therapy may range
of the vascular from intravenous (IV)
bed of that heparin, subcutaneous
structure or heparin, and oral
region. The anticoagulants to
important thing antiplatelet drugs. This
to remember is reduces the risk of
that nutrients thrombus
and oxygen are 11 Administer oxygen
delivered to the as needed
cells via the ® This saturates
capillaries. circulating hemoglobin and
Decrease increases the
resulting in the effectiveness of blood that
failure to is reaching the ischemic
nourish the tissues
tissues at the 11 Report changes in
capillary level. ABGs (e.g., hypoxemia,
Diminished metabolic acidosis,
tissue perfusion hypercapnia)
invariably ® This maintains maximal
results in tissue oxygenation and ion
or organ balance and reduces
damage or systemic effects of poor
death. perfusion
11 Explain all
Bibliography: procedures and
equipment to the
Gulanick, patient
Myers. ® Information is important
Nursing so that patient will be
Care Plans. aware of his condition and
6th edition. it will help in the
Singapore: cooperation of the patient
Elsevier Ltd 111 Provide
© 2007 p. 43 information on normal
 tissue perfusion and
® A tissue is a possible causes for
structure made impairment
of many similar ® Information is important
so that patient will be aware
cells to perform
of his condition and it will
one simple help in the cooperation of
the patient
function. That
function
depends on
what kind of
cells it is made
of.

®
Atherosclerosis
is a gradual
process by
which plaques
(collections) of
cholesterol are
deposited in the
walls of
arteries.
Cholesterol
plaques cause
hardening of
the arterial
walls and
narrowing of the
inner channel
(lumen) of the
artery. Arteries
that are
narrowed by
atherosclerosis
cannot deliver
enough blood to
maintain normal
function of the
parts of the
body they
supply.

® A heart
attack (also
known as a
myocardial
infarction) is the
death of heart
muscle from the
sudden
blockage of a
coronary artery
by a blood clot.
Coronary
arteries are
blood vessels
that supply the
heart muscle
with blood and
oxygen.
Blockage of a
coronary artery
deprives the
heart muscle of
blood and
oxygen,causing
injury to the
heart muscle. If
blood flow is not
restored to the
heart muscle
within 20 to 40
minutes,
irreversible
death of the
heart muscle
will begin to
occur. Muscle
continues to die
for six to eight
hours at which
time the heart
attack usually is
"complete." The
dead heart
muscle is
eventually
replaced by
scar tissue.

http://www.medi
cinenet.com/he
art_attack/articl
e.htm
Dat Cues
e ed
and
time
A Subjective cue:
U “dli na na siya ata
G kalakaw kron kay ni
U grabe na iyang sakit,
S dili parehas sauna
T na naka lakaw
pa.”as verbalized by
1 his sister.
4 secondary to
, Objective cue:
-Inability to
2 purposefully move
0 within the physical
1 environment such as
0 inability in moving
side to side.
@ E
- Limited range of
3p motion.
m A
-decreased muscle
strength specifically
right side muscle
strength.
- status post CVA.
Ne Nursing Objectives of Care Nursing Intervention Evaluation
Diagnosis
A Impaired After 8 hours span of 1. Assess functional August 14, 2010
C physical nursing care the patient ability/extent of impairment @
T mobility related will be able to increase initially and on a regular 11pm
I to strength and function of basis.
V neuromuscular affected body part as ® Identifies Goal Partially Met
I involvement: evidence by: strengths/deficiencies and
T right sided may provide information
Y weakness a. verbalization of regarding recovery. After 8 hours span of nursing
willingness to care the patient had partially
E cerebrovascular demonstrate and 2. Change positions at least increased the strength and
X accident . participate in the every 2 hr (supine, function of affected body part
E activities such as sidelying). as evidence by:
R ® stretching the fingers ® Reduces risk of tissue
C and feet and moving ischemia/injury. Affected a. “cge, gawin natin yan.
I from side to side. side has poorer circulation Turuan mo lang ako kung
S and reduced sensation and paano gagawin.”, as
b. demonstration of is more predisposed to skin verbalized by the patient.
techniques that breakdown/decubitus.
P enables resumption of b. He was not able to
activities such as 3. Position in prone position complete the exercise
T having passive range once or twice a day if specifically in his affected
T of motion exercises. patient can tolerate. right foot.
E ® Helps maintain functional
R c. verbalization of the hip extension; however, c. “kelangan ko talagang
N understanding of risk may increase anxiety, mag ehersisyo kahit sa
factor, treatment especially about ability to simpleng paraan lamang. at
regimen and safety breathe. hindi dapat ako mag higa sa
measures such as isang banda lamang.”, as
placing the knee and 4. Maintain neutral position verbalized by the patient.
hop in extended of head.
position, placing pillow ® Flaccid paralysis may
under axilla and interfere with ability to
Changing positions at support head, whereas
least every 2 hours. spastic paralysis may lead
to deviation of head to one
side.
5. Place pillow under axilla
to abduct arm
® Prevents adduction of
shoulder and flexion of
elbow.

6. Elevate arm and hand.

® Promotes venous return
and helps prevent edema
formation.

7. Maintain leg in neutral

position.
® Prevents external hip
rotation.

8. Encourage exercises
such as quadriceps/gluteal
exercise, hand grip exercise
and extension of fingers
and legs/feet.
® Minimizes muscle
atrophy, promotes
circulation, helps prevent
contractures.
Dat Cues Ne Nursing Objectives of Care Nursing Intervention Evaluation
e ed Diagnosis
and
time
A Objective cue: N Risk for After 8 hours span of 1 Review individual August 14, 2010
U - diagnosis of U impaired nursing care the patient pathology/ability to swallow, @
G cerebrovascular T swallowing will be able to maintain noting extent of paralysis; 11pm
U accident. R related to appropriate feeding clarity of speech; facial,
S I neuromuscular method appropriate to tongue involvement; ability Goal Met
T - coughing T impairment individual situation as to protect airway/episodes
I secondary to evidenced by: of coughing or choking; After 8 hours span of nursing
1 - think secretions O cerebrovascula presence of adventitious care the patient had able to
4 noted. N r accident. a. verbalization of breath sounds; maintain appropriate feeding
, A understanding of amount/character of oral method appropriate to
- lack of chewing L cauative factors of secretions. individual situation as
2 impairment in ® Nutritional evidenced by:
0 A swallowing. interventions/choice of
1 N feeding route is determined
0 D b. identify appropriate by these factors. a. “kelangan hindi masyado
interventions to promote matigas ang kakainin ko pra
@ M intake and prevent 2. Assist patient with head madali ko lang makain at
E aspirations. control/support, and kelangan uminon ng tubig
3p T position based on specific bago at pagkatapos kumain”,
m A c. maintain adequate dysfunction; as verbalized by the patient.
B hydration as evidenced ® Counteracts
O by good skin turgor and hyperextension, aiding in b. “dapat akong uminon ng
L moist skin. prevention of aspiration and tubig at hindi kakain ng
I enhancing ability to matigas na pagkain”, as
C swallow. verbalized by the patient.

P 3. Place patient in upright c. patient had maintained a

A position during/after feeding good skin turgor and moist
T as appropriate; skin.
T ® Uses gravity to facilitate
E swallowing and reduces risk
R of aspiration.
N
4. Serve foods at customary
temperature and water
always chilled.
® Lukewarm temperatures
are less likely to stimulate
salivation so foods/fluids
should be served cold or
warm as appropriate.

5. Place food of appropriate

consistency in unaffected
side of mouth;
® Provides sensory
stimulation (including taste),
which may increase
salivation and trigger
swallowing efforts,
enhancing intake.

6. Offer soft solid foods and

liquids at different times.
® Prevents patient from
swallowing food before it is
thoroughly chewed. In
general, liquids should be
offered only after patient
has finished eating foods.

7. Maintain upright position

for 45–60 min after eating.
® Helps patient manage
oral secretions and reduces
risk of regurgitation.
Dat Cues Ne Nursing Objectives of Care Nursing Intervention Evaluation
e ed Diagnosis
and
time
Subjective: R Impaired verbal That within our 5 hour 1. Assess patient's primary August 14, 2010
A Objective: O communication span of care our and preferred means of @
U -inability to L related to patient would be able communication (e.g., 10 pm
G modulate voice E slurring of to communicate verbal, written, gestures)
U -slurring of - speech verbally as evidenced  Patients may have skill "Goal Met!"
S speech R by: with many forms of
T -difficulty in using E ® Decreased, communication, yet they will After our 5 hours span of
facial expressions L delayed, or a. Making an eye prefer one method for care, our patient was able to
14, A absent ability to contact when talking. important communication. communicate verbally as
T receive 2. Assess for presence and evidenced by:
2 I process, b. Able to modulate history of dyspnea.
0 O transmit, and/or voice  Patients who are a. Having an eye contact
1 N use a system of experiencing breathing while talking with us
0 S symbols is one problems may reduce or
H manifestation c. Speak out cease verbal b. Modulated voice while
@ I after a stroke. thoughts and ideas communication that may conversing with us.
P The specific clearly complicate their respiratory
5 portion of the efforts.
PM P brain which 3. Assess energy level. c.Expressed thoughts and
A controls the  Fatigue and/or shortness ideas in words clearly using
T person’s of breath can make a short easily understandable
T capacity to communication difficult or words.
E express self is impossible.
R affected. 4. Assist patient in seeking
N an evaluation of his home
and work settings.
Doenges, This will evaluate the
Marilynn.Nurse’ need for assistive devices
s such as talking computers,
Pocket Guide. telephone typing device ,
11th edition and interpreters.
2008. F.A 5. Anticipate patients needs
Davis and pay attention to
Company.Phila nonverbal cues.
delphia,Pennsyl  Care measures may take
vania. longer to complete when
there is a communication
deficit.
7. Place important objects
within reach.
 Maximizes patient's
sense of independence.
8. Encourage the patient's
attempts to communicate;
praise attempts and
achievements.
 Positive feedback
enhances the patient's
efforts to overcome
communication barrier.
9.Never talk in front of the
patient as though he or she
comprehends nothing
 This prevents increasing
the patient's sense of
frustration and feelings of
helplessness.
10. Keep distractions such
as television and radio at a
minimum when talking to
the patient.
® This keeps the patient
focused, decreases stimuli
going to the brain
interpretation, and
enhances the nurse's ability
to listen.
11. Do not speak loudly
unless the patient is hearing
impaired.
® Loud talking does not
improve the patient's ability
to understand if the barriers
are primarily language,
dysphasia, or a sensory
deficit
12.Give the patient ample
time to respond.
® It may be difficult to
respond under pressure,
they may need extra time to
organize responses.
14. Use short sentences
and ask only one question
at a time.
® Allows patient to stay
focused on one thought.
Allows time for the brain to
keep pace with the
messages.
Reference:
Gulanick, Meg et.al.
Nursing
Care Plans.Nursing
diagnosis and
intervention 6th
edition.2007.
Mosby Inc.p. 38-43