CUES AND DATA NURSING DIAGNOSIS RATIONALE GOALS AND OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Independent:  After 3 days of

“nakaka apat na baso ng tubig Deficient fluid volume related Decrease fluid intake results to After 3 days of nursing nursing interventions
lang ako sa isang araw.” As to inadequate fluid intake. increase ADH secretion and interventions and health 1. Limit intake of 1. Tends to exert a and health teaching,
verbalized by the client. Renin-Angiotensin-Aldosterone teachings, the client will be alcohol/caffeinated diuretic effect. the client washable
System activation. able to verbalize understanding beverages. to verbalize her
Increased ADH secretion purpose of individual understanding about
results in increasing water therapeutic interventions and the purpose of
resorption. While the client will be able to 2. Encourage client to 2. To increase fluid individual therapeutic
activation of Renin- demonstrate behaviors to increase oral fluid volume. interventions and she
Angiotensin-Aldosterone monitor and correct deficit. intake. Be creative in was able to
System only increases the selecting fluid demonstrate
sodium and water resorption sources that suits the behaviors to monitor
which decreases the urine client’s budget (e.g., and correct deficit.
output. Deficient fluid volume flavored gelatin,
depletes the fluids available frozen juice bars,
therefore reacting to the sports drink, fruit
OBJECTIVE: hypothalamus that raises the juices, water)
 sudden weight loss body temperature. The cells
from 32kg to 31kg become unable to continue 3. Teach interventions 3. Patients need to
 not sufficient intake of providing water to replace ECF to prevent future understand the
water, 4 glasses a day losses. Resulting in dry mucous episodes of importance of
or 800ml water a day. membranes and dehydration. inadequate intake. drinking extra fluid.
 fatigue
 pale mucous
membrane 4. Provide oral hygiene. 4. This promotes
 hypotension with a BP interest in drinking.
of 90/60mmhg.
5. Advise client to use 5. To maintain skin
mild cleanser/soap in integrity and prevent
bathing. excessive dryness.
LIST OF PRIORITY PROBLEMS

1. Ineffective breathing Pattern related to Decrease lung Capacity

2. Activity Intolerance related to imbalance between O2 Supply and demand
3. Deficient fluid volume related to inadequate fluid intake.
4. Imbalanced Nutrition: less than body requirements related to loss of appetite
5. Ineffective sexuality pattern related to client’s underlying highly communicable disease
 CUES AND DATA NURSING DIAGNOSIS RATIONALE GOALS AND OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Imbalanced Nutrition: less Remaining bacilli causes After 3 days of nursing INDEPENDENT: INDEPENDENT:  After 3 days of
“Simula nung nagkasakit ako than body requirements formation of a granulomatous interventions and health nursing
madalas nakong mawalan ng related to loss of appetite lesion teachings, the client will be 1. Provide 1. Attention to the interventions, the
ganang kumain”, as verbalized able to verbalize and companionship social aspects of client was able to
by the client. Lesion becomes surrounded demonstrate selection of during mealtime. eating is important verbalize and
by macrophages foods or meals that will in home setting. demonstrate
achieve a cessation of weight selection of foods or
OBJECTIVE: Increases workload of lungs loss. 2. These may decrease meals that wil
 loss of weight, from 2. Discourage appetite and lead to achieve a cessation
32kgs to 31 kgs. beverages that are early satiety. of weight loss.
 Height=4’11 Tightness of chest caffeinated or
 Weight=31kgs. Dyspnea carbonated. 3. To help stimulate
 underweight Anorexia, weakness and loss the person's
 BMI=13.78 of weight 3. Family members appetite.
should try to supply
favourite foods that
suit the family’s
budget. 4. To appeal client’s
likes and dislikes.
Source: 4. Discuss eating
habits, including
Nursing Care Plan 3rd edition by food preferences,
Gulanick, Klopp, Galanes, intolerances/aversio
Gradishar and Puzas ns.

pp.75-77
 CUES AND DATA NURSING DIAGNOSIS RATIONALE GOALS AND OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective breathing Inhalation of After 2 hours of nursing Independent: After 2 hours of nursing
Pattern related to Decrease mycobacterium intervention, client’s intervention, client’s
“Nahihirapan ako lung Capacity tuberculosis breathing pattern will able  Push fluids and  To liquify breathing pattern was able
huminga” as verbalized by to maintain as evidenced promote secretions to maintain as evidenced
the client. by: hydration by:
Bacilli eludes upper airway
Objective: defense system  Induce sputum  To expedite
 Decreased use of with heated diagnosis and  Decreased use of
 Use of accessory accessory muscle aerosol if needed start early accessory muscle
muscle Enter the Lungs  Decreased RR treatment  Decreased RR of
 RR of 31 cycles  Decreased 29 cycles per
per minute amount of  Maintain semi-  To facilitate easy minute
 Excessive Sputum Bacilli implants in alveolus sputum fowlers position breathing  Decreased
 Restlessness in the upper lobe  Verbalization of amount of sputum
adequate rest  Verbalization of
Collaborative: adequate rest
Bacterial multiplication
 Administer O2 as  Decreases work of
Causes an inflammatory ordered Breathing
response in the lung area
 The inflammatory response
brings the phagocytic cells
Source: in the sight of invasion

Nursing Care Plan 3rd

edition by Gulanick, Klopp, Phagocytic cells engulf and
Galanes, Gradishar and destroy the bacilli
Puzas
Accumulation of exudates
pp.232

Production of Sputum

Remaining bacilli causes

formation of granulomatous
lesion

Lesion becomes surrounded

by macrophages

Increases workload of lungs

Tightness of the chess

occurs

Difficulty of Breathing
CUES AND DATA NURSING DIAGNOSIS RATIONALE GOALS AND OBJECTIVE INTERVENTIONS RATIONALE EVALUATION

Subjective: Activity Intolerance related Increased workload of the After 8 hours of nursing Independent: After 8 hours of nursing
to imbalance between O2 lungs interventions, client will interventions, client was
“Mabilis ako hingalin at Supply and demand able to maintain activity  Encourage able to maintain activity
 To reduce cardiac
mapagod” as verbalized by level within capabilities as adequate rest level within capabilities as
workload
the client evidenced by: periods, especially evidenced by:
Imbalance between O2 before meal
Objective: supply and demand ambulation and
 Verbal report of meals  Verbal report of
 Verbal report of adequate rest adequate rest
fatigue or  Ability to begin  Refrain of  Ability to begin
 To promote rest
weakness activity performing non activity
 Inability to begin Tightness of the chest  Normal BP essential  Normal BP
activity  Absence of procedures  Absence of
 Abnormal BP of shortness of shortness of
 To maintain
90/70 breath and fatigue  Encourage active breath and fatigue
muscle strength
 Exertional Shortness of Breath ROM exercises
and joint range of
discomfort or three times a day
motion
dyspnea

Easily get fatigue

Sources:

Nursing Care Plan 3rd

edition by Gulanick, Klopp,
Galanes, Gradishar and
Puzas

pp. 2