DATE CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION

TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS

CRITERIA
9/13/18 Subj: N Deficient fluid Osmotic diuresis After 8 hours of Independent: “GOAL
8:10 am “Sige kog U volume related is the increase nursing 1. Monitor vital 1. To obtain PARTIALLY
ihi-ihi sir” T to osmotic of urination rate interventions, signs baseline data MET”
as R diuresis caused by the patient will be
verbalized I secondary to presence of able to maintain 2. Assess peripheral 2. Indicators of After 8 hours of
by the T type 2 diabetes certain normal fluid and pulses, capillary level of hydration nursing
patient I mellitus substances in the electrolyte levels refill, skin turgor, and adequacy of interventions, the
O small tubes of as evidenced by: and mucous circulating volume. patient was able to
Obj: N the kidneys.[2] T membranes. improve his fluid
-fatigue A he excretion a.Normal urine volume imbalance
noted L occurs when frequency of 4-7 3. Monitor intake 3. Provides as evidenced by:
-thirst substances such times a day or and output ongoing estimate of
noted M as glucose enter about 30 cc per volume a. Serum
-polydipsia E the kidney hour replacement needs, electrolyte level
noted T tubules and kidney function and within normal
-dry skin A cannot be b. Balanced intake effectiveness of range
-cracked B reabsorbed (due and output therapy.
lips O to a pathological b. Good skin
-fluid L state or the c. Absent signs of 4. Maintain fluid 4. Maintains turgor
output I normal nature of dehydration intake of at least hydration and
higher than C the substance). 2,500 mL/day within circulating volume. c. Urine output of
intake d. Serum cardiac tolerance. 750 cc with fluid
I – 430 Review of electrolytes within 5. Avoids intake of 500 cc
O - 1000 Medical normal range 5. Promote overheating which
Physiology comfortable could promote
environment. further fluid loss.

6. Note changes in 6. Changes in

sensorium. sensorium can be
due to high
concentration of
glucose, electrolyte
imbalance and
acidosis.

38
 Collaborative:

1. Administer fluids 1. To replace fluid

as indicated. loss.

2. Administer 2. Lowers blood

insulin as ordered. sugar level and thus
preventing osmotic
diuresis.

3. Monitor 3. Elevated blood

laboratory studies sugar leads to
such as CBG, polyuria and
creatinine, and depletion of serum
serum electrolytes electrolytes.

4. Administer KCl 4. High doses of

as ordered insulin can lead to
hypokalemia
wherein K is
excreted in the
urine.

39
 DATE CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION
TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS
CRITERIA
9/14/18 Subj: N Risk for Type 2 diabetes After 8 hours of Independent: “GOAL MET”
8:00 am U unstable blood mellitus occurs nursing
“Luya ko sir T glucose level when there is a interventions, the 1. Monitor vital 1. To obtain After 8 hours of
unya sige R related to decreased patient will be signs. baseline data. nursing
pud kog I insulin sensitivity to able to control intervention,
tulon tulon. T deficiency insulin leading blood sugar level 2. Perform CBG 2. To identify patient was able to
Lami pud I secondary to to as evidenced by: monitoring. current blood control blood
kayo sigeg O type 2 hyperglycemia. glucose level. sugar level as
kaon.” As N diabetes a. Blood glucose evidenced by:
verbalized A mellitus Brunner and level within 3. Instruct patient to 3. Red meat is a
by the L Suddarth’s normal range avoid eating red high source of a. CBG within
patient. Textbook on meat. calories which in normal range (6.9)
M Medical b. Absence of turn raises blood
Obj: E Surgical fatigue sugar. b. Absent fatigue
T Nursing
-CBG of A c. Normal urine 4. Auscultate bowel 4. Hyperglycemia c. Balanced intake
10.9 B output sounds. can cause and output
-polyuria O gastroparesis.
-polyphagia L d. Absent
-polydipsia I 5. Observe signs of 5. Once polydipsia
fatigue C hypoglycemia. carbohydrate
metabolism
resumes, blood
glucose level will
fall, and as insulin
is being adjusted,
hypoglycemia may
occur.

Collaborative:

1. Monitor 1. Blood glucose

laboratory studies. will decrease
40
 slowly with
controlled fluid
replacement and
insulin therapy
2. Administer
Humulin R SQ as
ordered 2. Decreases blood
glucose
significantly.

41
 DATE CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION
TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS
CRITERIA
9/13/18 Subj: A Ineffective Normally the Within 8 hours of 1. Established 1. To gain “GOAL MET”
8:00 am “Sige ra kog C airway lungs are free nursing rapport cooperation
ubo unya T clearance r/t from secretions. interventions, the 2. Monitor vital 2. To obtain Within 8 hours of
nay plema” I increased Pneumonia patient will be signs baseline data nursing
V mucous bacteria are able to show signs 3. Elevated head of 3. To ease interventions, the
Obj. I production invading the of effective airway bed respiratory patient was able to
-coughing T secondary to lung clearance as 4. Administer O2 discomfort show signs of
noted Y bacterial parenchyma evidenced by: inhalation as 4. Provides proper effective airway
-yellowish infection thus ordered oxygenation clearance as
phlegm E , producing -decreased and reduce evidenced by:
noted X inflammatory frequency of 5. Encouraged to hypoxia
-dyspnea E process. And coughing increase OFI 5. To loosen -decreased phlegm
-shortness of R these -decreased phlegm secretions -decreased
breath C responses production 6. Encouraged frequency of
-nasal I leading to -absent dyspnea ambulation 6. To loosen cough
flaring noted S filling of the - RR within secretions -absent dyspnea
- RR of 24 E alveolar sacs normal range 7. Encouraged to -RR of 21
with exudates -absent nasal perform deep 7. Allows lung -absent respiratory
P leading to flaring breathing and expansion to discomfort
A consolidation coughing compensate for
T exercises low oxygen
T
E Kozier and
R Erb’s 8. Encouraged to 8. Reduces
Fundamentals have adequate fatigue and
N on Nursing bed rest discomfort

9. Promotes
9. Administer airway
nebulization as expansions
prescribed

10. Perform back 10. To loosen and

tapping excrete
secretions

42
 DATE CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION
TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS
CRITERIA
9/13/18 Subj. N Hyperthermia Pyrogens cause After 4 hours of 1. Monitor vital 1. To obtain “GOAL MET”
9:00 am -“Init akongU related to a rise in body nursing signs baseline data
paminaw T inflammatory temperature, it intervention, the 2. Provide tepid 2. Enhances heat After 4 hours of
sir” as
R process also acts as an patient will show sponge bath. loss by nursing
verbalized I secondary to antigen signs of regulated 3. Assess fluid loss evaporation & intervention, the
by the
T bacterial triggering body temperature & facilitate oral conduction. patient was able to
patient I infection immune system as evidenced by: intake. 3. Increases regulate body
O responses. The a. Temp of 36.5- 4. Promote bed metabolic rate temperature as
Obj. N hypothalamus 37.5 rest. & diaphoresis. evidenced by:
-Temp. of A reacts to raise b. PR of 70-80 5. Provide cool 4. Reduces body a. Temp of 37.2o
38.1o C L the set point and bpm circulating air heat C
-PR of 90 the body c. RR of 16-20 using a fan. production. b. PR of 74 bpm
bpm M respond by cpm 6. Assist patient in 5. Dissipates heat c. RR of 20 cpm
-RR of 22 E producing heat. d. Absence of changing into by convection. d. Hydrated skin
cpm T dehydration dry clothing. 6. Increases and mucous
-skin warm A Reference: 7. Provide oral comfort. membranes
to touch B Fundamentals of hygiene. Verbalization of
-fatigue O Nursing 8. Maintain IV 7. Prevents “Medyo okay na
noted L -Harry & Perry fluids as ordered herpetic lesions akong paminaw sir
-dry mucous I by physician. of the mouth. di na pud ko init”
membranes C 9. Administer anti-
-flushed pyretic as 8. Prevents
skin ordered. dehydration.

9. Reduces fever.

43
 DATE CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION
TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTIONS
CRITERIA
9/13/18 Subj: N Risk for The greater After 4 hours of Independent: “GOAL MET”
8:00 am U infection frequency of nursing After 4 hours of
“Dugay T related to infections in interventions, the 1. Observe for signs 1. Client may be nursing
mayo akong R hyperglycemia diabetic patients patient will be of infection. admitted with interventions, the
mga samad I secondary to is caused by the able to reduce the infection which patient was able to
sir.” as T diabetes hyperglycemic risk of infection as could have reduce the risk of
verbalized I mellitus type 2 environment evidenced by: precipitated from infection as
by the O that favors hyperglycemia evidenced by:
patient. N immune a. Remains free
A dysfunction. from the 2. Provide IV site 2. High glucose in a. VS within
Obj: L symptoms of care the blood creates an normal limits
Indian Journal infection excellent medium
-CBG of M of for bacterial growth b. Identifies the
14.9 E Endocrinology b. Identifies the symptoms of
-slowly T and Metabolism symptoms of 3. Provide 3. Peripheral infections such as
healing A infections such as conscientious skin circulation may be purulent dressing
wound at B purulent care. impaired placing and fever
right foot O discharges and patient at increased
-Temp of L fever risk for skin c. Demonstrate
38.1oC I irritation and appropriate
C c. Patient is able to breakdown and hygienic measures
clean the wound infection. such as hand
properly and apply washing, bathing,
dressing 4. Reposition and 4. Aids in hair and nail care.
encourage coughing ventilating all lung
d. Demonstrate and deep breathing areas and
appropriate exercises. mobilizing
hygienic measures secretions.
such as hand
washing, bathing, 5. Maintain aseptic 5.To prevent
hair and nail care. technique when contamination
changing dressing/
caring wound

6.Encourage to wear 6.Reduce

44
 clean loose likelihood of
clothing/covering worsening skin
breakdown

7. To maintain
7. Encourage to cleanliness.
maintain proper
hygiene.
8. Physical and
8. Encourage emotional stress
adequate rest to increase the clients
boost immune need for rest.
system

45