CUES NURSING DIAGNOSIS GOALS/OUTCOMES NURSING INTERVENTION IMPLEMENTATION EVALUATION

Subjective: Impaired verbal At the end of 24 hours  Establish rapport with the  Utilized therapeutic At the end of 24 hours of
“Hindi ko communication related to of nursing intervention, client communication while nursing intervention, the
masayado neuromuscular the patient will be able Rationale: Establish a caring for the patient. patient was able to:
naiintindihan ang impairment to: trusting relationship with
pananalita niya” client or family demonstrating  Encouraged SO/visitors to  Establish method of
as stated by the  Establish method of caring about the client as a persist in efforts to communication in which
sister communication in person communicate with patient needs can be expressed
which needs can be  Verbalize or indicate an
Translation: expressed  Involve family/SO in the  Communicated with the understanding of the
“I can’t understand  Verbalize or indicate plan of care as much as patient slowly by using communication difficulty
what he is saying” an understanding of possible simple words in a low and plans for ways of
the communication Rationale: This enhances tone. handling
Objective: difficulty and plans participation and commitment  Demonstrate congruent
Aphasia for ways of handling to communication.  Provided sufficient time for verbal and nonverbal
 Demonstrate the client to respond communication
congruent verbal  Keep communication
and nonverbal simple, speaking in short  Notified other health care
communication sentences, using provider about the client’s
appropriate words. speech impairment by
Rationale: Reduces writing a notice at the
confusion and allays anxiety nurses’ station and
at having to process and patient’s room.
respond to large amount of
information at one time.  Anticipated the needs of
the patient by attending to
 Anticipate and provide for the client's verbal and non-
patient’s needs. verbal cues.
Rationale: Helpful in
decreasing frustration when  Provided a special call bell
dependent on others and that can be activated by
unable to communication minimal pressure.
desires.
 Provided pad and pencil
 Advice other health care for the patient to use it to
providers of the client’s
 communication deficits communicate with the staff
and needed means for and SO.
communication
Rationale: To minimize  Consulted and referred the
client’s frustration and patient to a speech
promote understanding. therapist.

 Provide alternative
methods of
communication
Rationale: Provides
communication needs of
patient based on individual
situation and underlying
deficit.

 Refer patient to speech

therapist.
Rationale: Speech therapies
assesses individual verbal
capabilities and sensory,
motor, and cognitive
functioning to identify
deficits/therapy needs.
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 CUES NURSING DIAGNOSIS GOALS/OUTCOMES NURSING INTERVENSION IMPLEMENTATION EVALUATION
Subjective: Electrolyte imbalance At the end of 24 hours  Encourage potassium • Encourage SO/visitors
related to poor intake of of nursing intervention, intake through diet to persist in efforts to
potassium the patient will be able  Monitor I & O communicate with patient:
to: 
Provide pad and pencil for the
 patient


Objective:
 CUES NURSING DIAGNOSIS GOALS/OUTCOMES NURSING INTERVENSION IMPLEMENTATION EVALUATION
Subjective: Risk for fall related to At the end of 24 hours  Educate family members  Explained to the family At the end of 24 hours of
“nanghihina yung muscle weakness of nursing intervention of client’s condition. members about the nursing intervention
katawan ko” as Rationale: Providing health patient’s disease condition
stated by the  The patient will be teachings regarding client’s  The patient was free from
patient free from falls condition could assist family  Instructed family members falls and safety was
 The Family members in understanding to accompany the patient ensured
Translation: members will and taking care of at all times
“My body feels verbalize the client.
weak.” understanding of risk  Initiate demonstration and
factors that Rationale: This may reveal a return demonstration on
contribute to the lack of understanding, exercise training
Objective: possibility of fall insufficient resources, or
 Weak in  The health care simple disregard for personal  Placed the patient
appearance providers will modify safety. adjacent to the nurses’
environment as station
indicated to enhance  Ask family to stay with
safety the patient.  Essential items used by
Rationale: This is to prevent the patient are placed at
the patient from accidentally the bedside
falling or pulling out tubes.
 Adjusted the bed of the
 Allow the patient to patient at lowest position
participate in a program
of regular exercise  Raised the side rails
Rationale: Increased
physical conditioning reduces  Assessed patient’s
the risk for falls environment and provided
adequate lighting.
 Transfer the patient to a
room near the nurses’
station.
Rationale: Nearby location
provides more constant
observation and quick
 response to call needs.

 Move items used by the

patient within easy reach
Rationale: Items that are too
far from the patient may
cause hazard and can
contribute to falls.

 See to it that the beds

are at the lowest possible
position
Rationale: Keeping the beds
closer to the floor reduces
the risk of falls and serious
injury

 Use side rails on beds,

as needed.
Rationale: Disoriented or
confused patient is less likely
to fall when one of the four
rails is left down.

 Guarantee appropriate
room lighting, especially
during the night
Rationale: Lighting an
unfamiliar environment helps
increase visibility
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