NSG. DX.

OBJECTIVE NURSING
CUES NEED W/SCIENTIFIC EVALUATION
OF CARE ACTION
BASIS
Subjective Cues: Coping/Stress Fear related to Short Term: Independent: Short Term:
‘’Nabalaka ko sir Tolerance of change in health After 1 hour of nursing 1. Established a rapport to the patient. After 1 hour of nursing
kay basin mo Gordon’s status as evidenced intervention, the patient will R: To build a trusting relationship. intervention, the patient was
kalat ang cancer Functional by verbalization of be able to: 2. Encouraged the patient to explore able to:
sa pikas totoy’’ as Health Pattern fear and worry and A. Express her fears underlying feelings that may be A. Expressed their
verbalized by the distressed and concerns contributing to the fear. fears and concerns
patient. appearance. verbally during R: To confront unresolved conflicts and verbally during
therapeutic develop coping abilities. therapeutic
Objective cues: Scientific Basis: communication 3. Determined the cause of communication
- Distressed Response to sessions. fear/anxiety. sessions.
appearance perceived threat B. Demonstrate the use R: Actively listen to the patient to show B. Demonstrated the
that is consciously of relaxation them they can be open about what they use of relaxation
recognized as a techniques such as are feeling and will not be judged or techniques, such as
danger. deep breathing, dismissed. deep breathing or
reading, meditation, 4. Validated patient’s feelings regarding mindfulness
Reference: as a means to its fear. exercises, as a
NANDA manage fear. R: To let the patient to know that the means to manage
nurse had heard and understands what fear and anxiety.
Long Term: was said and promotes nurse-patient
After 2 days of nursing relationship.
intervention, the patient will 5. Assessed coping strategies. Long Term:
be able to: R: Assess the patient’s coping strategies After 2 days of nursing
A. Demonstrate coping in response to their anxiety/fear. To know intervention, the patient will
behaviors that what strategies are or aren’t working and be able to:
reduces own fear to determine if new strategies need to be A. Demonstrated
such as positive self- implemented. coping behaviors
talk, reassurance, 6. Promoted relaxation techniques. that reduces own
and emotional R: To aid in reducing fear, improving well- fear such as positive
support. being, and enhancing coping with health self-talk,
challenges. reassurance, and
emotional support.
 NSG. DX.
OBJECTIVE NURSING
CUES NEED W/SCIENTIFIC EVALUATION
OF CARE ACTION
BASIS
Subjective Cues: Health Readiness for Short Term: Independent: Short Term:
‘’Dapat lang jud Perception/ enhanced health After 1 hour of nursing 1. Provided detail information about the After 1 hour of nursing
ko mo comply sa Health management intervention, the patient will cancer diagnosis, treatment options, intervention, the patient was
akong meds tas Management by related to cancer be able to: and expected outcomes in a clear able to:
regular check-up Gordon’s management as A. Understand the and understandable manner. A. Understand the
sad’’ as Functional evidenced by cancer management R: To actively participate in their health cancer management
verbalized by the Health Pattern positivity towards to prevent further management. to prevent further
patient. treatment complications. 2. Identified steps necessary to reach complications by
B. Actively engage in desired health goals. verbalizing ‘’yes sir I
Objective cues: Scientific Basis: discussions about R: Understanding the process enhances follow nako na para
- Positivity A pattern of the cancer treatment commitment and likelihood of achieving sad di na mo katag
towards treatment regulating and plan such as the goals. sa uban lawas
integrating into compliance to 3. Provided emotional support by nako’’.
daily living a medications and creating a safe space for the patient B. Engaged in
therapeutic regimen follow-up check-up. to express fears, concerns, or discussions about
for treatment of positive emotions. the cancer treatment
illness and its R: Acknowledging and addressing plan such as
sequela, which can emotional needs helps the patient cope compliance to
be strengthened. with the psychological aspects of cancer medications and
management, contributing to a positive follow-up check-up.
Reference: mindset.
NANDA 4. Encouraged the patient to involve
family, friends, or support groups in
their care.
R: Social support reinforces the patient's
emotional well-being and provides
practical assistance, contributing to a
positive outlook on their health journey.
5. Emphasized the importance of self-
care practices, including adequate
rest, nutrition, and exercise.
R: Self-care contributes to overall well-
being, supporting the patient's physical
and emotional resilience during cancer
management.
 NSG. DX.
OBJECTIVE NURSING
CUES NEED W/SCIENTIFIC EVALUATION
OF CARE ACTION
BASIS
Subjective Cues: Safety and Risk for fall related Short Term: Independent: Short Term: Goal Met
‘’Malipong ko sir if Security of to seizure activity After 8 hour of nursing 1. Identified factors that affects safety needs. After 1 hour of nursing
mo bangon ko’’ as Maslow’s intervention, the intervention, the patient
verbalized by the Hierarchy of Scientific Basis: patient/watcher will be able R: To know intervention that will be was able to:
patient. Needs Increased to: established.
susceptibility to 2. Assessed the patient’s balance and gait. A: Understood the fall
Objective cues: falling that may A. Understand the R: To determine the client’s functional abilities. precaution by verbalizing
- Dizziness cause physical fall precaution 3. Evaluated the patient’s environment and ‘’yes sir I follow nako na
- Headache harm. such as raise side- thoroughly orient them about it. tapos magpabantay rasad
- Forgetfulness rails, clear path, R: A fall is more likely to be experienced by an ko sakong bana’’.
- Morse Fall Scale Reference: improve lighting, individual if the surroundings are unfamiliar.
of 35 (Moderate NANDA and never leave 4. Encouraged the watcher to stay with the Long Term: Goal Met
Fall Risk) patient unattended. client. After 2 days of nursing
- Episodes of R: To ensure client’s safety. intervention, the patient
Generalized Tonic- Long Term: 5. Instructed the patient/watcher to call for was able to:
Clonic Seizure After 2 days of nursing assistance when moving.
intervention, the patient will R: To prevent from falling on bed. A: Maintained safety as
Vital Signs: be able to: 6. Raised side rails. evidenced by no falls and
BP: 108/57 mmHg R: to reduce risk of falling. fall-related injuries.
A: Maintain safety by 7. Placed beds are at the lowest possible
having no falls and fall- position. Set the patient’s sleeping surface
related injuries during as near the floor as possible if needed.
hospital stay. R: Keeping the beds closer to the floor reduces
the risk of falls and serious injury.

Dependent:
1. Administered Diazepam 1amp IVTT prn for
active seizure as ordered by the AP.
R: To treat frequent seizure activity.
2. Administered Levetiracetam 500 mg IVTT
every 12 hours as ordered by the AP.
R: To treat tonic-clonic seizure.