CUES NURSING DIAGNOSIS SCIENTIFIC BASIS GOAL & OUTCOME CRITERIA NURSING ACTIONS & NURSING ORDERS RATIONALE OF NURSING ORDERS EVALUATION S- “Pirme lang gamay akong makaon diri kay dili jud ko ganahan sa timpla sa mga pagkaon nga i-rasyon.” as verbalized by the patient. O- Weight loss Lethargic Weak Vital signs taken as follows: BP: 130/70 mmHg Temp: 36.3 ºC HR: 87 bpm RR: 17 cpm Wt: 78 kg from 81.1 kg Imbalance Nutrition: Less than body requirements related to unwillingness to eat. Adequate nutrition is necessary to meet the body’s demand. Nutritional status can be affected by disease or injury state. In the case of my patient, her imbalanced nutrition is due to her unwillingness to eat due to unusual taste. Because of her medical condition, food preparations are changed appropriate for her, but the change in taste is not easily masked by the patient. (Gulanick/Myers; 2007; p. 134) After 3 days of nurse-patient interaction, the patient will be able to demonstrate behaviour, lifestyle changes to regain appropriate weight. Specifically the patient will be able to: Verbalize understanding with causative factors when known and necessary intervention. The nurse will assist the patient in demonstrating behaviour, lifestyle changes to regain appropriate weight. The nurse will: Ascertain understanding of individual nutritional needs. Discuss eating habits including food preferences, intolerance and aversion. Promote pleasant relieving environment including socialization when possible. To determine informational needs of the patient. ( Doenges, Morrhouse,Murr; 2009; p. 565) To appeal to client’s tasks. ( Doenges, Morrhouse, Murr; 2009; p. 565) To enhance intake. ( Doenges, Morrhouse, Murr; 2009; p. 565) GOAL MET Patient was able to demonstrate behaviour, lifestyle changes to regain appropriate weight. GOAL PARTIALLY MET Patient was able to partially demonstrate behaviour, lifestyle changes to regain appropriate weight. GOAL NOT MET Patient was not able to demonstrate behaviour, lifestyle changes to regain appropriate weight. 47
Demonstrate progressive weight gain toward goal. To promote wellness after interventions has been done. Assess weight, measure or calculate body fat. Evaluate total daily food intake. Encourage client to choose food or have family member to bring food that seams appealing. Weight at regular intervals and document results. Consult with dietician and nutritional support team as necessary. Refer to home health resources. To establish baseline parameters. ( Doenges, Morrhouse, Murr; 2009; p. 565) To reveal possible cause of malnutrition changes that could be made in client’s intake. ( Doenges, Morrhouse, Murr; 2009; p. 566) To stimulate appetite. ( Doenges, Morrhouse, Murr; 2009; p. 567) To monitor effectiveness of dietary plan. ( Doenges, Morrhouse, Murr; 2009; p. 568) To have an accurate dietary intake for long term needs. ( Doenges, Morrhouse, Murr; 2009; p. 568) For initiation and supervision of home nutrition therapy when used. ( Doenges, Morrhouse, Murr; 2009; p. 569) 48
CUES NURSING DIAGNOSIS SCIENTIFIC BASIS GOAL & OUTCOME CRITERIA NURSING ACTIONS & NURSING ORDERS RATIONALE OF NURSING ORDERS EVALUATION S- “ Permi lang jud ko nagluya diri, wa man gud koy lain mabuhat diri sige lang og higda.” as verbalized by the patient. O- Lethargic Weakness Drowsy Listless Decreased performance Vital signs taken as follow: BP: 130/ 70 mmHg Temp: 36.3 ºC HR: 87 bpm RR: 17 cpm Fatigue related to poor physical condition. Fatigue is subjective complaint of both acute and chronic illness. In the case of my patient, fatigue was felt by her due to poor physical condition, and persistent lying on bed. Due to hospitalization and her medical condition together with the treatment, barriers are also there to add on it. (Gulanick/ Myers; 2007; p. 65) After 3 days of nurse-patient interaction, the patient will be able to report improved sense of energy. Specifically, the patient will be able to: Identify basis of fatigue and individual areas of control. Participate in recommended treatment program. The nurse will assist the client in attaining the goal of reporting improved sense of energy. The nurse will: Assess the vital signs. Note daily energy pattern. Determine presence/ degree of sleep disturbances. Establish realistic activity goal with client and encourage forward movements. To evaluate fluid status and cardiopulmonary response to activity. ( Doenges, Morrhouse, Murr; 2009; p. 352) This may be helpful in determining pattern/ timing of activity. ( Doenges, Morrhouse, Murr; 2009; p. 563) Fatigue can be a consequence of exacerbated sleep. ( Doenges, Morrhouse, Murr; 2009; p. 352) Enhances commitment to promoting optimal outcomes. ( Doenges, Morrhouse, Murr; 2009; p. 354) GOAL MET Patient was able to report improved sense of energy. GOAL PARTIALLY MET Patient was able to partially report improved sense of energy. GOAL NOT MET Patient was not able to report improved sense of energy. 49
Participate in recommended treatment program. Schedule activities for periods when client has the most energy. Plan interventions to allow individually adequate rest periods. Encourage client to do whatever things as possible which are tolerated by her. Encourage patient to use assistive devices as needed. Instruct client in ways to monitor responses to activity and significant signs and symptoms that indicate a need to change activity level. To maximize client participation. ( Doenges, Morrhouse, Murr; 2009; p. 354) To provide patient a resting period in between activities. ( Doenges, Morrhouse, Murr; 2009; p. 354) To increase activity tolerance. ( Doenges, Morrhouse, Murr; 2009; p. 355) To extend active time or conserve energy for other tasks. ( Doenges, Morrhouse, Murr; 2009; p. 354) To avoid the occurrence of further problem related to activity. ( Doenges, Morrhouse, Murr; 2009; p. 354) 50
CUES NURSING DIAGNOSIS SCIENTIFIC BASIS GOAL & OUTCOME CRITERIA NURSING ACTIONS & NURSING ORDERS RATIONALE OF NURSING ORDERS EVALUATION S- “ Wa koy gana maligo og maglihok-lihok kay kapoy kaayo akong lawas.” as verbalized by the patient. O- Dry, tangled hair Lethargic Bedrest Frequent yawning Weak Vital signs taken as follows: BP: 130/ 70 mmHg Temp: 36.3 ºC HR: 87 bpm RR: 17 cpm Self-care deficit: bathing, dressing, feeding, toileting related to fatigue. Self-care deficit may be the result of transient limitations, such as those being hospitalized. In the case of my patient, she is deficit in self-care due to frequent fatigability she feels and weakness she usually met. Due to prolonged bedrest she is unable to fully provide herself care. (Gulanick/Myers; 2007; p. 156) After 3 days of nurse-patient interactions, the patient will be able to perform self-care activities within level of own ability. Specifically, the patient will be able to: Identify individual area of weakness or needs. The nurse will assist the patient in achieving the goal which is to perform self-care activities within level of activity. The nurse will: Assess barriers to participation. Promote client’s participation in problem identification and desired goals and decision making. Assist with necessary adaptations to accomplish ADL’s. To be able to provide deeper intervention depending on the assessed reasons of unparticipation. ( Doenges, Morrhouse, Murr; 2009; p. 710) To enhance commitment to plan, optimizing outcomes, and supporting recovery and health promotion. ( Doenges, Morrhouse, Murr; 2009; p. 711) To encourage client and build on success. ( Doenges, Morrhouse, Murr; 2009; p. 711) GOAL MET Patient was able to perform self-care activities within level of own ability. GOAL PARTIALLY MET Patient was able to partially perform self-care activities within level of own ability. GOAL NOT MET Patient was not able to perform self-care activities within level of own ability. 51
Verbalize knowledge of healthcare practices. Demonstrate techniques and lifestyle changes to meet self care needs. Plan time for listening to the client’s feelings and concern. Refer to and assist with rehabilitation Provide positive reinforcement for all activities attempted, note partial achievements. Provide ongoing evaluation of self-care program Encourage keeping a journal of progress and practicing of independent living skills. Review safety concern, modify activities or environment, To discover barriers to participate in regimen and to work on problem solution. ( Doenges, Morrhouse, Murr; 2009; p. 711) To enhance client’s capabilities and promote independence. ( Doenges, Morrhouse, Murr; 2009; p. 711) This provides the patient with an external source of positive reinforcement and promotes ongoing effects. ( Gulanick/Myers;2007;p. 157) To note if interventions are appropriate and working. ( Doenges, Morrhouse, Murr; 2009; p. 713) To foster self-care and self-determination. ( Doenges, Morrhouse, Murr; 2009; p. 712) To reduce risk with injury and promote successful community functioning. ( Doenges, Morrhouse, Murr; 2009; p. 712) 52