RANK

NURSING DIAGNOSIS

JUSTIFICATION

Ineffective airway clearance

In nearly all circumstances airway management is the highest priority for clinical care. This is because if there is no airway, there can be no breathing, hence no oxygenation of blood and therefore circulation (and hence all the other vital body processes) will soon cease. Getting oxygen to the lungs is the first step in almost all clinical treatments. Furthermore, the problem is categorized under first level of Maslows hierarchy of basic human need, which is the physiologic level. Since physiologic needs are the most essential in life therefore they have the highest priority. In addition, it is an actual problem that requires immediate interventions. An obstructed airway means that the body is deprived of oxygen. If ventilation is not reestablished, brain death will occur within minutes. Therefore, it has a high preventive potential.

Impaired gas exchange

In nearly all circumstances breathing management is the second priority for clinical care according to ABC management. This is because if there is an impaired gas exchange, there can be no oxygenation of blood and therefore circulation will soon cease. Getting oxygen to the lungs is a priority in almost all clinical treatments. Furthermore, the problem is categorized under first level of Maslows hierarchy of basic human needs, which is the physiologic level. Since physiologic needs are the most essential in life therefore they have the highest priority. In addition, it is an actual problem that requires immediate interventions. An impaired gas exchange means that the body can be deprived of oxygen. If proper ventilation is not reestablished, vital body processes will be affected. Therefore, it has a high preventive potential.

Ineffective breathing pattern related to hyperventilation secondary to status asthmaticus

The nursing diagnosis is an actual problem that needed prompt intervention. It is based on the principle of airway-breathing-circulation that needed to be addressed first.

Impaired/ineffective tissue perfusion: Cardiopulmonary

In nearly all circumstances breathing management is the second priority for clinical care according to ABC management. Hypoventilation is too shallow or too slow breathing, which does not meet the needs of the body. It may also refer to reduced lung function. If a person hypoventilates, the body's carbon dioxide level rises, which results in too little oxygen in the blood. This is because if there is a hypoventilation, there can be insufficiency of oxygenation of blood and therefore circulation will soon cease.

Decreased cardiac output related to dehydration

The nursing diagnosis is an actual problem that needs a prompt intervention. Addressing this problem can solve other conditions of the client.

Hyperthermia The nursing intervention is an actual problem that may cause harm to the client. Immediate attention is necessary to prevent further problem. Deficiency in fluid volume may cause imbalanced in fluid and electrolytes. The nursing diagnosis is an actual problem but can be manage through use of different resources. Food/ water/fluids for nutrition can be provided through an NGT or IVT. The nursing diagnosis is an actual problem that needs prompt intervention. Urinary elimination is a physiologic need and not addressing this problem can cause further complications.

Deficient fluid volume

Impaired swallowing

Impaired urinary elimination related to tissue hypoperfusion

10

Impaired oral mucous membrane related to frequent suctioning

The nursing intervention is an actual problem but it is not the main priority because it is not as critical as the other problems.

Hindi i2 applicable 11 Fatigue

12

Imbalance nutrition: less than body requirements Hindi i2 applicable

13

Acute confusion The nursing diagnosis is an actual problem but doesnt need immediate intervention. It is a long-term plan of care that needs ample time to be implemented.

14

Activity intolerance related to generalized weakness

15

Impaired physical mobility Hindi i2 applicable

16

Disturbed sensory perception Hindi i2 applicable

17

Impaired verbal communication The nursing diagnosis is actual problem but is manageable. Use of resources is utilized to communicate with the client even without talking.

18

Trauma related to loss of muscle coordination secondary to seizures.

The nursing diagnosis was an actual problem but it is not the main prioritization. The clients problem is a long-term process of care.

19

Self-care deficit

The nursing diagnosis is an actual problem but the main priority for ABC clients is to save them to possible death. The nursing diagnosis is preventable to occur. The risk can be eliminated through safety interventions.

20

risk for fall

ASSESSMENT

NURSING DIAGNOSIS INEFFECTIVE AIRWAY CLEARANCE related to Retained Mucous Secretion secondary to Presence of Wheezing.

ANALYSIS

PLANNING

NURSING INTERVENTION Independent: Monitor and record Vital Sign

RATIONALE

EVALUATION

SUBJECTIVE -The clients significant others verbalized Sobrangnahihirapansiyanghuminga kaya dinalananaminsa hospital. OBJECTIVE -Labored breathing -Cyanotic -Restlessness -Unproductive cough -Presence of wheezing -Tacypnea

Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.

Objectives:

After 4 hours of nursing intervention the client will maintain airway patency as manifest by Irritant(inhalation) expectorate secretions and no difficulty Inflammatory of breathing. response After 2 hours of nursing intervention the client:

To obtain baseline date. Notes progress & changes of condition.

Objectives met as manifested by:

Position the client in Semi fowler position

To prevent aspiration and to breathe more comfortably.

The client maintain airway patency as manifested by expectorate secretions and no difficulty of breathing.

Vital Signs: Temperature: 39 C BP: 120/ 80 mmHg PR: 110 beats/ min. RR: 42 breaths/ min. O2 Sat: 77%

Increase production of secretions

Monitor pulse oximetry to determine oxygenation; evaluate lung volumes and forced vital capacity

To assess for respiratory insufficiency

*Respirations is within the rate of 12-20 breaths/min.

Airway constriction

Dyspnea

*Respirations will normalize within the rate of 12-20 breaths/min. Provide Chest physiotherapy

To remove the secretion and it help to relieve difficulty of

* O2 Saturation is within normal range of 90100% * Presence of labor breathing

* O2 Saturation will increase from 77 to normal range of 90-100% * Presence of labor breathing will diminish as clients breath with rise and fall of the chest in normal rhythm. *The client cough will change from unproductive to productive cough.

breathing

was diminished as clients breath with rise and fall of the chest in normal rhythm. *The client cough change from unproductive to productive cough. * The clients adventitious breath sound was diminished as auscultated. * The client become undistress and uncyanotic as client color of conjunctiva and lips become pink.

Dependent Administer oxygen as ordered by the physician For management of respiratory distress

Suctioning as ordered by the physician

To remove the secretion

Administer IV therapy as ordered by the physician Administer medications as ordered by the physician.

To prevent dehydration

For continuous wellness.

* The clients adventitious Collaborative breath sound will diminish Discuss the as auscultated. condition of the client with other * The client member of the will become health care team. undistress and uncyanotic as client color of conjunctiva and lips will become pink.

Ensures continuous intervention.

ASSESSMENT

NURSING DIAGNOSIS

ANALYSIS

PLANNING

NURSING RATIONALE EVALUATION INTERVENTION Independent: Monitor and record To obtain Vital Sign baseline date. Notes progress & changes of condition. Elevate the head of the bed and position the client at semi fowler. Note respiratory rate, depth, use of The objectives met as evidenced by :

SUBJECTIVE -The clients significant others verbalized Sobrangnahihirapansiyanghuminga kaya dinalananaminsa hospital. OBJECTIVE -Labored breathing -Cyanotic -Restlessness -Tacypnea -Tachycardia -Diaphoresis

Entry of Impaired Gas noxiousparticles or Exchange gasesto the lungs related to altered oxygensupply Release of mediators (obstruction of airways Abnormalinflammation bysecretion) of thelungs asevidenced bywheezes uponauscultation Chronicinflammation Scar tissueformation Narrowing of airway lumen

Objectives After 4 hours of nursing intervention the client will demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within clients normal limits

To prevent aspiration and to breathe more comfortably.

The client demonstrated improved ventilation and adequate oxygenation of tissues by ABGs within clients normal limits and absence of

Vital Signs: Temperature: 39 C BP: 120/ 80 PR: 110 beats/min. RR: 42 breathes/ min. ABG: Ph: 7.25 PCO2: 30 HCO3: 23 O2 Sat: 77%

Airflow limitations Impaired gasexchange wheezes

and absence of symptoms of respiratory distress. ABG Results will become : Ph: 7.35-7.45 PCO2: 35-45 HCO3: 22-26 O2 Sat: 95100 %

accessory muscles, pursed-lip breathing, and areas of pallor/ cyanosis.

To assess for respiratory insufficiency

symptoms of respiratory distress. ABG Results will: Ph: 7.40 PCO2: 37 HCO3: 25 O2 Sat: 98 %

Reference: Pathophysiology by Gold, 4th edition, Pg. 345

Monitor pulse oximetry to determine oxygenation; evaluate lung volumes and forced vital capacity

To assess for respiratory insufficiency

*Respirations within the rate of 12-20 breaths/min.

After 2 hours of nursing intervention the client: Auscultate the *Respirations lungs and not for will adventitious breath normalize sounds within the rate of 12-20 breaths/min.

* Pulse rate will be normal within the rat of 60-100 beats/ min.

Provide Chest physiotherapy

Presence of adventitious breath sounds note as a pulmonary congestion and secretion collection, indicating need for further intervention.

* Pulse rate within the rate of 60-100 beats/ min.

* O2 Saturation within normal range of 90100% *No presence of labor breathing as clients breaths with rise and fall of the chest in normal rhythm. * Diminished adventitious

* O2 Saturation

Dependent

Promotes optimal lung expansion and drainage of secretion.

will increase from 77 to normal range of 90-100% * Presence of labor breathing will diminish as clients breath with rise and fall of the chest in normal rhythm.

Administer oxygen as ordered by the physician

breath sound as auscultated. * The client is undistress and uncyanotic as client color of conjunctiva and lips is pink.

Suctioning as ordered by the physician

For management of respiratory distress

Administer IV therapy as ordered by the physician

To remove the secretion

Administer medications as * The clients ordered by the adventitious physician. breath sound will diminish Collaborative as auscultated. Discuss the condition of the * The client client with other will become member of the undistress health care team. and uncyanotic as client color of conjunctiva and lips will become pink.

To prevent dehydration

*No presence of diaphoresis as the client perspire normally with moist skin.

For continuous wellness.

Ensures continuous intervention.

* Presence of diaphoresis

will diminish as the client perspire normally with moist skin.

ASSESSMENT (cues) Subjective: The significant other stated that

NURSING DIAGNOSIS Ineffective breathing pattern related to

ANALYSIS

GOALS AND OBJECTIVES Goal: After 8 hours of nursing

NURSING INTERVENTION

RATIONALE

EVALUATION

Inspiration and expiration that does not provide adequate

After 8 hours of nursing intervention, goal was met as

the client is having a difficulty of breathing before arriving at the hospital.. Objective: Dyspnea Tachypnea Pale Irritability Wheezing Grimace Use of accessory muscles to breath Nasal flaring Increased anteriorposterior diameter Alterations in depth of breathing Pursed lip breathing

hyperventilation secondary to status asthmaticus

ventilation. The pathophysiology of asthma is complex and involves airway inflammation, intermittent airflow obstruction, and bronchial hyper responsiveness. Airway hyperresponsiven ess or bronchial hyperreactivity in asthma is an exaggerated response to numerous exogenous and endogenous stimuli. The mechanisms involved include direct stimulation of airway smooth muscle and indirect stimulation by pharmacologically active substances from mediatorsecreting cells such as mast cells or nonmyelinated sensory neurons. The degree of airway hyperresponsiven

interventions, the client will be able to have effective breathing pattern. Objectives: After 8 hours of nursing interventions the client will manifest: A. Vital signs within normal limits. Respiratory rate of 1220 breathes/mi n

Administer oxygen at lowest concentration indicated and prescribed respiratory medications. Monitor pulse oximetry, as indicated. Elevate head of bed or have client sit-up in chair, as appropriate. Encourage slower/deeper respirations, use of pursedlip technique. Have client breath into a paper bag, if

For management of underlying pulmonary condition, respiratory distress or cyanosis.

manifested by clients respiratory rate of 18 breaths/min, vesicular breath sound over the lung fields, normal depth and rate of breathing, distress upon breathing, relax and comfortable.

To verify maintenance/ improvement in oxygen saturation. To promote physiological/psych ological ease of maximal inspiration. To assist client in taking control of the situation.

B. Normal depth and rate of respiration

To correct hyperventilation.

ess generally correlates with the clinical severity of asthma. (NANDA 11th edition page 140) (http://emedicine. medscape.com/ar ticle/296301overview0)

appropriate. Avoid overeating/ gas forming foods. C. Normal breath sounds Maintain emergency equipment in readily accessible location and include age/size appropriate ET/ tracheostomy tubes. Provide health teachings as follows: May cause abdominal distention. When ventilator support might be needed.

D. Verbalizatio n of understandi ng to health teaching

To promote wellness.

a. Stress importance of good posture and effective use of accessory muscles. Assist client in breathing training. (diaphragmatic , abdominal breathing, pursed lip) b. Encourage adequate rest periods

To maximize respiratory effort.

To limit fatigue.

between activity. c. Review environmental factors (exposure to dust, high pollen counts, severe weather, perfumes, household chemicals, second-hand smoke) d. Advise regular medical evaluation with primary care provider. E. Desired response to regimen Administer analgesics as ordered by the physician. It may require avoidance/modifica tion of lifestyle or environment to limit impact on clients breathing.

To determine effectiveness of current therapeutic regimen and to promote general wellbeing. To promote deeper respiration. (NANDA 11th ed. 142-144)

ASSESSMENT

NURSING DIAGNOSIS

ANALYSIS

PLANNING

NURSING INTERVENTION Independent: Monitor and record Vital Sign

RATIONALE

EVALUATION

SUBJECTIVE Ineffective -The clients significant others Cardiopulmonary verbalized Tissue Perfusion Sobrangnahihirapansiyanghuminga related to kaya dinalananaminsa hospital. Hypoventilation OBJECTIVE -Labored breathing -Cyanotic -Restlessness -Tachypnea -Tachycardia -Bronchospasm

Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level. Hypoventilation is too shallow or too slow breathing, which does not meet the needs of the body. It may also refer to reduced lung function.If a person hypoventilates, the body's carbon dioxide level rises, which results in too little oxygen in the blood.

Objectives After 4 hours the client will demonstrate increased perfusion as individually appropriate vital signs within the normal rate. Vital Sign: Temperature: 36.5-37.5 C BP: 120/ 80 mmHg PR: 60-100 beats/min. RR: 12-20 breathes/ min.

To obtain baseline date. Notes progress & changes of condition.

The objectives met as evidenced by: * The client demonstrate increased perfusion as individually appropriate vital signs within the normal rate. Vital Sign: Temperature: 37C BP: 120/ 80 mmHg PR: 80 beats/min. RR: 16 breathes/ min.

Elevate the head of the bed and position the client at semi fowler.

To prevent aspiration and to breathe more comfortably.

Vital Signs: Temperature: 39 C BP: 120/ 80 PR: 110 beats/min. RR: 42 breathes/ min. O2 Sat: 77%

Note respiratory rate, depth, use of accessory muscles, To assess for pursed-lip respiratory breathing, and areas insufficiency of pallor/ cyanosis.

Monitor pulse oximetry to *Respirations determine will normalize oxygenation; within the rate evaluate lung of 12-20 volumes and forced breaths/min. vital capacity

To assess for respiratory insufficiency

*Respirations within the rate of 12-20 breaths/min.

* Pulse rate will be normal within the rat of 60-100 beats/ min. Dependent

* Pulse rate within the rate of 60-100 beats/ min.

* O2 Saturation will increase from 77 to normal range of 90-100% * Presence of labor breathing will diminish as clients breath with rise and fall of the chest in normal rhythm.

Administer oxygen as ordered by the physician

For management of respiratory distress

* O2 Saturation within normal range of 90100% *No presence of labor breathing as clients breaths with rise and fall of the chest in normal rhythm.

Administer IV therapy as ordered by the physician Administer medications as ordered by the physician. Collaborative

To prevent dehydration

For continuous wellness.

* The client will become undistress and uncyanotic as client color of conjunctiva and lips will become pink.

Discuss the condition of the client with other member of the health care team.

Ensures continuous intervention.

* The client is undistress and uncyanotic as client color of conjunctiva and lips is pink.

ASSESSMENT (cues)

NURSING DIAGNOSIS

ANALYSIS

GOALS AND OBJECTIVES

NURSING INTERVENTION

RATIONALE

EVALUATION

S: O: -blood pressure: 100/70 -pulse rate: 140 bpm -Respiratory rate: 40 bcm -temperature: 39C -poor skin turgor -capillary refill:2sec -confusion -O2 saturation: 83% -diaphoresis Decreased cardiac output related to dehydration High fever, diaphoresis and vomiting will lead to dehydration which can decrease the circulating blood volume. Another condition that may have caused the low cardiac output is the retention of carbon dioxide that may lead to acidosis which causes vasodilation resulting to hypotension. Decreased cardiac output is a condition wherein there is an inadequate blood pumped by the heart to meet the metabolic demand of the body. After 8 hours of nursing intervention the client will maintain blood pressure within normal range. INDEPENDENT: Assess vital signs. Provides basis for comparison to follow trends and evaluate response to interventions.

Assess for impending failure/shock.

Early detection of changes in these parameters promotes timely intervention to limit degree of cardiac dysfunction.

Keep the patient on bed rest.

To decrease oxygen and metabolic demands To regulate body fluids To increase oxygen available for tissue perfusion

DEPENDENT: Administer IV fluids as prescribed Administer high flow oxygen via mask or ventilator as prescribed. Administer drugs as ordered.

1. Impaired/ineffective tissue perfusion: Cerebral- edam

ASSESSMENT (cues) * Increase in body

NURSING DIAGNOSIS Elevated body temperature

ANALYSIS

GOALS AND OBJECTIVES After giving nursing intervention, the

NURSING INTERVENTION

RATIONALE

EVALUATION

Body temperature is

Does the client able to maintain

temperature (40 C) * Flushed skin *Tachypnea *Tachycardia *Seizures

related to disturbance in the hypothalamus.

elevated above normal range due to physical manifestations (as convulsions, sensory disturbances, or loss of consciousness) resulting from abnormal electrical discharges in the brain.

client will be able to be free of complication such as irreversible brain damage.

core temperature? YES__ NO__ WHY? Does the client able to be free of seizures? YES__ NO__ WHY? Does the client condition able to improve? YES__ NO__ WHY? Does the intervention appropriate for the client? YES__ NO__ WHY?

After 15 minutes of nursing intervention, the client will be able to maintain core temperature within normal range.

Monitor core temperature.

After 10 minutes of nursing intervention, the client will be able to be free of seizure activity.

To evaluate degree of hyperthermi a

Monitor respirations

To evaluate the effects of hyperthermi a

After 20 minutes of nursing intervention, the client condition will improve.

Perform tepid sponge bath

to control shivering and seizures

Assess neurological response, noting level of consciousnessa nd orientation, reaction to

Does the intervention done within the allotted time? YES__ NO__ WHY?

To assist with measures to reduce body temperature

stimuli, reaction to pupil. administered prescribed medications (diazepam or chlorpromazine)

/ restore normal body / organ function.

>Administer antipyretics, orally or rectally. (acetaminophen , aspirin) as ordered. >Promote surface cooling by means of undressing.

7.

ASSESSMENT (cues)

NURSING DIAGNOSIS Deficient fluid

ANALYSIS

GOALS AND OBJECTIVES After 8 hours

NURSING INTERVENTION Assess

RATIONALE

EVALUATION

A decrease

After 8

Subjective: Objective: Diaphoresis Delayed capillary refill (4 seconds) Oliguria hypotension poor skin turgor altered serum sodium

volume related to renal dysfunction

blood volume leads to decreased tissue perfusion. As volume loss occurs, various compensatory mechanisms produce vasoconstriction of the vasculature, retain fluid via the renal tubules, and increased cardiac output. These compensatory mechanismsuch as stimulation of the sympathetic nervous system; releases renin, angiotensin aldosterone and antidiuretic hormones; and fluid shiftscontinue in an effort to restore tissue perfusion, thus ensuring cell survival. However these mechanisms are limited in scope, and if the loss of volume is not restored eventually

of nursing intervention the client will be able to maintain fluid volume at a functional level as evidence by adequate urinary output, stable v/s, moist mucous membranes, and good skin turgor.

physical signs of fluid volume deficit Observe urinary output, color, and amount Administer IV to replace fluid losses

To evaluate degree of fluid deficit

To know how much fluid the client is losing. To correct/ reverse fluid volume deficit

hours of nursing intervention was the client able to maintain fluid volume at a functional level as evidence by adequate urinary output, stable v/s, moist mucous membranes , and good skin turgor?

cellular structures incur irreversible damage from oxygen debt.

8. ASSESSMENT (cues) Objective: NURSING DIAGNOSIS Impaired ANALYSIS GOALS AND OBJECTIVES After 8 hours NURSING INTERVENTION Assess the RATIONALE EVALUATION

Frequent

To check

After 8

 Coughing before swallowing Long meals with little consumption Food refusal Difficulty of swallowing

swallowing related to frequent suctioning

suctioning can cause trauma to oral, pharyngeal, or esophageal structure leading to difficulty in taking in food.

of nursing intervention the client will be able to pass food and fluid from mouth to stomach safely with less discomfort.

clients ability to swallow

Auscultate breath sounds

Record current weight

the capacity of the client for food intake. To evaluate the presence of aspiration Baseline data to monitor the nutritional status of the client To prevent aspiration and maintain airway patency

Identify individual factors that can precipitate aspiration/ compromise airway Determine the food preferences of the client Provide consistency of food and fluids Encourage rest periods before meals Provide analgesics if allowed before meals or prior to feeding

hours of nursing interventi on was the client able to pass food and fluid from mouth to stomach safely with less discomfo rt?

To incorporate as possible enhancing intake To promote easier swallowing To minimize fatigue during feeding To relieve discomfort during feeding

9. ASSESSMENT (cues) S: NURSING DIAGNOSIS ANALYSIS GOALS AND OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

O: -Open wound in the lips and buccal mucosa -frequent irritation from frequent suctioning

Impaired oral mucous membrane related to frequent suctioning

Frequent suctioning is needed to remove excessive mucus secretions in the airway. Repeated suctioning can irritate and disrupt the surrounding soft tissue.

After 8 hours of nursing interventions the clients will demonstrate a decrease in the symptoms as noted in the defining characteristics.

INDEPENDENT: Encourage adequate fluid intake To prevent dry mouth and dehydration. To prevent added injury.

Use suction machine cautiously Provide gentle gum massage and tongue brushing with soft tooth brush Provide dietary modifications

Limits mucosal and gum irritation.

After 8 hours of nursing interventions Was the client able to demonstrate a decrease in the symptoms as noted in the defining characteristics?

To reduce discomfort.

DEPENDENT Administer meds as ordered.

ASSESSMENT (cues) S: O: -Increase BUN -oliguria -Urinary retention

NURSING DIAGNOSIS Impaired urinary elimination related to tissue hypoperfusion

ANALYSIS

GOALS AND OBJECTIVES After 8 hours of nursing intervention the client will achieve normal urinary elimination.

NURSING INTERVENTION INDEPENDENT: Assess patency of the foley catheter.

RATIONALE

EVALUATION

Adequate tissue perfusion is needed by the organs to facilitate proper distribution of oxygen and nutrients that is essential for the organs to function efficiently. Without this vital organs such as kidney starts to degenerate. Having this conditions waste products of the body is not filtered proper and not will not be properly disposed.

Use asepsis and hand hygiene in providing care and manipulating drainage system

Provides basis for further assessment and actions. Prevents contamination of the foley catheter.

After 8 hours of nursing intervention, Was the client able to achieve normal urinary elimination?

Assess color, volume and odor of the urine components

DEPENDENT: Administer IV fluids as prescribed

Provides information about the adequacy of the urine output, condition of the foley catheter and debris in the urine.

11. Fati gueeda m 12.

ASSESSMENT (cues)

NURSING DIAGNOSIS

ANALYSIS

GOALS AND OBJECTIVES Goal:

NURSING INTERVENTION

To regulate body fluids RATIONALE

EVALUATION

Cues: Weak in appearance Cues: Loss of weight Hyperactive bowel sounds Pallor Pale mucous membrane

Imbalanced Nutrition: less than body requirements

Intake of nutrients insufficient to meet metabolic needs. Adequate nutrition is necessary to meet the bodys demands. Nutritional status can be affected by disease or injury states (e.g., gastrointestinal [GI] malabsorption, cancer, burns); physical factors (e.g., muscle weakness, poor dentition, activity intolerance, pain, substance abuse); social factors (e.g., lack of financial resources to obtain nutritious foods); or psychological factors (e.g., depression, boredom). During times of illness (e.g., trauma, surgery, sepsis, burns), adequate nutrition plays an

After 2 weeks of Nursing Intervention the client will be able to improve her nutritional status.

Objectives: After 2 weeks of nursing intervention the client will be able to: Gain Obtain clients and Baseline weight maintai n appropri ate weight. For evaluation of the nursing intervention Was the client able to Gain and maintain appropriate weight? Yes__ No__ If No, Why? ____ Discuss the importance of maintaining adequate The S.O caloric intake and will be four basic food able to groups as well as the verbaliz need for specific e minerals and underst vitamins. anding about

Subjective: Reported food intake less than RDA Lack of interest in food Abdominal pain Malaise stated by the client

Patients may not understand what is involved in a balanced diet. They are better being able to ask questions and seek

Was the S.O able to verbalize understandin g about the importance of proper nutrition?

important role in healing and recovery. Cultural and religious factors strongly affect the food habits of patients. Women exhibit a higher incidence of voluntary restriction of food intake secondary to anorexia, bulimia, and selfconstructed fad dieting. Patients who are elderly likewise experience problems in nutrition related to lack of financial resources, cognitive impairments causing them to forget to eat, physical limitations that interfere with preparing food, deterioration of their sense of taste and smell, reduction of gastric secretion that accompanies aging and

the importa nce of proper nutrition .

assistance when they know basic information.

Yes__ No__ If No, Why? ____

With collabor ation with the nurses, make a set of nutritiou s foods to be included in her diet.

Plan with the client her desired but nutritious meals.

To promote the feeling of independence. It also personalizes the plan of care since the client does make the choices in some aspect of the plan.

Was the client able to with collaboratio n with the nurses, make a set of nutritious foods to be included in her diet? Yes__ No__ If No, Why? ____

Monitor the clients weight daily. Demonstrat e behaviors, lifestyle changes to regain and/ or maintain appropriate weight.

For evaluation of the plan of care

Was the client able to demonstrate behaviors, lifestyle changes to regain and/ or maintain appropriate weight? Yes__ No__ If No, Why? ____

interferes with digestion, and social isolation and boredom that cause a lack of interest in eating. This care plan addresses general concerns related to nutritional deficits for the hospital or home setting.

Exercise regularly

Discourage the client to drink beverages that are caffeinated or carbonated.

This may decrease appetite and lead to early satiety.

Was the client able to exercise regularly? Yes__ No__ If No, Why? ____

Make a plan of minimal exercise and encourage the client to participate

Metabolism and utilization of nutrients are enhanced by activity

13.

ASSESSMENT (cues)

NURSING DIAGNOSIS

ANALYSIS

GOALS AND OBJECTIVES After giving

NURSING INTERVENTION

RATIONALE

EVALUATION

*Fluctuation in Acute confusion cognition / level related to of consciousness delirium

Abrupt onset of reversible disturbances to

Does the client able to maintain level of

*Increase agitation *restlessness *Fluctuation in psychomotor activity *Lack of motivation to inititate / followthrough purposeful behavior

consciousness, attention, cognition, and perception that develop over a certain period of time.

nursing intervent ion, the client will be able to regain usual reality orientati on. After 3days of nursing intervent ion the client will be able to maintain level of conscio usness

consciousness? YES__ NO__ WHY? Does the client able to verbalize understanding of causative factors? YES__ NO__ WHY? Des the client able to initiate behavior changes to prevent further deterioration? YES__ NO__ WHY? Does the intervention appropriate for the client? YES__ NO__ >To assess WHY? causative Does the or intervention contributin done within the g factors allotted time? YES__

Evaluate mental status, noting extent of impairment in orientation, attention span, ability to follow directions, ability to send / receive communication , appropriatenes s of response.

>To determine degree of impairment

After 2days of nursing intervent ion, the client will be

>Identify factors present such as acute illness, trauma/fall, history or current seizures,

able to verbaliz e understa nding of causativ e factors when known

history of fever and pain.

NO__ WHY?

After a week of nursing intervent ion, the client will be able to initiate behavior changes to prevent recurren ce of problem

>Evaluate Vital signs

>Note presence of anxiety and agitation >Assist with treatment of underlying problems >Monitor / adjust medication regimen and note response >Orient client to surroundings, staff, necessary activities as needed. > Maintain

>To identify indicators of poor tissue perfusion

> To maximize level of function and prevent deterioratio n

calm environment and eliminate extraneous noise / stimuli

14. ASSESSMENT (cues) NURSING DIAGNOSIS ANALYSIS GOALS AND OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

Subjective: Since her seizure, she cant do her daily activities on her own. She always needs assistance as verbalized by the mother of the patient. Objective: Dyspnea Fatigue at rest Pallor Poor capillary refill Weakness

Activity intolerance related to generalized weakness.

Insufficient physiological or psychological energy to endure or compete required or desired daily activities. Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. (http://www1.us.el sevierhealth.com/ MERLIN/Gulanick /archive/Construc tor/gulanick01.ht ml) (NANDA 10th Edition, page 65)

Long Term: After 1 month of nursing interventions the client will: A. Be able to tolerate activities; perform activities of daily living from minimal to maximal independenc e and without assistance.

After 1 month of nursing intervention the goal was met as manifested by patients toleration to activities of daily living independently and without assistance.

Monitor vital/cognitive signs, watching for changes in blood pressure, heart and respiratory rate; note skin pallor/cyanosi s presence of confusion. Monitor response to supplemental oxygen and medications and changes in treatment regimen. Assist with activities and provide clients use of assistive

For baseline data and to manage activities within individuals limit.

To protect client from injury.

devised. (cane) Adjust activities. Reduce intensity level or discontinue activities that cause undesired physiological changes. To prevent overexerti on

Increase exercise/ activity level gradually; teach methods, such as stopping to rest for 3 minutes during a 10minute walk. Plan care with rest periods between activities. Provide positive atmosphere. Involve significant others in planning of activities as much as

To conserve energy.

To reduce fatigue.

Helps to minimize frustration, rechannel injury.

possible. Promote comfort measures and provide for relief of pain. To enhance ability to participate in activities. To develop individually appropriat e regimen.

Provide referral to other disciplines as indicated (physical therapists).

Provide health teaching to the patient as well with significant others: A. Review expectatio ns of clients/sig nificant others. B. Instruct client/ significant others in monitorin g response to activity and

To promote wellness.

To establish individual goals.

Indicates need to alter activity level.

recognizin g signs and symptoms .

C. Give client informatio n that provides evidence daily/wee kly. D. Assist client in learning and demonstr ating appropriat e safety measures . E. Provide informatio n about the effect of lifestyle and overall health factors on activity tolerance. (nutrition, adequate fluid intake).

To sustain motivation.

To prevent injuries.

To enhance sense of well-being.

(NANDA 10th Edition)

Encourag e client to maintain positive attitude; suggest use of relaxation technique s, such as visualizati on/ guided imagery as appropriat e 15.Impaired physical mobility- angel

16. ASSESSMENT (cues) NURSING DIAGNOSIS ANALYSIS GOALS AND OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

Objective: *Change in usual response to stimuli *Change in behavior pattern (restlessness) *Disorientation *Impaired communication

Disturbed sensory perception related to altered sensory reception

Change in the amount of patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.

After giving nursing intervention, the client will be able to regain usual level of cognition After 3 days of nursing intervention, the client will be to compensate for sensory impairment

Does the client able to compensate for sensory impairment? YES__ NO__ WHY? >Provide means of communication, as indicated >To promote normalization of response to stimuli >To assist in managing auditory impairment Does the able to identify / modify external factors that can contribute to alteration in sensory? YES__ NO__ WHY? Does the client able to be free of injury? YES__ NO__ WHY? >To assess causative / contributing factors Does the intervention appropriate for the client? YES__ NO__ WHY? Does the intervention done within the

>Encourage use of listening devices >Avoid isolation of client, physically or emotionally

>To prevent sensory deprivation / limit >Reorient to person, confusion place, time, and events, as necessary >Identify client condition that can affect sensing, interpreting, and communicating stimuli. >Assist with/review of diagnostic studies and sensory/motor neurological testing >Record perceptual deficit on chart

After 5 days of nursing intervention, the client will be able to identify / modify external factors that contribute to alterations in sensory

allotted time? After 8 hours of nursing intervention, the client will be able to be free of injury >Provide safety measures (secure side rails, bed in low position, adequate lighting) YES__ NO__ WHY? >For the caregivers to be aware >To prevent injury / complications

17. ASSESSMENT (cues) Objective: The patient does not speak Difficulty to use facial or body expressions NURSING DIAGNOSIS Impaired verbal communication related to presence of physical barrier(intubation) ANALYSIS GOAL and OBJECTIVES After 8 hours of nursing intervention the client will be able to establish another method of communication on which the client needs are expressed. NURSING INTERVENTION Determine the ability to read/ write. RATIONALE EVALUATION

An ET tube provides a stable airway and facilitates removal of secretions. It also prevents verbal communication because it passes through the vocal chords, and the distal tip is positioned just above the bifurcation of the main stem of the bronchus(carina).

To know the possible way of communicatin g with the client

Establish relationship with the client, observing carefully and attending to clients nonverbal expressions Keep communicatio n simple using all modes for accessing information: Visual, auditory, and kinesthetic

Non- verbal cues are important. This will give you signal of clients concern/ needs.

After 8 hours of nursing intervention was the client able to establish another method of communication on which the client needs are expressed?

Alternative ways of communicatin g with the client will give you information to attend to clients needs.

18

ASSESSMENT (cues) Subjective: Objective: Pale Tachycardia Tachypnea Facial grimace Irritability Weakness Decreased level of awareness to surroundings Less social interactions

NURSING DIAGNOSIS Trauma related to loss of muscle coordination secondary to seizures.

ANALYSIS

GOAL and OBJECTIVES Long term: After 3 days of nursing interventions the client will regain muscle integrity and coordination. Objectives: After 8 hours of nursing interventions the client will show evidence of: a. Vital signs within normal range

NURSING INTERVENTION

RATIONALE

EVALUATION

As a result of conditions interacting with the individuals adaptive and defensive resources. A seizure is the physical findings or changes in behavior that occur after an episode of abnormal electrical activity in the brain. The term "seizure" is often used interchangeably with "convulsion." Convulsions are when a person's body shakes rapidly and uncontrollably. During convulsions, the person's muscles contract and relax repeatedly that may cause trauma to the person who experiences it.

After 3 days of nursing intervention, goal was met as evidenced by patients performing activities of daily living independently with proper muscle coordination. Provide bed rest. To gain strength and reduce fatigue.

b. Increased level of awarenes s

Provide information regarding conditions that may result in increase injury. Identify interventions /safety devices.

To reduce individual risk factors.

To promote safe physical environmen t and individual safety.

(NANDA 10th Edition pg. 325 ) (http://www.nlm.ni h.gov/medlineplu s/ency/article/003 200.htm) Encourage use of techniques to manage stress and vent emotions. Discuss importance of self monitoring of conditions/e motions. Provide written resources. To increase awareness and wellbeing.

For later review and self-paced learning. To enhance self-esteem and worth.

Encourage participation in self-help programs such as assertivenes s and training positive selfimage. Refer to other sources as indicated (counseling, physical therapists)

To promote wellness.

c. Improve

social interaction

d. Recovering muscular strength

Provide range of motion exercises, passive/activ e. Administer medications prescribed by the physician.

Increase muscle strength.

To facilitate treatment.

(NANDA 10th and 11th Edition)

19.

ASSESSMENT (cues) (+) Impaired physical mobility

NURSING DIAGNOSIS Self care Deficit specific: partial grooming related to neuromuscularimpairment

ANALYSIS Self Care Deficit When an individual is very unable to meet their own self-care requisites

GOAL and OBJECTIVES Goals: After 2 weeks of nursing intervention, the client will be able to assist at least 50% of self care effectively. Objectives: After 30 minutes of nursing intervention, the client and the S.O will be able to express cooperation for the plan of care.

NURSING INTERVENTION

RATIONALE

EVALUATION

After 2 weeks of nursing intervention, was the client will be able to assist at least 50% of self care effectively? ___Yes ___No, Why? ___ Explain the plan of care to the client and the S.O and how they can cooperate in it. To build rapport and to promote cooperation of the client and the S.O. After 30 minutes of nursing intervention, were the client and the S.O able to express cooperation for the plan of care? ___Yes ___No, Why? ___ After 30 minutes of nursing intervention, was the client able to verbalize understanding of self care and its importance by citing at least 3 out of 5 importance of self care via writing or hand signals. ___Yes ___No, Why? ___

After 30 minutes of nursing intervention, the client will be able to verbalize understanding of self care and its importance by citing at least 3 out of 5 importance of self care via writing or hand signals.

Discuss with the client and the S.O about the self care and its importance.

To give the client basic knowledge about the subject.

 Oral Care: After 20 minutes of nursing intervention, the significant other will be able to perform proper oral care for the client with the client to assist.

Perform oral care and allow the S.O to assist during oral care. Then repeat for the return demonstration.

To maintain the client`s self esteem.

Oral Care: After 20 minutes of nursing intervention, was the significant other able to perform proper oral care for the client with the client to assist? ___Yes ___No, Why? ___

Feeding: After 30 minutes of nursing intervention, the client will be able to identify proper nutrition and cite at least 3 out of 5 importance of proper nutrition via writing or hand signals. The significant other will be able to feed the client with Naso-gastric tube properly, with strict aspiration

Discuss with the client the nutrition and its importance.

To educate the client and the S.O.

Feeding: After 30 minutes of nursing intervention, was the client able to identify proper nutrition and cite at least 3 out of 5 importance of proper nutrition via writing or hand signals? ___Yes ___No, Why? ___

Demonstrate proper NGT feeding and evaluate by return demonstration .

To prevent aspiration.

Was the significant other will be able to feed the client with Naso-gastric tube properly, with strict aspiration

precaution.

precaution? ___Yes ___No, Why? ___ For evaluation of client`s feelings to the care plan.

After 30 minutes of nursing intervention, the client will be able to express maintenance of self-esteem

Encourage the client to express his feelings about the care plan.

After 30 minutes of nursing intervention, was the client able to express maintenance of self-esteem ___Yes ___No, Why? ___

Encourage the client to express appreciation via smiling of hand shaking.

For evaluation of client`s feelings to the care plan.

20. ASSESSMENT (cues) Risk Factors: Fatigue Confusion Difficulty moving NURSING DIAGNOSIS Risk for falls ANALYSIS GOAL and OBJECTIVES After 8 hours of nursing intervention the client will not be able to be at risk for fall and will gain knowledge regarding disease process. NURSING INTERVENTION Provide knowledge/ information for the clients disease condition. RATIONALE To gain knowledge and awareness of the clients disease process to gain awareness of the contributing risk factors for fall. To prevent injury EVALUATION

Temporary loss of energy or stamina due to over stimulation of motor and sensory organs after occurrence of seizure.

After 8 hours of nursing intervention is client not at risk for fall and did the client gain knowledge regarding disease process.

Discuss the importance of monitoring the clients condition that can contribute to occurrence of injury. Always put side rails up

Prevention of falling out of bed especially when sleeping.