Chapter X

Prioritization of Problems

This chapter present the identified nursing diagnoses based on the cue clusters being observed. This was based

on Gordon’s Functional Health Pattern. Also included in this chapter are the prioritizations made for each problem and the

rationale of doing such.

Functional Cue Clusters Inference Nursing Priority Rationale

Health Pattern Diagnosis Problem
1. Health • Complies with Ineffective Ineffective High 3 This is a High 3
perception – treatment and doctor’s therapeutic therapeutic problem because
Health orders within hospital regimen regimen adherence to
Management. setting. Patient stops management management r/t therapeutic
Pattern taking medications economical regimen is very
after signs and difficulties vital for a good
symptoms are prognosis of
relieved. Verbalized rheumatic heart
“naga-undang ko inom disease. The
ug tuambal kay wala patient must be
na man mi’y kwarta.” able to address
• Unable to go to this problem
regular check-ups due promptly because
to financial constraints it is one factor for
her being re-
admitted to the
hospital.
2. Nutrition – • On Readiness for Readiness for Low 1 This has a low
Metabolic hospitalization, on enhanced enhanced priority since it is

83
Pattern low-fat, low salt nutrition nutrition a readiness
diet. No caffeine diagnosis.
and acidic However,
drinks/food and enhancing the
eats 3 times a day. nutrition of the
• Verbalized client, especially
“dili gyud ko for her case is
nagakaon ug bawal great step
kay lisod na. sakit towards healthy
gyuud baya pag lifestyle and
mag-atake ang preventing signs
sakit.” and symptoms of
RHD to recur.
3. Elimination No significant cues No problem No problem. ---------------- -----------------------
Pattern
4. Activity- • On admission: lies Fatigue Fatigue r/t stress, High 2 This is a high 2
Exercise supine or side-lying humidity and priority since a
on the bed anemia patient cannot
• Sleeping most of function well if she
the time. If not, is feeling fatigued.
lying down on the Fatigue means
bed and texting less energy and
• verbalized “kapoy addressing this
abi ko. Sakit akong problem will allow
lawas gamay. Init the patient to
pa abi.” recover more
• T: 37.2 C energy to perform
P: 100 bpm her ADL.
RR:24cpm
BP:130/50 mmHg

84
5. Sleep – Rest No significant cues No problem No problem. ---------------- -----------------------
pattern
6. Cognitive – • With pain at joints Acute Pain Acute Pain r/t High 1 This is the highest
Perceptual at lower disease process priority since pain
pattern extremities; rated 5 felt by the patient
out of 10 which disables her to
occurs from time to perform well in
time her daily life.
• verbalized “gasakit Addressing this
akong lawas will allow patient
minsan pero kung to perform self-
maghigda higda care activities
lang ko, mawala independently and
man.” adhere to therapy
more promptly.
7. Self- • Expresses dismay Situational Low Situational Low Medium 1 This is a medium
perception – about disease Self-Esteem Self-Esteem r/t 2 problem since
Self-concept • Verbalized “unta developmental the patient is an
Pattern mawala na ni. Bata changes adolescent and
pa man gud ko (adolescence) she is fighting
unya naa na koy over identity
sakit sa puso. versus identity
Maayo pa ang confusion. At her
uban na ka-age age, she must be
nako kay wala silay able to feel
sakit na ing ani.” hopeful of her
• Body language recovery and not
implies feeling of be ashamed of it
shyness since it is a

85
 curable disease.
8. Role • Living with mother Readiness for Readiness for Low 2 The family is a
performance and one sibling enhanced family enhanced family primary support
Pattern • During duty, there processes processes group which plays
were no watchers a vital role in the
around. Patient health of a
verbalized person.
“naglakaw man Enhancing this
akong mama. will strengthen the
Nangita ug kwarta support group
pambayad diri sa therefore
ospital” improving health.
• Considers
relationship with
family as fine
because although
they are not living
in the same house,
they still
communicate
regularly and her
sibling and mother
takes care of her
when she is sick
9. Sexuality / No significant cues No problem No problem ---------------- ------------------------
Reproductive
Pattern\

10. Coping – No significant cues No problem No problem ---------------- ------------------------

Stress Pattern

86
11. Value – No significant cues No problem No problem ----------------- ------------------------
Belief Pattern

87
 Prioritization of Nursing Problems

High Priority

1. Acute Pain r/t disease process

2. Fatigue r/t stress, humidity and anemia

3. Ineffective therapeutic regimen management r/t economical difficulties

Medium Priority

1. Situational Low Self-Esteem r/t developmental changes (adolescence)

Low Priority

1. Readiness for enhanced nutrition

2. Readiness for enhanced family processes

88
 Chapter XI

Nursing Care Plan

This chapter presents the top 3 prioritized nursing problems and their corresponding management. This chapter also presents the

outcomes of each nursing interventions and the modifications that were done to totally manage the patients health condition.

Name: Missy Date/Time of Admission: September 21,2009/ 2:00PM

Age/Sex: 17/F Final Diagnosis: Rheumatic Heart Disease

Chief Complaint: fever and joint pains Attending Physician: Dra. Annie Yabut
Need Evaluation
Diagnosis/Cue Desired outcomes Nursing Intervention Rationale Evaluation Nursing
rationale
statement Modification
Acute Pain r/t P After 8 hours of nursing INDEPENDENT
disease process H interventions, the
patient will be able to; 1. assess causative 1.to determine underlying Continue Since the
SUBJECTIVE Y factor for pain cause of pain because it Nursing pain is
CUES: S General: including location, is subjective and treat interventions intermitte
I • Become characteristics, onset, accordingly. when nt, there
verbalized “gasakit O relieved of duration, frequency, problem is still a
akong lawas minsan L signs and quality, intensity and persists possibility
pero kung maghigda symptoms of precipitating factors that it will
higda lang ko, O fatigue (with rheumatic heart return if
mawala man.” G experienced as disease, positive pain not
I evidenced by: at lower extremities properly
With pain at joints at C especially in joints) addresse
lower extremities; Specific: d.
rated 5 out of 10 • Verbalize that 2. evaluate client’s 2.assist patient in Goal met.
which occurs from pain is relieved response to pain and evaluating impact of pain Patient
time to time rate from 0-10 pain on client’s life verbalized that
scale (rated as 5 out pain was gone.
of 10 and tolerable) “Okay na man.
Maka lihok
3. monitor vital signs 3.vital signs give an lihok na gani

89
OBJECTIVE CUES: overview on extent of ko. Dili na siya
pain since it is altered sakit.”
With slight facial when there is pain.
grimace
• Use relaxation 4. provide comfort 4.to promote non Goal met.
skills and measures (touch, pharmacologic pain Patient was
BACKGROUND diversional respositioning and management able to use
KNOWLEDGE: activities as nurse’s presence), diversional
indicated for quiet environment and activities such
Acute pain is individual calm activites (deep as texting and
defined as an situation breathing, meditating, sleeping.
unpleasant sensory (sleeping, deep sleeping, back
and emotional breathing, massage as tolerated)
experience arising texting, back
from actual or massage) 5. encourage use of 5. to divert attention
potential tissue relaxation techniques and reduce tension
damage or and diversional
described in terms activities (texting,
of such damage; • Be relieved by socializing with others) Goal met.
sudden or slow nonpharmacolo Patient was
onset of any gic methods to 6. encourage adequate 6. to prevent fatigue able to become
intensity from mild to provide relief. rest periods relieved by
severe with an nonpharmacolo
anticipated or gic methods
predictable end and COLLABORATIVE: such as texting
a duration of less and sleeping.
than 6 months
7. Administer 7. These medications
medications as block pain impulses by
REFERENCE: needed; inhibiting prostaglandin
a. Analgesics synthesis in the CNS.
Nurse’s Pocket
Guide (11th edition) 8. Monitor for signs and 8. To identify readily and
symptoms of side manage effectively
effects. those side effects that
is detrimental to the
patient’s health.

90
 9. Document prescribed 9. Documenting the care
analgesics, patients done would provide
response to the basis for evaluation of
pharmacologic nursing actions and
regimen would be concrete
evidence that care was
done to the patient.

10. Evaluate the 10. Evaluating

effectiveness of actions/interventions
intervention to relieve would be a basis for
pain. revisions on the
interventions made
and to be able to
deliver quality health
care to the patient.

91
Diagnosis/Cue Need
Desired outcomes Nursing Intervention Rationale Evaluation Nursing Evaluation
rationale
statement Modification
Fatigue r/t sress, P After 8 hours of nursing INDEPENDENT
humidity and anemia H interventions, the
patient will be able to; 1. assess causative 1. to determine underlying Give patient The
SUBJECTIVE Y cause of fatigue and teachings for
factor for fatigue patient is
CUES: S General: (acute paint felt at treat accordingly. long term still
I • Become joints) care susceptib
verbalized “kapoy O relieved of le to
abi ko. Sakit akong L signs and fatigue
lawas gamay. Init pa symptoms of 2. ask client to rate 2. to assist in evaluating because
abi.” O fatigue impact of fatigue on
fatigue on 0-10 scale of her
G experienced as (rated as 7 out of 10) client’s life. disease
I evidenced by: process.
OBJECTIVE CUES: C Educatin
Specific: 3. encourage client to do 3. to gradually increase g the
On admission: lies • Verbalize whatever possible energy level as patient
supine or side-lying improved activities as tolerated tolerated Goal met. on how to
on the bed sense of (self-care, sitting up) Patient manage
energy verbalized she it on her
Sleeping most of the feels well own will
time. If not, lying 4. instruct patient in 4. to allow patient not to rested and provide
down on the bed methods to conserve over exert energy and ready to go client
and texting energy (e.g. ask for/ still be able to home. “Okay independ
accept assistance, say cooperate in na man ko. ence and
T: 37.2 C “no” or “later”.) and interventions for own Wala na sakit.” proper
P: 100 bpm plan steps of activity well-being self-care.
RR:24cpm before beginning
BP:130/50 mmHg • Increase in
Goal met.
activity such as
BACKGROUND 5. provide diversional 5. to avoid overstimulation Patient needs
performing
KNOWLEDGE: activities such as and understimulation no assistance
ADLs as
texting or chatting with which can diminish for self-care
independently
Fatigue is defined as others as tolerated feelings of activities and is
as possible and
an overwhelming sluggishness able to perform
other desired
sustained sense of accompanying fatigue desired
activities not
exhaustion and activities not
contraindicated

92
decreased capacity by physician contraindicated
for physical and by the doctor
mental work at usual 6. assist with self-care 6. to conserve energy of (texting, etc)
level needs and ambulation the patient
as needed and
REFERENCE: • Participate in indicated Goal met.
treatment Patient
Nurse’s pocket regimen cooperative
guide ( 11th Edition) actively and 7. provide peaceful and 7. to enhance quality and tolerates
tolerate patient adequate resting sleep and promote rest nursing
care activities environment (dim which harnesses procedures
as much as lights, adjust energy for future use. such as taking
possible temperature, wrinkle- vital signs
free bed, quiet
• Participate in surroundings)
recommended Goal met.
health Patient able to
treatment perform
programs. recommended
activities such
as returning
gradually to not
contraindicated
activities and
resting as
much as
possible.

93
Diagnosis/Cue Need
Desired outcomes Nursing Intervention Rationale Evaluation Nursing Evaluation
rationale
statement Modification
Ineffective P After 8 hours of nursing INDEPENDENT
Therapeutic H interventions, the
Regimen patient will be able to; 1. Determine the 1. Assessing the client’s Continue Emphasi
Management r/t Y client’s knowledge of level of knowledge will nursing s to the
S
financial constraints General: her condition, assist in the development of interventions client
I Goal partially
• Verbalize prognosis and an individualized learning together
Subjective: O treatment measures. program. Providing met. Patient with the
understanding
“Naga-undang ko accurate information can was able to family the
L of factors
verbalize
inom ug tuambal kay involved in decrease clients anxiety advantag
wala na man mi’y O associated with the understanding
individual es of
kwarta.” G unknown and unfamiliar of the factors drug
situation.
I involved that complian
C lead to ce and
Objective: 2.Emphasize the 2. This will motivate them to ineffective disadvant
importance of the need comply the medications therapeutic ages of
Unable to go to for treatment/medication prescribed regimen neglectin
regular check-ups as well as consequences g one,
due to financial Specific: of action/choices
constraints Goal not met.
• Enumerate
ways how to Patient wasn’t
solve factors able to give
Background ways how to
interfering
Knowledge: 3. Provide the client and 3. The information on how eradicate those
effective family with to “work the system” will factors
therapeutic
Patient’s with RHD information about to help the client and family to
regimen
are given continuous utilize health care feel more comfortable and
monthly or daily system more in control of clients
antibiotic treatment, • Recognize the health care. this will Goal met.
maybe for life since importance of positively influence Patient was
they are more drug compliance with the health able to
susceptible to compliance care regimen understand the
recurrent attacks importance of
and heart damage 4. identify home and 4. For assessment , follow- compliance of
and noncompliance community-based nursing up care and education in medications .”o
of these medications services clients home. o bal-an ko

94
would result to man nga
further complications kinanglan ko
of the said disease mag-inom sang
or might result to bulong , ang
death if not properly problema lang
treated kay wala gid
kami kwarta” as
Reference: verbalized by
the patient

95