NCP & PRIO!!!
Transcript of NCP & PRIO!!!
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RANK NURSING DIAGNOSIS JUSTIFICATION
1 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 nooxygenation of blood and therefore circulation (and
hence all the other vital body processes) will sooncease. Getting oxygen to the lungs is the first step in
almost all clinical treatments. Furthermore, the problemis categorized under first level of Maslows hierarchyof 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, itis an actual problem that requires immediate
interventions. An obstructed airway means that thebody is deprived of oxygen. If ventilation is not
reestablished, brain death will occur within minutes.Therefore, it has a high preventive potential.
2 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 gasexchange, there can be no oxygenation of blood and
therefore circulation will soon cease. Getting oxygen tothe 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 thehighest priority. In addition, it is an actual problem that
requires immediate interventions. An impaired gas
exchange means that the body can be deprived ofoxygen. If proper ventilation is not reestablished, vital
body processes will be affected. Therefore, it has a
high preventive potential.
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3 Ineffective breathing pattern related
to hyperventilation secondary tostatus asthmaticus
The nursing diagnosis is an actual problem thatneeded prompt intervention. It is based on the principleof airway-breathing-circulation that needed to beaddressed first.
4 Impaired/ineffective tissueperfusion: Cardiopulmonary
In nearly all circumstances breathing management is
the second priority for clinical care according to ABC
management. Hypoventilation is too shallow or tooslow breathing, which does not meet the needs of the
body. It may also refer to reduced lung function. If aperson 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 canbe insufficiency of oxygenation of blood and therefore
circulation will soon cease.
5 Decreased cardiac output related todehydration
The nursing diagnosis is an actual problem that needsa prompt intervention. Addressing this problem cansolve other conditions of the client.
6 Hyperthermia
7 Deficient fluid volumeThe nursing intervention is an actual problem that maycause harm to the client. Immediate attention is
necessary to prevent further problem. Deficiency influid volume may cause imbalanced in fluid andelectrolytes.
8 Impaired swallowing The nursing diagnosis is an actual problem but can bemanage through use of different resources. Food/water/fluids for nutrition can be provided through anNGT or IVT.
9 Impaired urinary elimination relatedto tissue hypoperfusion
The nursing diagnosis is an actual problem that needsprompt intervention. Urinary elimination is a
physiologic need and not addressing this problem cancause further complications.
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10 Impaired oral mucous membrane
related to frequent suctioningThe nursing intervention is an actual problem but it isnot the main priority because it is not as critical as theother problems.
11 FatigueHindi i2 applicable
12 Imbalance nutrition: less than bodyrequirements
13 Acute confusion Hindi i2 applicable
14 Activity intolerance related togeneralized weakness
The nursing diagnosis is an actual problem but doesntneed immediate intervention. It is a long-term plan ofcare that needs ample time to be implemented.
15 Impaired physical mobility
16 Disturbed sensory perception Hindi i2 applicable
17 Impaired verbal communicationHindi i2 applicable
The nursing diagnosis is actual problem but ismanageable. Use of resources is utilized tocommunicate 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 along-term process of care.
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ASSESSMENT NURSING
DIAGNOSIS
ANALYSIS PLANNING NURSING
INTERVENTION
RATIONALE EVALUATION
SUBJECTIVE-The clients significant others
verbalizedSobrangnahihirapansiyanghuminga
kaya dinalananaminsa hospital.
OBJECTIVE
-Labored breathing-Cyanotic
-Restlessness
-Unproductive cough-Presence of wheezing
-Tacypnea
Vital Signs:Temperature: 39 C
BP: 120/ 80 mmHgPR: 110 beats/ min.
RR: 42 breaths/ min.
O2 Sat: 77%
INEFFECTIVE
AIRWAY
CLEARANCE
related to
Retained
Mucous
Secretion
secondary to
Presence of
Wheezing.
Inability to clearsecretions or
obstructions fromthe respiratory
tract to maintain a
clear airway.
Irritant(inhalation)
Inflammatory
response
Increaseproduction
of secretions
Airwayconstriction
Dyspnea
Objectives:
After 4 hoursof nursing
intervention
the client willmaintain
airwaypatency as
manifest by
expectoratesecretions and
no difficultyof breathing.
After 2 hours
of nursingintervention
the client:
*Respirations
will normalizewithin the rate
of 12-20
breaths/min.
Independent:
Monitor and recordVital Sign
Position the client
in Semi fowler
position
Monitor pulse
oximetry todetermine
oxygenation;evaluate lung
volumes and forced
vital capacity
Provide Chestphysiotherapy
To obtainbaseline date.
Notes progress
& changes ofcondition.
To prevent
aspiration andto breathe more
comfortably.
To assess forrespiratory
insufficiency
To remove the
secretion and ithelp to relieve
difficulty of
Objectives metas manifested
by:
The clientmaintain airway
patency asmanifested by
expectorate
secretions andno difficulty of
breathing.
*Respirations iswithin the rate of
12-20breaths/min.
* O2 Saturation
is within normalrange of 90-
100%
* Presence of
labor breathing
19 Self-care deficit The nursing diagnosis is an actual problem but themain priority for ABC clients is to save them topossible death.
20 risk for fall The nursing diagnosis is preventable to occur. The riskcan be eliminated through safety interventions.
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* O2
Saturation
will increasefrom 77 to
normal rangeof 90-100%
* Presence oflabor
breathing willdiminish as
clients breath
with rise andfall of the
chest innormal
rhythm.
*The client
cough willchange from
unproductiveto productive
cough.
* The clients
adventitious
breath soundwill diminish
as auscultated.
* The clientwill become
undistress and
uncyanotic asclient color of
conjunctiva
and lips willbecome pink.
Dependent
Administer oxygenas ordered by the
physician
Suctioning asordered by the
physician
Administer IVtherapy as ordered
by the physician
Administermedications as
ordered by the
physician.
Collaborative
Discuss the
condition of theclient with other
member of thehealth care team.
breathing
Formanagement of
respiratorydistress
To remove thesecretion
To prevent
dehydration
For continuous
wellness.
Ensurescontinuous
intervention.
was diminished
as clients breath
with rise and fallof the chest in
normal rhythm.
*The client
cough changefrom
unproductive toproductive
cough.
* The clients
adventitiousbreath sound
was diminished
as auscultated.
* The clientbecome
undistress anduncyanotic as
client color of
conjunctiva andlips become
pink.
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ASSESSMENT NURSING
DIAGNOSIS
ANALYSIS PLANNING NURSING
INTERVENTION
RATIONALE EVALUATION
SUBJECTIVE
-The clients significant others
verbalized
Sobrangnahihirapansiyanghumingakaya dinalananaminsa hospital.
OBJECTIVE
-Labored breathing-Cyanotic
-Restlessness-Tacypnea
-Tachycardia
-Diaphoresis
Impaired Gas
Exchange
related to altered
oxygensupply(obstruction
of airways
bysecretion)
asevidenced
bywheezes
uponauscultation
Entry of
noxiousparticles or
gasesto the lungs
Release of mediators
Abnormalinflammation
of thelungs
Chronicinflammation
Scar tissueformation
Narrowing of airway
lumen
Objectives
After 4 hours
of nursinginterventionthe client will
demonstrate
improvedventilation
and adequateoxygenation
of tissues by
ABGs withinclients
normal limits
Independent:
Monitor and record
Vital Sign
Elevate the head of
the bed andposition the client
at semi fowler.
Note respiratory
rate, depth, use of
To obtain
baseline date.Notes progress& changes of
condition.
To preventaspiration and
to breathe
morecomfortably.
The objectives
met as
evidenced by :
The client
demonstrated
improvedventilation and
adequateoxygenation of
tissues by ABGs
within clientsnormal limits
and absence of
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Vital Signs:
Temperature: 39 C
BP: 120/ 80PR: 110 beats/min.
RR: 42 breathes/ min.
ABG:
Ph: 7.25
PCO2: 30HCO3: 23
O2 Sat: 77%
Airflow limitations
Impaired gasexchange
wheezes
Reference:Pathophysiology by
Gold, 4th
edition, Pg.
345
and absence
of symptoms
of respiratorydistress.
ABG Results
will become :
Ph: 7.35-7.45PCO2: 35-45
HCO3: 22-26O2 Sat: 95-
100 %
After 2 hours
of nursingintervention
the client:
*Respirationswill
normalize
within therate of 12-20
breaths/min.
* Pulse ratewill be
normalwithin the rat
of 60-100
beats/ min.
* O2Saturation
accessory muscles,
pursed-lip
breathing, andareas of pallor/
cyanosis.
Monitor pulseoximetry to
determineoxygenation;
evaluate lung
volumes andforced vital
capacity
Auscultate the
lungs and not foradventitious breath
sounds
Provide Chest
physiotherapy
Dependent
To assess for
respiratoryinsufficiency
To assess forrespiratory
insufficiency
Presence ofadventitious
breath soundsnote as a
pulmonary
congestion andsecretion
collection,
indicatingneed for
furtherintervention.
Promotes
optimal lungexpansion and
drainage of
secretion.
symptoms of
respiratory
distress.
ABG Resultswill:
Ph: 7.40
PCO2: 37HCO3: 25
O2 Sat: 98 %
*Respirationswithin the rate
of 12-20breaths/min.
* Pulse rate
within the rateof 60-100 beats/
min.
* O2 Saturationwithin normal
range of 90-
100%
*No presence oflabor breathing
as clientsbreaths with rise
and fall of the
chest in normalrhythm.
* Diminishedadventitious
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will increase
from 77 to
normal rangeof 90-100%
* Presence of
labor
breathingwill diminish
as clientsbreath with
rise and fall
of the chestin normal
rhythm.
* The clients
adventitiousbreath sound
will diminishas
auscultated.
* The client
will becomeundistress
and
uncyanotic asclient color
ofconjunctiva
and lips willbecome pink.
* Presence ofdiaphoresis
Administer oxygen
as ordered by the
physician
Suctioning as
ordered by the
physician
Administer IV
therapy as ordered
by the physician
Administermedications as
ordered by the
physician.
Collaborative
Discuss thecondition of the
client with other
member of thehealth care team.
For
management
of respiratorydistress
To remove thesecretion
To prevent
dehydration
For continuous
wellness.
Ensurescontinuous
intervention.
breath sound as
auscultated.
* The client is
undistress anduncyanotic as
client color of
conjunctiva andlips is pink.
*No presence of
diaphoresis asthe client
perspire
normally withmoist skin.
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will diminish
as the client
perspirenormally
with moistskin.
ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOALS ANDOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
Subjective:
The significantother stated that
Ineffectivebreathing
pattern relatedto
Inspiration andexpiration that
does not provideadequate
Goal:
After 8 hours ofnursing
After 8 hours ofnursing
intervention, goalwas met as
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the client ishaving a difficultyof breathingbefore arriving atthe hospital..
Objective:
Dyspnea
Tachypnea
Pale
Irritability
Wheezing
Grimace
Use ofaccessorymuscles tobreath
Nasal flaring Increased
anterior-posteriordiameter
Alterations indepth ofbreathing
Pursed lipbreathing
hyperventilationsecondary tostatusasthmaticus
ventilation.
Thepathophysiologyof asthma iscomplex andinvolves airwayinflammation,
intermittentairflowobstruction, andbronchial hyperresponsiveness.
Airwayhyperresponsiveness or bronchialhyperreactivity inasthma is anexaggeratedresponse tonumerousexogenous andendogenousstimuli. Themechanismsinvolved includedirect stimulationof airway smoothmuscle andindirectstimulation bypharmacologicallyactive substancesfrom mediator-secreting cellssuch as mastcells ornonmyelinatedsensory neurons.The degree ofairwayhyperresponsiven
interventions, theclient will be able tohave effectivebreathing pattern.
Objectives:
After 8 hours of
nursinginterventions theclient will manifest:
A. Vital signswithinnormallimits.Respiratoryrate of 12-20breathes/min
B. Normaldepth andrate ofrespiration
Administeroxygen atlowestconcentrationindicated andprescribedrespiratorymedications.
Monitor pulseoximetry, asindicated.
Elevate head ofbed or haveclient sit-up inchair, asappropriate.
Encourageslower/deeperrespirations,use of pursed-lip technique.
Have client
breath into apaper bag, if
For managementof underlyingpulmonarycondition,respiratory distressor cyanosis.
To verifymaintenance/improvement inoxygen saturation.
To promotephysiological/psychological ease ofmaximalinspiration.
To assist client intaking control ofthe situation.
To correct
hyperventilation.
manifested byclients respiratoryrate of 18breaths/min,vesicular breathsound over thelung fields, normaldepth and rate of
breathing, distressupon breathing,relax andcomfortable.
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ess generallycorrelates withthe clinicalseverity ofasthma.
(NANDA 11th
edition page 140)
(http://emedicine.medscape.com/article/296301-overview0)
C. Normal
breathsounds
D. Verbalization ofunderstanding to healthteaching
appropriate.
Avoidovereating/ gasforming foods.
Maintainemergencyequipment inreadilyaccessiblelocation andincludeage/sizeappropriate ET/tracheostomytubes.
Provide healthteachings asfollows:
a. Stressimportance ofgood postureand effectiveuse ofaccessorymuscles.
Assist client inbreathingtraining.(diaphragmatic, abdominalbreathing,pursed lip)
b. Encourageadequate restperiods
May causeabdominaldistention.
When ventilatorsupport might beneeded.
To promotewellness.
To maximizerespiratory effort.
To limit fatigue.
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E. Desiredresponse toregimen
betweenactivity.
c. Reviewenvironmentalfactors(exposure todust, high
pollen counts,severeweather,perfumes,householdchemicals,second-handsmoke)
d. Advise regularmedical
evaluation withprimary careprovider.
Administeranalgesics asordered by thephysician.
It may requireavoidance/modification of lifestyle orenvironment tolimit impact onclients breathing.
To determineeffectiveness ofcurrent therapeuticregimen and topromote generalwellbeing.
To promote deeperrespiration.
(NANDA 11th
ed.142-144)
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ASSESSMENT NURSING
DIAGNOSIS
ANALYSIS PLANNING NURSING
INTERVENTION
RATIONALE EVALUATION
SUBJECTIVE-The clients significant others
verbalized
Sobrangnahihirapansiyanghuminga
kaya dinalananaminsa hospital.
OBJECTIVE
-Labored breathing
-Cyanotic-Restlessness
-Tachypnea-Tachycardia
-Bronchospasm
Vital Signs:Temperature: 39 C
BP: 120/ 80
PR: 110 beats/min.RR: 42 breathes/ min.
O2 Sat: 77%
Ineffective
Cardiopulmonary
Tissue Perfusion
related to
Hypoventilation
Decrease inoxygen
resulting in the
failure to
nourish thetissues at the
capillary level.
Hypoventilationis too shallow or
too slowbreathing,
which does not
meet the needs
of the body. Itmay also referto reduced lung
function.If a
personhypoventilates,
the body'scarbon dioxide
level rises,
which results in
too little oxygenin the blood.
Objectives
After 4 hours
the client will
demonstrateincreased
perfusion as
individually
appropriatevital signs
within thenormal rate.
Vital Sign:
Temperature:36.5-37.5 CBP: 120/ 80
mmHg
PR: 60-100beats/min.
RR: 12-20breathes/ min.
*Respirations
will normalizewithin the rateof 12-20
breaths/min.
* Pulse ratewill be normal
within the rat
of 60-100
beats/ min.
Independent:
Monitor and record
Vital Sign
Elevate the head ofthe bed and
position the clientat semi fowler.
Note respiratory
rate, depth, use ofaccessory muscles,pursed-lip
breathing, and areas
of pallor/ cyanosis.
Monitor pulse
oximetry to
determine
oxygenation;evaluate lungvolumes and forced
vital capacity
Dependent
To obtain
baseline date.
Notes progress& changes ofcondition.
To prevent
aspiration andto breathe more
comfortably.
To assess forrespiratory
insufficiency
To assess for
respiratoryinsufficiency
The objectives
met as
evidenced by:
* The clientdemonstrateincreased
perfusion as
individuallyappropriate vital
signs within thenormal rate.
Vital Sign:
Temperature:37CBP: 120/ 80
mmHg
PR: 80beats/min.
RR: 16 breathes/min.
*Respirationswithin the rate of12-20
breaths/min.
* Pulse ratewithin the rate of
60-100 beats/
min.
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* O2
Saturationwill increase
from 77 tonormal range
of 90-100%
* Presence of
laborbreathing will
diminish as
clients breathwith rise and
fall of thechest in
normal
rhythm.
* The client
will becomeundistress and
uncyanotic as
client color ofconjunctiva
and lips will
become pink.
Administer oxygen
as ordered by the
physician
Administer IV
therapy as ordered
by the physician
Administermedications as
ordered by the
physician.
Collaborative
Discuss thecondition of the
client with othermember of the
health care team.
For
management of
respiratorydistress
To preventdehydration
For continuous
wellness.
Ensurescontinuous
intervention.
* O2 Saturation
within normal
range of 90-100%
*No presence of
labor breathing
as clientsbreaths with rise
and fall of thechest in normal
rhythm.
* The client isundistress and
uncyanotic as
client color ofconjunctiva and
lips is pink.
ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOALS ANDOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
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S:
O:-blood pressure:100/70-pulse rate: 140bpm-Respiratory rate:
40 bcm-temperature:39C-poor skin turgor-capillaryrefill:2sec-confusion-O2 saturation:83%-diaphoresis
Decreasedcardiac outputrelated todehydration
High fever,diaphoresis andvomiting will leadto dehydrationwhich candecrease thecirculating blood
volume. Anothercondition thatmay havecaused the lowcardiac output isthe retention ofcarbon dioxidethat may lead toacidosis whichcausesvasodilation
resulting tohypotension.Decreasedcardiac output isa conditionwherein there isan inadequateblood pumpedby the heart tomeet themetabolic
demand of thebody.
After 8 hours ofnursing interventionthe client willmaintain bloodpressure withinnormal range.
INDEPENDENT:
Assess vitalsigns.
Assess forimpendingfailure/shock.
Keep thepatient on bedrest.
DEPENDENT:
Administer IVfluids asprescribed
Administerhigh flowoxygen viamask orventilator asprescribed.
Administer
drugs asordered.
Provides basis forcomparison tofollow trends andevaluateresponse to
interventions.
Early detection ofchanges in theseparameterspromotes timelyintervention tolimit degree ofcardiacdysfunction.
To decreaseoxygen andmetabolicdemands
To regulate bodyfluids
To increaseoxygen availablefor tissueperfusion
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1. Impaired/ineffective tissue perfusion: Cerebral- edam
ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOALS ANDOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
* Increase inbody
Elevated bodytemperature
Bodytemperature is
After giving nursingintervention, the
Does the clientable to maintain
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temperature(40 C)* Flushed skin*Tachypnea*Tachycardia*Seizures
related todisturbance inthehypothalamus.
elevated abovenormal rangedue to physicalmanifestations(asconvulsions,sensorydisturbances,
or loss ofconsciousness)resulting fromabnormalelectricaldischarges inthe brain.
client will be able tobe free ofcomplication suchas irreversible braindamage.
After 15 minutes of
nursing intervention,the client will beable to maintaincore temperaturewithin normal range.
After 10 minutes ofnursing intervention,the client will beable to be free of
seizure activity.
After 20 minutes ofnursing intervention,
the client conditionwill improve.
Monitor coretemperature.
Monitorrespirations
Perform tepidsponge bath
Assessneurologicalresponse,noting level ofconsciousnessand orientation,reaction to
To evaluatedegree ofhyperthermia
To evaluatethe effectsofhyperthermia
to controlshiveringandseizures
To assistwithmeasures toreduce bodytemperature
core temperature?
YES__NO__WHY?
Does the clientable to be free of
seizures?
YES__NO__WHY?
Does the clientcondition able toimprove?
YES__
NO__WHY?
Does theinterventionappropriate for theclient?
YES__NO__WHY?
Does theintervention donewithin the allottedtime?
YES__NO__WHY?
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7.
stimuli, reactionto pupil.
administeredprescribedmedications
(diazepam orchlorpromazine)
>Administerantipyretics,orally or rectally.(acetaminophen, aspirin) asordered.
>Promotesurface coolingby means ofundressing.
/ restorenormal body/ organfunction.
ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOALS ANDOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
Deficient fluid A decrease After 8 hours Assess After 8
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Subjective:
Objective:
Diaphoresis
Delayedcapillary refill(4 seconds)
Oliguria
hypotension
poor skinturgor
altered serumsodium
volume relatedto renaldysfunction
blood volumeleads todecreased tissueperfusion. Asvolume lossoccurs, variouscompensatorymechanisms
producevasoconstrictionof thevasculature,retain fluid viathe renaltubules, andincreasedcardiac output.Thesecompensatory
mechanism-such asstimulation of thesympatheticnervous system;releases renin,angiotensinaldosterone andantidiuretichormones; andfluid shifts-
continue in aneffort to restoretissue perfusion,thus ensuringcell survival.However thesemechanisms arelimited in scope,and if the loss ofvolume is notrestored
eventually
of nursinginterventionthe client willbe able tomaintain fluidvolume at afunctionallevel as
evidence byadequateurinaryoutput, stablev/s, moistmucousmembranes,and goodskin turgor.
physicalsigns of fluidvolumedeficit
Observeurinaryoutput, color,
and amount
Administer IVto replacefluid losses
To evaluate
degree of
fluid deficit
To know
how muchfluid theclient islosing.
To correct/reverse fluidvolumedeficit
hours ofnursinginterventionwas theclient ableto maintainfluid volumeat a
functionallevel asevidence byadequateurinaryoutput,stable v/s,moistmucousmembranes, and good
skin turgor?
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8.
ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOALS ANDOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
Objective: Impaired Frequent After 8 hours Assess the To check After 8
cellularstructures incurirreversibledamage fromoxygen debt.
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Coughingbeforeswallowing
Long mealswith littleconsumption
Food refusal
Difficulty ofswallowing
swallowingrelated tofrequentsuctioning
suctioning cancause trauma tooral, pharyngeal,or esophagealstructure leadingto difficulty intaking in food.
of nursinginterventionthe client willbe able topass foodand fluidfrom mouthto stomach
safely withlessdiscomfort.
clients abilityto swallow
Auscultatebreath sounds
Recordcurrent weight
Identifyindividualfactors thatcanprecipitateaspiration/compromiseairway
Determine thefoodpreferences ofthe client
Provideconsistency offood andfluids
Encouragerest periodsbefore meals
Provideanalgesics ifallowedbefore meals
or prior tofeeding
the capacityof the clientfor foodintake.
To evaluatethepresence ofaspiration
Baselinedata tomonitor thenutritionalstatus of theclient
To preventaspirationandmaintainairwaypatency
Toincorporateas possibleenhancingintake
To promoteeasierswallowing
To minimizefatigueduringfeeding
To relievediscomfortduring
feeding
hours ofnursingintervention wasthe clientable topassfood and
fluid frommouth tostomachsafelywith lessdiscomfort?
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9.
ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOALS ANDOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
S:
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O:-Open wound inthe lips andbuccal mucosa
-frequentirritation from
frequentsuctioning
Impaired oralmucousmembranerelated tofrequentsuctioning
Frequentsuctioning isneeded toremoveexcessivemucussecretions in theairway.
Repeatedsuctioning canirritate anddisrupt thesurrounding softtissue.
After 8 hours ofnursinginterventions theclients willdemonstrate adecrease in thesymptoms asnoted in the
definingcharacteristics.
INDEPENDENT:
Encourageadequate fluidintake
Use suction
machinecautiously
Provide gentlegum massage andtongue brushingwith soft toothbrush
Provide dietarymodifications
DEPENDENT
Administer medsas ordered.
To prevent drymouth anddehydration.
To preventadded injury.
Limits mucosaland gumirritation.
To reducediscomfort.
After 8 hours ofnursinginterventionsWas the clientable todemonstrate adecrease in thesymptoms as
noted in thedefiningcharacteristics?
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11.
Fatigue-
eda
m
12.
ASSESSMENT
(cues)
NURSING
DIAGNOSIS
ANALYSIS GOALS AND
OBJECTIVES
NURSING
INTERVENTION
RATIONALE EVALUATION
Goal:
ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOALS ANDOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
S:
O:-Increase BUN-oliguria-Urinaryretention
Impaired urinary
eliminationrelated to tissuehypoperfusion
Adequate tissue
perfusion isneeded by theorgans tofacilitate properdistribution ofoxygen andnutrients that isessential for theorgans tofunctionefficiently.
Without this vitalorgans such askidney starts todegenerate.Having thisconditions wasteproducts of thebody is notfiltered properand not will notbe properly
disposed.
After 8 hours of
nursingintervention theclient willachieve normalurinaryelimination.
INDEPENDENT:
Assess patency ofthe foley catheter.
Use asepsis andhand hygiene inproviding care andmanipulatingdrainage system
Assess color,volume and odorof the urinecomponents
DEPENDENT:
Administer IVfluids asprescribed
Provides basisfor furtherassessmentand actions.
Preventscontaminationof the foleycatheter.
Providesinformationabout theadequacy ofthe urineoutput,condition of thefoley catheter
and debris inthe urine.
To regulatebody fluids
After 8 hours of
nursingintervention,Was the clientable to achievenormal urinaryelimination?
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Cues:
Weak in
appearance
Cues:
Loss of
weight
Hyperactive
bowel
sounds
Pallor
Pale mucous
membrane
Subjective:
Reported
food intake
less than
RDA
Lack ofinterest in
food
Abdominal
pain
Malaise stated
by the client
Imbalanced
Nutrition: less
than body
requirements
Intake ofnutrientsinsufficient tomeet metabolicneeds.
Adequatenutrition is
necessary tomeet the bodysdemands.Nutritional statuscan be affectedby disease orinjury states(e.g.,gastrointestinal[GI]malabsorption,
cancer, burns);physical factors(e.g., muscleweakness, poordentition, activityintolerance,pain, substanceabuse); socialfactors (e.g.,lack of financialresources to
obtain nutritiousfoods); orpsychologicalfactors (e.g.,depression,boredom).During times ofillness (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:
Gainandmaintainappropriateweight.
The S.Owill beable toverbalizeunderstanding
about
Obtain clientsBaseline weight
Discuss theimportance ofmaintaining adequatecaloric intake andfour basic foodgroups as well as theneed for specificminerals andvitamins.
For evaluationof the nursingintervention
Patients maynot understandwhat isinvolved in abalanced diet.They arebetter beingable to askquestions andseek
Was theclient able toGain andmaintainappropriateweight?
Yes__ No__
If No, Why?
____
Was the S.Oable toverbalizeunderstanding about theimportance of
propernutrition?
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important role inhealing andrecovery.Cultural andreligious factorsstrongly affectthe food habitsof patients.
Women exhibit ahigher incidenceof voluntaryrestriction offood intakesecondary toanorexia,bulimia, and self-constructed faddieting. Patientswho are elderly
likewiseexperienceproblems innutrition relatedto lack offinancialresources,cognitiveimpairmentscausing them toforget to eat,
physicallimitations thatinterfere withpreparing food,deterioration oftheir sense oftaste and smell,reduction ofgastric secretionthataccompanies
aging and
theimportance ofpropernutrition.
Withcollaborationwith thenurses,make aset of
nutritious foodsto beincludedin herdiet.
Demonstrate behaviors,lifestylechanges toregain and/or maintainappropriateweight.
Plan with the clienther desired butnutritious meals.
Monitor the clientsweight daily.
assistancewhen theyknow basicinformation.
To promotethe feeling ofindependence.It alsopersonalizesthe plan ofcare since theclient doesmake the
choices insome aspectof the plan.
For evaluationof the plan of
care
Yes__ No__
If No, Why?
____
Was theclient ableto withcollaboration with thenurses,make a setof nutritiousfoods to beincluded in
her diet?Yes__ No__
If No, Why?
____
Was theclient able todemonstrate
behaviors,lifestylechanges toregain and/or maintainappropriateweight?
Yes__ No__
If No, Why?
____
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interferes withdigestion, andsocial isolationand boredomthat cause a lackof interest ineating. This careplan addresses
generalconcerns relatedto nutritionaldeficits for thehospital or homesetting.
Exerciseregularly
Discourage theclient to drinkbeverages that arecaffeinated orcarbonated.
Make a plan ofminimalexercise andencourage theclient toparticipate
This maydecreaseappetite andlead to earlysatiety.
Metabolismand utilizationof nutrients areenhanced byactivity
Was the clientable to exerciseregularly?
Yes__ No__
If No, Why?
____
13.
ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOALS ANDOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
*Fluctuation in
cognition / levelof consciousness
Acute confusion
related todelirium
Abrupt onset of
reversibledisturbances to
After
giving
Does the client
able to maintainlevel of
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*Increaseagitation
*restlessness
*Fluctuation inpsychomotor
activity
*Lack ofmotivation toinititate / follow-throughpurposefulbehavior
consciousness,attention,cognition, andperception thatdevelop over acertain period oftime.
nursingintervention, theclientwill beable toregainusual
realityorientation.
After3days ofnursingintervention the
clientwill beable tomaintainlevel ofconsciousness
After2days ofnursingintervention, theclient
will be
Evaluatemental status,noting extentof impairmentin orientation,attention span,
ability to followdirections,ability to send /receivecommunication,appropriateness of response.
>Identifyfactors presentsuch as acuteillness,trauma/fall,history orcurrent
seizures,
>Todeterminedegree ofimpairment
>To assesscausativeorcontributing factors
consciousness?
YES__NO__WHY?
Does the clientable to verbalize
understanding ofcausativefactors?
YES__NO__WHY?
Des the clientable to initiatebehavior
changes toprevent furtherdeterioration?
YES__NO__WHY?
Does theinterventionappropriate for
the client?
YES__NO__WHY?
Does theinterventiondone within theallotted time?
YES__
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able toverbalizeunderstanding ofcausative factorswhen
known
After aweek ofnursingintervention, the
clientwill beable toinitiatebehaviorchangestopreventrecurrence ofproblem
history of feverand pain.
>Evaluate Vitalsigns
>Notepresence of
anxiety andagitation
>Assist withtreatment ofunderlyingproblems
>Monitor /adjustmedication
regimen andnote response
>Orient clienttosurroundings,staff,necessaryactivities asneeded.
> Maintain
>Toidentifyindicatorsof poortissueperfusion
> Tomaximizelevel offunctionandpreventdeterioration
NO__WHY?
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calmenvironmentand eliminateextraneousnoise / stimuli
14.
ASSESSMENT
(cues)
NURSING
DIAGNOSIS
ANALYSIS GOALS AND
OBJECTIVES
NURSING
INTERVENTION
RATIONALE EVALUATION
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Subjective:Since her seizure,she cant do herdaily activities on herown. She alwaysneeds assistanceas verbalized by the
mother of thepatient.
Objective:
Dyspnea
Fatigue atrest
Pallor
Poor capillaryrefill
Weakness
Activity intolerancerelated togeneralizedweakness.
Insufficientphysiological orpsychologicalenergy to endureor competerequired ordesired daily
activities.
Most activityintolerance isrelated togeneralizedweakness anddebilitationsecondary toacute or chronicillness and
disease.
(http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick01.ht
ml)
(NANDA 10th
Edition, page 65)
Long Term:
After 1 month ofnursinginterventions theclient will:
A. Be able to
tolerateactivities;performactivities ofdaily livingfrom minimalto maximalindependence and withoutassistance.
Monitorvital/cognitivesigns,watching for
changes inbloodpressure,heart andrespiratoryrate; note skinpallor/cyanosis presence ofconfusion.Monitorresponse to
supplementaloxygen andmedicationsand changesin treatmentregimen.
Assist withactivities andprovideclients use of
assistive
Forbaselinedata andto manage
activitieswithinindividualslimit.
To protectclient frominjury.
After 1 month ofnursingintervention thegoal was met asmanifested bypatientstoleration to
activities of dailylivingindependentlyand withoutassistance.
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devised.(cane)
Adjustactivities.Reduceintensity levelor discontinue
activities thatcauseundesiredphysiologicalchanges.
Increaseexercise/activity levelgradually;
teachmethods,such asstopping torest for 3minutesduring a 10-minute walk.
Plan care withrest periods
betweenactivities.
Providepositiveatmosphere.Involvesignificantothers inplanning ofactivities as
much as
To preventoverexertion
Toconserveenergy.
To reducefatigue.
Helps tominimizefrustration,rechannelinjury.
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possible.
Promotecomfortmeasures andprovide forrelief of pain.
Providereferral tootherdisciplines asindicated(physicaltherapists).
Provide
healthteaching tothe patient aswell withsignificantothers:
A. Reviewexpectations ofclients/sig
nificantothers.
B. Instructclient/significantothers inmonitoringresponseto activity
and
Toenhanceability toparticipateinactivities.
Todevelopindividuallyappropriate regimen.
To
promotewellness.
Toestablishindividualgoals.
Indicatesneed toalteractivitylevel.
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recognizing signsandsymptoms.
C. Give
clientinformation thatprovidesevidencedaily/weekly.
D. Assistclient inlearning
anddemonstratingappropriate safetymeasures.
E. Provideinformation about
the effectof lifestyleandoverallhealthfactors onactivitytolerance.(nutrition,adequatefluid
intake).
To sustain
motivation.
To preventinjuries.
Toenhancesense of
well-being.
(NANDA 10th
Edition)
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Encourage client tomaintainpositiveattitude;suggestuse ofrelaxation
techniques, such asvisualization/guidedimageryasappropriate
15.Impaired physical mobility- angel
16.
ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOALS ANDOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
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Objective:
*Change in usualresponse to stimuli
*Change inbehavior pattern
(restlessness)
*Disorientation
*Impairedcommunication
Disturbedsensoryperceptionrelated toaltered sensoryreception
Change in theamount ofpatterning ofincoming stimuliaccompanied bya diminished,exaggerated,
distorted, orimpairedresponse tosuch stimuli.
After givingnursingintervention, theclient will beable to regainusual level ofcognition
After 3 days ofnursingintervention, theclient will be tocompensate forsensoryimpairment
After 5 days ofnursingintervention, theclient will beable to identify /modify externalfactors thatcontribute toalterations insensory
>Provide means ofcommunication, asindicated
>Encourage use oflistening devices
>Avoid isolation ofclient, physically oremotionally
>Reorient to person,place, time, andevents, asnecessary
>Identify clientcondition that can
affect sensing,interpreting, andcommunicatingstimuli.
>Assist with/reviewof diagnostic studiesand sensory/motorneurological testing
>Record perceptual
deficit on chart
>To promotenormalization ofresponse tostimuli
>To assist inmanagingauditoryimpairment
>To preventsensorydeprivation / limitconfusion
>To assesscausative /contributingfactors
Does the clientable tocompensate forsensoryimpairment?
YES__
NO__WHY?
Does the able toidentify / modifyexternal factorsthat cancontribute toalteration insensory?
YES__NO__WHY?
Does the clientable to be freeof injury?
YES__NO__WHY?
Does theinterventionappropriate forthe client?YES__NO__WHY?
Does theintervention
done within the
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After 8 hours ofnursingintervention, theclient will beable to be freeof injury
>Provide safetymeasures (secureside rails, bed in lowposition, adequatelighting) >For the
caregivers to beaware
>To preventinjury /complications
allotted time?
YES__NO__WHY?
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17.
ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOAL andOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
Objective:
The patientdoes notspeak
Difficulty touse facial orbodyexpressions
Impaired verbal
communicationrelated topresence ofphysicalbarrier(intubation)
An ET tube
provides a stableairway andfacilitatesremoval ofsecretions. It alsoprevents verbalcommunicationbecause itpasses throughthe vocal chords,and the distal tip
is positioned justabove thebifurcation of themain stem of thebronchus(carina).
After 8 hours
of nursingintervention theclient will beable toestablishanother methodofcommunicationon which theclient needs areexpressed.
Determine the
ability to read/write.
Establishrelationship
with the client,observingcarefully andattending toclients non-verbalexpressions
Keepcommunicatio
n simple usingall modes foraccessinginformation:Visual,auditory, andkinesthetic
To know the
possible wayofcommunicating with theclient
Non- verbalcues are
important.This will giveyou signal ofclients
concern/needs.
Alternativeways ofcommunicatin
g with theclient will giveyouinformation toattend toclients needs.
After 8 hours of
nursinginterventionwas the clientable toestablishanother methodofcommunicationon which theclient needs areexpressed?
18
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ASSESSMENT
(cues)
NURSING
DIAGNOSIS
ANALYSIS GOAL and
OBJECTIVES
NURSING
INTERVENTION
RATIONALE EVALUATION
Subjective:
Objective:
Pale
Tachycardia Tachypnea
Facial grimace
Irritability
Weakness
Decreased levelof awareness tosurroundings
Less socialinteractions
Trauma related toloss of musclecoordinationsecondary to
seizures.
As a result ofconditionsinteracting withthe individuals
adaptive anddefensiveresources.
A seizure is the
physical findings
or changes in
behavior that
occur after an
episode of
abnormal
electrical activityin the brain.
The term
"seizure" is often
used
interchangeably
with "convulsion."
Convulsions are
when a person's
body shakes
rapidly anduncontrollably.
During
convulsions, the
person's muscles
contract and relax
repeatedly that
may cause
trauma to the
person who
experiences it.
Long term:After 3 days ofnursinginterventions the
client will regainmuscle integrityand coordination.
Objectives:
After 8 hours ofnursinginterventions theclient will showevidence of:
a. Vital signswithinnormalrange
b. Increasedlevel ofawareness
Provide bedrest.
Provideinformationregardingconditions
that mayresult inincreaseinjury.
Identifyinterventions/safetydevices.
To gainstrengthand reducefatigue.
To reduceindividualrisk factors.
To promotesafephysicalenvironment andindividual
safety.
After 3 days ofnursingintervention,goal was met as
evidenced bypatientsperformingactivities of dailylivingindependentlywith propermusclecoordination.
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(NANDA 10th
Edition pg. 325 )
(http://www.nlm.nih.gov/medlineplus/ency/article/003200.htm)
c. Improve
Encourageuse oftechniquesto manage
stress andventemotions.Discussimportanceof selfmonitoring ofconditions/emotions.
Provide
writtenresources.
Encourageparticipationin self-helpprogramssuch asassertivenes
s andtrainingpositive self-image.
Refer toothersources asindicated(counseling,physical
therapists)
To increaseawarenessand well-being.
For later
review andself-pacedlearning.
Toenhanceself-esteemand worth.
To promotewellness.
http://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htm -
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socialinteraction
d. Recoveringmuscular
strength
Providerange ofmotionexercises,passive/active.
Administermedicationsprescribedby thephysician.
Increasemusclestrength.
To facilitatetreatment.
(NANDA 10th
and 11th
Edition)
19.
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ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOAL andOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
(+) Impairedphysical mobility
Self care Deficitspecific: partial
groomingrelated to
neuromuscular-impairment
Self Care Deficit -When an individualis very unable tomeet their ownself-care requisites
Goals:
After 2 weeksof nursingintervention, theclient will be able toassist at least 50%
of self careeffectively.
Objectives:
After 30 minutesof nursingintervention, theclient and theS.O will be ableto express
cooperation forthe plan of care.
After 30 minutesof nursingintervention, theclient will beable to verbalizeunderstanding
of self care andits importanceby citing at least3 out of 5importance ofself care viawriting or handsignals.
Explain the planof care to theclient and theS.O and howthey cancooperate in it.
Discuss withthe client andthe S.O aboutthe self careand itsimportance.
To build rapportand to promotecooperation ofthe client and theS.O.
To give the clientbasic knowledgeabout thesubject.
After 2 weeks ofnursingintervention, wasthe client will beable to assist at
least 50% of selfcare effectively?
___Yes ___No,Why? ___
After 30 minutesof nursingintervention,were the clientand the S.O ableto express
cooperation forthe plan of care?
___Yes ___No,Why? ___
After 30 minutesof nursingintervention, wasthe client able toverbalizeunderstanding of
self care and itsimportance byciting at least 3out of 5importance ofself care viawriting or handsignals.
___Yes ___No,Why? ___
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Oral Care: After 20
minutes ofnursingintervention,the significant
other will beable toperformproper oralcare for theclient with theclient to assist.
Feeding:
After 30
minutes ofnursingintervention,the client willbe able toidentify propernutrition andcite at least 3out of 5importance ofproper
nutrition viawriting or handsignals.
The significantother will beable to feedthe client withNaso-gastrictube properly,with strict
aspiration
Perform oralcare and allowthe S.O toassist duringoral care. Thenrepeat for the
returndemonstration.
Discuss withthe client the
nutrition and itsimportance.
Demonstrateproper NGTfeeding andevaluate byreturndemonstration.
To maintain theclient`s selfesteem.
To educate theclient and the
S.O.
To preventaspiration.
Oral Care:After 20 minutesof nursingintervention, wasthe significantother able to
perform properoral care for theclient with theclient to assist?
___Yes ___No,Why? ___
Feeding:After 30 minutes
of nursingintervention, wasthe client able toidentify propernutrition and citeat least 3 out of 5importance ofproper nutritionvia writing orhand signals?
___Yes ___No,
Why? ___
Was thesignificant otherwill be able tofeed the clientwith Naso-gastrictube properly,with strict
aspiration
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precaution.
After 30 minutesof nursingintervention, the
client will beable to expressmaintenance ofself-esteem
Encouragethe client toexpress his
feelings aboutthe care plan.
Encouragethe client toexpress
appreciationvia smiling ofhand shaking.
For evaluation ofclient`s feelingsto the care plan.
For evaluation ofclient`s feelingsto the care plan.
precaution?___Yes ___No,Why? ___
After 30minutes ofnursing
intervention,was the clientable toexpressmaintenanceof self-esteem
___Yes ___No,Why? ___
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20.
ASSESSMENT(cues)
NURSINGDIAGNOSIS
ANALYSIS GOAL andOBJECTIVES
NURSINGINTERVENTION
RATIONALE EVALUATION
Risk Factors:
Fatigue
Confusion Difficulty
moving
Risk for falls Temporary loss ofenergy or staminadue to over
stimulation of motorand sensory organsafter occurrence ofseizure.
After 8 hours ofnursing interventionthe client will not be
able to be at risk forfall and will gainknowledgeregarding diseaseprocess.
Provideknowledge/information for
the clientsdiseasecondition.
Discuss theimportance ofmonitoring theclients
condition thatcan contributeto occurrenceof injury.
Always put siderails up
To gainknowledgeand
awareness ofthe clientsdiseaseprocess togainawareness ofthecontributingrisk factorsfor fall.
To preventinjury
Prevention offalling out of
bedespeciallywhensleeping.
After 8 hours ofnursingintervention is
client not at riskfor fall and didthe client gainknowledgeregardingdisease process.