Cues Nursing

Diagnosis
Goal
Objectives
Nursing
Interventions
Rationale Evaluation
Subjectives:
During the
assessment, the
mother verbalized:
Lagi nalang siyang
iyak ng iyak, ang
bilis pa ng
paghinga niya
Objectives:
During the
assessment, the
client as observed
to be:
!irritability
!rales sound as
heard
!pale nail beds
!"achypnea #$%
breaths&min'
(mpaired gas
e)change r&t
alveolar!capillary
di**usion changes
+oal:
,*ter - to . hours o*
interventions,
symptoms
respiratory distress
ill lessen/
Objective:
"he signi*icant other
ould verbalize
understanding o*
causative *actors
and appropriate
interventions/
"he client0s
breathing pattern ill
demonstrate
improvement/
Demonstrate
improved ventilation
and ade1uate
o)ygenation ithin
client0s normal limits/
"each the SO to
encourage *re1uent
position changes/
2mphasize to the
SO the importance
o* nutrition/
2levate head o*
bed&position client
appropriately/
,dminister o)ygen
depending on the
client0s status/
3revent the child
*rom crying or be
e)hausted/
4eep environment
allergen and
pollutant *ree/
5hen the client
3romotes drainage
o* secretions/
"his improves
stamina and
reduces the ork o*
breathing/
"o maintain airay/
"o alleviate O.
deprivation and
6O. retention/
6rying could alter
the breathing
pattern o* the client
thus, he may have
more di**iculty on
breathing/
"o reduce irritant
e**ect o* dust and
chemicals on
airays/
7acilitates easier
,*ter - to . hour o*
interventions, the
client0s breathing
pattern shos or
demonstrates an
improvement *rom
$% to $8 breaths
per minute/ 9ales
sound as also
minimize/ "hus, the
goal as met/
X. NCP
Cues Nursing
Diagnosis
Goal
Objectives
Nursing
Interventions
Rationale Evaluation
Subjectives:
During the
assessment, the
mother
verbalized:
Sabi ng doctor
maputla da
siya
Objectives:
During the
assessment, the
client as
observed to be:
!irritability
!pale nail beds,
poor capillary
re*ill #:;sec'
! ,ltered 99
!"achypnea #$%
breaths&min'
!decreased <gb
and <ct count
(ne**ective
6ardiopulmonar
y "issue
3er*usion r&t
e)change
problems as
mani*ested by
lo <gb and <ct
count
+oal:
,*ter - to . hours
o* interventions,
the SO ould
verbalize
understanding o*
condition, therapy
regimen and hen
to contact
healthcare
provider/
Objective:
Demonstrate
behavior changes
to improve
circulation # dietary
program '
Demonstrate
increased
per*usion as
individually
appropriate #=S
ithin normal
range'
2)plain to the SO
the current
condition o* the
client/
(nstruct the SO to
note the
presence&degree o*
dyspnea, cyanosis,
hemoptysis/
"ogether ith the
SO, revie speci*ic
dietary
changes&restrictions
*or the client/
Discuss preventing
e)posure to colds,
"o provide
ade1uate
in*ormation
regarding the
client0s status/
"o administer
necessary
intervention
needed to alter
the condition/
"o determine
hat *oods are
needed by the
client and hat
*oods he must
avoid even at
early age/
"o retain heat
more e**ectively/
,*ter - to . hour
o* interventions,
the SO
understand the
condition,
response to the
teachings and
actions ere
per*ormed/