Nursing Scientific Nursing Nursing Scientific

CUES Evaluatio
Diagnosis Explanation Objective Intervention Explanation
Subjective: Impaired skin Situation Goal: 1. Note skin -To document The cl
N/A integrity analysis: By the end color, texture, status and developed
related to post Impaired skin of the shift, and turgor. provide and
Objective: surgery of the integrity was the client 2. Palpate skin baseline for maintained
-disruption abdomen as due to the will develop lesions for size, future optimal
of skin evidenced by clients tissue and shape, comparisons. conditions
surface sutures in the trauma on the maintain consistency, NANDA 11th wound
abdominal surgical optimal texture, Edi. p. 620-621 healing
area. incision site conditions temperature, - To monitor evidenced
from his recent for wound and hydration. progress of responses
surgery caused healing. 3. Inspect wound healing. interventio
by small bowel surrounding NANDA 11th and teach
obstruction. Objectives: skin for Edi. p. 621 and acti
1. After 30 erythema, -Promotes performed
Health minutes, the induration, and circulation and and grad
Implication: nurse will be maceration. reduces risks healing of
The skin is a able to 4. Note odors associated with wound.
barrier to assess the emitted from immobility.
infectious extent of the wound. NANDA 11th
agents; involvement 5. Inspect skin, Edi. p. 622
however, any or injury. describing
break in the wound
skin can readily 2. After the characteristics
serve as a shift, the and changes
portal of entry nurse will be observed.
putting the able to 6. Remeasure
individual at assist the wound and
risk for client with observe for
potential correcting complications.
infections. and 7. Use
(Fundamentals minimizing appropriate
of Nursing by condition dressings,
Kozier, et.al., and promote wound
7th edition, optimal coverings,
page 633) healing of drainage
wound. appliances for
open or
draining
wounds.

Nursing Scientific Nursing Nursing Scientific

CUES Evaluation
Diagnosis Explanation Objective Intervention Explanation
Subjective: Activity Activity Short Term Independent -Rapport is Goal was
-makirot intolerance intolerance Goal: important to gain met. After 3
itong tahi ko related to defined as a -after 8 hrs. of -Establish rapport patients cooperation days of
noong presence of state in which nursing -Monitor vital signs and reduce anxiety. nursing
pagkatapos surgical a person has intervention -Establish guidelines
intervention
kong incision as insufficient the patient and goals of activity -Baseline data is
maoperahan manifested physiological will gradually with the patient and important to help s the patient
kaya by limited or sit or slowly caregiver. determine patients was able to
nakahiga lang mobility psychological move from -Encourage adequate current health status walk around
ako sa kama energy to one place to rest periods, and evaluate the room
magdamag endure or another with especially before effiectiveness of without
hirap akong complete full assistance meals, other ADLs, nursing intervention assistance.
magkikikilos necessary or exercise sessions, rendered.
as verbalized desired daily LONG TERM and ambulation.
by the client. activities. GOAL: -Encourage -Motivation is
verbalization of enhanced if the
Objective: After 3 days of feelings regarding patient participates
-pain scale of nursing limitations in goal setting.
8 out of 10 interventions -Maintain a quiet, -Rest between
-guarded the client will comfortable activities provides
movement be able to environment time for energy
-limited maintain -Teach conservation and
mobility activity level patient/caregivers to recovery.
within recognize signs of
capabilities physical over
activity. -Acknowledgment
that living with
-Teach energy activity intolerance
conservation is both physically
techniques. and emotionally
difficult, aids
coping.

-Promotes rest and

sleep and prevents
anxiety thereby
decreasing the
patients oxygen
demands

-This promotes
awareness of when
to reduce activity.

-To conserve energy

and decrease the
need for oxygen
supply
 Nursing Scientific Nursing Nursing Scientific
CUES Evaluation
Diagnosis Explanation Objective Intervention Explanation

Objective: Risk for Wounds Short-Term Assess signs Fever may

-body infection involving injury Goal : and indicate Goal met:
weakness related to to soft tissue Within the symptoms of infection.
-clean, post op can vary from shift, patient infection Patient was
will be able to especially free from
dry incision minor tears to
identify ways temperature. any signs
abdomina severe to reduce risk and
l dressing crushing for infection. It serves symptoms of
injuries. The Emphasize as a first infections as
decision to Long-Term the line of manifested
suture a Goal importance defense by absence
wound : At the end of of against of fever.
depends on hospitalization, handwashin infection.
the nature of patient will not g technique.
the wound the manifest any
signs and Maintain
time since the Regular
symptoms of aseptic
injury was infection. wound
technique
sustained the dressing
when
degree of changing promotes
contamination. dressing/cari fast
ng wound. healing
Reference: and drying
Brunner & Keep area of wounds.
Suddarths around
Textbook of wound clean Wet area
Medical- and dry.
can be
Surgical lodge area
Nursing 11th Emphasized
necessity of of bacteria
edition by
taking
Smeltzer, Premature
antibiotics as
Bare, Hinkle, ordered. discontinu
Cheever ation of
treatment
when client
begins to
feel well
may result
in return of
infection.
Diagnostic exam

Chest X-ray (Feb. 01, 2017): Right costrophenic sulcus is blunted attributed to pleural effusion
and or thickening
Suspicious infiltrates are seen on the right apex obscured by overlying bones.
Rest is not enlarged
Aorta is atheromnatous
Left costrophenic sulcus is intact.
Thoracentesis (Feb. 02, 2017): free fluid noted in the right lung with an estimated volume of 453
ml.

LABORATORY 1ST RESULT 2ND RESULT NORMAL SIGNIFICANCE

TEST 02/04/17 02/05/17 VALUES
Hemoglobin 118 g/L 131.5 120-150 g/L Blood loss due
to surgery. BT
done 02/04/17
Hematocrit 0.39 0.43 0.38-0.48 Within normal
range
WBC 5.9 6.0 5.0-10.0 x 10/L Within normal
range
RBC 5.27 5.30 4.10-5.60 x 10/L Within normal
range
 Genogram
Mothers side Fathers side
Lolo LOLA (+) Lolo (+) 78 LOLA (+)
(Arthritis) 79 Gallbladder 88
80 CA

BROTH PATIEN BROTH

BROTH SIST BRO SPOUS
ER T LB ER
ER ER 67 THE E 60
65 64 59
69 R 65

SON 34

DAUGHTE
R 30