CUES NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
S> “Masakit yung Acute pain of the Antigen-antibody After 30 > encourage deep > to prevent The patient
dito ko.” (pointing at (adductor longus) reaction in response minutes to 1 breathing exercises exhaustion verbalized
the thigh and waist) anterior thigh and to presence of E. hour interval of > offer pillows to be > to increase comfort signs of
O> antalgic anteroposterior coli in the urinary rendering placed on thighs and waist comfort and
positioning to avoid (external abdominal tract fosters proper nursing > offer comics, >to provide pain scale
pain oblique) waist inflammatory interventions newspapers and/or other destructions decreased
> soothing related to reaction leading to and supportive divertional activities >to furtherly assess from 6/10 to
gestures inflammation of the redness, heat, measures, the > encourage patient to the underlying cause 4/10.
> grimace urinary tract swelling and pain patient will be elaborate more on the >to allocate more
> weak in secondary to UTI. that may lead to able to location of pain priority on that part
appearance loss of function. increase > assist patient in >to assess the
> slowed Pain receptors are feeling of determining which behavior of pain
movements located at different comfort; pain particular part is the most occurrence
> mild diaphoresis parts of the body. scale from 6/10 painful >for emotional
> narrowed focus Pain rooted from will be lowered > discuss to the patient support
> CBC results: the urinary tract to 4/10. with SO the location, >to increase comfort
WBC: 11.37 radiates to the characteristics, onset, > to increase comfort
Neutro%: 90.5 proximal adductor duration, frequency, >Analgesic
Mono%: 4.5 longus and external quality, intensity, and
Neutro #: 10.29 abdominal oblique precipitating and
Mono #: 0.51 muscles aggravating factors
> pain scale: 6/10 > encourage SO to advise
> vital signs taken friends and important ones
as follows: to visit her in the hospital
temp: 39.6oC > assist patient in
RR: 24 cpm assuming comfortable
PR: 74 bpm position in bed
BP:160/80 mmhg > maintain silent and neat
environment
> administers meds as
ordered
 ASSESSMENT INTERVENTION EVALUATION

CUES NURSING SCIENTIFIC PROBLEM NURSING RATIONALE

DIAGNOSIS EXPLANATION STATEMENT (GOAL) INTERVENTION

S – “Mainit ang Hyperthermia Urinary tract, unlike After 1 hour interval 1. Give tepid sponge 1. To aid in Goal Partially Met
pakiramdam related to any other body parts, of rendering nursing bath. thermoregulation. After 1 hour interval
ko” growth of houses no resident interventions, 2. Assess body 2. Assess body of rendering
O – weak in microorganisms flora. E-coli which is patient’s temperature after TSB. thermoregulation. nursing
appearance in the blood commonly found in temperature will 3. Position patient 3. Allow patient’s interventions,
-skin warm to secondary to the colon would decrease from 39.6 comfortably in bed. self dependency. patient’s
touch Urinary Tract stimulate immune to 37.5 degree 4. Impart health 4. Prevent temperature
-warm breath Infection response upon Centigrade. knowledge about occurrence of decreased from
-irritable dislodgement to proper body and hand further 39.6 to 38 degree
-vital signs urinary tract. Antigen- hygiene. complications. Centigrade.
taken as antibody response will 5. Maintain ventilation. -antipyretic
follows: now lead to process of 6. Increase fluid intake.
T-39.6 inflammation leading 7. Loosen clothing.
RR-24cpm to increase body Dependent:
PR-74bpm temperature. Administer medications
Bp-160/80 according to physician’s
mmHg order.
 ASSESSMENT INTERVENTION EVALUATION
CUES NURSING SCIENTIFIC PROBLEM STATEMENT (GOAL) NURSING RATIONALE
DIAGNOSIS EXPLANATION INTERVENTION
S – “pwede Activity Due to the pain After 1 to 2 hour interval of Note patient’s Symptoms After 1 to 2 hour interval of
na ba akong Intolerance felt on thighs proper nursing interventions, report of may be result proper nursing interventions,
humiga?” related to which consist of the patient will report weakness, of or the patient was able to perform
O – weak in pain nociceptors measurable increase in activity fatigue, pain, and contribute to __________________________
appearance which transmits tolerance as manifested by difficulty intolerance
- facial pain impulses to patient’s accomplishing of activity.
grimace the brain which __________________________ tasks.
- easy then causes
fatigability insufficient Promote comfort To enhance
- PS: 6/10 physiological measures and ability to
energy for daily provide relief of participate
activities. pain. in activities.

Assist patient in To prevent

learning and injuries.
demonstrating
appropriate
safety measures.
 Nursing
Assessment Scientific Explanation Planning Interventions Rationale Evaluation
Diagnosis

S> Ø Ineffective As aging takes place, After 2 hours of > Monitor >to allow nurse > after 2 hours of
protection the human body nursing temperature every 10 to formulate nursing
O> Decreased adipose relatedASSESSMENT
to loses its adipose interventions, minutes
INTERVENTION
interventions
EVALUATION
interventions
tissues
CUES on body NURSING SCIENTIFIC PROBLEM NURSING
impaired tissues which are patient’s: betterRATIONALE patient’s:
DIAGNOSIS EXPLANATION
thermoregulation essential in the STATEMENT (GOAL) >monitor
INTERVENTION
>loose, wrinkled skin a. temperature of >environmental a. Environmental
RISK FACTORS: Risk for Injury secondaryVisual
to disturbances
regulation of After 2 hours of • Ascertain • To prevent After 2 hours of
>Vital signs taken as extremesandof age temperature Environmental patient’s temperature may temperature was
-inborn defect hearing difficulties in proper
the nursing knowledge of injury at proper nursing
follows: temperature environment affect the maintained at 23C.
(tropia) on the attribute tobody, and as a result
potential interventions, the safety home, interventions,
geriatric patients will be patient’s body
left eye. injury. It directly patient will needs/injury
>manage drafts in community.b. Body the patient
T-39.6ْ C maintained at temperature
-with cataract tend toofabsorb and
affects activities verbalize prevention and
patient’s • To prevent temperature
verbalizedwas
20-25C.
on her rightRCPM
RR-24 daily living.release heat more understanding of motivation.
environment patient fromlowered
>to prevent understanding
to 38C.
eye. rapidly from andfactors
to that will
b. body • Assess muscle fall
hypothermia or injury. of factors that
-withPR-74
historyBPM
of the environment contribute to injury
temperature >keepstrength,
patient’sgross
back • To promote will contribute
CVA respectively. This and be free
will from it.
be lowered dry and fine motor >to prevent patient’s to injury and be
BP-160/80 mmHg
-with hearing circumstance makes and maintained coordination hypothermia
safety. free from it.
>render tepid sponge
difficulties.
Lab results: the body lose its between 36.5 and assist the • To prevent
bath as needed >to prevent
protection and also to 37.5C. patient when in error that
-Elevated WBC- hyperthermia
makes it prone to need.
>administer may result
11.37% () develop • Maintainas tofever
patient’s
paracetamol >to lower
complications. bed/chair
ordered in injury.
-Decreased
lowest position
Hemoglobin-10.8 (12-
with wheels
15g/100mL)
locked.
-Decreased • Monitor
Hematocrit- 30.9 (38- environment
47%) for potentially
unsafe
condition and
modified as
needed.
 CUES NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
O> Halitosis Impaired Ineffective oral After 8 hours > inspect oral cavity > to determined After 8 hours shift,
> Teeth dentition r/t hygiene by shift, the patient and evaluate dental needs for the patient
discoloration ineffective oral improper oral care will be able to hygiene and oral instruction or verbalized and
(yellowish) hygiene such as tooth demonstrate health referral to dental demonstrated
>Abraded teeth brushing and effective dental > instruct client to care provider techniques of
> 3 molar of maxillary increase intake of hygiene skills as increase fluid intake > to enhance proper oral
teeth and 2 molar of sugary and high tooth brushing. > assist patient in hydration and well hygiene
mandible teeth are carbohydrate foods oral care being of oral
black in color at central can lead to > instruct client to mucous
part formation of plaque limit sugary/high membranes
> Absence of 5 teeth and disruption of carbohydrate foods > to promote good
in the maxillary and 4 the tooth structure in diet/snacks hygiene
teeth in the mandible by the invasion and > teach patient in > to reduce build
ASSESSMENT INTERVENTION EVALUATION
area colonization of proper oral care up of plaque and
CUES NURSING SCIENTIFIC
bacteria in mouth PROBLEM NURSING
technique such as RATIONALE
risk of cavity
DIAGNOSIS EXPLANATION STATEMENT (GOAL)
producing acids that INTERVENTION
tooth brushing > to promote
can breakdown the > encourage patient proper oral
enamel and to undergo dental hygiene
integrity of teeth check up > to correct
and gums. properly the dental
problem with the
dentist supervision
S – “Namimiss Deficient Urinary Tract Infection After 2 to 8 hours of • Offer reading Distraction After 2 to 8 hours of
ko yung diversional predispose the patient rendering proper materials Provide rendering proper
inaalagaan activity related to to further nursing (comics, opportunity to nursing
kong apo sa UTI complications (sepsis, interventions, newspapers), or perform desired interventions,
bahay” pyelonephritis, etc) patient will other substitute activity in patient gradually
O - inattentive requiring her to seek gradually develop diversional different way. developed
- weak and for medical support substitute activities. Emotional substitute
pale in resulting to recreational • Assist patient in support. recreational
appearance hospitalization for activities. caring for activities.
further evaluation and herself.
management which • Encourage
fosters environmental visitation.
deprivation to perform
desired diversional
activities.