CUES NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: • Thermo After 3 hours of • Provide tepid • to decrease • After 3 hours

“ Mainit at regulation nursing sponge bath temperature by of
masama ang Ineffective intervention, means of Nursing
pakiramdam related to the patient’s evaporation intervention, the
ko”, as Disease body and patient’s body
verbalized by Process temperature conduction Temperature
the (presence of will alleviate at alleviated at
patient.. Bacterial normal/desirable • Change dress • to reduce normal/desirable
infection) as level into body level.
Objective: manifested by loose clothing temperature • Goal met
• dry lips elevated body
• febrile 38.9 temperature • Ensure proper • to provide
• skin warm to room cool
touch ventilation environment
• grimace
• pale • Advised patient • to release
• (-) oral heat from
dehydration fluid intake he body
• irritable
• Administer • to facilitate
analgesics as fast
ordered by the recovery
physician

• Ambulate the • to facilitate

patient blood
circulation
turn side by
side)

• Maintain bed • to metabolic

rest demands/
Oxygen
consumption
CUES NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Ineffective After 4 hours • Advise increase • To liquefy • After 4 hours

“nahihirapan Breathing of nursing fluid intake secretion of nursing
akong related to intervention, Intervention
huminga dahil Retained the patient • Performed Chest • To facilitate the patient’s
narin sa secretions in will Physiotherapy expectorations secretion has
ubo ko.” As the bronchi. Loosen (Back Tapping) of retained been loosen
verbalized by secretions in secretions and she has
the patient the lungs. been able
• Administer • to facilitate to breath
Objective: medications as fast At tolerable
• (+) ordered recovery level.
productive Goal partially
cough met
• weak • Instruct patient to • To prevent
• pale expectorate the further
• irritable mucus retention of
• (+) crackles secretion secretion
Upon
auscultation
CUES NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Impaired Gas After 4hrs of  Pace activities  Even After 4 hours of
“nahihirapan Exchange r/t nursing and Simple nursing
akong altered oxygen intervention provide rest activities, such intervention
huminga lalo supply the periods to as bathing, can The patient has
n pag wla tong patient will prevent fatigue. increase able to
oxygen” as demonstrate oxygen demonstrate
verbalized by normal depth consumption a normal depth
the patient. rate and pattern and rate and pattern
Of respirations. cause fatigue. Of respirations
Objective Goal partially
 Pale in met.
appearance  Keep  To prevent
 weak environment allergic
 With allergen free reactions
changes
in rate,
rhythm and  Administer  To treat
depth of medications underlying
breathing such as conditions
 With DOB bronchodilators/ and
and expectorant mobilize
(+) wheezes s as secretions
 (+) ordered
productive
cough
CUES NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Imbalanced After 4 hours > Assess for > The

“hindi ako Nutrition due of recent consequences
makakain ng to not eating Nursing changes in of malnutrition
maayos hndi the usual foods Intervention, physiological can
taken as the lead to a further
ko mailunon at status
manifested by Pt will start decline in the
wla dn akong decreased taking that may interfere patient's
gana kumain” weight, food foods which with nutrition condition
as verbalized aversion, and she that then
by the Patient weakness. usually eat becomes
(rice, self-
crackers, perpetuating if
objective: chicken not recognized
 Pale breast,etc) and
 Weak treated.
 Irritable
 Dry lips > Promote > to enhance
and skin pleasant, relaxing intake
environment,
including
socialization
when possible