CUES NURSING DIAGNOSIS SCIENTIFIC GOALS NURSING RATIONALE EVALUATION

RATIONALE INTERVENTIONS
SUBJECTIVE: Impaired gas Bronchial asthma is aPatient will improve 1. Establish rapport 1. To gain patient’s Patient will improve
“ asya la ini hiya it exchange related to condition wherein gas exchenge AEB: trust gas exchenge AEB:
may hika haamon. ventilation perfusionthe airway’s diameter- Absence of 2. Assesst patient’s - Absence of
Last week baga imbalance as is highly reduced. respiratory distress condition 2. To obtain baselinerespiratory distress
nakurian nagud hiya evidence by dyspnea,This is due to severe - pt. Will data - pt. Will
pag ginhawa asya and tachypnea bronchospasm, demonstrate 3. VS monitor and demonstrate
pumakadto ak haiyo mucosal edema and improved ventilationrecord improved ventilation
ha BHS kay bangin la mucus plug and adequate 3. Serve to track and adequate
mayda kamo formation. There is aoxygenation of important changes oxygenation of
medisina nga ig rise in airway tissues by ABG’s 4. Auscultate breath tissues by ABG’s
hahatag, kaso waray resistance which within client’s normalsounds and assess 4. To check for the within client’s normal
asya gin updan ak leads to decreased limits and absence ofairway pattern presence of limits and absence of
niyo ha RHU tas gin amount of air that symtoms of adventitious breath symtoms of
paasuhan manla hiya enters upon repiratory distress 5. Elevate head of thesounds repiratory distress
tas gin pauli liwat inspiration as well as bed and change
dayon” as verbalized expiration. Thus, position of the 5. To minimize
by the SO ventilation is patient every 2 hoursdifficult of breathing
impaired. In
bronchial asthma, 6. Encourage deep
OBJECTIVE: perfusion is not breathing and
- Wheezing upon directly affected. coughing 6. To maximize effort
inspiration and However, the balance for expectoration
expiration between ventilation 7. Demonstrate
- Cough and perfusion (V/Q) diaprhragmatic and 7. To decrease air
- Restlessness is lost because purse-lip breathing trapping and for
- Dyspnea despite the adequate efficient breathing
- RR: 28 cpm perfusion (capillary 8. Encourage
- O2sat: 93% circulation), not increase in fluid 8. To prevent fatigue
much gas is available intake
to diffuse from the
alveoli to the 9. Encourage 9. To prevent
capillaries. opportunities for restsituations that will
Conversely, the gases and limit physical aggravate the
in the capillaries do activities condition
diffuse to the alveoli
but since expiration is 10. Reinforce low 10. To mobilize
impaired, such gases salt, low fat diet as secretion
fail to be ventilated ordered
out. Thus, gas
exchange is impaired.
 CUES NURSING SCIENTIFIC RATIONALE GOALS NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Deficient Health literacy is the ability to after 30 mins. of INDEPENDENT: after 30 mins. of nursing
“nainom manla akknowledge read, understand and act on nursing 1. Establish rapport 1. To gain trust and interventions, pt. was
hadto hin herbal related to health information, including interventions, pt. will cooperation able to:
pan paubos hin unfamiliarity withsuch tasks as comprehending be able to: - Verbalize knowledge of
sugar ha dugo nature and prescription labels interpreting - Verbalize 2. Grant a calm and 2. A calm environment causes and treatment of
sugad paman treatment of DM appointment slips, completing knowledge of causespeaceful environment andallows the pt. to DM
insulin, mayabas, as evidence by health insurance form and and treatment of interruption. concentrate and focus - Control risk factor
blue ternate, nganrecurrent high following instructions for DM more completely
tigda laak CBG and diagnostic test. - Control risk factor
nahimatay kay verbalizing 3. Frequent recurrences
naduro liwat ini questions, or limited health literacy skills are 3. Explain to the pt. about of high/low blood sugar
kahamubo,” as unfamiliar of often greater among certain DM, risk factors, may indicate that the pt.
verbalized by the information groups; older adults, people with prevention and treatment.has no understanding of
pt. limited education, poor people the disease and its
with limited English proficiency management.
OBJECTIVE: skills are associated with poor
- health costs. 4. This would be a good
time to get the dietician
For example, a client may not 4. Educate about involved. The client
able to read prescription. Client nutritional changes and needs to learn at a
with low literacy skills have less monitoring minimum, how to count
information about health carbs and which foods to
promotion and/or management avoid such as beer. A pt’s
of the disease process for glucose should be
themselves and their families checked once when the
because they are unable to read pt. wakes up, before
educational materials. As a meals, and before going
result, they level higher rates of to bed. If the pt. is
hospitalizations than people with hypoglycemic, and they
adequate health. can eat or drink, give
them some orange juice
Source: and graham crackers
Nursing Care Plan Deficient with peanut butter.
Knowledge. Increase water intake if
(n.d)Scrib.https://www.scrib.co the pt. has
m/document/532294802/Nursin hyperglycemia.
g-Care-Plan-Deficient-Knowledge
5. With a healthy weight,
the pt. is likely also
implementing a healthy
diet as well as
implementing more
5. Educate about movement. These three
maintaining a healthy things (weight, diet,
weight and keeping active exercise) can help to
manage or even reverse
diabetes.
6. To empower patient
monitor his/her blood
sugar levels at home

7. To inform the patient

of each prescribed drug
and to ensure that the
6. Demonstrate how to patient fully understands
perform blood sugar the purpose , possible
monitoring side effects, adverse
events andself
7. Inform the patient the administration details
details about the
prescribed medication to
control blood sugar levels,
and explain how to
properly self-administer
each of them. Ask the
patient to repeat or
 demonstrate the self-
administration detail to
you
8.

CUES NURSING DIAGNOSIS SCIENTIFIC RATIONALE GOALS NURSING INTERVENTIONS RATIONALE EVALUATION
SUBJECTIVE: Anxiety related to After 3 hours of INDEPENDENT: After 3 hours of nursing
“ dire pala dugay deficient knowledge Facial tension is a natural nursing 1. Assess the client’s 1. Establishes baseline interventions, the
ak naka sabot kayand experience occurrence in response to interventions, the knowledge prenancy and assessment and identifiesclient was able to:
waray anay it hiyaregarding pregnancy emotional or physical stress. client will able to: childbirth. needs. - verbalize awareness
pagsusumat haakcare as evidence by The body responds to severe - verbalize of implications and
kay nahadlok nganverbalization of awareness of 2. Assess the client’s 2. Factors such as anxietypossible outcomes of
stress by releasing hormones
dire maaram ano concerns, implications and readiness to learn. or lack of awareness of pregnancy.
that activate the sympathetic
it bubuhaton, quantification of possible outcomes of the need for information
ngan tungod nga anxiety, worried nervous system. Meanwhile, apregnancy. can interfere with - Establish rapport
maundang hiya expression and number of factors could be at readiness to learn.
pag skwela” as mannerisms exhibited play when it comes to - Establish rapport Retention of information- Identify signs and
verbalized by the by patient. restlessness but, as with most is enhanced when the symptoms requiring
SO things related to anxiety, the - Identify signs and client is motivated and evaluation and
OBJECTIVE: "flight or fight" reflexes must symptoms requiring ready to learn. intervention.
- 19 year old shoulder some of the blame. evaluation and
female, When a person experiences intervention. 3. With prenatal patient - Demonstrate
primigravida anxiety, the nervous system education, patients understanding of hoe
- Restlessness has no sense of moderation. it- Demonstrate 3. Explain all activities, experience less anxiety therapy and/or self-
and fidgeting understanding of procedures, and issues and emotional distress care needs.
won't distinguish between
- Voice quivering hoe therapy and/or that involve the patient; and have increased
minor worries and life-or- self-care needs. use nonmedical terms andcoping skills because - Verbalize knowledge
death situations. As a result, it calm, slow speech. Do thisthey know what to about continuity of
will trigger the release of - Verbalize in advance of procedures expect. Uncertainly and care and support
inflammatory steroid knowledge about when possible and validatelack of predictability systems available to
hormones like adrenaline andcontinuity of care patient’s undeerstand. contribute to anxiety. her during and after
cortisol. These are designed toand support systems pregnancy
redirect attention to key available to her 4. Client may need to
organs and tissues such as theduring and after return on regular basis
lungs, heart, and muscles in pregnancy. 4. Provide information for monitoring and/or
about necessary prenatal treatments.
addition to heightening
check-ups and other
sensations of alertness and follow-up tests.
wakefulness, so one can
respond to any threat as
quickly as possible. 5. Prompt evaluatrion
5. Identify signs and/or and interventions may
Sources: symptoms that should be improve the outcome of
https://www.avogel.co.uk/ reported immediately to pregnancy and avert
health/stress-anxiety-low- the healthcare provider. complications.
mood/anxiety/is-restlessness-
6. Periodic review of data
a-symptom-of-anxiety/
6. Stress importance of will be used to adjust
maintaining daily record therapy.
uterine activity and other
pertinent information as
individually appropriate.

7. Demonstrate proper
self-care techniques 7. Prepares patient to
applicable for different properly deal with
body changes and signs. physiologic changes that
comes with pregnancy.
8. Provide a list of what
pregnant women should or8. Equips client with
should not do. knowledge of how to
stay healthy throughout
entirely of pregnancy.
9. Provide list of available
 and accessible support 9. Helps dissuade
programs. anxieties about lack of
resources and support
during pregnancy.
10. Provide regular
telephone contact. 10. Assures the client
that they can reach out
for help whenever and
encourages her to
update healthcare team
about her pregnancy.

CUES NURSING SCIENTIFIC RATIONALE GOALS NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS