NURSING LONGTERM SHORT NURSING RATIONALE EVALUATION

CUES DIAGNOSIS GOAL TERM INTERVENTION

GOAL
S”Konti lang Disturbed After 5 days After 4 hrs. >Monitored v/s To note changes and a LONGTERM GOAL:
ang tulog sleep pattern of nursing Of nursing of serves as baseline data
niya mga 2 r/t interventions intervention After 5 days of
hours at biochemical the patient the patient nursing, interventions
paputol- agents such will be able to relatives will >Assessed patient It may contribute in the patient able to
putol.” as medicines maintain and be able to schedule of sleep. disturbing sleep maintained and;
verbalized by improve sleep verbalize pattern at night. improved sleep
husband of pattern. understandin pattern as evidenced
the patient g of by 4-6 hours of sleep
necessary >Instructed patient To decrease tension, at night
O: intervention relaxation techniques. prepare for sleep.
(+)Sunken to improve SHORTTERM
eye balls sleep pattern. >Instructed patient to To reduce need for GOAL:
limit fluid intake at nighttime elimination.
(+) Weakness night. After 4 hours of
nursing intervention
(+) Yawning the patient relatives
>Instructed patient To reduce stimulation was able to verbalized
(+) Fatigue family to provide that the client may understanding of
appearance quite environment. relax and fall asleep. necessary intervention
to improve sleep
pattern.
 CUES NURSING LONGTER SHORTTERM NURSING RATIONALE EVALUATION
DIAGNOSI M GOAL GOAL INTERVENTION
S
S:”di nga Impaired After 5 days After 8 hrs of >Monitored v/s To note changes and After 5 days of nursing
siya physical of nursing nursing possible signs of intervention the pt will
pwedeng mobility r/t intervention intervention the complication and be able to maintain
tumayo sabi prescribed the pt will be patient relatives serves as baseline data position of function and
ni Dok” movement able to will be able to skin integrity as
verbalized restriction. maintain verbalize >Assessed patient It may result in evidence by absence of
by the (Functional position of understanding signs of fatigue, pain activity intolerance contractures, footdrop,
husband of level IV; function and of situation and and difficulty of decubitus and etc..
the pt. Dependent, skin integrity risk factors and breathing
does not as evidence by individual SHORTTERM GOAL:
O: participate in absence of treatment and >Assisted client in Optimizes circulation After 8 hrs of nursing
(+) Leg activity.) contractures, regimen and repositioning every 2 and to all tissue and intervention the patient
muscle footdrop, safety hours or as needed relieves pressure. relatives will be able to
weakness decubitus and measures. verbalize understanding
>Inability to etc.. of situation and risk
performed > Provided patient To enhance more his factors and individual
ADL daily scheduled of body mechanics treatment and regimen
>Reluctance exercise and safety measures.
to attempt
movement > Instruct A safe environment is a
> Limited patient/family prerequisite to
range of regarding needs to improved mobility.
motion make home
>Doctors environment safe
order of
CBR. > Provide safety For safety of the pt.
(+) measures as indicated
Tracheostom in pt situation.
y
 NURSING LONGTERM SHORTTERM NURSING RATIONALE EVALUATION
CUES DIAGNOSIS GOAL GOAL INTERVENTION

S:”Di pa Impaired skin After 5 days After 8 hours of >Monitored vital To note changes and LONGTERM
magaling ung integrity r/t of nursing nursing signs possible signs of GOAL:
suagat niya mechanical intervention intervention the complication and After 5 days of
gawa ng pag factors the pt relatives patient relatives serves as a baseline nursing
papaopera secondary to will be able to will be able to data intervention the pt
niya sa surgery. participate in verbalize relatives was able
lalamunan” as prevention understanding to participate in
verbalized by measures and of how to >Monitored fluid To note fluid retention prevention
the husband treatment promote early intake and output. measures and
of the pt. program. healing of treatment
wound. >Assessed patient To assess extent of program.
O: skin color, texture involvement
(+) Floppy and turgor. SHORTTERM
skin GOAL:
76 yrs old >Instructed pt. To prevent further After 8 hours of
(+) relatives to keep area complication nursing
Tracheostomy clean and dry intervention the
patient relatives
>Instructed patient to To maintain was able to
apply lotion moisturize skin verbalized
understanding of
>Instructed patients To provide a positive how to promote
Family to provide nitrogen balance to early healing of
optimum nutrition aid in skin healing wound.
including vitamins
and increase protein
intake

>Encouraged patient To increase immunity

to take multivitamins
 NURSING LONGTERM SHORTTERM NURSING RATIONALE EVALUATION
CUES DIAGNOSIS GOAL GOAL INTERVENTION

O: Risk for After 5 days of After 4 hours of >Monitored vital To note changes and LONGTERM
76 yrs old infection nursing nursing signs possible signs of GOAL:
(+) related to intervention intervention the complication and After 5 days of
Tracheostomy inadequate the patient will patient relatives serve as baseline nursing intervention
primary be able to will be able to data the patient was able
defense maintain good identify to maintained good
hygiene intervention that hygiene
will >Assessed patient Patients with poor
prevent/reduce nutritional status nutritional status may SHORTTERM
risk of infection including history of be anergic, or unable GOAL:
of the patient weight loss to muster a cellular After 4 hours of
immune response to nursing intervention
pathogens and are
the patient relatives
therefore more
susceptible to was able to
infection. identified
intervention that
>Instructed patient of To reduce risk will prevent/reduce
daily bathing and risk of infection of
hand washing the pt.

>Encourage intake of This maintains

protein- and calorie- optimal nutritional
rich foods. status.

>Encouraged patient To increase and

to take vitamins such strengthen immunity
as vitamin C
 NURSING LONGTERM SHORTTERM NURSING RATIONALE EVALUATION
CUES DIAGNOSIS GOAL GOAL INTERVENTION

Ineffective In 5 days of After rendering >Suction To clear airway LONGTERM GOAL:

S; “ Inuubo pa airway nursing immediate endotracheal when secretion After rendering immediate
rin siya.” clearance r/t intervention nursing are blocking nursing intervention the pt
Verbalized by excessive the patient will intervention the airway. was able to maintain
the husband of mucus be able to pt will be able airway patency
the pt. secretions expectorate/ to maintain To take
clear airway patency >Elevated head of advantage of SHORTTERM GOAL:
secretions the bed, change gravity In 5 days of nursing
readily position every 2 decreasing intervention the patient was
O; hours. pressure on the able to expectorate but not
(+) productive diaphragm and cleared the secretions
cough enhancing readily
(+)Wide eyed drainage of
(+)Restlessness ventilation to
different lung
segment.

To note the any

>Monitored vital progress
sign

Lessen fatigue
>Provided
opportunities for
rest
To provide
> Administered O2 airway
as needed