CUES NURSING

DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
Objective Cues (based
on interview):

Very poor
eyesight due to
macular
degeneration


86 years old
widow

Living alone
in a new
environment
Risk for Injury related
to poor eyesight due
to macular
degeneration and new
environment
After an eight-hour
(8)shift of
collaborative nursing
intervention:

There would
be no
incidence of
injury or any
fall

The patient
would be able
to verbalize
feelings of
security about
personal safety
1. Alter patients
environment

2. Assist with
ambulation
and activities
of daily living
(ADL)


3. Teach patient
about possible
sources of
injury in the
home
environment

4. Continue to
asses any
potential harm
in the patients
environment
1. To reduce
possibility of
injuries
resulting from
unfamiliarity
with the
environment

2. To reduce
opportunities
for injuries
and provide
verbal cueing


3. To allow
patient to
identify and
correct
potentially
harmful
situations

4. To prevent any
potential
injury and to
modify
patients
environment
for safety
GOAL MET: After the
eight-hour (8)shift of
collaborative nursing
intervention:

There were no
incidence of
injury or any
fall

The patient
was able to
verbalize
feelings of
security about
personal safety





CUES NURSING
DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
Objective Cues (based
on interview):

Very poor
eyesight due to
macular
degeneration


86 years old
widow

Living alone in
a new
environment
Risk for self-care
deficit related to poor
eyesight and activity
restrictions
After a continuous
collaborative nursing
intervention:

Patient care
needs would
be met, with or
without
assistance
1. Assist patient
with activities
of daily living
as needed or
requested

2. Help patient
identify self-
care deficits
and alternative
methods of
accomplishing
those activities


3. Refer to
community
agencies if
necessary
1. To maintain
health and
self-esteem

2. To assure
availability of
information
and help after
discharge


3. To ensure
continuity of
care outside
the hospital
GOAL MET: After a
continuous
collaborative nursing
intervention:

Patient care needs are
met, with and without
assistance










CUES NURSING
DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
Objective Cues (based
on interview):

Very poor
eyesight due to
macular
degeneration


86 years old
widow

Living alone in
a new
environment

Subjective Cues:

Patient has hip
fracture upon
admission and
is scheduled
for surgery


Pain related to
movement of bone
fragments due to hip
fracture
After a two to four
hours of collaborative
nursing intervention:

There would
be a decrease
in or absence
of pain

Patient would
have a
satisfaction
with pain
relief (rates
pain as 3 out
of 10 from an
8 out of 10
score on a 10
point pain
rating scale)
1. Align and
position
extremity and
patient
correctly

2. Gently position
or turn patient


3. Administer
analgesics,
NSAIDs, and
muscle
relaxants as
ordered

4. Use pain
rating scale to
asses pain
1. To reduce
pressure on
nerves and
tissues

2. To prevent
muscle spasm
and
malalignment
of bone
fragments

3. To reduce
pain, edema
and muscle
spasm

4. To assess
effectiveness of
nursing care
in relation to
patients pain
GOAL MET: After a
two to four hours of
collaborative nursing
intervention:

There was a
decrease in
pain

Patient has
satisfaction
with pain
relief (rates
pain as 3 out
of 10 from an
8 out of 10
score on a 10
point pain
rating scale)







CUES NURSING
DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
Objective Cues (based
on interview):

Very poor
eyesight due to
macular
degeneration


86 years old
widow

Living alone in
a new
environment

Subjective Cues:

Patient has hip
fracture upon
admission and
is scheduled
for surgery

Impaired physical
mobility related to
decreased muscle
strength and pain due
to hip fracture
After a continuous
collaborative nursing
intervention:

Patient would
have a
sufficient
muscle
strength to
participate in
gait-training
program

Patient would
achieve
optimal level
of function
with
ambulatory
assistive device




1. Cooperate
with physical
therapist in
muscle-
strengthening
program

2. Teach and
assist patient
in exercise
program,
include
resistive
strengthening
exercise of
uninvolved
lower and both
upper limbs,
elbow
extension,
shoulder
depressors,
and knee and
hip extension

3. Provide
written
instruction or
videos for
exercises

4. Encourage
quadriceps
exercise, arm-
strengthening
exercises, and
abdominal and
1. To maximize
patients
progress in
rehabilitation

2. To develop
strength in all
extremities
preparatory to
initiation of
ambulation

3. For patient to
refer or
inquire to as
needed

4. To develop
muscle
strength which
will help with
rehabilitation

5. Because soft
tissue
surrounding
hip requires
about 3 to 5
months of
healing to
sufficiently
stabilize the
patient

6. To reduce
complications
related to
GOAL MET: After a
continuous
collaborative nursing
intervention:

Patient now
have a
sufficient
muscle
strength to
participate in
gait-training
program

Patient
achieved an
optimal level
of function
with
ambulatory
assistive device


gluteal
contraction
exercises

5. Be aware that
ordered
weight-
bearing status
of involved
extremity must
be maintained
unless
changed by the
physician

6. Get patient out
of bed and into
chair, usually
within 24 to
48 hours after
surgery

7. Instruct and
assist patient
with transfer
from bed to
chair
immobility
most especially
pressure sores
and muscle
atrophy

7. To prevent
accident
falling and
improper
movements,
which could
cause hip
malalignment
and further
damage











CUES NURSING
DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
Objective Cues (based
on interview):

Very poor
eyesight due to
macular
degeneration


86 years old
widow

Living alone in
a new
environment

Subjective Cues:

Patient has hip
fracture upon
admission and
is scheduled
for surgery


Ineffective coping
related to stress of
living alone and poor
eyesight
After a continuous
collaborative nursing
intervention:

Patient would
identify
effective and
ineffective
coping
patterns,
verbalize sense
of control,
report
decrease in
negative
feelings and
modify
lifestyle as
needed


1. Provide an
atmosphere of
acceptance

2. Provide factual
information
concerning the
diagnosis,
treatment and
prognosis

3. Arrange
situations that
encourage her
autonomy.
Give her as
many
opportunities
as possible to
make decisions
for herself

4. Encourage
verbalization
of feelings,
perceptions
and fears

5. Encourage
patient to
identify her
own strengths
and abilities

6. Determine
barriers to
using support
1. Establishing
rapport is
essential to a
therapeutic
relationship
and supports
the client in
self-reflection.
Recognizing
problems and
sharing
feelings is best
brought about
in an
atmosphere of
warmth and
trust

2. Factual
information
serves as a
foundation for
the patient to
explore
feelings and
alternative
coping
strategies.
Stressed clients
often
misunderstand
facts and
require
frequent
clarification so
that
appropriate
GOAL MET: After a
continuous
collaborative nursing
intervention:

Patient was
able to identify
effective and
ineffective
coping
patterns,
verbalize sense
of control,
report
decrease in
negative
feelings and
modified
lifestyle


systems

7. Refer patient
to a
community-
based support
group
conclusions
can be drawn

3. Enhances a
sense of
control,
personal
achievement
and self-esteem

4. Open,
nonthreatening
discussions
facilitate the
identification
of causative
and
contributing
factors

5. Assists the
patient in
developing
appropriate
strategies for
coping based
on personal
strengths and
previous
experiences.
Improves self-
concept and
sense of ability
to manage
stress

6. To help the
patient achieve
maximum
usage of
available
support system

7. Community
support is
beneficial in
helping to meet
unresolved
needs,
decreasing
feelings of
social isolation,
and facilitating
positive self-
image
















CUES NURSING
DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
Objective Cues (based
on interview):

Very poor
eyesight due
to macular
degeneration


86 years old
widow

Living alone
in a new
environment

Subjective Cues:

Patient has hip
fracture upon
admission and
is scheduled
for surgery
Anxiety related to
internalized feelings
of inadequacy,
resentment,
frustration,
situational crises,
unmet needs,
separation from
support system
(daughter) and
change in health
status (hip fracture)
as evidenced by
expressed concern
regarding changes in
life events
After a continuous
collaborative nursing
intervention:

Patient will
ac-
knowledge
and discuss
fears/con-
cerns

Patient
would be
able to
verbalize
awareness
of feelings
of anxiety
and healthy
ways to deal
with them

The patient
will be able
to
demonstrate
problem
solving and
use
resources
effectively

1. Note
palpitations,
elevated
pulse/respi-
ratory rate

2. Acknowledge
fears/anxieties,
validate
observations
with patient


3. Identify patients
perceptions of
the situations
and events

4. Evaluate coping
mechanisms
being used by
the patient

5. Maintain
frequent contact
with the patient.
Be available for
listening and
talking as
needed

6. Acknowledge
feelings as
expressed

7. Identify ways in
which the
1. Changes in
vital signs may
suggest the
degree of
anxiety the
patient is
experiencing
or reflect the
impact of
physiological
factors

2. Feelings are
real, and it is
helpful to
bring them out
in the open so
they can be
discussed and
dealt with

3. Regardless of
the reality of
the situation,
perception
affects how
each
individual
deals with the
illness/
stress

4. May be
dealing well
with the
situation at the
moment; e.g.,
GOAL MET: After a
continuous
collaborative nursing
intervention:

Patient ac-
knowledged
and
discussed
fears/con-
cerns

Patient was
able to
verbalize
awareness
of feelings
of anxiety
and healthy
ways to deal
with them

The patient
de-
monstrated
problem
solving and
use
resources
effectively


patient can get
help when
needed,
including
telephone
numbers of
contact persons

8. Stay with or
arrange to have
someone stay
with the patient
as indicated


denial and
regression may
be helpful
coping
mechanisms
for a time.
However, use
of such
mechanisms
diverts energy
the patient
needs for
healing, and
problems need
to be dealt
with at some
point in time

5. Establishes
rapport,
promotes
expression of
feelings

6. Often
acknowledgin
g feelings
enables patient
to deal more
appropriately
with situation

7. Provides
assurance that
staff/resources
are available
for
assistance/su-
pport

8. Continuous
support may
help patient
regain internal
locus of
control and
reduce
anxiety/fear to
a manageable
level


















CUES NURSING
DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
Objective Cues
(based on
interview):

Very poor
eyesight due
to macular
degeneration


86 years old
widow

Living alone
in a new
environment

Subjective Cues:

Patient has
hip fracture
upon
admission
and is
scheduled
for surgery


Situational low
Self-esteem related
to changes in
health status and
role performance
and loss of control
of some aspect of
life
After a continuous
collaborative nursing
intervention:

Patient would be
able to verbalize
realistic view
and acceptance
of self in
situation

Identify existing
strengths and
view self as
capable person

Recognize and
incorporate
change into self-
concept in
accurate
manner without
negating self-
worth

Demonstrate
adaptation to
changes/events
that have
occurred as
evidenced by
setting of
realistic goals
and active
participation in
work/play/pers
onal
1. Ask what the
patient would
like to be called

2. Identify basic
sense of self-
esteem, image
patient has of
existential,
physical,
psychological
self. Identify
locus of control

3. Active-Listen
patient concerns
and fears

4. Encourage
verbalization of
feelings,
accepting what
is said

5. Provide
nonthreatening
environment

6. Observe
nonverbal
communication,
e.g., body
posture and
movements, eye
contact,
gestures, use of
1. Shows
courtesy/respe
ct and
acknowledges
person

2. May provide
insight into
whether this is
a single
episode or
recurrent/chr
onic situation
and can help
determine
needs and
treatment
plan. It is
helpful to
know whether
the
individuals
locus of
control is
internal or
external to
provide most
helpful
interventions

3. Conveys sense
of caring and
can be helpful
in identifying
the patients
needs,
problems, and
GOAL MET: After a two
to four hours of
collaborative nursing
intervention:

Patient was able
to verbalize
realistic view
and acceptance
of self in
situation

Patient
identified
existing
strengths and
view self as
capable person

Mrs. Sarmiento
recognized and
incorporated
change into self-
concept in
accurate
manner without
negating self-
worth

The patient was
able to
demonstrate
adaptation to
changes/events
that have
occurred as
evidenced by
relationships touch

7. Encourage
discussion of
physical changes
in a simple,
direct, and
factual manner.
Give realistic
feedback and
discuss future
options, e.g.,
rehabilitation
services

8. Acknowledge
efforts at
problem solving,
resolution of
current
situation, and
future planning

9. Introduce tasks
at patients level
of functioning,
progressing to
more complex
activities as
tolerated


coping
strategies and
how effective
they are.
Provides
opportunity to
duplicate and
begin a
problem-
solving
process

4. Helps patient
begin to adapt
to change and
reduces
anxiety about
altered
function/life-
style

5. Promotes
feelings of
safety,
encouraging
verbalization

6. Nonverbal
language is a
large portion
of
communicatio
n and
therefore is
extremely
important.
How the
person uses
touch provides
information
about how it is
setting of
realistic goals
and active
participation in
work/play/pers
onal
relationships
accepted and
how
comfortable
the individual
is with being
touched

7. Provides
opportunity to
begin
incorporating
actual changes
in an
accepting and
hopeful
atmosphere

8. Provides
encouragemen
t and
reinforces
continuation
of desired
behaviors

9. Provides
opportunity
for patient to
experience
successes,
reaffirming
capabilities
and enhancing
self-esteem




CUES NURSING
DIAGNOSIS
PLANNING INTERVENTION RATIONALE EVALUATION
Objective Cues
(based on
interview):

Very
poor
eyesight
due to
macular
degener
ation


86 years
old
widow

Living
alone in
a new
environ
ment

Subjective
Cues:

Patient
has hip
fracture
upon
admissi
on and
is
schedul
ed for
surgery

Has
surgery
Decisional conflict
related to
situational
crises/personal
vulnerability;
multiple life
changes/maturatio
nal crises as
evidenced by
delayed decision
making or
uncertainty about
choices seen
through her
unsigned consent
form
After a continuous
collaborative nursing
intervention:

Patient
would be
able to
identify
ineffective
coping
behaviors
and
consequen
ces

Mrs.
Sarmiento
would
verbalize
awareness
of own
coping/pr
oblem-
solving
abilities.


Patient will
meet
psychologica
l needs as
evidenced by
appropriate
expression of
feelings,
identification
of options,
and use of
resources
1. Review
pathophysiology
affecting the patient
and extent of feelings
of
hopelessness/helplessn
ess/loss of control over
life, level of anxiety;
perception of situation

2. Establish therapeutic
nurse-patient
relationship

3. Note expressions of
indecision, dependence
on others, and inability
to manage own ADLs

4. Assess presence of
positive coping
skills/inner strengths,
e.g., use of relaxation
techniques, willingness
to express feelings, use
of support systems

5. Encourage patient to
talk about what is
happening at this time
and what has occurred
to precipitate feelings
of helplessness and
anxiety

6. Evaluate ability to
understand events.
Correct misperceptions,
provide factual
1. Impairment of
normal functioning
for more than 2
weeks, especially in
presence of chronic
condition, may
reflect depression,
requiring further
evaluation

2. Patient may feel
freer in the context
of this relationship
to verbalize feelings
of
helplessness/powerl
essness and to
discuss changes that
may be necessary in
the patients life

3. May indicate need to
lean on others for a
time. Early
recognition and
intervention can
help patient regain
equilibrium

4. When the individual
has coping skills that
have been successful
in the past, they may
be used in the
current situation to
relieve tension and
preserve the
individuals sense of
control
GOAL MET: After a
two to four hours of
collaborative
nursing
intervention:

Patient was
able to
identify
ineffective
coping
behaviors
and
consequen
ces

Mrs. Sar-
miento
ver-
balized
aware-
ness of
own
coping/pr
oblem-
solving
abilities.


Patient met
psychologica
l needs as
evidenced by
appropriate
expression of
feelings,
identification
of options,
and use of
resources
the next
day but
still not
signed
her
consent
yet


information

7. Discuss feelings of self-
blame/projection of
blame on others

8. Note expressions of
inability to find
meaning in life/
reason for living,
feelings of futility or
alienation from God

9. Promote safe and
hopeful environment,
as needed. Identify
positive aspects of this
experience and assist
patient to view it as a
learning opportunity

10. Inform Medical
Officer-on-duty
regarding
reinforcement on
explaining consent for
surgery and the
procedure itself

5. Provides clues to
assist patient to
develop coping and
regain equilibrium

6. Assists in
identification and
correction of
perception of reality
and enables problem
solving to begin

7. Although these
mechanisms may be
protective at the
moment of crisis,
they eventually are
counterproductive
and intensify
feelings of
helplessness and
hopelessness

8. Crisis situation may
evoke questioning of
spiritual beliefs,
affecting ability to
cope with current
situation and plan
for the future

9. May be helpful
while patient
regains inner
control

10. Serves as a guide for
patient in decision
making (client
advocate role)