NCP

CUES NURSING SCIENTIFIC GOAL INTERVENTIO RATIONALE EVALUA

DIAGNOSIS RATIONALE N PLAN TION
Subjective: Decreased Hypovolemic After 1-2 weeks INDEPENDENT: Goal
Oo cardiac shock is of nursing partially
nagmamata output characterized by
interventions, 1. Assessed *Sinus met.
hiya pero related to hypotension; a the client will the clients tachycardia and
maluyahon, fluid volume rapid, thready be able to vital signs increased arterial
as verbalized loss of 30% pulse; cold, pale,
maintain particularly the BP are seen in the
by the SO. or more as clammy skin; adequate HR and the BP. early stages to
evidenced intense thirst;cardiac output, maintain an
by rapid respiration;
as evidenced adequate cardiac
decreased and restlessness
by strong output.
hemoglobin or, alternatively,
peripheral Hypotension
and torpor. Urine pulses, systolic happens as
Objective: hematocrit, volume is BP within 20 condition
*Decreased body malaise, markedly mm Hg of deteriorates.
hemoglobin: body decreased. baseline, HR 60 Vasoconstriction
91 g/ml weakness, to 100 beats may lead to
(reference: pallor, & cold SOURCE: per minute unreliable blood
120- clammy skin. PATHOPHYSIOLO with regular pressure. Pulse
160g/ml) GY OF DISEASE rhythm, urinary pressure
*Decreased 7TH EDITION, output 30 ml/hr decreases in
hematocrit: page 315 (Gary or greater, shock. Older
0.29 D. Hammer, warm and dry client have
(reference: Stephen J. skin, and reduced response
0.40-0.54) McPhee) normal level of to
*Body consciousness. catecholamines;
malaise thus their
*Body 2. Assessed response to
weakness the clients decreased cardiac
*Pallor ECG for output may be
*Cold dysrhythmias. blunted, with less
clammy skin increase in HR.
 *Cardiac dysrhyth
mias may occur
from the low
3. Assessed perfusion state,
the central and acidosis, or
peripheral hypoxia, as well
pulses. as from side
effects of cardiac
4. Assessed medications used
capillary refill to treat this
time. condition.

*Pulses are weak

with
5. Assessed reduced stroke vol
the respiratory ume and cardiac
rate, rhythm output.
and auscultate
breath sounds. *Capillary refill is
slow and
sometimes absent
6. Monitored due to deficient
oxygen fluid volume.
saturation and
arterial blood *Characteristics of
gasses. a shock
include rapid,
shallow
respirations and
adventitious
breath
 sounds such as
crackles and
wheezes.

*Pulse oximetry is
used in
measuring
7. Assessed oxygen
urine output. saturation. The
normal oxygen
saturation should
be maintained at
90% or higher. As
shock progresses,
aerobic
metabolism stops
and lactic acidosis
occurs, resulting
in the increased
DEPENDENT: level of carbon
dioxide and
1. decreasing pH.
Administered
supplemental
oxygen at 3 *The renal system
LPM, as compensates for
needed. low BP by
retaining water.
2. Measured Oliguria is a
CO and other classic sign of
functional inadequate renal
parameters as perfusion from
appropriate. reduced cardiac
 output.

*Increases the
amount of oxygen
available.

*Cardiac index,
preload and
afterload,
contractility and
cardiac work can
be measured
noninvasively.

CUES NURSING SCIENTIFIC GOAL INTERVENTION RATIONALE EVALUATIO

DIAGNOSIS RATIONALE PLAN N
Subjectiv Impaired liver Cirrhosis is After 1-2 INDEPENDENT: Goal
e: function due ultimately the weeks of partially
1. Determined *Influences choice
to Hepatitis B consequence of nursing met.
Nananara presence of of interventions
Infection as progressive liver interventions,
g hiya condition(s), as and guides in the
evidenced by injury. Cirrhosis can the client will
pagkit-on listed above. treatment.
reactive occur in a subset of be able to be
pero di gad Note whether
HbsAg and cases of chronic free of signs of
masyado, problem is acute
increased AST. hepatitis that do liver failure as
as viral hepatitis
not resolve evidenced by
verbalized
spontaneously or liver function 2. Ascertained if *Helps in
by the SO.
after repeated studies within client works in identifying source
episodes of acute normal limits high-risk of infection
liver injury, as in (WNL) and occupation; for occupational high
the case of chronic absence of example, risk for exposure
alcoholism. In jaundice, performs tasks to HBV and HCV.
Objective cirrhosis, the liver hepatic that involve
s: becomes hard, enlargement, contact with
shrunken, and or altered blood, blood
*HbsAg:
nodular and mental status. contaminated
reactive
displays impaired body fluids,
*AST: 55 function and other body
U/L diminished reserve fluids, or sharps
*Helps in
(reference because of a or needles.
identifying source
range: Up decreased amount
of infectionrisk
to 37 U/L) of functioning liver
for exposure to
tissue. One may 3. Assessed for
enteric viruses,
present with yellow exposure to
such as HAV and
eyes and skina contaminated
HEV.
manifestation of food or
impaired liver untreated
function. drinking water
or for evidence
of poor
 SOURCE: sanitation
PATHOPHYSIOLO practices by
GY OF DISEASE foodservice
7TH EDITION, workers, if
page 402 (Gary source is known.
*Identifies cause of
D. Hammer,
DEPENDENT: hepatitis,
Stephen J.
influences choice
McPhee) 1. Reviewed
of interventions,
results of
and monitors
laboratory tests,
response to
such as hepatitis
therapies.
viral titers, liver
function, and *Supports organ
other diagnostic function and
studies. minimizes liver
damage and risk of
2. Assisted with
organ failure. For
treatment of
chronic HBV and
underlying
HCV infections, in
condition.
particular, the
goals of therapy
are to reduce liver
inflammation and
fibrosis and to
prevent
progression to
cirrhosis and the
associated
complications.

CUES NURSING SCIENTIFIC GOAL INTERVENTION RATIONALE EVALUATIO

DIAGNOSIS RATIONALE PLAN N
Subjective: Imbalanced The clinical After 1-2 INDEPENDENT: Goal
Nutrition: manifestations of weeks of partially
Dati medjo 1. Monitored *Large meals are
Less than progressive nursing met.
matamboka dietary intake difficult to manage
Body hepatocellular interventions,
y hiya pero and calorie when client is
Requirements dysfunction in the client will
tikang han count. Provided anorexic. Anorexia
related to cirrhosis are similar be able to
iya meals in several may also worsen
Insufficient to those of acute or display an
pagkinahos small feedings during the day,
intake to chronic hepatitis improved
pital, nag- and offer largest making intake of
meet and include appetite and
ginasa na meal at food difficult later
metabolic constitutional gain
hiya. Waray breakfast. in the day.
demands as symptoms and appropriate
na
evidenced by signs: fatigue, loss body weight. *Eliminating
manggud
anorexia, of vigor, and weight unpleasant taste
hiya 2. Encouraged
nausea, loss; GI symptoms may enhance
madalas mouth care
vomiting. and signs: nausea, appetite.
gana before meals.
vomiting, jaundice,
pagkaon, *Reduces
and tender
as sensation of
hepatomegaly; and
verbalized 3. abdominal fullness
extrahepatic
by the SO. Recommended and may enhance
symptoms and
eating in upright intake.
signs: palmar
position.
erythema, spider
angiomas, muscle
*Hyperglycemia or
wasting, parotid and
DEPENDENT: hypoglycemia may
lacrimal gland
Objective: develop,
enlargement, 1. Monitored
necessitating
*Weight gynecomastia and serum glucose,
dietary changes or
loss testicular atrophy in as indicated.
insulin
men, menstrual
Previous administration.
irregularities in
weight: 60
women, and *Useful in
kg
coagulopathy. formulating dietary
2. Consulted
Previous program to meet
BMI: 26.7 with dietitian or individual needs.
(overweight nutritional Fat metabolism
SOURCE:
) support team to varies according to
PATHOPHYSIOLOG
provide diet bile production
Current Y OF DISEASE 7TH
according to and excretion and
weight: 50 EDITION, page
clients needs, may necessitate
kg 417 (Gary D.
with fat and restriction of fat
Hammer, Stephen
Current protein intake as intake if diarrhea
J. McPhee)
BMI: 22.2 tolerated. develops. If
(Normal) tolerated, a normal
or increased
*Anorexia
protein intake
*Nausea helps with liver
regeneration.
*Vomiting
Protein restriction
may be indicated
in severe disease,
such as
fulminating
hepatitis, because
the accumulation
of the end
products of protein
metabolism can
potentiate hepatic
encephalopathy.

CUES NURSING SCIENTIFIC GOAL INTERVENTIO RATIONALE EVALUATIO

DIAGNOSIS RATIONALE N PLAN N
SUBJECTIVE IMPARIED Due to the Short Term: Independent: Goals
: PHYSICAL decreased cardiac 1. Strength or partially
Nakakatuk MOBILITY output, there is less 1. Assessed deficiencies and met.
daw gad related to perfusion in the functional may provide
After 1- 2
hiya pero limitations tissues, resulting to ability/ extent information
weeks of
gin- imposed by body weakness. of impairment regarding
nursing
kakaptan la condition Accounting for a initially and on recovery. Assists in
intervention
kay evidenced by massive blood loss, a regular basis. choice of
client and
nanluluya decreased the body interventions.
significant
hiya, as muscle compensates by
others will be
verbalized strength and prioritizing the vital
able to: 2. Assessed 2. Allows the nurse
by SO. control. organs in sparing the
clients usual to identified
remaining blood,
activities on previous activities
leaving behind the
- Assume affected and initiating plan of
muscles which in
proper unaffected care regarding
turn reflects as an
positioning sides. things to do in
impairment in
such as order for the client
OBJECTIVE: physical mobility.
moderate high to perform the said
> LIMITED
Reference: back rest and activities. Maybe
ROM
FOCUS ON turning the reduced but still
>
PATHOPHYSIOLOGY, client side- promotes client
WEAKNESS
by Barbara L. side every two self-esteem and
ON
Bullock, p. 949 hours. easy rehabilitation.
EXTREMITIE
S - Use safety
measure to 3. Activity and rest
>Assistanc 3. Scheduled
minimize enhances healing
e with activity or
potential risk and build muscle
ADLs. procedures with strength and
for injury.
rest periods. endurance. Client
Encourage participation
- Demonstrate
participation in promotes sense of
the use of
ADLs within independence and
adaptive
individual control
devices to
limitations.
increase 4. Strengthen
mobility 4. Provided or abdominal
assisted with muscles and
passive and flexors of spine
- Maximize
active ROM and and promote good
tolerated ROM
strengthen body mechanics
with minimal
exercises,
pain
depending on
surgical
5. Until healing
procedure
occurs, activity is
limited and
5. Assisted with
advanced slowly
activity or
according to
progressive
individual
ambulation
tolerance

6. Proper body
6. Reviewed
mechanics reduces
proper body
the risk of muscle
mechanics or
strain, injury, or
techniques for
pain. It also
participation in
increases
activities

7. Assisted the 7. Reduces risk of

SO to have tissue ischemia/
regular injury. Affected
schedule of side has poorer
repositioning of circulation and
client (at least reduced sensation
every 2 hours; and is more
supine, side predisposed to
lying) as skin breakdown/
ordered by decubitus ulcer.
physician.

8. Prevents
contractures/
footdrop and
facilitated use
when/ if function
8. Positioned in
returns. Flaccid
prone position
paralysis may
once or twice a
interfere with
day if client can
ability to support
tolerate.
head, whereas
spastic paralysis
may lead to
deviation of head
to one side.

9. Pressure points
over bony
prominences are
most at risk for
9. Inspected decreased
skin regularly, perfusion/
particularly ischemia.
over bony
prominences.
Gently massage
10. Minimizes
any reddened
muscle atrophy,
areas.
promotes
circulation, and
10. Exercise
helps prevent
therapy: Begun
passive ROM to contractures.
all extremities
on admission.
Encourage
exercises such
as
11. Involved the
quadriceps/glut
client and SO in
eal exercise,
setting for
squeezing
increasing
rubber ball.
participation in
activities/ exercise.
11. Involved the
client and SO in
setting for
12. Individualized
increasing
program can be
participation in
developed to meet
activities/
particular needs/
exercise.
deal with deficits
in balance,
Collaborative:
coordination,
12. Consulted strength.
with physical
therapist
regarding
active, resistive
exercises and
client
ambulation.
 CUES NURSING SCIENTIFIC GOAL INTERVENTIO RATIONALE EVALUATI
DIAGNOSIS RATIONALE N PLAN ON
Subjective:Deficient Fluid In hypovolemic Short term:
Volume related shock, there is
Oo After 1-2 Independent: Goal
to hemorrhage inadequate
nagmamata weeks of partially
from ruptured circulating blood 1. Obtained 1. Helps estimate
hiya pero nursing met.
esophageal volume as a result history from total depletion.
maluyahon, interventions,
varices from of an advanced client and Symptoms may
as the client will
portal decline in the significant have been
verbalized be able to
hypertension cardiac output. The other (S0) present for
by the SO. demonstrate
as evidenced vasoconstrictive related to varying amounts
adequate
by upper compensatory duration and of time hours
hydration as
gastrointestina mechanisms of the intensity of to days.
evidence by
l bleeding. body have failed at symptoms Presenvce of
stable vital
this time, hence the such as infection process
 microcirculation signs, bleeding results in fever
dilates, leading to palpable and and
further blood loss. peripheral vomiting hypermetabolic
pulses, good and state, increasing
skin turgor excessive insensible fluid
and capillary urination. losses.
refill, 2. Hypovolemia
individually may be
appropriate manifested by
Objective:
urinary hypotension and
*Decreased
output, and tachycardia.
hemoglobin: 2. Monitored
electrolyte Estimates of
91 g/ml vital sign,
levels within severity of
(reference: specifically
normal range. hypovolemia
120- BP and the
may be made
160g/ml) RR.
when clients
*Decreased
systolic BP drops
hematocrit:
more than 10
0.29
mmhg from a
(reference:
recumbent to
0.40-0.54)
sitting or
*Body
standing
malaise
position.
*Body
Increased work
weakness
of breathing
*Pallor
shallow , rapid
*Cold
respirations and
clammy
presence of
skin
cyanosis may
indicate
respiratory
fatigue and
client is losing
 ability to
compensate for
acidosis.

3. Indicators of
level of
hydration and
3. Assessed adequacy of
peripheral circulating
pulses, volume.
capillary
refill, skin
4. Provides
turgor, and
ongoing
mucous
estimate of
membranes.
volume
replacement
4. Monitored needs, kidney
fluid intake function, and
and output effective ness of
(I&O); note therapy.
urine
specific
5. Provides the
gravity.
best assessment
of current fluid
status and
adequacy of
fluid
5. Weighed
replacement.
patient daily.

6. Changes in
mentation can
 be due
electrolyte
abnormalities,
6. Investigated acidosis,
changes in decreased
mentation cerebral
and perfusion, or
sensorium. developing
hypoxia,
Regardless of
the cause ,
impaired
consciousness
can predispose
client to
aspiration.

Types and amount

of fluid depends on
degree of deficit
and individual
clients response.

Dependent:

Administered IV
fluids, as
indicated.
 CUES NURSING SCIENTIFIC GOAL INTERVENTIO RATIONALE EVALUATI
DIAGNOSIS RATIONALE N PLAN ON
Short term: Independent
SUBJECTIV Impaired Gas Dyspnea typically Goal
E Exchange occur during shock Partially
After 2 hours 1. Assessed 1. Manifestation of
related to because of Met.
Baga man of nursing respiratory respiratory
decreased decreased tissue
iton hiya intervention rate, depth, distress are
tissue perfusion. The and ease. dependent on
hin the client will
perfusion as a respiratory rate and indicative of
nagkukuri be able:
result of the increases as the the degree of
pagginhaw
decrease in oxygen-carrying lung
a han
cardiac output capacity of the involvement and
amon a) Demonstr
brought about blood decreased. underlying
pagdad-a ate
by general health
ngadi. There is imbalance improved
hypovolemia. status.
Gintauran in amount of oxygen ventilatio
nla hiya demand and supply n and
intawon due to decreased oxygenati 2. Observed 2. Cyanosis of
on of color of skin,
hin amount of oxygen in nailbeds may
tissues by mucous
oxygen, the blood due to represent
ABGs membranes
as decrease cardiac vasoconstriction
within and nail bed,
or the bodys
verbalized output caused by noting
clients response to
by fluid loss that had acceptabl presence of fever or chills;
patients caused the e range peripheral however,
daughter. hypovolemic shock and cyanosis or cyanosis of
where the body cant absence central earlobes,
compensate the loss of cyanosis. mucous
of blood. symptom membranes ,
s of and skin around
(Focus on respirator the mouth is
Pathophysiology by y distress. indicative of
Objective: Barbara L. Bullock b) Participat systemic.
Dizzines and Reet L. Henze) e in
s actions to
Weakne maximize
oxygenati 3. Tachycardia is
ss 3. Monitored usually present
on.
BP: 70 heart rate as a result of
palpato and rhythm. fever and
ry dehydration, but
PR: 116 may represent a
BPM response of
RR: 24 hypoxia.
CPM
4. These measures
promote
maximal
4. Elevated
inspiration and
head and
enhance
positioned at
expectoration of
MHBR.
secretion to
Encouraged
improve
deep
ventilation.
breathing
and effective
coughing. 5. Identifies
problems, such
as ventilator
Collaborative
failure; follows
5. Monitored progress of
 ABGs and disease process
pulse or improvement.
oximetry.
6. Increase
amount of
oxygen available
for myocardial
6. Administered uptake;
oxygen as Oximetry
ordered; measures
maintained peripheral
continuous oxygen-
oximetry. saturation.

7. With increasing
hypoxia,
mechanical
ventilation may
be necessary to
7. Prepared for oxygenate the
intubation client
and adequately.
mechanical
ventilation if
hypoxia
increases.

(Nursing Care
Plans-
Guidelines for
individualizing
Client Care
Across the Life
Span by Marilyn
e.
 Doenges,Mary
Frances
Moorhouse,
Alice C. Murr)

CUES NURSING SCIENTIFIC GOAL INTERVENTIO RATIONALE EVALUATI

DIAGNOSIS RATIONALE N PLAN ON
Subjective: Activity Hypovolemia results Independent:
Intolerance after hemorrhage Short Term: Goals
Yana kay partially
related to due to the failure of
naghihinig After 1-2 met.
Imbalance the compensatory 1. Documente 1. Trends
da naman weeks of
between mechanisms to d heart rate determine
la iton nursing
oxygen supply maintain adequate and rhythm patients
hiya. intervention and response to
and demand as circulating blood
Waray na the patient changes in activity and
evidenced by volume. As the
hiya will be able to: BP before, may indicate
decreased condition
masyadon during, and myocardial
muscle progresses, the
g a) Demons after oxygen
strength. tissue become
ginhihimo trate activity. deprivation that
hypoxic, thus
kay dara measura Correlated may require
causing imbalance
manggud ble or with reports decrease in
in the supply and of chest activity level
na progress
demand of oxygen pain or and/or return to
maluyahon ive
at the tissue and shortness of bedrest,
na hiya, increase
cellular level. in breath. changes in
as
toleranc medication
verbalized (Focus on
e for regimen, or use
by Pathophysiology by
activity of supplemental
patients Barbara L. Bullock oxygen.
with
daughter. and Reet L. Henze)
heart
rate/rhyt
2. Reduces
hm and
Objective: myocardial
BP
workload and
 2. Encouraged oxygen
within rest initially. consumption,
Body patients Thereafter, reducing risk of
weakn normal limited complications.
ess limits activity on
Limited and skin basis of
ROM warm, pain and/or
BP: 70 pink, adverse 3. To keep the
PR: 116 dry. cardiac client diverted,
BPM response. thus less
RR: 24 focusing on his
CPM 3. Provided intolerance for
nonstress activity.
b) Report
absence diversional
of activities. 4. Activities that
angina require holding
with the breath and
activity. bearing down
4. Instructed (Valsalva
patient to maneuver) can
Long Term: avoid result in
increasing bradycardia
After 3-6 abdominal (temporarily
months of pressure reduced cardiac
nursing (coughing output) and
interventio or straining rebound
n the during tachycardia
client will defecation). with elevated
be able to BP.
easily do
ADLs 5. Progressive
without activity
any provides a
complain controlled
of demand on the
weakness heart,
and chest increasing
pain. 5. Explained strength and
pattern of preventing
graded overexertion.
increase of
activity
level: gettin
g up to
commode
or sitting in
chair, 6. Palpitations,
progressive pulse
ambulation, irregularities,
and resting development of
after meals. chest pain, or
dyspnea may
indicate need
6. Reviewed for changes in
signs and exercise
symptoms regimen or
reflecting medication.
intolerance
of present
activity 7. Provides
level or continued
requiring support and/or
notification additional
of nurse or supervision and
physician. participation in
recovery and
wellness
Collaborative: process.
7. Referred to
cardiac (8 Ed.,Nursing Care
rehabilitatio Plans- Guidelines
n program. for individualizing
Client Care Across
the Life Span by
 Marilyn e.
Doenges,Mary
Frances Moorhouse,
(8 Ed.,Nursing Alice C. Murr)
Care Plans-
Guidelines for
individualizing
Client Care
Across the Life
Span by Marilyn
e.
Doenges,Mary
Frances
Moorhouse,
Alice C. Murr)

CUES NURSING SCIENTIFIC GOAL INTERVENTION RATIONALE EVALUATI

DIAGNOSIS RATIONALE PLAN ON
Subjective: After 1-2 Independent:
weeks of
Gin Ineffective There is imbalance 1. A change in Goal
nursing 1. Assessed
kukurian ito Tissue in amount of level of partially
intervention neurologic
hiya pag Perfusion oxygen demand consciousness is met.
the patient status and
hinga hin Related to and supply due to the first signs of
will be able to vital signs
iya nga Decreased decreased amount increasing
frequently
waray Cardiac Output of oxygen in the * Maintain intracranial
and
oxygen, as as evidence by blood due to usual or pressure (ICP).
compare
verbalized dyspnea, body decreased cardiac improved LOC,
with
by SO weakness, and output caused by cognition, and
baseline
pallor. fluid loss that had motor and
values
caused the sensory 2. Elevation
.
Objective: hypovolemic shock function. facilities venous
2. Elevated
where the body drainage.
-Dyspnea *Demonstrate head of the
cant compensate
stable vital bed to 30
-Body the loss of blood.
signs, normal degree
weakness
skin color and
3. Cool, pale skin
-Pallor warm to 3. Noted color
is indicative of
touch. and
Hemoglobin decreased
temperature
: 76 * Display no peripheral tissue
of the skin
further perfusion.
Hematocrit: every 4 hrs.
deterioration
0.24
or recurrence 4. Decreased
4. Monitored
of deficits. pulses are
peripheral
indicative of
pulses every
decreased tissue
4 hrs.
perfusion from
vasoconstriction
5. Provided a
of the vessels.
warm
5. A warm
environment
environment
.
 promotes
vasodilation
which decreases
preload and
promotes tissue
6. Encouraged perfusion.
active range
of motion. 6. Range of
motion helps
decrease venous
pooling and
7. Monitored promotes tissue
urine output perfusion.
every 4 hrs.
7. Decreased
perfusion to the
8. Protected kidney may
the skin result in oliguria.
from trauma
by applying 8. Poorly
cotton sock. perfused skin
heals slowly, if at
all, once injured.