CUES NURSING DIAGNOSIS

OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective

Cues:“Kabalo ko nga naa koy high blood pero karon wala naku gatumaron nga tambal kalimot napud ko kung unsa too gihatag sa akong doctor,” as verbalized by Mrs. U.

Objective No

medications

Risk for noncompliance related to lack of knowledge about the health status, cost of therapy, and multiple changes in lifestyle.

At the end of 1 week, the client will actively participate in creating a treatment plan, expressing commitment to and adhering to scheduled follow-up appointments.

INDEPENDENT:

1. Provide guidelines that include information about hypertension.

2. Instruct the client about strict compliance of medications.

3. Teach the client about stress management and importance of divertional activities and lifestyle changes

DEPENDENT:4. Consult a physician and follow scheduled check-up

1. To teach and inform the client about his condition

2. To minimize onset of high BP.

3. To provide an outlet for emotional tensions; to minimize the occurrence of high BP

4. To check current health status

Goal partially met.After 1 week, the client was able to participate in the treatment plan.

A. ACTUAL NURSING MANAGEMENT

CUES NURSING DIAGNOSIS

OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective cues:“Sakit akong kilid sa akong dughan kay nadigyas man gud ko daun nabunggo ko sa kilid sa akong lamesa,” as verbalized by Mrs. U.

Objective

Facial grimace

Guarding on the painful site

Rubbing the painful area

Severity of pain (pain scale: 5)

Pain related to bone injury as evidenced by facial grimace.

At the end of 15 minutes, client will report alleviation of pain onset.

INDEPENDENT:

1. Provide cutaneous stimulation (therapeutic touch)

2. Apply heating pads and warming towel

3. Provide cold applications (if warm application was not done)

DEPENDENT:

4. Administer pain meds (analgesics), per doctor’s order

1. to decrease intensity of pain that the client perceives

2. To promote vasodilation thus allowing sufficient blood flow changes

3. to prevent edema formation and inflammation

4. To obtain satisfactory pain relief

Goal partially met.

After 15 minutes, the client was able to verbalize alleviation of pain onset.

CUES NURSING DIAGNOSIS

OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective Cues:

“Gasakit akong tiil,usahay, samot na kung mag lakaw ko ug layo, maghawoy napud daun ug maminhod,” As verbalized by Mrs. U.Objective Cues:

Patient cannot walk without her crutches

Impaired physical mobility related to musculoskeletal pain and discomfort as evidenced by reports of pain and decreased muscle strength

At the end of 1 week, client will be able to display increased strength and function.

INDEPENDENT:

1. Demonstrate/ assist with transfer techniques and use of mobility aids e.g. crutches.

2. Support position with pillow

3. Investigate sudden increase in pain

DEPENDENT

4. Consult with physical or occupational therapists or rehabilitation specialists

1. To facilitate self-care and client’s independence.

2. to avoid prolonged tissue pressure and prevent risk of tissue breakdown

3. to monitor signs of possible development of complications

4. It is useful in creating individualized activity or exercise program

Goal partially met.After 1 week, the patient was able to verbalize increased muscle strength and functioning of the affected limb.

XV. FAMILY HEALTH CARE PLAN:

CUES HEALTHPROBLEM

FAMILYNURSING

PROBLEMSGOAL OF

CAREOBJECTIVES

OF CAREINTERVENTION

MEASURES

METHODSOF NURSE-

FAMILYCONTACT

EVALUATION

Subjective:“Gamay ra jud akong kita kada adlaw, igo ra na maka kaon ko, as verbalized by Mrs. U.

Objective:Earnings: 50-70 php/day

Low family income as a foreseeable crisis

Inability to make decisions with respect to taking appropriate health action and inability to decide which action to take from among a list of alternatives.

The families will find enough resources that could sustain family health needs.

Identify ways to utilize family income wisely and earn money from health civilization.

1. Encourage the family to find additional ways to earn money.

2. Encourage family to prioritize needs.

3. Encourage the family to minimize unnecessary spending.

Home visit 1. The family was encouraged to find additional ways to earn money.

2. The family was encouraged to prioritize needs.

3. The family was encouraged to minimize unnecessary spending.

CUES FAMILY HEALTH PROBLEM

OBJECTIVES INTERVENTIONS EVALUATION

Subjective: “Wala mi sakto nga agianan sa tubig, wala mi kanal nga permanente”, as verbalized by the wife.

Objective: No proper

drainage

Presence of health threat due to lack of sanitation and danger with regards to waste management.

At the end of 30 minutes of discussing the hazards of having no proper drainage at home, Mrs. Eva Alaan will do something about this and to achieve proper drainage.

 Discuss and demonstrate to the family the importance of having a clean environment, proper drainage system and the advantages it brings to the family.

At the end of the 30 minutes discussion on cleanliness and the importance of having proper drainage system, the family showed eagerness to do their best in cleaning their area especially making proper drainage system.

CUES HEALTHPROBLEM

FAMILYNURSING

PROBLEMSGOAL OF

CAREOBJECTIVES

OF CAREINTERVENTION

MEASURES

METHODSOF NURSE-

FAMILYCONTACT

EVALUATION

Subjective:“Gamay ra jud akong kita kada adlaw, igo ra na maka kaon ko, as verbalized by Mrs. U.

Objective:Earnings: 50-70 php/day

Low family income as a foreseeable crisis

Inability to make decisions with respect to taking appropriate health action and inability to decide which action to take from among a list of alternatives.

The families will find enough resources that could sustain family health needs.

Identify ways to utilize family income wisely and earn money from health civilization.

1. Encourage the family to find additional ways to earn money.

2. Encourage family to prioritize needs.

3. Encourage the family to minimize unnecessary spending.

Home visit 1. The family was encouraged to find additional ways to earn money.

2. The family was encouraged to prioritize needs.

3. The family was encouraged to minimize unnecessary spending.