CUES NURSING SCIENTIFIC GOAL & OUTCOME NURSING RATIONALE OF EVALUATION DIAGNOSIS BASIS CRITERIA ACTIONS & NURSING NURSING ORDERS ORDERS S- Fatigue related Fatigue is subjective After 3 days of nurse-patient The nurse will assist GOAL MET lang jud ko to poor physical complaint of both acute interaction, the patient will the client in attaining “ Permi nagluya diri, wa man condition. and chronic illness. be able to report improved the goal of reporting Patient was able to gud koy lain mabuhat sense of energy. improved sense of report improved diri sige lang energy. og higda.” sense of energy. as verbalized by the In the case of my Specifically, the patient will patient. patient, fatigue was felt be able to: The nurse will: by her due to poor GOAL physical condition, and PARTIALLY MET persistent lying on bed. Identify basis of Assess the vital To evaluate fluid status O- Due to hospitalization fatigue and signs. and cardiopulmonary Patient was able to Lethargic and her medical individual areas of response to activity. partially report Weakness condition together with control. ( Doenges, Morrhouse, improved sense of Drowsy the treatment, barriers Murr; 2009; p. 352) energy. Listless are also there to add on Decreased it. Note daily energy This may be helpful in performance pattern. determining pattern/ GOAL NOT MET Vital signs taken (Gulanick/ Myers; timing of activity. as follow: 2007; p. 65) ( Doenges, Morrhouse, Patient was not Murr; 2009; p. 563) able to report BP: 130/ 70 mmHg improved sense of Temp: 36.3 ºC Determine Fatigue can be a energy. HR: 87 bpm presence/ degree consequence of RR: 17 cpm of sleep exacerbated sleep. disturbances. ( Doenges, Morrhouse, Murr; 2009; p. 352) Participate in Establish realistic Enhances commitment recommended activity goal with to promoting optimal treatment program. client and outcomes. encourage ( Doenges, Morrhouse, forward Murr; 2009; p. 354) movements. 49
CUES NURSING DIAGNOSIS SCIENTIFIC BASIS GOAL & OUTCOME CRITERIA NURSING ACTIONS & NURSING ORDERS RATIONALE OF NURSING ORDERS EVALUATION S- “ Permi lang jud ko nagluya diri, wa man gud koy lain mabuhat diri sige lang og higda.” as verbalized by the patient. O- Lethargic Weakness Drowsy Listless Decreased performance Vital signs taken as follow: BP: 130/ 70 mmHg Temp: 36.3 ºC HR: 87 bpm RR: 17 cpm Fatigue related to poor physical condition. Fatigue is subjective complaint of both acute and chronic illness. In the case of my patient, fatigue was felt by her due to poor physical condition, and persistent lying on bed. Due to hospitalization and her medical condition together with the treatment, barriers are also there to add on it. (Gulanick/ Myers; 2007; p. 65) After 3 days of nurse-patient interaction, the patient will be able to report improved sense of energy. Specifically, the patient will be able to: Identify basis of fatigue and individual areas of control. Participate in recommended treatment program. The nurse will assist the client in attaining the goal of reporting improved sense of energy. The nurse will: Assess the vital signs. Note daily energy pattern. Determine presence/ degree of sleep disturbances. Establish realistic activity goal with client and encourage forward movements. To evaluate fluid status and cardiopulmonary response to activity. ( Doenges, Morrhouse, Murr; 2009; p. 352) This may be helpful in determining pattern/ timing of activity. ( Doenges, Morrhouse, Murr; 2009; p. 563) Fatigue can be a consequence of exacerbated sleep. ( Doenges, Morrhouse, Murr; 2009; p. 352) Enhances commitment to promoting optimal outcomes. ( Doenges, Morrhouse, Murr; 2009; p. 354) GOAL MET Patient was able to report improved sense of energy. GOAL PARTIALLY MET Patient was able to partially report improved sense of energy. GOAL NOT MET Patient was not able to report improved sense of energy. 49
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