CUES NURSING SCIENTIFIC GOAL & OUTCOME NURSING RATIONALE OF EVALUATION DIAGNOSIS BASIS CRITERIA ACTIONS & NURSING NURSING ORDERS ORDERS S- Self-care Self-care deficit may be After 3 days of nurse-patient The nurse will assist GOAL MET Wa koy gana maligo deficit: bathing, the result of transient interactions, the patient will the patient in achieving “ og maglihok-lihok kay dressing, limitations, such as be able to perform self-care the goal which is to Patient was able to kapoy kaayo akong feeding, those being activities within level of perform self-care perform self-care as verbalized by toileting related hospitalized. own ability. activities within level activities within lawas.” the patient. to fatigue. of activity. level of own In the case of my Specifically, the patient will ability. patient, she is deficit in be able to: The nurse will: self-care due to frequent O- fatigability she feels GOAL Dry, tangled and weakness she Identify individual Assess barriers to To be able to provide PARTIALLY MET hair usually met. Due to area of weakness or participation. deeper intervention Lethargic prolonged bedrest she is needs. depending on the Patient was able to Bedrest unable to fully provide assessed reasons of partially perform Frequent herself care. unparticipation. self-care activities yawning ( Doenges, Morrhouse, within level of own Weak (Gulanick/Myers; 2007; Murr; 2009; p. 710) ability. Vital signs taken p. 156) as follows: Promote To enhance commitment client’s participation in to plan, optimizing GOAL NOT MET BP: 130/ 70 mmHg problem outcomes, and Temp: 36.3 ºC identification and supporting recovery and Patient was not HR: 87 bpm desired goals and health promotion. able to perform RR: 17 cpm decision making. ( Doenges, Morrhouse, self-care activities Murr; 2009; p. 711) within level of own ability. Assist with To encourage client and necessary build on success. adaptations to ( Doenges, Morrhouse, accomplish Murr; 2009; p. 711) ADL’s. 51
CUES NURSING DIAGNOSIS SCIENTIFIC BASIS GOAL & OUTCOME CRITERIA NURSING ACTIONS & NURSING ORDERS RATIONALE OF NURSING ORDERS EVALUATION S- “ Wa koy gana maligo og maglihok-lihok kay kapoy kaayo akong lawas.” as verbalized by the patient. O- Dry, tangled hair Lethargic Bedrest Frequent yawning Weak Vital signs taken as follows: BP: 130/ 70 mmHg Temp: 36.3 ºC HR: 87 bpm RR: 17 cpm Self-care deficit: bathing, dressing, feeding, toileting related to fatigue. Self-care deficit may be the result of transient limitations, such as those being hospitalized. In the case of my patient, she is deficit in self-care due to frequent fatigability she feels and weakness she usually met. Due to prolonged bedrest she is unable to fully provide herself care. (Gulanick/Myers; 2007; p. 156) After 3 days of nurse-patient interactions, the patient will be able to perform self-care activities within level of own ability. Specifically, the patient will be able to: Identify individual area of weakness or needs. The nurse will assist the patient in achieving the goal which is to perform self-care activities within level of activity. The nurse will: Assess barriers to participation. Promote client’s participation in problem identification and desired goals and decision making. Assist with necessary adaptations to accomplish ADL’s. To be able to provide deeper intervention depending on the assessed reasons of unparticipation. ( Doenges, Morrhouse, Murr; 2009; p. 710) To enhance commitment to plan, optimizing outcomes, and supporting recovery and health promotion. ( Doenges, Morrhouse, Murr; 2009; p. 711) To encourage client and build on success. ( Doenges, Morrhouse, Murr; 2009; p. 711) GOAL MET Patient was able to perform self-care activities within level of own ability. GOAL PARTIALLY MET Patient was able to partially perform self-care activities within level of own ability. GOAL NOT MET Patient was not able to perform self-care activities within level of own ability. 51
39575185-NCP-diabetes-mellitus.docx