CUES NURSING SCIENTIFIC GOAL & OUTCOME NURSING RATIONALE OF EVALUATION DIAGNOSIS BASIS CRITERIA ACTIONS & NURSING NURSING ORDERS ORDERS S- Imbalance Adequate nutrition is After 3 days of nurse-patient The nurse will assist GOAL MET Nutrition: Less necessary to meet the interaction, the patient will the patient in gamay than body be able to demonstrate demonstrating Patient was able to “Pirme lang body’s demand. akong makaon diri kay requirements Nutritional status can be behaviour, lifestyle changes behaviour, lifestyle demonstrate dili jud ko ganahan sa related to affected by disease or to regain appropriate weight. changes to regain behaviour, lifestyle timpla sa mga pagkaon unwillingness to injury state. appropriate weight. changes to regain nga i-rasyon.” as eat. Specifically the patient will appropriate weight. verbalized by the In the case of my be able to: The nurse will: patient. patient, her imbalanced nutrition is due to her unwillingness to eat due Verbalize Ascertain To determine GOAL to unusual taste. understanding with understanding of informational needs of PARTIALLY MET Because of her medical causative factors when individual nutritional the patient. ( Doenges, condition, food known and necessary needs. Morrhouse,Murr; 2009; Patient was able to O- preparations are intervention. p. 565) partially changed appropriate for demonstrate Weight loss her, but the change in behaviour, lifestyle Lethargic taste is not easily Discuss eating habits To appeal to changes to regain client’s Weak masked by the patient. including food tasks. ( Doenges, appropriate weight. Vital signs taken preferences, Morrhouse, Murr; 2009; as follows: intolerance and p. 565) BP: 130/70 mmHg (Gulanick/Myers; 2007; aversion. Temp: 36.3 ºC p. 134) GOAL NOT MET HR: 87 bpm Promote pleasant To enhance intake. RR: 17 cpm relieving ( Doenges, Patient was not Wt: 78 kg from environment Morrhouse, Murr; able to demonstrate 81.1 kg including 2009; p. 565) behaviour, lifestyle socialization when changes to regain possible. appropriate weight. 47
CUES NURSING DIAGNOSIS SCIENTIFIC BASIS GOAL & OUTCOME CRITERIA NURSING ACTIONS & NURSING ORDERS RATIONALE OF NURSING ORDERS EVALUATION S- “Pirme lang gamay akong makaon diri kay dili jud ko ganahan sa timpla sa mga pagkaon nga i-rasyon.” as verbalized by the patient. O- Weight loss Lethargic Weak Vital signs taken as follows: BP: 130/70 mmHg Temp: 36.3 ºC HR: 87 bpm RR: 17 cpm Wt: 78 kg from 81.1 kg Imbalance Nutrition: Less than body requirements related to unwillingness to eat. Adequate nutrition is necessary to meet the body’s demand. Nutritional status can be affected by disease or injury state. In the case of my patient, her imbalanced nutrition is due to her unwillingness to eat due to unusual taste. Because of her medical condition, food preparations are changed appropriate for her, but the change in taste is not easily masked by the patient. (Gulanick/Myers; 2007; p. 134) After 3 days of nurse-patient interaction, the patient will be able to demonstrate behaviour, lifestyle changes to regain appropriate weight. Specifically the patient will be able to: Verbalize understanding with causative factors when known and necessary intervention. The nurse will assist the patient in demonstrating behaviour, lifestyle changes to regain appropriate weight. The nurse will: Ascertain understanding of individual nutritional needs. Discuss eating habits including food preferences, intolerance and aversion. Promote pleasant relieving environment including socialization when possible. To determine informational needs of the patient. ( Doenges, Morrhouse,Murr; 2009; p. 565) To appeal to client’s tasks. ( Doenges, Morrhouse, Murr; 2009; p. 565) To enhance intake. ( Doenges, Morrhouse, Murr; 2009; p. 565) GOAL MET Patient was able to demonstrate behaviour, lifestyle changes to regain appropriate weight. GOAL PARTIALLY MET Patient was able to partially demonstrate behaviour, lifestyle changes to regain appropriate weight. GOAL NOT MET Patient was not able to demonstrate behaviour, lifestyle changes to regain appropriate weight. 47
39575185-NCP-diabetes-mellitus.docx