CUES NURSING SCIENTIFIC BASIS GOALS AND OUTCOME NURSING RESPONSIBILITIES RATIONALE EVALUATION

DIAGNOSIS CRITERIA
SUBJECTIVE Imbalanced Goal:
CUES: nutrition: Less After 72 hours of  Estimate/calculate coloric  Identifies nutritional
 “wa man ko than body rendering nursing care, intake. Keep comments deficiencies/needs focusing on
gana mo requirements patient will be able to about appetite a problem creator and negative
kaon day related to improve its nutritional minimum. atmosphere and may interfere with
kay decreased status. intake ( Doenges, M.E. ; pg. 369)
kapoyan appetite.  Consult with client about  Involving client in planning enables
ko” as OUTCOME CRITERIA: like/dislikes foods that client to have a sense of control and
verbalized 1.) Patient will be able cause distress, and encourages eating.
by the to demonstrate preferred meal schedule. (Doenges, M.C. , pg. 369)
patient. behaviors, lifestyle
OBJECTIVE changes to regain  Assess for abdominal  Nonverbal signs of discomfort
CUES: and/or maintain distention, frequent associated with impaired digestion,
V/S: appropriate weight. belciting , guarding, gas pain
BP: reluctance to move. (Doenges, M. E., pg 369)
T: 2.) Patient will Collaborative:
P: demonstrate  Administer intravenous  Parenteral administration of fluid &
R: progressive weight fluid and electrolytes, electrolytes, & enteral or parenteral
gain towards goal. enteral or parenteral nutrients are essential to provide
nutrition as prescribed. fluid, calories, electrolytes, &
3.) Patient will be able nutrients when oral intake is
to verbalize  Consult with prohibited.(Smeltzer., pg 1187)
understanding of dietitian/nutritional  Useful in establishing individual
causative factors support team as nutritional needs and most
when known and indicated. appropriate route (Doenges, M.
necessary E.,pg369)
interventions.  Monitor laboratory  Provides information about
studies: eq. Bun, nutritional deficit/ effectiveness of
prealbumin, albumin, therapy. (Doenges, M. E.,pg 369)
total protein, transferring
level.

CUES NURSING SCIENTIFIC BASIS GOALS AND OUTCOME NURSING RESPONSIBILITIES RATIONALE EVALUATION
 DIAGNOSIS CRITERIA
SUBJECTIVE Activity Goal: After 72 hours of
CUES: intolerance rendering nursing care,  Assess for other  Fatigue is a side effect of some
related to body patient will be able to precipitating/ causes of medication. Pain and stressful
weaknesses achieve measurable fatigue e.g., treatments, regimens also extract energy and
increase in activity pain, medication produce fatigue (Doenges, M.E. ; pg.
tolerance by reduced 55)
fatigue and weakness.  Evaluate accelerating  May denote increasing cardiac
activity intolerance. decomposition rather than over
OUTCOME CRITERIA: activity (Doenges, M.E. ; pg. 55)
1.) Patient will be able  Provide assistance with  Meets client’s personal care needs
OBJECTIVE to use identified self –care activities as without undue excessive oxygen
CUES: techniques to indicated. Interspace demand (Doenges, M.E. ; pg. 55)
enhance activity activity periods with rest
tolerance periods

2.) Patient will be able  Encourage expression of  To reduce fatigue. (Doenges, M.E. ;
to participate feelings contributing to/ pg. 67)
willingly in resulting from condition
necessary/ desired
activity  Give client information  To sustain motivation. (Doenges,
that provide evidence of M.E. ; pg. 67)
3.) Patient will identify daily/ weekly progress
negative factors
affecting activity  Encourage client to  To enhance sense of well – being
tolerance and maintain positive (Doenges, M.E. ; pg. 67)
eliminate or reduce attitude; suggest use of
their effects when relaxation techniques,
possible. such as visualization/
guided imagery as
appropriate.