NOTE: 1 SUBJECTIVE AND DIAGNOSIS AND 5 INTERVENTIONS (BSE)
Defining Nursing Diagnosis Scientific Analysis Goal of care Intervention Rationale
Characteristics
SUBJECTIVE: Impaired gas exchange Pneumonia is an SHORT TERM: INDependent: Dependent:
Pt verbalized related to pneumonia inflammatory condition After 2 hrs of nursing 1. Monitor oxygen saturation 1. TPulse oximetry is a useful tool to
“Mobarog ko of the lung. It is often intervention, the continuously, using a pulse detect changes in oxygenation
ganahan ko characterized as patient will have oximeter. 2. A proper positioning increases
mangluwa” including inflammation oxygen saturation 2. Assess client’s position to lung expansion
of the parenchyma of of greater than increase oxygenation 3. Retained secretions weaken
the lung and abnormal 95%. 3. Assess the client’s gas exchange
OBJECTIVE alveolar filling with ability to cough out
fluid. Typical symptoms secretions INDEPENDENT:
-Difficulty associated with 1. Oxygen therapy can increase
breathing pneumonia include LONG TERM: dependent: the oxygen levels, preventing
-Use of accessory cough, chest pain, fever, After a week of 1. Administer 02 at 4 LPM via hypoxia and hypoxemia
muscles and difficulty in nursing intervention, nasal cannula 2. Medications are ordered based
-Decreased oxygen breathing. patient will be able 2. Administer on the cause of the impaired gas
saturation to maintain 02 medications as ordered exchange
-Increased heart saturation level
rate within normal range
-Productive cough and demonstrate Collaborative:
with sputum Source: Hinkle, J. L., & effective coughing. Collaborative 1. Respiratory therapists may
Cheever, K. H. 1. Collaborate with the recommend the appropriate
BP – 130/70 respiratory therapist intervention for the patient.
(2014). Brunner &
T – 35.5 Suddarth's textbook of
P- 112 medical-surgical
R - 21 nursing (Edition 13.).
02 - 93 Wolters Kluwer
Health/Lippincott
Williams & Wilkins.
Defining Nursing Diagnosis Scientific Analysis Goal of care Intervention Rationale
Characteristics
SUBJECTIVE Diabetes mellitus AEB Hyperglycemia or SHORT TERM GOAL: INDEPENDENT: DEPENDENT:
- increase in blood elevated blood glucose After 1-2 weeks of 1. Encourage lifestyle 1. Lifestyle modifications
glucose level levels happen when the nursing intervention, modifications including healthy eating habits
body has too little patient will be able 2. Monitor the 2. In an attempt to rid the body
OBJECTIVE: insulin or when the understand the of excess glucose, the kidneys
-Blood glucose body can't use insulin factors that can client’s urine output.
excrete glucose along with water
level of 221mg/dl properly. It may occur in contribute to high and electrolytes which would lead to
-Client looks weak a variety of situations. blood glucose levels, DEPENDENT:
dehydration.
-Swelling of Diabetes mellitus is the will enhance lifestyle 1. Administer medications
as indicated.
extremities most common disorder modifications and INDEPENDENT:
2. Instruct on the use of
associated with adhere to glucometers or other 1. Insulin and other
elevated blood glucose medications. equipment. antidiabetic agents may be
BP – 130/70 levels. Certain drugs administered to help lower
T – 35.5 have hyperglycemia as a LONG TERM GOAL: blood glucose levels
P- 112 side effect After 3-6 weeks of COLLABORATIVE: 2. To properly assess and
R - 21 nursing intervention, manage hyperglycemia, the
02 - 93 patient will be able 1. Refer to a dietician.
patient must understand how
Source: Hinkle, J. L., & to maintain a blood to check their glucose levels.
Cheever, K. H. glucose level within
(2014). Brunner & normal range. COLLABORATIVE:
Suddarth's textbook of 1. Dieticians can instruct on
medical-surgical specific dietary changes and
nursing (Edition 13.). provide resources on which
Wolters Kluwer foods to eat, what to limit,
Health/Lippincott and how to read food labels.
Williams & Wilkins.
NOTE: 1 SUBJECTIVE AND DIAGNOSIS AND 5 INTERVENTIONS (INDWELLING CATHETER INSERTION)
Defining Nursing Diagnosis Scientific Analysis Goal of care Intervention Rationale
Characteristics
Impaired skin integrity Edema SHORT TERM: INDEPENDENT: INDEPENDENT:
SUBJECTIVE: AEB swelling in the After 8 hours of 1. Perform a complete skin 1. Routine skin assessments help
“Pt verbalized arm nursing intervention, assessment determine progression and
“ngolngol akong SOURCE: Pilliteri, Adele the patient will 2. Keep the skin clean appropriate interventions for patient
and dry care.
kamot” and Silbert-Flagg, verbalize
2. To reduce the risk of skin
JoAnne (2018) Maternal understanding of risk
and Child Health factors and damage, the affected area
Nursing, 8th Edition demonstrate DEPENDENT: must be kept clean and dry.
OBJECTIVE: interventions that 1. Administer medication as
-Swelling in the left prevent impaired ordered by the physician
arm skin integrity DEPENDENT:
-Tight, shiny skin 1. Medication that alleviate
-Warmth LONG TERM: COLLABORATIVE: swelling on extremities
After 3-4 days of 1. Consult a specialist
nursing intervention, COLLABORATIVE:
BP – 130/70 the client will be able 1. Depending on the underlying
T – 35.5 to improved skin cause of the swelling,
P- 112 integrity and consultation with a specialist,
R - 21 decrease swelling in may be warranted
02 - 93 the extremities
NOTE: 1 SUBJECTIVE AND DIAGNOSIS AND 5 INTERVENTIONS (NASOGASTRIC TUBE INTUBATION)
Defining Nursing Diagnosis Scientific Analysis Goal of care Intervention Rationale
Characteristics
Subjective: Short term: Independent:
Long term: Dependent:
Objective:
Collaboration:
NOTE: 1 SUBJECTIVE AND DIAGNOSIS AND 5 INTERVENTIONS (OBTAINING CAPILLARY BLOOD SAMPLE FOR GLUCOSE TEST)
Defining Nursing Diagnosis Scientific Analysis Goal of care Intervention Rationale
Characteristics
Subjective: Anemia related to Chronic kidney disease (CKD) is SHORT TERM: Independent: Independent:
“naa koy anemia chronic kidney an umbrella term that After one to two 1. Monitor the level of 1. Anemia may cause cerebral hypoxia
describes kidney damage or a consciousness and behavior. manifested by changes in mentation,
ma’am og usahay disease as evidenced weeks of nursing
decrease in the glomerular 2. Support the patient in orientation, and behavioral responses.
maka pamati ko og by decrease filtration rate (GFR) for 3 or more intervention, the
coping with a chronic disease. 2. It can be unsettling for the patient to
kalipong .” erythropoietin months (Thomas-Hawkins & patient will
3. Educate patient on receive a chronic renal disease
Zazworsky, 2005). CKD is demonstrate an diagnosis. Give the patient time to adjust
nutritional diet and accept the diagnosis.
associated with decreased quality increase in
of life, increased health care hemoglobin levels. 3. recommend a specialized diet for
expenditures, and pre patients with CKD, ensuring careful
mature death. Untreated CKD can consideration of the patient’s nutritional
Objective: result in end-stage renal disease status, fluid needs, and kidney health.
Dependent:
-Hypertension (ESRD) and necessitate renal 1. Administer erythropoietin as
-Dizziness replacement therapy (dialysis or prescribed.
-Decrease RBC kidney transplantation). LONG TERM: 2. Monitor Hemoglobin and
-Decrease After three to six Hematocrit Level AS ORDERED Dependent:
hemoglobin SOURCE: months of nursing 1. Iron deficiency is common in CKD,
-Decrease Brunner, L. S., Suddarth, intervention, the Collaborative: and anemia is a risk factor for poor
hematocrit D. S., Smeltzer, S. patient with chronic 2 Collaborate with the
scores on neuropsychological tests.
2. Regularly assess hemoglobin and
C.. (2010). Brunner & kidney disease interdisciplinary team.
hematocrit levels to monitor the
Vital signs: (CKD) and evidence
Suddarth's textbook of severity of anemia and the
BP of decreased effectiveness of interventions.
T medical-surgical erythropoietin
P nursing. (12th). Lippincott production will
R Williams & Wilkins. achieve and Collaborative:
O2 maintain
hemoglobin levels 2. Nephrologists are the
within the normal providers who manage and
range. guide the treatment of patients
with CKD.
EVALUATION
After one to two weeks of nursing intervention, the patient was able to demonstrate an increase in hemoglobin levels.
After three to six months of nursing intervention, the patient with chronic kidney disease (CKD) and evidence of decreased erythropoietin
production was able to achieve and maintain hemoglobin levels within the normal range.
