CUES/DATA NURSING DIAGNOSIS GOALS AND NURSING RATIONALE EVALUATION

OBJECTIVES INTERVENTIONS
Objective Data: Hyperthermia related Long term goal: - Assess clients - To assess Goal met as
Patient M.N. is to inflammatory After 3 hours of condition causative evidenced by:
diagnosed with Acute process secondary to nursing intervention, condition.
Cholecystitis. disease process as the patient will be - Established - To gain clients - Reduced body
VS as follows: manifested by able to reduce body Rapport trust and temperature
- Body elevated body temperature from cooperation. from 38.3 C to
temperature temperature above 38.3 C to 37.2 and - Monitor VS - To obtain base 37.2
above normal normal range. other vital signs line data.
range 101oC within normal range. - Other vital signs
(38.3oC) - Perform Tepid - To reduce body within normal
- Tachycardia (118 Short term goal: Sponge Bath temperature range.
beats/min) After 30 mins. of
- Tachypnea (24 nursing intervention - Adjust and - Room
breaths/min) client will be able to: monitor temperature may
- Blood pressure a.) Gain knowledge environmental be accustomed
above normal about ways to factors like room to near normal
range 148/82 reduce body temperature and body
mm Hg temperature to bed linens as temperature and
- SpO2 below normal range indicated. blankets and
normal range linens may be
92% b.) Maintain body adjusted as
temperature indicated to
within normal regulate
range temperature of
the patient.

- Eliminate excess - Exposing skin to

clothing and room air
covers. decreases
warmth and
increases
 evaporative
cooling.

- Give antipyretic - Antipyretic

medications as medications
prescribed. lower body
temperature by
blocking the
synthesis of
prostaglandins
that act in the
hypothalamus.

- Administer - an antibiotic
Ampicillin used to prevent
(Omnipen) 2g and treat a
IVPB q6h number of
bacterial
infections
 CUES/DATA NURSING DIAGNOSIS GOALS AND NURSING RATIONALE EVALUATION
OBJECTIVES INTERVENTION
Objective: Ineffective Breathing After 3 hours of - Assess clients - To assess Goal met as
- Decreased pattern related to Nursing Intervention condition causative evidenced by:
breath sounds decreased rate and the client will condition
- Crackles in the depth of respirations experience adequate - Established - To gain clients - Normal rate and
right base associated with the respiratory function Rapport cooperation depth of
posteriorly depressant effect of as evidence by: respirations
- Right middle and anesthesia and some a. Normal rate and - Monitor VS - To obtain - Absence of
lower lobes medications as depth of baseline data dyspnea and
percussed manifested by respirations hypoxia
slightly dull dyspnea and hypoxia b. Absence of - Apply oxygen per - To return Oxygen - Normal breath
- Splinting dyspnea and protocol because saturation within sounds
- Skin is pale, hypoxia her spo2 is below normal range - Spo2 within
warm and dry c. Normal breath 95% normal range as
- Use of Morphine sounds evidenced by
Sulfate 10 mg IM d. Oximetry results - Cough and - Helps in resolving increase in spo2
q4h prn for pain within normal Breathing the post- from 92% to 95%
range exercise every operative
VS as follows: hour. pulmonary
- BP> 148/82 mm Hg complications
- HR> 118 one may suffer.
beats/min
- RR> 24 - Explain and - Helps improving
breaths/min demonstrate the the functioning
- Temperature> correct use of the of the lungs.
101oF(38.3oC) IS
- 15:30 SpO2> 92%
(Hypoxia) - dangle on the - Help in
- 18:30 SpO2> side of the bed as maintaining
93%(Hypoxia) ordered. muscle strength,
tone and
flexibility of
joints.
- Turn and - Helps in resolving
Reposition every the post-
2 hours operative
pulmonary
complications
one may suffer.
 CUES/DATA NURSING DIAGNOSIS GOALS AND NURSING RATIONALE EVALUATION
OBJECTIVES INTERVENTIONS
Subjective: Knowledge Deficit After 30minutes of - Assess clients - To assess The patient and
Patient M.N.s related to lack of Nursing Intervention condition causative guardian expressed
guardian verbalized information about the guardian and the condition an understanding of
I dont understand. the disease process, client will gain - Established - To gain clients the condition/
She came in here treatment knowledge about the Rapport trust and disease process
with a bad procedures at the diseases process, cooperation
gallbladder. What hospital as treatment procedure - Render health - To gain Identify the
has happened to her manifested by at the hospital as teaching as knowledge about relationship sign /
lungs? occurrence of evidenced by: follows: the disease symptom of the
complications that process disease process and
can be prevented. - The patient and a. What is connect with the
guardian atelectasis causes.
expressed b. Risk factors of
understanding of atelectasis Making changes to
the Anesthesia lifestyle and
condition/disease Prolonged participating in
process and bed rest treatment programs.
treatment. with few
- Patient and changes in
guardian position
identifying c. Sign and
relationships symptoms of
signs / symptoms atelectasis
of the disease d. Ways to
process and its manage the
relation to factor disease
causes. e. Treatments
- Patient initiating that will be
lifestyle changes used
and participate in
treatment
measures.