NURSING SCIENTIFIC NURSING

CUES/CLUES OBJECTIVES ANALYSIS EVALUATION

DIAGNOSIS RATIONALE INTERVENTIONS
• Coughing is the most
effective way to remove
• Assess cough
• Patient will effectiveness and
secretions.
maintain productivity
• Airway clearance is
• Objective:
Impaired gas optimal gas
hindered with inadequate
exchange as • Assess the patient’s
1. RR: 32 bpm exchange hydration and thickening
Impaired happens with evidenced hydration status.
of secretions. • Patient has
Gas an excess o by a normal decreased and
Subjective: • Elevate head of bed,
Exchange deficit in respiratory • promote chest expansion, normal RR of 20
change position
1. Complaint of related to aeration of lung segments, bpm.
oxygenation rate. frequently.
Difficulty of mobilization and
Breathing collection of and/or expectoration of • Patient verbalized
mucus in the carbon • Patient will • Teach and assist ease in breathing
2. Verbalized secretions.
dioxide verbalize patient with proper
feeling of airways deep-breathing
and better
“Hingal”
(Pneumonia) elimination at ease of • facilitates maximum expectoration of
3. Reported and the veolar- breathing expansion, most helpful sputum.
• Maintain adequate
greenish capillary after hydration by forcing
way to remove most
sputum upon secretions.
coughing membrane performing fluids to at least 3000
• aid in mobilization and
nursing mL/day unless
expectoration of
contraindicated
interventions secretions.
• Encourage ambulation
• Helps mobilize secretions
and prevent atelectasis
 NURSING SCIENTIFIC NURSING
CUES/CLUES OBJECTIVES ANALYSIS EVALUATION
DIAGNOSIS RATIONALE INTERVENTIONS
• Patient is
• Objective:
state or normovolemic
- Dark Yellow condition where as evidenced • Oral fluid replacement is
urine
the fluid output indicated for mild fluid deficit
by systolic BP • Urge to increase oral • Patient has
- Turbid urine exceeds the fluid and is a cost-effective method
greater than or fluid intake or for replacement treatment. normalized BP
intake. It prescribed fluid Older patients have a
- Decreased Na and HR as well as
happens when equal to 90 decreased sense of thirst and
(120 meq) intake.
water mm HG (or may need ongoing reminders Sodium values.
- Decreased BP
• Maintain IV flow rate to drink.
and electrolytes 
90/50 Fluid Volume patient’s • Provide measure to • To be able to properly monitor • Patient and
are lost as they
exist in normal baseline) and prevent excessive the amount of fluid going into
relatives can
- Tachycardia: Deficit electrolyte loss the patient’s system.
129 bpm body fluids. with a normal • Fluid losses from diarrhea and interventions to
Common • Emphasize the or vomiting should be prevent further
• Subjective: HR. relevance of
sources of fluid replaced or treated with
antidiarrheals and anti-emetics water loss to
- Report of watery loss are the maintaining proper
• Patient • increasing the patient’s prevent
stools gastrointestinal hydration and knowledge would help
explains nutrition. dehydration.
tract, polyuria, prevent and manage the
- 9 episodes of
vomiting and increased measures to problem.
perspiration prevent water
loss.