Cues

Nursing Diagnosis

Planning

Interventions

Rationale

Evaluation

Objective:

Situational low selfesteem related to

After 8 hours of nursing interventions, the patient will verbalize concerns and indicate healthy ways of dealing with them

Provide time to listen to concerns and fears of client

To make opportunities for support, teaching and correction for misconception

Goal partially met as evidenced by: The patient was able to verbalize her feelings and concern

Lack of eye contact Passivity Limited movement

concerns about femininity, effect on sexual relationship and inability to have children

Ascertain individual strength and identify previous positive coping behaviors

To build on strengths already available for client to use in coping with current situation

Provide open environment for client to discuss concerns about sexuality

To promote sharing of beliefs/values about sensitive subject, and identifies misconceptions/myths that may interfere with adjustment to the situation

Refer to pastoral staff, psychiatric clinical nurse specialist, and other professionals for counseling as necessary

To have additional help to resolve feelings about loss

Cues

Nursing Diagnosis

Planning

Interventions

Rationale

Evaluation

Objective: Temperature 38.1 Weakness Restlessness Flushed skin

Hyperthermia related to inappropriate clothing factor

After 4 hours of nursing interventions, the patient will be maintaining a normal body temperature

Establish good working condition with the patient.

To gain the patients trust

Goal partially met as evidenced by: The patients body temperature have

Monitors vital signs every 2 hours

To have a baseline data

maintained normal body temprature

Provide TSB

To maintain a normal body temperature

Encourage increase fluid intake

To replace fluid loss

Review sign/symptoms of hyperthermia

To promote wellness and indicate need for prompt intervention

Encourage food rich in Vitamin C

To boost body resistance to infection

Provide client safety

To prevent further injuries

Maintain bed rest

To preserve energy