ASSESSME DIAGNOSI ANLYSIS OBJECTIV NURSING NURSING RATIONA EVALUATIO

NT S OF THE ES ACTIONS ORDERS LE N

PROBLE
M
Subjective: Ineffective Decreas Within 2- -To -Identify -To After 2-3
“My legs Tissue e in 3 days of assess changes easily days of
feel cramp- Perfusion oxygen nursing causative/ related to treat and nursing
like pain Related to resultin interventi contributi systemic focus the interventio
which relative g in the on, the ng factors and/or causes n, the
increases hypovolem failure patient peripheral patient
when ia as to will alterations demonstrat
moving it.” evidenced nourish demonstr in es
by the ate circulation increased
Objective: reduced tissues increased like vital perfusion
-edema weight at the perfusion sign as
-PR- gain capillary as -To changes -To individually
level individuall maximize - enhance appropriate
y tissue encourage venous .
appropria perfusion early return
te. ambulatio
n, when -To
possible reduce
-To -apply ice edema
promote and -to
wellness elevate decrease
limb tension
- level
Demonstra
te/ -Promote
encourage good
use of circulatio
relaxation n
activities
-promote
regular
exercise
ASSESSME DIAGNOSI ANALYSIS OBJECTIVES NURSING NURSIN RATIONAL EVALUATI
NT S OF THE ACTION G E ON
PROBLEM ORDER
Subjective: Knowledg Absence or Within 1-2 -To -To - After 1-2
“What e deficit deficiency hours of assess determi Individual hours of
should I do regarding of cognitive nursing readines ne may not nursing
to self- information interventio s to learn client’s be interventio
maintain care/nutri n, the and ability/r physically n, the
my normal tional patient will individua eadines , patient will
health needs verbalize l learning s and emotional verbalize
status?” related to understand needs barriers ly or understan
lack of ing of to mentally ding of
informati condition learning capable condition
on/recall -To at this
as assess time
evidence the -identify -
d by client’s motivati motivatio
asking motivatio ng n may be
questions n factors negative
for the or
individu positive
al -can
-provide encourag
informat e
-to ion continuati
establish relevant on of
priorities only to efforts
in the -for client
conjuncti situatio to feel
on n competen
-relate t and
informat respected
 ion to
client’s
personal
desires
or
needs
and
values/b
eliefs

ASSESSME DIAGNO ANALYSI OBJECTIV NURSING NURSSI RATIONA EVALUATI

NT SIS S OF E ACTION NG LE ON
PROBLE ORDER
M
Subjective Decreas Alteratio Within 2-3 -to -Monitor -to After 2-3
: ed n in the days of assess vital provide days of
“I feel cardiac blood nursing degree signs baseline nursing
dizzy output pumped interventi of for interventi
sometime related by the on, the debilitati comparis on, the
s.” to heart to patient on on to patient
decreas meet will follow will
Objective: ed the maintain trends maintain
-BP venous metaboli normal normal
- return c blood - -to blood
tachycardi as demand pressure -to administ increase pressure
a evidence s of the minimize er high oxygen
d by body or flow available
increase correct oxygen for
d blood causativ via cardiac
pressure e factors mask or function
ventilato
r as
indicate
 d

ASSESSM DIAGNO ANALYS OBJECTIV NURSING NURSSING ORDER RATIONALE EVALUATI

ENT SIS IS OF E ACTION ON
PROBLE
M
Subjective Acute Within 1-2 -to assess -determine presence -to easily treat the After 1-2
: pain hours of etiology/precipit of possible patho- cause of pain hours of
“My back nursing ating physiological/psychol nursing
hurts a interventi contributory ogical cause of pain interventi
bit” on, the factors -to rule out on, the
patient -obtain client’s worsening of patient
Objective: will assessment of pain underlying will
Restlessn verbalize -to evaluate to include location, condition/develop verbalize
ess relief client’s response characteristic, ment of relief from
PR- from pain to pain onset/duration, complications pain
frequency etc
-provide comfort
measures such as
-to assist client touch, repositioning , -to promote non-
to explore use of heat/cold pharmacological
methods for packs pain management
alleviation/contr -encourage adequate
ol of pain rest periods -to prevent fatigue
-to promote
wellness

ASSESSMEN DIAGNOSIS ANALYSIS OBJECTIVES NURSING ACTION NURSING RATIONALE EVALUATIO

T OF THE ORDER N
PROBLEM
Subjective: Deficient Decreased Within 3-5 -to assess -note -to easily After 3-5
“I feel weak Fluid intravascula days of causative/precipit possible treat the days of
and tired.” Volume r, nursing ating factors diagnosis possible nursing
related to a intestinal , intervention that may cause of intervention
Objective: plasma and/or , the create a dehydration , the
UO- 1x protein loss intracellular patient will -to correct/replace fluid patient
-edema as fluid. maintain losses to reverse volume -prevents maintains
evidenced fluid pathophysiologica deficit peak/valley fluid
by edema volume at a l mechanisms -establish s in fluid volume at a
functional 24-hour level functional
level as fluid level as
evidenced -to promote replacemen evidenced
by comfort and t needs and by
individually safety routes to be -to prevent individually
adequate used. injury from adequate
urinary -provide dryness urinary
output. frequent output.
oral as well
as eye care