CUES

NURSING
OBJECTIVE
INTERVENTION
DIAGNOSIS
Subjective
Risk
forAt the end of 1INDEPENDENT:
noncompliance
week, the client will
Cues:Kabalo
korelated to lack ofactively participateProvide guidelines
nga naa koy highknowledge
aboutin
creating
a
that
include
blood pero karonthe health status,treatment
plan,
information
wala
nakucost of therapy, andexpressing
about
gatumaron
ngamultiple changes incommitment to and
hypertension.
tambal
kalimotlifestyle.
adhering
to
napud ko kung
scheduled follow-up Instruct the client
unsa too gihatag sa
appointments.
about
strict
akong doctor, as
compliance
of
verbalized by Mrs.
medications.
U.
Teach the client
Objective
about
stress
management
No
and importance
medications
of
divertional
activities
and
lifestyle changes
DEPENDENT:
4.
Consult
a
physician and follow
scheduled check-up

RATIONALE

EVALUATION

Goal partially met.

After 1 week, the
1. To teach andclient was able to
inform
theparticipate in the
client abouttreatment plan.
his condition

2. To minimize
onset of high
BP.
3. To
provide
an outlet for
emotional
tensions; to
minimize the
occurrence
of high BP

4. To
check
current
health status

A. ACTUAL NURSING MANAGEMENT

CUES

NURSING OBJECTIVE
INTERVENTION
DIAGNOSIS
Subjective cues: Pain related toAt the end ofINDEPENDENT:
Sakit akong kilid sabone injury as15 minutes,
akong dughan kayevidenced
byclient
will
1. Provide
cutaneous
nadigyas man gudfacial grimace. report
stimulation
(therapeutic
ko daun nabunggo
alleviation of
touch)
ko sa kilid sa akong
pain onset.
lamesa,
as
2. Apply heating pads and
verbalized by Mrs.
warming towel
U.
Objective

Facial
grimace
Guarding on
the
painful
site
Rubbing the
painful area
Severity
of
pain
(pain
scale: 5)

3. Provide cold applications (if

warm application was not
done)

RATIONALE

EVALUATION
Goal
met.

1. to
decrease
intensity
ofAfter
15
pain that theminutes,
the
client
client was able
perceives
to
verbalize
alleviation of
2. To
promotepain onset.
vasodilation
thus allowing
sufficient blood
flow changes
3. to
prevent
edema
formation and
inflammation

DEPENDENT:
4. Administer pain meds
(analgesics), per doctors order

partially

4. To
obtain
satisfactory
pain relief

CUES

NURSING OBJECTIVE
INTERVENTION
DIAGNOSIS
Subjective Cues: Impaired
At the end of
physical mobility1
week,INDEPENDENT:
Gasakit
akongrelated
toclient will be
tiil,usahay,
samotmusculoskeletal able
to 1. Demonstrate/ assist
na kung mag lakawpain
anddisplay
transfer techniques
ko
ug
layo,discomfort
asincreased
use of mobility aids
maghawoy napudevidenced
bystrength and
crutches.
daun
ugreports of painfunction.
maminhod,
Asand decreased
2. Support position
verbalized by Mrs.muscle strength
pillow
U.
Objective Cues:

Patient
cannot walk
without her
crutches

RATIONALE

with
and
e.g.
with

Goal partially
met.
After 1 week,
1. To
facilitatethe
patient
self-care andwas able to
clients
verbalize
independence. increased
muscle
2. to
avoidstrength and
prolonged
functioning of
tissue
the
affected
pressure andlimb.
prevent risk of
tissue
breakdown
3.

3.

Investigate
increase in pain

sudden

to monitor
signs
of
possible
development
of
complications

DEPENDENT
4. Consult with physical or
occupational therapists or
rehabilitation specialists

EVALUATION

4. It is useful in
creating
individualized
activity
or
exercise

program

XV. FAMILY HEALTH CARE PLAN:

CUES

Subjective:
Gamay ra
jud akong
kita kada
adlaw, igo ra
na maka
kaon ko, as
verbalized by
Mrs. U.
Objective:
Earnings: 5070 php/day

HEALTH
PROBLEM
Low family
income as
a
foreseeabl
e crisis

FAMILY
NURSING
PROBLEM
S
Inability to
make
decisions
with respect
to
taking
appropriate
health
action and
inability to
decide
which action
to take from
among a list
of
alternatives.

GOAL OF
CARE

OBJECTIVES
OF CARE

INTERVENTION
MEASURES

The
families
will
find
enough
resources that
could sustain
family health
needs.

Identify ways
to utilize family
income wisely
and
earn
money
from
health
civilization.

1. Encourage the
family to
find
additional ways to
earn money.
2.
Encourage
family to prioritize
needs.
3. Encourage the
family to minimize
unnecessary
spending.

METHODS
OF NURSEFAMILY
CONTACT
Home visit

EVALUATION

1. The family was

encouraged
to
find
additional
ways to
earn
money.
2. The family was
encouraged
to
prioritize needs.
3. The family was
encouraged
to
minimize
unnecessary
spending.

CUES

FAMILY HEALTH
PROBLEM

OBJECTIVES

INTERVENTIONS

EVALUATION

Subjective:
Wala mi sakto nga
agianan sa tubig, wala
mi
kanal
nga
permanente,
as
verbalized by the wife.

Presence of health
threat due to lack of
sanitation and danger
with regards to waste
management.

At the end of 30
minutes of discussing
the hazards of having
no proper drainage at
home, Mrs. Eva Alaan
will do something
about this and to
achieve
proper
drainage.

Discuss
and
demonstrate to the
family the importance
of having a clean
environment, proper
drainage system and
the
advantages it
brings to the family.

At the end of the 30

minutes discussion on
cleanliness and the
importance of having
proper
drainage
system, the family
showed eagerness to
do their best in
cleaning their area
especially
making
proper
drainage
system.

Objective:
No
proper
drainage

CUES

Subjective:
Gamay ra
jud akong
kita kada
adlaw, igo ra
na maka
kaon ko, as
verbalized by
Mrs. U.
Objective:
Earnings: 5070 php/day

HEALTH
PROBLEM
Low family
income as
a
foreseeabl
e crisis

FAMILY
NURSING
PROBLEM
S
Inability to
make
decisions
with respect
to
taking
appropriate
health
action and
inability to
decide
which action
to take from
among a list
of
alternatives.

GOAL OF
CARE

OBJECTIVES
OF CARE

INTERVENTION
MEASURES

The
families
will
find
enough
resources that
could sustain
family health
needs.

Identify ways
to utilize family
income wisely
and
earn
money
from
health
civilization.

1. Encourage the
family to
find
additional ways to
earn money.
2.
Encourage
family to prioritize
needs.
3. Encourage the
family to minimize
unnecessary
spending.

METHODS
OF NURSEFAMILY
CONTACT
Home visit

EVALUATION

1. The family was

encouraged
to
find
additional
ways to
earn
money.
2. The family was
encouraged
to
prioritize needs.
3. The family was
encouraged
to
minimize
unnecessary
spending.