CUES NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

Subjective: Imbalanced Fluid Volume related to At the end of an 8-hr shift, patient/ Independent: After the 8-hr of shift , patient/
“Sige na siya suka tas libang. Vomiting and Diaphoresis as patient’s watcher will be able to; • Monitor Vital Signs of the • To have a baseline of care needed patient’s watcher was able to;
Murag ika-3 na siya nag suka evidenced by 65mL intake and • Demonstrate adequate fluid patient. to provide
karon og ika-2 na naglibang na 475mL output. balance as evidenced by stable • Measure and record intake and • To help evaluate patient’s fluid Goal Met:
medyo basa” as verbalized by the vital signs, palpable pulses of output. balance • Demonstrate adequate fluid
patient’s watcher good quality, normal skin turgor, • Measure and record vomiting; • Evaluating and recording balance as evidenced by stable
moist mucous membrane, and time which vomiting occurs, vomiting pattern will help for vital signs, palpable pulses of
Objective: appropriate urinary output frequency, consistency, amount, direct treatment good quality, normal skin turgor,
Vital Signs: SCIENTIFIC BASIS • Verbalize that vomiting and loose and color. moist mucous membrane, and
Temperature stools are reduced • Observe the color of all appropriate urinary output
Pulse Rate • Consume at least 1000mL to secretions. • To evaluate for bleeding • Verbalized that no vomiting
Respiratory Rate 1500mL of fluid per day. • Weigh the patient daily and occurs and loose stools was one
Blood Pressure • Verbalize factors that cause evaluate changes as they relate to • This provides for early detection times only
vomiting and how to avoid it. fluid status. and prompt intervention as • Consumed a total of 1500mL of
I&O • Encourage watcher to increase needed fluid for 8 hours.
Intake the fluid intake of the patient. • To replace the fluid losses • Verbalized factors that cause
Output • Assess for clinical signs of vomiting such as; using different
dehydration. brands of milk formula and
• 2x Loose Stools • Discuss with the watcher the risk • To initiate intermediate action avoiding it by using consistent
• 3x Vomiting factors or potential problems and formula that the infant prefer.
• Weakness appearance observed specific interventions. • To prevent or limit fluid
• Dry lips observed imbalance and complications
• Slightly sunken eyes observed Dependent:
• Inadequate fluid intake (20mL) • Administer antiemetic drug as
ordered.
• Submit specimen to the Medical
Technologist for Culture and • To help reduce or prevent nausea
Sensitivity as for doctor’s order. and vomiting
• To administer the right drug
Collaborative:
• Collaborate with the Nutritionist
as to what foods or fluids
appropriate for a patient
experiencing vomiting.
• Water-rich food can help for
hydration
 CUES NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

Subjective: Hyperthermia related to At the end of an 8-hr shift, patient/ Independent: After the 8-hr of shift , patient/
N/A dehydration as evidenced by patient’s watcher will be able to; • Monitor Vital Signs of the • To have a baseline of care needed patient’s watcher was able to;
diaphoresis, 65mL intake, and • Maintain core temperature within patient. to provide
Objective:
475mL output. normal range (36.5 ° C to 37.5 ° • Measure and record intake and • To help evaluate patient’s fluid Goal Met:
Vital Signs: C) output. balance • Maintained core temperature
Temperature • Identify cause or contributing • Adjust room temperature. • To avoid chilling of the patient within normal range.
Pulse Rate factors and importance of • Eliminate excess clothing and • Excess clothing can cause more Temperature is now 36.8 ° C
Respiratory Rate treatment covers. heat production • Identified cause or contributing
Blood Pressure • Demonstrate behaviors to • Apply tepid sponge bath as • To help reduce high temperature factors such as over clothing
SCIENTIFIC BASIS
monitor and promote needed and one of the best cooling when they notice that the baby is
normothermia treatment shivering and importance of
I&O • Be free of seizure activity • Encourage watcher to increase • To maintain hydration treatment that helps prevent
Intake the fluid intake of the patient. seizure
Output • Raise the side rails at all times. • Demonstrate behaviors to
• To ensure patient’s safety monitor and promote
Skin is warm to touch • Educate family about the signs even without the presence of normothermia such as tepid
Weakness appearance observed and symptoms of hyperthermia seizure sponge bath
and how to take actions when • Health teachings aids in • Not experience any seizure
signs are noted coping with the condition and
could help prevent further
Dependent: complications of hyperthermia
Administer antipyretic drug as
ordered.
• Antipyretic medications lower
body temperature
 CUES NURSING DIAGNOSIS GOALS AND OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

Subjective: Imbalanced Nutrition: less than At the end of an 8-hr shift, patient/ Independent: After the 8-hr of shift , patient/
N/A body requirement related to loss of patient’s watcher will be able to; • Monitor Vital Signs of the • To have a baseline of care needed patient’s watcher was able to;
appetite as evidenced by decreased • Regain and increase appetite patient. to provide
Objective:
fluid intake (65mL intake) • Increase fluid intake and maintain • Measure and record intake and • To help evaluate patient’s fluid Goal Met:
Vital Signs: fluid balance output. balance • Regained and increased his
Temperature • Maintain balanced nutrition • Encourage patient’s watcher to • To maintain hydration appetite
Pulse Rate required for an infant increase fluid intake • Increased fluid intake and
Respiratory Rate • Presents understanding of • Educate the patient’s watcher • To enhance food satisfaction and maintain fluid balance. Total fluid
Blood Pressure significance of nutrition to about the use of flavoring agents. stimulate appetite intake is 1500mL for 8 hours.
SCIENTIFIC BASIS
healing process and general • Encourage to choose foods that • Maintained balanced nutrition
health. seem appealing • To stimulate appetite required for an infant. Which are;
I&O • Instruct patient’s watcher to avoid 8-15% Protein, 35-55% Fat, and
Intake food that is not nutritional. • Unnecessary food gives very little 30-50% Carbohydrates.
Output or no effect to nutritional intake • Present understanding of the
Dependent: and it is not good for health significance of nutrition to
• Administer Intravenous Fluid healing process and general
therapy as per doctor’s order health. Such as; proper and
• Used for fluid volume adequate nutrition can protect
replacement, to correct him against diseases, and help
electrolyte imbalances, and to him stay healthy as he grows
• Administer Vitamins as per deliver medication older.
doctor’s order • To provide additional nutrition
supplement
Collaborative:
• Collaborate with the Nutritionist
as to what food appropriate for an • For proper and safety nutritional
infant intake