DEFINING NURSING SCIENTIFIC EVALUATION

GOAL OF CARE INTERVENTION RATIONALE

CHARACTERISTICS DIAGNOSIS ANALYSIS
SHORT-TERM GOAL: INDEPENDENT: After 8 hours of
SUBJECTIVE: Unstable blood Type 2 Diabetes After 8 hours of 1. Auscultate bowel sounds. 1. Hyperglycemia and fluid and appropriate nursing
glucose level Mellitus occurs when appropriate nursing Note reports of abdominal electrolyte disturbances decrease interventions, the
related to the pancreas interventions, the patient pain and bloating, gastric motility and function patient was able to:
nausea, or vomiting. resulting in gastroparesis, affecting
insufficient produces insufficient will be able to:
2. Observe for signs of choice of interventions.
diabetes amount of the 2. Once carbohydrate metabolism
hypoglycemia. a. Maintain blood
management as hormone insulin a. Maintain blood 3. Teach patient how to resumes, blood glucose level
evidenced by and/or the body’s glucose reading will fall, and as insulin is being glucose reading
perform home glucose
HBA1C test of tissues become of less than 180 monitoring. adjusted, hypoglycemia may occur. of less than 180
OBJECTIVE: 8.5% and HGT resistant to normal or mg/dL; fasting 4. Instruct patient on the 3. Blood glucose is monitored mg/dL; fasting
monitoring test of even high levels of blood glucose proper injection of insulin. before meals and at bedtime. blood glucose
- High blood 349 mg/dL insulin. This causes levels of less than 5. Stress the importance of Glucose values are used to adjust levels of less
glucose level high blood glucose 140 mg/dL achieving blood glucose insulin doses. than 140 mg/dL
- Patient (sugar) levels, which b. Acknowledge control. 4. The absorption of insulin is more b. Acknowledge
exhibits can lead to a number factors that may 6. Review client’s dietary consistent when insulin is always factors that may
program and usual injected in the same anatomical contribute to
anxiety of complications if contribute to site.
pattern; compare with unstable
- Experiencing untreated. unstable glucose recent intake. 5. Control of blood glucose levels
dizziness levels within non diabetic range can glucose levels
- HBA1C test: COLLABORATIVE: significantly reduce the
8.5% LONG-TERM GOAL: 1. Monitor laboratory studies development and progression of
- HGT After 2 days of 2. Administer rapid (short)- complications.
monitoring: appropriate nursing acting insulin 6. Identifies deficits and deviations After 2 days of
349 mg/dL interventions, the patient 3. Consult with nutritionist or from therapeutic plan, which may appropriate nursing
will be able to: dietitian for resumption of precipitate unstable glucose and interventions, the
oral intake. uncontrolled hyperglycemia. patient was able to:
V/S taken as follow:
• BP: 110/80 a. Achieve and 1. Blood glucose will decrease a. Achieve and
mmHg maintain glucose slowly with controlled fluid maintain
• HR: 114 bpm in satisfactory replacement and insulin therapy. glucose in
• RR: 39 cpm range. 2. Rapid- acting insulin is used in satisfactory
• Temp: 36.6 °C b. Increase hyperglycemic crisis. range.
• O2 sat: 98 % knowledge on the 3. Useful in calculating and
b. Increase
Source: importance of adjusting diet to meet client’s
Hinkle, Janice L., specific needs; answer questions knowledge on
maintaining the
Cheever, Kerry H. and assist client and SO in the importance
normal blood
(2018). BRUNNER & developing meal plans. of maintaining
glucose level.
SUDDARTH’S Source: the normal
TEXTBOOK OF Doenges, Marilynn E. et.al (2006). blood glucose
Nursing Care Plans. 10th edition. level.
Medical-Surgical
C&E Publishing, F.A Company.
Nursing. 14th edition.
 DEFINING NURSING SCIENTIFIC EVALUATION
GOAL OF CARE INTERVENTION RATIONALE
CHARACTERISTICS DIAGNOSIS ANALYSIS
SHORT-TERM GOAL: INDEPENDENT: After 8 hours of
SUBJECTIVE: Activity Patients with After 8 hours of 1. To have a better appropriate nursing
Intolerance Hypertensive appropriate nursing 1. Note presence of understanding of patient’s interventions, the
related to Cardiovascular interventions, the patient factors contributing to condition patient was able to:
imbalance Disease have will be able to: fatigue
2. To provide comparative
between oxygen alterations in a. Report 2. Evaluate current a. Report
baseline
supply and cardiac output and measurable limitations measurable
OBJECTIVE: demand side effects of increase in 3. Assess increase in
antihypertensive activity cardiopulmonary 3. To assess severity of activity
- Dyspnea upon medications, causing tolerance response to physical patient’s condition tolerance
exertion noted insufficient b. Participate activity b. Participate
- ECG changes physiological willingly in 4. Plan care with rest willingly in
noted energy to complete necessary/ periods between 4. To reduce fatigue necessary/
- Abnormal daily activities. desired activities activities desired
heart rate c. Demonstrate a 5. Promote comfort 5. To enhance ability to activities
participate in activities c. Demonstrate a
noted (114 decrease in measures and provide
bpm) physiological for relief of pain decrease in
- Increased signs of physiological
respiratory intolerance COLLABORATIVE: signs of
rate intolerance
- Generalized LONG-TERM GOAL: 1. Note treatment related 1. Note treatment related
weakness After 2 days of factors, such as side factors, such as side effects
appropriate nursing effects of drugs of drugs After 2 days of
interventions, the patient 2. Provide supplemental 2. Provide supplemental appropriate nursing
V/S taken as follow: will be able to: oxygen and oxygen and medications as interventions, the
indicated patient was able to:
• BP: 110/80 medications as
3. Provide referral to
mmHg a. Identify negative indicated
psychological counseling as a. Identify
• HR: 114 bpm factors affecting 3. Provide referral to appropriate
psychological negative factors
• RR: 39 cpm activity
counseling as affecting activity
• Temp: 36.6 °C intolerance and
intolerance and
• O2 sat: 98 % Source: eliminate or appropriate
Doenges, E., reduce their eliminate or
Moorhouse F. M., & effects when reduce their
Murry A., 2010. Nursing possible effects when
Care Plans: Source: possible
b. Use identified
Guidelines for Doenges, Marilynn E. et.al (2006). b. Use identified
Individualizing Client techniques to
enhance activity Nursing Care Plans. 10th edition. techniques to
Care Across the Life C&E Publishing, F.A Company. enhance activity
Span tolerance
tolerance