NURSING SCIENTIFIC NURSING

CUES/CLUES OBJECTIVE ANALYSIS

DIAGNOSIS RATIONALE INTERVENTION

Subjective: Anxiety related to Anxiety is normal After 1 to 2 hours of - Establish and - Therapeutic skills need to
Patient’s mother stress as evidenced reaction to stress. It is nursing intervention: maintain a trusting be directed toward first to
verbalized “ang by prolonged the state in which an relationship by talking the parents to gain trust of
- Patient has facial
tagal na naming hospitalization. individual experience and listening first to the patient and putting the
expressions,
dito halos mag 2 feeling of uneasiness the parent then to the patient at ease, because
gestures, and
linggo na, gusto or apprehension and patient the nurse who is a stranger
activity levels that
na nga niya activation of the may pose a threat.
reflect decreased
umuwi eh” autonomic nervous
distress.
system in response to a - Maintain calmness to - The client will feel more
Objective: - Patient feels
vague, nonspecific approach the patient secure if you are calm and
secure and
- Crying threat. inf the client feels you are
decreases fear of
- Irritability in control of the situation.
seeing a doctor
Nursing Care Plan and
Diagnosis for Anxiety. - introduce diversional - To divert the patient’s
(2015, June 11). activities such as attention to non-less fearful
Retrieved from playing or coloring situations
https://www.registered books
nursern.com/nursing-
care-plan-and- - allow patient and - Promotes security and
diagnosis-for-anxiety/ parents to incorporate reduces anxiety with new
home routines such experiences
as bringing toys,
watching movies, and
bringing her favorite
food
- use therapeutic play - Permits child to
to explain and understand and become
prepare the child for a familiar with articles used
procedure or for care.
administering
medication.
 NURSING SCIENTIFIC NURSING
CUES/CLUES OBJECTIVE ANALYSIS
DIAGNOSIS RATIONALE INTERVENTION

Objective: Impaired comfort Pediatric After 1 hour of nursing - established rapport to - To build trust
related prolonged patient becomes intervention, patient will: the patient’s primary between the patient’s
- Crying parents as well as
hospitalization anxious, administering caregiver as well as the
- Facial grimace - Express reduction the patient to have
secondary to treatment can become patient
- Clinging to her of discomfort an effective care of
abdominal pain especially difficult. It plan
mother
can be especially - Appear calm and
Subjective: traumatic. In addition to relaxed - Eliminate additional - patients may
that, stressful on its stressors or sources of experience an
- Patient’s exaggeration
own, they’re introduced discomfort.
mother in pain or a
to an environment full
verbalized decreased ability to
of unusual sights and
“ganto kami tolerate
sounds. Depending on painful stimuli if
lagi buhat
their age, they may environmental,
buhat ko kasi
have unpleasant intrapersonal, or
iiyak pag
memories of previous intrapsychic factors
nilapag” are
hospital visits.
further stressing
them.
Filion, J. (n.d.). Ease - Provide diversional - Distraction
the Way Blog. activities techniques heighten
Retrieved from such as coloring book one’s
https://www.gebauer.c and watching concentration upon
om/blog/7-ways- educational videos non-painful stimuli
nurses-can-ease- to decrease one’s
hospital-anxiety-for- awareness and
children experience of pain.
- Maintain a calm and - To minimize stimulus
quiet environment that could aggravate
the condition

- position may
- Promote comfort by aggravate pain felt.
making sure patient is properly position may
positioned properly promote comfort and
ensure good
circulation.
 NURSING SCIENTIFIC NURSING
CUES/CLUES OBJECTIVE ANALYSIS
DIAGNOSIS RATIONALE INTERVENTION

Subjective: Acute pain related to Unpleasant sensory After 1 hour of nursing - Monitor vital signs - To have baseline data
liver abscess and emotional intervention: that would help to
Patient’s mother
secondary to infection experience arising from monitor the condition of
verbalized “ayaw - Patient will
as evidenced by actual or potential the patient
niya nagpapahawak demonstrate relief
laboratory results. tissue damage or
sa tiyan kasi masakit or control of pain
described in terms of - Asses the pain - Document pain
tsaka wala siya - Patient’s parents
such damage (medical characteristic and characteristics each
gana kumain” verbalized
problems). Liver intensity by Wong- time pain occurs to
nonpharmacologica
Objective: abscess is a pus that Baker faces pain identify an appropriate
l ways to provide
forms in the liver due to scale intervention and pain
- guarding relief
bacterial infection that parameters based on
behavior
would display a pain in age
- WBC increase
the right upper
- Few bacteria
quadrant.
present in urine
- Teach patient’s - The use of noninvasive
- T : 38.5
parents about non- pain relief measures
RR: 22
Source: pharmacological can increase the
BP: 100 / 70
pain management re- lease of endorphins
PR: 111 - International
and enhance the
Association for the
therapeutic effects of
Study of Pain
pain relief
- Healthline by
Stacy Sampson,
DO and Lydia
Krause
-
- Encourage - To divert the attention
diversional activities of pain stimuli and
such as playing toys patient would
and coloring book experience an
exaggeration in
pain due to several
factors

- Administer - Medications such as

medication as analgesic for relief of
ordered pain and antibiotic for
infection
 NURSING SCIENTIFIC NURSING
CUES/CLUES OBJECTIVE ANALYSIS
DIAGNOSIS RATIONALE INTERVENTION

Subjective: Imbalanced nutrition It refers to food intake of After 1 hour of nursing - Teach patient’s - To have a knowledge
less than body nutrients insufficient to intervention: parents about on what food is
Patient’s mother
requirements related meet metabolic needs. family meal appropriate to serve to
verbalized “bumaba - Primary caregiver
to unwillingness to eat An inadequate food planning, as their child in order to
timbang niya dahil verbalizes and
as evidenced by intake may be caused by appropriate achieve weight gain
walang gana demonstrates
discomfort due to the inability to acquire or
kumain kasi masakit selection of foods or
abdominal pain prepare food, inadequate
yung tiyan niya” meals that will
knowledge about - Consider patient’s - Assess food
accomplish a preferences and offer
Objective: essential nutrients and a food preferences,
termination of more than one diet
balanced diet, discomfort as governed by
- Weight of 12 weight loss. option to enhance their
during or after eating. personal choices
kilograms - The patient will chances of healthy
Several diseases can weight gain
- Inadequate experience an
greatly affect the
food intake increase in the
nutritional status of an
- Restlessness amount or type of
individual such as GI
nutrients ingested.
illness, physical factors - Schedule rest - Nursing assistance with
(pain, muscle weakness) periods before activities of daily living
or social factors. meals and open will conserve the
Adequate nutrition is vital packages and cut patient’s energy for
to healing and recovery up food for patient. activities the patient
of a patient. values.

-
Imbalanced Nutrition:
Less Than Body - Teach techniques - Oral hygiene has a
Requirements – Nursing to maintain positive effect on
Diagnosis & Care Plan. adequate nutritional appetite and on
(2017, September 23). intake and the taste of food.
Retrieved from stimulate
https://nurseslabs.com/im appetite such as
balanced-nutrition-less- good oral hygiene
body-requirements/ before and after
feedings

- A pleasing atmosphere
- Provide a pleasant
helps in decreasing
environment.
stress and is more
favorable to eating.
 NURSING SCIENTIFIC NURSING
CUES/CLUES OBJECTIVE ANALYSIS
DIAGNOSIS RATIONALE INTERVENTION

Subjective: ineffective family It is the family’s pattern After 1 hour of nursing - Evaluate the patient’s - the patient’s
therapeutic regimen of regulating and intervention: individual thoughts of perceived
Patient’s mother said
management related integrating into daily health problems susceptibility to and
“nung nilalagnat nga - Patient’s parents will
to knowledge deficit living a program and perceived
ng mga ilang araw be able to verbalize
beliefs for treatment seriousness and
na di pa naming acceptance of need
and managing of threat of disease
dinala sa hospital to change actions to
illness that is influence compliance
kasi sabi ng asawa achieve agreed- on
unsatisfactory for with the treatment
ko baka pilay lang. health goals.
meeting specific program.
ipahilot daw muna
health goals - Patient’s parents
Objective:
recognize the - to asses the
- Determine patient’s
- Failure to act to importance of complexity of the
family’s health goals
reduce risk family’s beliefs
utilizing the health and patterns of
factors of the towards health goals
care system. healthcare
condition and pattern of health
care

- Identify individual - there are a lot of

perceptions and factors that affects
expectations of the how the family
health management members views and
manages health
- Teach the importance - For the members of
of utilizing the the family able to
resources of the utilize and gain more
health care system to trust to the health
care system

- Promote client and - This enhances

family participation in commitment to the
planning and plan and promotes
evaluating process competent in
managing the health
goals of the family