CUES/NEEDS NURSING SCIENTIFIC OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS BASIS
OBJECTIVE  Risk for Injury General: INDEPENDENT
Vulnerable for
related to After 10 days of 1. Assess general status 1. This is to determine the
Hallucinations injury as a holistic student of the patient. patient’s condition that may
nurse-patient cause injury.
result of interaction, the 2. Assess mood coping 2. Mood coping abilities and
environmental patient will not
abilities, personality style style of personality aid to
experience physical
conditions injury. that may result in determine the patient’s
carelessnes. level of cooperation.
interacting with
Specific: 3. Recognize racial/ethnic 3. Discovering
the individual’s After 40 hours of diversity at the onset of race/ethnicity issues will
adaptive and holistic intervention, care. enhance communication,
the patient will be establish rapport, and
defensive able to: promote treatment
resources, which outcomes.
1. Explain 4. Evaluate the 4. What the patient
may
importance of cultural considers risky behavior
compromise methods
beliefs, norms, and may be based on cultural
health. to prevent values on the patient’s perceptions.
injury. perceptions of risk for
injury.
Instead of being 2. Patient 5. Thoroughly conform 5. The patient must get
viewed as a identifies patient to surroundings. used to the layout of the
environment to
major public factors
avoid accidents. 
health problem, that 6. Avoid use of restraints. 6. If patients are restrained,
increase Obtain a physician’s order they can sustain injuries,
injuries have
if restraints are needed. including strangulation,
been recognized risk for asphyxiation, or head injury
as inevitable injury. from leading with their
heads to get out of the bed.
accidents that 3. Patient
7. Eliminate or drop all 7. This is to prevent the
happen in our relates possible hazards in the patient from any unpleasant
intent to room such as razors, experience due to
daily life.
medications, and dangerous objects.
However, a practice matches.
considerable selected 8. If patient is notably 8. Special beds can be an
disturbed, consider using efficient and useful
epidemiological prevention
a special safety bed that alternative to restraints and
and medical measures. surrounds patient.  can help keep the patient
safe during periods
study has shown
of confusion and anxiety.
that injuries,
unlike accidents
do not occur by
chance. Like
any disease, the
risk of injury
follows a
predictable
pattern, thus
making them
preventable.

Source:
https://nurseslabs.c
om/risk-for-injury/

CUES/NEEDS NURSING SCIENTIFIC OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS BASIS
OBJECTIVE: Self-care deficit: Impaired ability to General: INDEPENDENT Goal met:
Inability to: toileting r/t perform feeding, After 5 days of 1. Determine existing condition/ 1. Etiological factor may need -Performed
 Get to toilet neuromuscular/ bathing/hygiene, holistic student developmental level. more explicit interventions. self care
or commode neuromuskolos dressing, and nurse-patient 2. Identify degree of individual 2. Assistive device improve activities within
 Carry out keletal grooming, or interaction, the impairments/functional level. confidence in performance of level of ability.
proper toilet impairment; toileting activities patient will achieve activities of daily living.
hygiene impairment (on a temporary, his optimum level 3. Promote client/SO 3. Enhances commitment to
transfer ability permanent, or of functioning. participation in problem plan, optimizing outcomes.
(self-toileting) progressive basis) identification and decision
. Specific: making. 4. To enhance capabilities.
After 6-8 hours of 4. Assist in rehabilitation 5. Reduce risk of injury.
holistic intervention, program. 6. To discover barriers to
the patient/SO will participation regimen.
5. Review safety concern.
be able to: 7. Enhances coordination and
6. Plan time for listening to the continuity of care.
1. Verbalize client.
knowledge of
7. Provide for communication 8. Patient’s rights must be
healthcare
among those who are observed.
practices.
involved in caring for/
2. Demonstrate assisting the client. 9. To assist in patient’s tolerance
techniques or
lifestyle changes
8. Provide privacy during to activities.
personal care activities. 10. To note the patient’s energy
to meet self-care
needs. 9. Assist the medication saving behavior.
regimen as necessary.
3. Performs self-
Source: Nurse’s care activities 10. Identify energy-saving
Pocket Guide 12 within level of behavior.
Edition ( page 708- own activity.
714)
 CUES/NEEDS NURSING SCIENTIFIC BASIS OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

OBJECTIVE: Impaired Limitation in General: INDEPENDENT Goal me:

Limited range physical independent, After 5 days of 1. Determine dx that contributes 1. To know and improve Verbalized
of motion; mobility r/t purposeful physical holistic student to immobility. restriction. understanding
limited ability decreased movement of the nurse-patient 2. Ascertain client’s perception of tuition and
to perform muscle body of one or more interaction, the of activity/exercise needs. 2. To know the tolerance of the individual
gross fine strength, extremities due to patient will achieve 3. Determine degree of client in performing activities. treatment
motor skills; control and/or spinal stiffness in his optimum level immobility. 2= requires help 3. To know the client’s assistive regimen and
difficulty more; joint Ankylosing of functioning. from another person or needs. safety
turning stiffness; loss spondlitis or POT’s assistant. measues.
in integrity of disease Specific: 4. Observe movement when 4. To note any incongruence
Engages in bone structure, After 6-8 hours of client is unaware of with reports with abilities.
substitution for neuromuscular holistic intervention, observation. 5. Feelings of
movement impairment Source: Nurse’s the patient/SO will frustration/powerlessness
5. Note emotional/behavioral
(playing Pocket Guide 12 be able to: may impede goal.
response to problem of
intablet) Edition ( page 708- 1. Verbalize 6. To avoid pressure ulcers.
immobility.
714) willingness to
6. Assist client to reposition self
demonstrate
on a regular schedule as
participation in 7. To maintain position of f(x)
indicated by individual
activities. and reduce risk of pressure
situation.
2. Demonstrate ulcer.
7. Support affected body 8. To avoid worsening of
behavioral
parts/joints using pillows/rolls. pressure ulcer.’
techniques that
enable
8. Provide regular skin care to
include pressure area 9. To reduce fatigue.
resumption of
management
activities.
3. Maintain 9. Schedule activities and
adequate rest periods during
position of
the day. DEPENDENT 10. To promote maximal effort.
function and skin
integrity. 10. Administer medications
prior to activity as needed for
pain relief.

CUES/NEEDS NURSING SCIENTIFIC BASIS OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
OBJECTIVE: Impaired Skin Altered epidermis General: INDEPENDENT Goal partially
 Disruption Integrity r/t and/or dermis due to After 5 days of 1. Determine etiology. 1. Prior assessment of normal met:
of skin physical inability to turn self holistic student etiology is critical for proper -Display timely
surface immobilization because of nurse-patient identification of nursing healing of skin
 Presence of decreased muscle interaction, the intervention. lesions,
pressure strength caused by patient will achieve 2. Assess site of impaired tissue 2. Indication of inflammation. wounds,
ulcer at neuromuscular his optimum level integrity and its condition. pressure sores
lower back impairment in of functioning. 3. Know signs of itching and 3. Alleviate extreme itching without
with lxw POTT’s disease. scratching. may open skin lesion and complicatins.
16.1 Specific: risk of infection.
-26 sq cm; After 6-8 hours of 4. Monitor site for color changes, 4. Systemic infection can
by report holistic intervention, redness, swelling, pain. identify impeding problem
necrosis Source: Nurse’s the patient/SO will early.
5. Provide tissue care as needed.
Pocket Guide 12 be able to: 5. Improve healing process.
6. Keep a sterile dressing
Edition ( page 757- 1. Display timely 6. Reduces the risk for
technique during normal care.
763) healing of skin infection.
lesion/pressure
7. Encourage a diet that meets
nutritional needs. 7. A high-protein, high calorie
sore and
complications. diet may be needed to
2. Maintain optimal 8. Tell patient to avoid rubbing promote healing.
and scratching. 8. May came further injury and
nutrition/ physical
DEPENDENT delay healing.
well-being.
3. Verbalize 9. Premedicate for dressing
changes as necessary. 9. To reduce pain.
feelings of
increased self- 10. Administer antibiotics as
esteem ordered. 10. To manage wound infection.

CUES/NEEDS NURSING SCIENTIFIC BASIS OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
OBJECTIVE Risk for disuse At risk for General: 1.Ascertain perception of 1. Maximize involvement in self- Goal met
Limited range Syndrome deterioration of body After 5 days of activity and exercise needs. care. -Maintained
of motion, systems as the holistic student 2.Monitor skin over bony optimal level of
inability to result of prescribed nurse-patient prominences. 2. For early detection of cognitive,
perform gross or unavoidable interaction, the 3.Reposition every 2 hours complications. neurosensory
and fine motor muskoloskeletal patient will achieve interval as ordered. and
skill on the inactivity. his optimum level 4.Support affected body parts 3. To relieve pressure. musculoskelet
lower of functioning. and joints using pillows and 4.To reduce pressure. al unctioning
extremities and towels.
inability to Source: Nurse’s Specific: 5.Encourage balance diet 5. For optimal stool consistency
reposition self- Pocket Guide 12 After 6-8 hours of including fruits and vegetables and to facilitate passage through
noted; with Edition ( page 302- holistic intervention, high in fiber and with adequate colon.
muscle 308) the patient/SO will fluids.
strength of 1 at be able to: 6.Encourage coughing and 6.To facilitate clearing of
both feet noted. 1.Express sense of deep breathing exercises on secretions.
control over the intervals.
present situation 7.Provide range-of-motion 7.For strengthening and
and potential exercises for bed as tolerated restoration of optimal Range-of-
outcome. by the patient. motion and prevention of
8.Promote self-care and circulatory problems.
2.Demonstrate significant other supported 8.Maximize involvement in self-
adequate activities. care
peripheral
 perfusion with
stable vital signs,
skin warm and dry,
palpable peripheral
pulses.

3.Recognize and
incorporate change
into self-concept in
accurate manner
without negative
self-esteem.

CUES/NEEDS NURSING SCIENTIFIC BASIS OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Acute pain r/t Acute General: 1Assess pain characteristics: 1.Assessment of pain experience Goal met:
Report of injuring agents Pain: Unpleasant Quality (e.g., burning, sharp, is the first step in planning pain With pain scale
After holistic
tingling pain on sensory and shooting) management strategies. The of 2 out of 10.
the lower emotional student nurse and Severity (scale of 0 or no pain most reliable source of
extremities experience arising to 10 or most severe pain) information about the pain is the
patient interaction
from actual or Location (anatomical patient.
Objective: potential tissue the pt will be able description) Descriptive scales such as a
Wth pain scale damage or Onset (gradual or sudden) visual analogue can be utilized to
to gain his optimum
of 3, wherein 1 described in terms Duration (how long; intermittent distinguish the degree of pain.
is the lowest of such damage level of functioning. or continuous) 2. Such variables play a big role
pain perceived The unpleasant Precipitating or relieving factors in modifying the patient’s
Specific:
& 10 is the feeling of pain is 2.Assess to what degree expression of pain. Some
After 8 hours
highest highly subjective in cultural, environmental, cultures simply express feelings,
student nurse and
With facial nature that may be intrapersonal, and intrapsychic whereas others hold such
patient interaction
grimace experienced by the factors may contribute to pain expression. 
the pt will be able
&irritability patient. Acute or pain relief. 3.Other patients may be
to;
noted Pain serves a overlooking of the effectiveness
 Patient
With dry & protective function to 3. Assess the patient’s of nonpharmacological methods
describes
intact dressing make the patient willingness or ability to explore and may be willing to try them,
satisfactory
at the lumbar informed and a range of techniques aimed at either with or instead of traditional
pain control
region knowledgeable controlling pain. analgesic medications.
at a level
about the presence 4. Observe nonverbal cues and 4. Observations may not be
less than 3
of an injury or pain behaviors and other congruent with verbal reports or
to 4 on a
illness. objective. maybe only indicator present
rating scale
5.Monitored skin color and when client is unable to verbalize.
of 0 to 10.
temperature 5. which actually altered in acute
 Patient 6. Provide comfort measures pain.
displays (e.g touch and repositioning), 6. To promote
improved nonpharmacological pain
well-being 7.Instruct and encourage use of management.
such as relaxation techniques such as 7. To distract attention and
Source: Source: baseline focused breathing. reduce tension.
Nurse’s Pocket levels for 8. To divert patients attention
Guide 12 Edition pulse, BP, 8. Encourage diversional 9. To prevent fatigue.
( page 587-590) respirations, activities (e.g socialization with 10. It is essential to assist
and others). patients express as factually as
relaxed mus possible (i.e., without the effect of
cle tone or 9. Encourage adequate rest mood, emotion, or anxiety) the
body periods effect of pain relief
posture.
 Patient uses 10.Evaluate the patient’s
pharmacolo measures. response to pain
gical and and management strategies.
nonpharmac
ological
pain-relief
strategies.
 Patient
displays
improvemen
t in mood,
coping.