NAME: A. B.

AGE: 74
years old

MEDICAL DIAGNOSIS: Acute Stroke Syndrome STATUS:

MARRIED

CUES/DATA NURSING NSG GOAL AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective Data: Impaired Within 8 hours of 1. Established rapport. 1. To promote trust and At the end of nursing
Verbal proper nursing build patient-nurse interventions patient
“Dili man siya ka communicatio intervention the relationships. was able to;
sturya og tarung n related to patient will be to:
sir.” as verbalized neuromuscula 2. Monitor skin 2. To provide baseline data ● Indicated an
by the patient’s r impairment color/temperature and and usually altered in acute understanding of
SO. secondary to ● Patient will vital signs. pain. the
Acute stroke indicate an
communication
syndrome understanding
problems.
of the 3. Pay attention to 3. Patients may have ● Established
Objective Data: Scientific communicatio nonverbal cues and specific gestures or cues
method of
Basis: n problems. gestures. they use to communicate.
communication in
● Slurred Speech ● Patient will
Problems with 4. Try short questions 4. Patients who have which needs can
establish
Vital signs: speech were a with short answers. difficulty forming words or be expressed.
method of
common early communicatio who are aphasic may ● Used resources
T: 34.5°C symptom of a require longer to process appropriately.
n in which
stroke (see speech and respond.
needs can be
P: 72 bpm 'The event: A
stroke or TIA'). expressed. 5. Eliminate 5. Reduces anxiety and
R: 22 cpm People often ● Patient will extraneous noise and exaggerated emotional
recalled that use resources stimuli as necessary. responses and confusion
BP: 120/70 mmHg their speech appropriately. associated with sensory
had been overload.
slurred or 6. Display proper 6. Never speak loudly at a
occasionally speech etiquette. speech-impaired person
that they could unless they are hard of
not make hearing.
sounds that
were 7. Assess the patient 7. The inability to talk,
understandabl for signs of communicate, and
e as speech. depression. participate in a
This was conversation can often
usually due to cause frustrations, anger,
weakness of and hopelessness.
the muscles
that are crucial 8. Provide alternative 8. A communication board
for speech methods of that has pictures of
production on communication. common needs and
one side of the phrases may help the
face. patient. This provides a
method of communicating
needs based on the
individual situation and
underlying deficit.
 NAME: A. B. AGE: 74
years old

MEDICAL DIAGNOSIS: Acute Stroke Syndrome STATUS:

MARRIED

CUES/DATA NURSING NSG GOAL AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective Data: Risk for Within 8 hours of 1. Established rapport. 1. To promote trust and At the end of nursing
Ineffective proper nursing build patient-nurse interventions patient
“Dili man siya ka Tissue intervention the relationships. was able to;
sturya og tarung Perfusion patient will be to:
sir.” as verbalized related to ● Maintained
by the patient’s Acute stroke 2. Monitor skin 2. To provide baseline data
usual/improved
SO. Syndrome as ● Patient will color/temperature and and usually altered in acute level of
evidenced by maintain vital signs. pain. consciousness,
slurred speech usual/improve
cognition, and
d level of
motor/sensory
Objective Data: Scientific consciousnes 3. Assess airway 3. Neurologic deficits of a function.
Basis: s, cognition, patency and stroke may include loss of ● Demonstrated
● Slurred Speech and
● Dizziness A stroke is a respiratory pattern. gag reflex or cough reflex; stable vital signs
motor/sensory
● Weakness sudden thus, airway patency and and absence of
function.
disruption of breathing pattern must be signs of increased
● Patient will
Vital signs: continuous part of the initial ICP.
demonstrate
blood flow to assessment. ● Display no further
stable vital
T: 34.5°C the brain that deterioration/recur
results in signs and
4. Frequently assess 4. Assess trends in the rence of deficits.
P: 72 bpm neurological absence of
function loss. signs of and monitor level of consciousness
R: 22 cpm A blockage increased neurological status. (LOC), the potential for
can interrupt ICP. increased ICP, and helps
blood flow, ● Patient will determine location, extent,
 display no and progression of
BP: 120/70 mmHg resulting in the further damage.
more deterioration/r
prevalent ecurrence of
ischemic deficits.
stroke, 5. Monitor changes in 5. Hypertension is a
bleeding in the blood pressure, significant risk factor for
brain, or fatal compare BP readings stroke
hemorrhagic in both arms.
stroke.
6. Monitor heart rate 6. Changes in rate,
and rhythm, assess especially bradycardia, can
for murmurs. occur because of brain
damage.

7. Monitor 7. Irregular respiration can

respirations, noting suggest the location of
patterns and rhythm, cerebral insult or increasing
Cheyne-Stokes ICP and the need for
respiration. further intervention,
including possible
respiratory support.

8. Position with head 8. Reduces arterial

slightly elevated and pressure by promoting
in a neutral position. venous drainage and may
improve cerebral perfusion.

9. Maintain bedrest, 9. Continuous stimulation

 provide a quiet and or activity can increase
relaxing environment. intracranial pressure (ICP).
Absolute rest and quiet
may be needed to prevent
rebleeding.

10. Administer
supplemental oxygen
as indicated. 10. Reduces hypoxemia.
Hypoxemia can cause
cerebral vasodilation and
increase pressure or
edema formation.

NAME: J. R. AGE: 30
years old

MEDICAL DIAGNOSIS: Acute Pyelonephritis STATUS:

MARRIED

CUES/DATA NURSING NSG GOAL AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective Data: Acute pain Within 8 hours of 1. Established rapport. 1. To promote trust and At the end of nursing
related to proper nursing build patient-nurse interventions patient
“Sakit ako kilid og infection of the intervention the relationships. was able to;
mag og sakit pud urinary tract patient will be to:
inig ihi '' as secondary to 2. Monitor skin 2. To provide baseline data ● Verbalized an
verbalized by the acute color/temperature and and usually altered in acute absence of flank
patient. pyelonephritis ● The patient vital signs. pain. pain and dysuria.
 will verbalize ● Reported
Scientific an absence of decreased pain
Basis: flank pain and 3. Perform a 3. To rule out worsening of scale of 3/10
Objective Data: dysuria. comprehensive underlying
A urinary tract ● The patient assessment of pain to condition/development of
● Reports of infection will report include COLDSPA complications. And in order
pain/burning/di causes the to plan effective treatment.
satisfactory
scomfort when lining of the
pain control at
urinating urinary tract to 4. Place the patient in 4. To promote optimal
● Dysuria become red a level of less a quiet, comfortable comfort for patient.
● Facial grimace and irritated than 3 on a and well-ventilated
● Guarding (inflammation) scale of 0-10. room. 5. To promote
behavior , which may 5. Provide comfort nonpharmacological pain
● Right lower produce some measure: management and to
quadrant pain. of the ● encourage use of distract attention and
● Pain scale of following relaxation reduce tension.
7/10 symptoms: techniques such
Pain in the as touch,
Vital signs: side (flank), repositioning, deep
abdomen or breathing
T: 35.6°C pelvic area. exercises
● encourage use of
P: 56 bpm diversional
activities such as
R: 24 cpm socialization with
others.
BP: 120/70 mmHg 6. Urinalysis indicating
6. Monitor laboratory pyelonephritis will show a
tests as indicated. positive leukocyte esterase,
presence of white blood
cells, bacteria, and
occasional protein and red
blood cells.
 7. Adequate fluid intake at
7. Increase fluids as 2 liters per day will help
ordered. with urine dilution, promote
renal blood flow, reduce
bladder irritation, and flush
bacteria from the urinary
tract.

8. Encourage the 8. Sodas, spices, tea,

patient to avoid alcoholic beverages, and
urinary tract irritants. coffee are considered
urinary tract irritants and
should be avoided.

9. Encourage the 9. Frequent voiding will

patient to void help to empty the bladder,
frequently. avoiding bladder distention,
reducing urine stasis,
preventing reinfection, and
lowering bacterial count.

10. Administer 10. Antibiotics are

medications as prescribed to treat the
indicated. infection. Antipyretics like
acetaminophen are
prescribed to help reduce
fever and pain.
 NAME: J. R. AGE: 30
years old

MEDICAL DIAGNOSIS: Acute Pyelonephritis STATUS:

MARRIED

CUES/DATA NURSING NSG GOAL AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective Data: Hyperthermia Within 8 hours of 1. Established rapport. 1. To promote trust and At the end of nursing
related to proper nursing build patient-nurse interventions patient
“Nanginit man ko Infectious intervention the relationships. was able to;
sir unya gi tugnaw process patient will be to:
sad ko '' as secondary to 2. Monitor skin 2. To provide baseline data ● Indicated an
verbalized by the pyelonephritis color/temperature and and usually altered in acute understanding of
patient. ● The patient vital signs. pain. the
Scientific will maintain
communication
Basis: core body
problems.
Infections temperature 3. Assess and monitor 3. Changes in vital signs ● Established
Objective Data: cause most within the vital signs. including tachycardia and
method of
fevers. You normal range. hypertension indicate
progression of communication in
● Increased body get a fever ● The patient
temperature because your hyperthermia. which needs can
will maintain
above the body is trying be expressed.
vital signs
 within normal 4.Assess intake, 4. Hyperthermia can result ● Used resources
normal range to kill the virus limits. output, and signs of in dehydration. Signs and appropriately.
● Chills or bacteria dehydration. symptoms of dehydration
● Warm, flushed that caused include thirst, poor skin
skin the infection. turgor, dry oral
Most of those membranes, weak and fast
Vital signs: bacteria and pulse, decreased urine
viruses do well output, and increased urine
T: 38°C when your concentration.
body is at your
P: 100 bpm normal 5. Provide a tepid
temperature. sponge bath as 5. A sponge bath with tepid
R: 25 cpm But if you needed water will reduce fever by
have a fever, it dilating the superficial
BP: 130/80 mmHg is harder for blood vessels, ultimately
them to releasing heat and lowering
survive. body temperature.
6. Monitor laboratory
tests as indicated. 6. Urinalysis indicating
pyelonephritis will show a
positive leukocyte esterase,
presence of white blood
cells, bacteria, and
occasional protein and red
blood cells.
7. Encourage
adequate fluid intake. 7. Adequate fluid intake will
help prevent dehydration,
which is precipitated by the
increase in body
temperature.

8. Maintain bed rest.

 8. Adequate rest allows the
reduction of metabolic
demands and oxygen
consumption, resulting in a
decrease in body
temperature.
9. Measure intake and
output accurately. 9. A record of the patient’s
intake and output can help
determine changes in urine
characteristics (amount and
concentration), which can
indicate the progression of
pyelonephritis.
10. Administer
antipyretic 10. Antipyretic medications
medications as reduce prostaglandin
indicated. synthesis to lower body
temperature.

NAME: J. R. AGE: 30
years old

MEDICAL DIAGNOSIS: Acute Pyelonephritis STATUS:

MARRIED

CUES/DATA NURSING NSG GOAL AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS
Subjective Data: Impaired Within 8 hours of 1. Established rapport. 1. To promote trust and At the end of nursing
Urinary proper nursing build patient-nurse interventions patient
“Sakit man siya i Elimination intervention the relationships. was able to;
ihi sir '' as related to patient will be to:
verbalized by the Kidney 2. Monitor skin 2. To provide baseline data ● Indicated an
patient. infection color/temperature and and usually altered in acute understanding of
secondary to ● The patient vital signs. pain. the
pyelonephritis will achieve a
communication
normal
problems.
Objective Data: Scientific urinary 3. Assess the patient’s 3. The patient’s elimination ● Established
Basis: elimination elimination patterns. patterns can offer insight
method of
● Dysuria pattern, as into causes of infection
such as incontinence, communication in
● Irritability When you evidenced by
have a Kidney delayed urination, or which needs can
the absence
Vital signs: infection, the incomplete urination. be expressed.
of urinary
lining of the ● Used resources
frequency,
T: 35.6°C bladder and 4.Assess the patient’s 4. The patient should be appropriately.
urgency, and
urethra hygiene practices. instructed to urinate after
hesitancy.
P: 56 bpm become red sexual activity, wipe front to
and irritated ● The patient back after bathroom use,
R: 24 cpm this will result will establish and clean the perineal area
in a painful or lifestyle daily to avoid infections of
BP: 120/70 mmHg burning techniques to the urinary tract.
sensation prevent
upon urinary 5. Measure intake and 5. A record of the patient’s
urination. infections. output accurately. intake and output can help
determine changes in urine
characteristics (amount and
concentration), which can
indicate the progression of
pyelonephritis.

6. Instruct the patient 6. This will help to empty

to void every 2-3 the bladder and prevent the
hours. buildup of urine.

7. Check for 7. This can help determine

distention with a bladder distention or
bladder scanner. incomplete emptying after
urination.

8. Encourage 8. Adequate fluid intake

increased fluid intake. promotes hydration,
increases urine production,
and flushes out bacteria
from the urinary tract
system.

9. Discomfort can affect the

9. Facilitate a patient’s elimination
comfortable voiding patterns.
position, making use
of urinals or bedpans
as needed.
10. Antibiotics are
10. Administer prescribed to treat the
medications as infection. Antipyretics like
indicated. acetaminophen are
prescribed to help reduce
fever and pain.