CUES NURSING ANALYSIS GOAL INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Impaired Physical Guillain-Barré Short-Term 1.Assess motor strength or 1.Understanding the After 8 hours of
Mobility related to syndrome is the result functional level of mobility. particular level guides the nursing
“Maluya po it akon neuromuscular of a cell-mediated After 8 hours of design of best possible interventions, the
mga tiil, nakikiwa impairment and humoral immune nursing management plan. patient was be able
ko man kaso di attack on peripheral interventions, the to:
ako nakakatukdaw, nerve myelin patient will be 2.Monitor nutritional needs 2.Good nutrition also
kun nakadto ha CR proteins that cause able to: as they associate with gives required energy for a) Maintain and
gin wheelchair ako inflammatory immobility. participating in an increase strength and
ngan gin-aalalayan demyelination. The a) Maintain and exercise or rehabilitative function
kun kailangan,” as immune increase strength activities.
verbalized. system cannot and function b) Participate in
distinguish between activities of daily living
the two proteins and b) Participate in 3.Place the client in a 3.Promotes relaxation and desired activities
attacks and destroys activities of daily comfortable position. and prevent the
Objective: peripheral nerve living and desired Provide frequent position development of decubitus c) Know the
(+) weakness of myelin. With the activities changes as tolerated ulcers. importance and
lower extremities autoimmune attack, participate in PROM
there is an influx of c) Know the . exercises
(+) numbness, macrophages and importance and 4.Provide padding to bony 4.Maintain extremities in
tingling sensation other immune- participate in prominences such as elbow a physiological position, Goals were met
mediated agents that PROM exercises and heels. reduces the risk of
(+)inability to walk attack myelin and pressure ulcers.
cause inflammation
(+) Passive ROM and destruction, 5.Perform active and 5.Improves joint mobility,
interruption of nerve passive range of motion stimulates circulation and
(+) Grade 1 - reflex conduction, exercises as appropriate. enhances muscle tone.
scale on lower and axonal loss.
extremities Guillain-Barré
syndrome typically 6.Correct utilization of
begins with muscle 6.Evaluate the need for wheelchairs, canes,
weakness and assistive devices and transfer bars, and other
diminished reflexes of provide a safe environment assistance can promote
the lower extremities such as bed in low position mobility and reduces the
causing impaired and side rails up. risk of falls.
mobility.
7.Rest periods are
Source: Marilynn E. 7.Provide rest periods essential to conserve
Doenges, Mary between activities. Consider energy and avoid fatigue.
Moorhouse and Alice energy-saving techniques.
Murr. Nurse's Pocket
Guide. Diagnoses, 8.Consider the need for 8.Formulates a course of
Prioritized assistance such as physical treatment with specific
Interventions, and therapy. interventions to improve
Rationales 15th muscle function and to
EDITION p. 1044 retrain in performing
activities of daily living
(ADLs).
Source: Source: Nursing
Care Plan 9th edition.
Marilyn Doenges, Mary
Frances Moorhouse &Alice
C. Murr. Page: 209-210
 CUES NURSING ANALYSIS GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Disturbed Guillain-Barré syndrome Short Term Independent: After 8 hours of

“Maluya po it sensory is an autoimmune Objectives: 1. Monitor neurological 1. Development and nursing interventions,
akon mga tiil tas perception disorder that affects the Within 8 hours of status on a periodic basis reappearance of signs and the patient was able
nabanhod nak related to altered nerves. Autoimmune nursing such as the ability to symptoms may vary greatly. to:
tiil asya di ako sensory reception disorders occur when interventions, the respond to simple These developments are ● Recognize and
nakakatukdaw.” and changes in the immune system patient will be able commands and responds to often quite quickly and compensate for
as verbalized. reception and malfunctions and to: pain stimulation. possibly culminating in a few sensory
transmission. attacks the body's own ● Recognize and days / weeks. The healing impairments.
Objective: tissues and organs. In correct for process begins 2-4 weeks ● Verbalized
(+) numbness, Guillain-Barré sensory after the process ends and awareness of
tingling syndrome, the immune impairments. the progression of the sensory needs
sensation response damages ● Verbalize disease and most slowly. and presence of
(+) weakness of peripheral nerves, which awareness of overload and/or
lower extremities are the nerves that sensory needs 2. Provide a safe 2. Loss of sensation and deprivation
connect the central and presence of environment (bed barrier motor control patients make ● Identified
nervous system (the overload and/or protection against thermal major concern of caregivers interventions to
brain and spinal cord) to deprivation trauma). who must maintain a minimize damage
the limbs and organs. ● Identify therapeutic environment and / sensory
Specifically, the immune interventions to prevent trauma. complications.
response affects a minimize
particular part of damage / 3. Provide an opportunity 3. Reduce the excessive Goals were met.
peripheral nerves called sensory for resting on areas that are stimulus and can increase
axons, which are the complications. not susceptible to anxiety and minimize great
extensions of nerve interference and provide coping skills.
cells (neurons) that other activities appropriate
transmit nerve impulses. to the patient's ability
Guillain-Barré syndrome boundaries.
can affect the neurons
that control muscle 4. Orient the patient 4. Helps reduce anxiety and
movement (motor returned to the environment is particularly useful in case
neurons); the neurons as needed. of visual impairment.
that transmit sensory
signals such as pain, 5. Provide appropriate
temperature, and touch sensory stimulation,
(sensory neurons); or encompass sound of soft
both. As a result, music, television (news or a
affected individuals can show).
experience muscle
weakness or lose the 6. Suggest person closest
ability to feel certain to speak and give a touch of
sensations. the patient and to maintain
engagement with what is
happening in the family.
Reference:
MedlinePlus (2011.) Dependent
Guillain-Barré 1. Administer medications
syndrome. Retrieved as needed, such as
from pregabalin and vitamin B
https://medlineplus.gov/ complex.
genetics/condition/guilla
in-barre-syndrome/ Collaborative
1. Refer every related
sources to aid speech
therapy.
2. Auxiliary perform
plasmapheresis as needed.
5. Patients feel isolated due
to total paralysis and during
the healing phase.
6. Helping people nearby,
felt the mask on the patient's
life (decrease feelings of
helplessness / no
expectations) and decrease
patient anxiety during the
breakup of the family.
1. Used to treat neuropathic
pain conditions, neuritis,
myalgia.
1. Increases the healing
process / minimize residual
symptoms of neurological
impairment.
2. Handling the throw
immunoglobulins,
complement, vibrinogen and
acute phase proteins that
cause disease and
respiratory depression in
patients.
 CUES NURSING ANALYSIS GOAL INTERVENTION RATIONALE Evaluation
DIAGNOSIS

Subjective: Anxiety related to Anxiety is a vague, uneasy Sto: 1. 1.Acknowledge ➢ Feelings are After 8 hours of
“Napapisip ako change in health feeling of discomfort or presence of anxiety real, and it is nursing
ngan nahadlok ako status dread accompanied by an After 8 hours of nursing helpful to bring interventions the
na di na makalakat autonomic response; a interventions the client them out in the client will be able
utro” as verbalized feeling of apprehension will be able to: open so they to:
caused by anticipation of can be
“Madali la danger. Anxiety represents a. Appear relaxed discussed and a. Appear relaxed
bumanhod tak mga an emotional response to and report anxiety dealt with. and report
kamot bangin environmental stressors is reduced to a anxiety is
sunod dire na ini and is therefore part of the manageable level.2. 2. Determine client’s ➢ Regardless of reduced to a
makakiwa” as person’s stress response. and SO’s perception(s) the reality of the manageable
vebralized Each individual’s b. Verbalize of the situation. situation, level.
experience with anxiety is awareness of perception
Objective: different. Some people are feelings towards affects how b. Verbalize
-inability to move able to use the emotional the disease each individual awareness of
lower extremities edge that anxiety provokes deals with the feelings toward
to stimulate creativity or c. Use effective illness and the disease
-numbness on the problem-solving abilities; coping stress.
upper extremties others can become mechanisms to c. Use effective
immobilized to a reduce anxiety coping
pathological degree. 3.Review coping ➢ Provides mechanisms to
mechanisms used in the opportunity to reduce anxiety
Source: Gulanick.M, Myers, past, such as build on
J. Nursing Care Plans 8th problemsolving skills resources the Goals were met
edition. Page 16 and recognizing and client and SO
asking for help may have used
successfully.

4. Assist client to use ➢ Moderate

the energy of anxiety for anxiety
coping with the situation heightens
when possible. awareness and
can help
motivate the
client to focus
on dealing with
problems.

5. Maintain frequent ➢ Establishes

contact with the client rapport,
and SO. Be available promotes
for listening and talking, expression of
as needed. feelings, and
helps client and
SO look at
realities of the
illness and
treatment

6. Provide accurate ➢ Words and

information as phrases may
appropriate and when have different
requested by the client meanings for
and SO. Answer each individual;
questions freely and therefore,
honestly and in clarification is
language that is necessary to
understandable by all. ensure
understanding

7.Instruct in ways to use ➢ The client

positive self-talk: becomes aware
and can be
directed in the
use of positive
self-talk, which
can help reduce
 anxiety.

8. Encourage client to ➢ Enhance

develop regular sense of well-
exercise and activity being and help
program. reduce level of
anxiety.

➢ Promotes
9. Encourage and release of
instruct in guided endorphins and
imagery or other aids in
relaxation methods, developing
such as imagining a internal locus of
pleasant place, use of control,
music, deep breathing. reducing
anxiety.
Source: Nursing Care
Plan 9th edition. Marilyn
Doenges, Mary Frances
Moorhouse &Alice C.
Murr. Page: 735-736
 CUES NURSING ANALYSIS GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Risk for fall related The sensory component STO Independent Independent After 8 hours of
“Maluya it akon mga to weakness on calls upon contributions After 8 hours of 1. Assess the use 1. Inappropriate Nursing Intervention
tiil, gin aalalayan nala lower extremities. from vision, peripheral Nursing Intervention of mobility use, improper the patient was able
ako kun nakadto ako sensation and vestibular the patient will be assistive selection, and to:
ha banyo” as sense, while the motor able to: devices. maintenance of
verbalized. component requires mobility aids ● Relate the
muscle strength, ● Relate the such as canes, intent to use
Objective: neuromuscular control intent to use walkers, and safety
● (+) and reaction time. safety wheelchairs can measures to
numbness, Linking these two measures to increase energy prevent falls.
tingling components together are prevent falls. expenditure, ● Demonstrate
sensation the higher level ● Demonstrate unsteady gait, selective
● Needs neurological processes selective overload, and prevention
assistance in enabling anticipatory prevention joint damage measures.
performing mechanisms responsible measures. and ultimately ● Implement
ADLs for planning a ● Implement increase the strategies to
movement, and adaptive strategies to patient’s risk for increase
mechanisms responsible increase falls. safety and
for the ability to react to safety and prevent falls.
changing demands of prevent falls. 2. Assess for 2. Clothing and
the particular task. unsafe shoes that are Goals were met.
clothing. poor fitting or
https:// overly tight can
www.physoc.org/ restrict the
abstracts/ person’s
pathophysiology-of-falls- movement and
balance-and-fall- ambulation
prevention/ contributing to
fall risk.

3. Evaluate the 3. A fall is more

patient’s likely to be
environment. experienced by
 an individual if
the surroundings
are unfamiliar,
such as furniture
and equipment
placement in a
certain area.

4. Design an 4. Planning an
individualized individualized fall
plan of care for prevention
preventing program is
falls. Provide a essential for
plan of care nursing care in
that is any healthcare
individualized environment and
to the patient’s needs a
unique needs. multifaceted
approach. Avoid
relying too much
on universal fall
precautions as
different
individuals have
different needs.
Universal fall
precautions are
established for
all patients to
reduce their risk
of falling.

5. Place items 5. Items that are

the patient too far may
uses within require the
easy reach, patient to reach
such as call out or ambulate
light, urinal, unnecessarily
 water, and and can
telephone. potentially be a
hazard or
contribute to
falls.

6. Low beds are

6. Place beds designed to
are at the lessen the
lowest possible distance a
position. patient falls after
moving out of
bed.

7. Raise side rails 7. According to

on beds, as research, a
needed. For disoriented or
beds with split confused patient
side rails, is less likely to
leave at least fall when one of
one of the rails the four rails is
at the foot of left down.
the bed down.

8. Provide the
patient with 8. The use of gait
assistive belts by all
devices for health care
transfer and providers can
ambulation. promote safety
when assisting
patients with
transfers from
bed to chair.
Assistive aids
such as canes,
walkers, and
wheelchairs can
 improve patient
stability and
balance when
ambulating.

Collaborative
Collaborative
1. Refer the
patient with 1. Bone mineral
musculoskelet density testing
al problems for will help identify
diagnostic the risk for
evaluation. fractures from
falls. Physical
therapy
evaluation can
identify problems
with balance and
gait that can
increase a
person’s fall risk.
2. A review of the
patient’s
2. Collaborate medications by
with other the prescribing
health care health care
team members provider and the
to assess and pharmacist can
evaluate identify side
patients’ effects and drug
medications interactions that
that contribute increase the
to falling. patient’s fall risk.

Nursing Care Plan 7th

edition. Marilyn
Doenges, Mary
Frances Moorhouse
 &Alice C. Murr

CUES NURSING ANALYSIS GOAL INTERVENTION RATIONALE Evaluation

DIAGNOSIS

Subjective: Impaired skin integrity The mildest form of SD is a After 8 hours of nursing Independent: After 8 hours of
related to dry and non-inflammatory variant interventions, client will be nursing interventions,
“Mahapdos ko tak flakiness of skin commonly referred to as able to: 1. Assess skin daily. 1. Establishes client was able to:
panit kun gin secondary to seborrheic pityriasis capitis or sicca. It ● Demonstrate Note color, comparative baseline · Demonstrate
babalhas ako labi na dermatitis affects the scalp and “beard behaviors or turgor, providing opportunity behaviors or
Haakon liog, agtang region” and is associated with techniques to circulation, and for timely techniques to
ngan bayhon” as the shedding of small light- prevent skin sensation. intervention. prevent skin
verbalized. colored flakes of skin, often breakdown and Describe and breakdown and
promote healing. measure lesions promote healing.
seen on a background of dark
clothing as “dandruff.”The and observe
● Be free of or display changes. Goal were met.
Objective: face, scalp, and chest are the
improvement in
sites most commonly involved wound or lesion
· Erythema on
in ASD, with around 88%, healing. 2. Maintaining
neck and cheek 2. Provide and
70%, and 27% of cases clean, dry skin
· White patches instruct in good
developing lesions in these provides a
on forehead skin hygiene—
areas, respectively. barrier to
Warmth to touch wash thoroughly, infection.
pat dry carefully, Patting skin
and gently dry instead of
massage with rubbing
Tucker, D., & Masood, S. appropriate reduces risk of
(2022, May 8). Seborrheic cream. dermal trauma
Dermatitis. Retrieved August to dry, fragile
24, 2022, from Nih.gov
skin.
website:
Massaging
https://www.ncbi.nlm.nih.gov
increases
/books/NBK551707/
circulation to
 the skin and
promotes
comfort.

3. Skin friction
3. Maintain clean, caused by
dry, wrinkle-free movement
linen, preferably over wet,
soft cotton wrinkled, or
fabric. rough sheets
leads to
irritation of
fragile skin and
increases risk
of infection.

4. File nails 4. Long or rough

regularly. nails increase
risk of dermal
damage.

Collaborative: 1. Use of agents

can stimulate
1. Apply topical drugs,
circulation,
as indicated such as:
enhancing the
· Miconazole cream
healing process.
· Mupirocin cream
Source:

Doenges, M., Moorhouse,

M., & Murr, A. (2014).
Nursing Care Plan:
Guidelines for
Individualizing Client Care
Across the Life Span (9th
ed.). Philadelphia,
Pennsylvania: F.A. Davis
Company.