Cues Nursing diagnosis Objectives Intervention Rationale Evaluation

“ Gasuka og ga kalibanga Electrolyte imbalance rt/ fluid After five hours of nursing  Monitor vital signs To have a baseline data At the of five hours nursing
akong anak” – as verbalized imbalance intervention, the patient will: intervention, the goal was
by the pt’s mother. partially met as evidenced by:
 Be free of
complications  Assess skin turgor Signs of dehydration are also  Be free of
resulting from and oral mucous detected through the skin. complications
Objectives: electrolyte imbalance membranes for signs Poor skin turgor is a sign of resulting from
Palor of dehydration dehydration electrolyte imbalance
Watery stool  Identify individual
Dry lips risks and engage in  Identifying individual
White patches appropriate Helps evaluate client’s fluid risks and engage in
behaviors or lifestyle  Monitor intake and and electrolyte imbalance appropriate
Vital signs: changes to prevent or output behaviors or lifestyle
Temp- 37.1*C reduce frequency of changes to prevent or
BP- 100/40 electrolyte reduce frequency of
PR- 126bpm imbalances electrolyte
Oxygen Saturation- 95% imbalances

Imbalanced nutrition: less  Verbalizes  Determine client’s To assess causative or  Verbalized

than body requirements understanding of ability to chew, contributing factors understanding of
causative factors swallow and taste causative factors
when known and food when known and
necessary necessary
interventions interventions

 Demonstrate  As certain To determine informational  Demonstrated

behaviors, lifestyle understanding of needs of clients or SO behaviors, lifestyle
changes to regain individual nutritional changes to regain
and/ or maintain needs and/or maintain
appropriate weight. appropriate weight.
Knowledge Deficit r/t lack of  Participate in learning  Determine client’s Individual may not be Participated in learning
information process ability, readiness and physically, emotionally, or process
barriers to learning mentally capable at this time

 Identify interferences  Assess the level of the To help SO to learn Identified interferences to
to learning and client or the SO’s learning and specific actions
specific actions to capabilities and the to deal with them
deal with them possibilities of the
situation

 Verbalize  Identify information To establish the content to be Verbalized understanding of

understanding of that needs to be included condition, disease process,
condition, disease remembered and treatment
process, and
treatment