| NANDA nursing diagnosis | Patient Goal | Nursing interventions | Rationale | Evaluation |
Assessment Data: The questions used are usually open-ended. It involved taking patient history and holistic assessment of the whole-body system including the vital signs. The patient has a medical history of coronary artery bypass surgery and diabetes mellitus type II. Besides, the patient has poor feeding habits and Vital signs: HR 62, BP 128/48, RR 24, SpO2 94 % on 2 LPM nasal cannula, Temp 36.7oC (Ladwig et al., 2019). Nursing Diagnosis: After clustering information within the client story, the nurse formulates judgement in form of evaluation about the health status of the patient. Appropriate diagnosis includes clinical reasoning ( Kume & Yamaguchi, 2017) . The type of diagnosis depends on holistic assessment of the patient. R/T (correlated to patient data): Physical and occupation therapy twice a day. As evidenced by (Subjective/objective data): The general appearance of the patient, which was thin and an appearance that is older than his age, poor appetite and hypoactive bowel sounds. | Patient will: Remain free of falls, adapt in the environment to reduce the risk of falls, have a decreased risk of injury in case of falls and explain methods to prevent injury. Live independently in the care facility. Short-term goal: Have healthy sleeping patterns and good eating habits. Long-term goal: Maintain a healthy weight. To maintain good electrolyte balance. As exhibited by: the chemistry results from the laboratory and the concentration of urine. | 1. Priority intervention: Support the patient and his family to engage in healthcare decisions. 2. Priority intervention: Provide timely, appropriate and relevant information. 3. Priority intervention: Design educational interventions for decision support. | To improve adherence to treatment and patient outcomes. To help the patient in decision-making and improve satisfaction. To improve patient’s decision-making based on his preferences in alignment with treatment options. To provide the patient with the understanding of all the risks and benefits of all the available treatment options. | This stage involves assessing how the patient responded to the medications and therapies and whether the patient had no side effects or not. The long-term goals were met. The blood sugar levels of the patient reduced. The patient has maintained a healthy weight. The patient had improved sleeping patterns and improved appetite. |
References
Kume, Y., & Yamaguchi, H. (2017). Experiences of nurses in the process of determining a nursing diagnosis and needs for applying a nursing diagnosis: fostering understanding to support the use of nursing diagnoses in clinical practice. J Comprehen Nurs ResCare , 2 , 107.
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Ladwig, G. B., Ackley, B. J., & Makic, M. B. (2019). Mosby's Guide to Nursing Diagnosis E-Book . Elsevier Health Sciences.
