NURSING CARE PLAN PROBLEM IDENTIFIED: difficulty of swallowing NURSING DIAGNOSIS: Risk for Altered Nutrition: Less than

body requirements related to inability to swallow secondary to stroke. TAXONOMY: Nutritional – Metabolic Pattern CAUSE ANALYSIS: Swallowing is a complex process that requires the function of several cranial nerves. The mouth must open, the lips must close, and the tongue must move. The mouth must sense the quantity and quality of the food bolus and must send messages to the swallowing center. A stroke in the territory of the vertibrobasilar system causes dysphagia (the difficulty of swallowing). (Medical Surgical Nursing by Joyce Black p 2114). CUES SUBJECTIVE • Client may report difficulty of swallowing. • Client may verbalize decreased sense of taste. OBJECTIVE • Loss of appetite • 10% to 20% below ideal body weight • documented inadequate caloric intake. OBJECTIVES STO After 24 hours of giving nursing intervention, the client will be able to verbalize and demonstrate selection of food or meals that will achieve a cessation of weight loss. LTO After 3 days of giving nursing intervention, the client will be able to demonstrate manifestations of adequate nutrition as evidenced by maintenance of stable weight, intake equaling output, and consumption of adequate calories for age, height and weight. INTERVENTIONS INDEPENDENT 1. Carefully assess the client’s diet to ensure adequate nutrition. Assess total intake. RATIONALE EXPECTED OUTCOME STO LTO

1. Many psychological, psychosocial, and cultural factor determine the type, amount, and appropriateness of the food consumed. 2. Attention to the social aspects of eating is important in both the hospital and home setting. 3. These may decrease appetite and lead to early satiety. 4. Remind the client not to throw the head back to propel food because this can lead to aspiration. 5. Support the client’s head to counteract hyper extension. 6. Stroking the muscle under the chin, without crossing the midline, also stimulates mouth

2. Provide companionship during mealtime. 3. Discourage beverages that are caffeinated or carbonated. 4. If the patient has limited or no voluntary head control, placing a hand on the forehead may help. 5. Have the client in an upright position, as close to 90 degrees as possible, either in bed or in a chair. 6. If the client does not open the mouth, lightly touch both lips with

the tip of a spoon. Stroking the lips will stimulate lip closure. COLLABORATIVE 1. Consult dietitian for further assessment and recommendations regarding food preferences and nutritional support. Use thickening agents as appropriate. If a client does not close the lips. Dietitians have a greater understanding of the nutritional value of foods. Stroke the lips with a finger or ice or by applying gentle pressure just above the upper lip with your thumb or forefinger. Offer foods with consistency that patient can swallow. 1. swallowing is more difficult. Reference: Medical Surgical Nursing 7th Edition by Joyce Black pp 2124 – 2125. opening. Nursing Care Plans 5th Edition by Gulanick and Myers pp 113 – 114. 8. Semisolid foods like pudding and hot cereal are easily swallowed. If this does not work. apply light pressure with a finger to the chin just below the lower lip. 8. NURSING CARE PLAN . 7. Liquids and thin foods like creamed soups are most difficult for patient with dysphagia. Cut foods into small pieces. 7.

no choking or coughing while eating. OBJECTIVE • Difficulty in swallowing – in opening the mouth. LTO After 3 days of giving nursing intervention. Decreased gastrointestinal motility increases the risk of aspiration because foods or fluids accumulate in the stomach. no fever and no crackles or rhonchi. This is necessary to maintain patent airway. 5. INTERVENTIONS INDEPENDENT 1. RATIONALE EXPECTED OUTCOME STO LTO 1. Monitor level of consciousness. 6. • Assess for regurgitation of food or fluid through nares. 2. CUES SUBJECTIVE • Client may report altered sensing the quantity and quality of food. the patient will be able to maintain patent airway as evidenced by easily managing saliva. • Monitor for choking during eating and drinking. Auscultate bowel sounds to evaluate bowel motility.PROBLEM IDENTIFIED: Decreased level of consciousness NURSING DIAGNOSIS: Risk for aspiration related to depressed cough and gag reflex secondary to stroke. Keep suction setup available and use as needed. 6. Proper positioning can 5. OBJECTIVES STO After 24 hours of giving nursing intervention. the patient will be able to demonstrate the different ways on preventing the risk for aspiration. Monitor swallowing ability: • Assess for coughing or clearing of throat after a swallow. 2. TAXONOMY: Activty – Exercise Pattern CAUSE ANALYSIS: Clients with stroke are at high risk for aspiration. Decreased level of consciousness is a prime risk factor for aspiration. Assess cough and gag reflex. Aspiration is most common in early period and is related to loss of pharyngeal sensation. moving the tongue • Choking • Coughing • Presence of crackles or rhonchi. A depressed cough or gag reflex increases the risk for aspiration. Pockets of food can be easily aspirated at a later time. closing the lips. Position patient who have decreased level of consciousness . loss of oropharyngeal motor control. (Medical Surgical Nursing by Joyce Black p 2122). 4. 3. 4. This protects the airway. and decreased level of consciousness. choking indicates aspiration. 3.

If the head of the bed cannot be elevated because of the patient’s condition. Offer foods with consistency that patient can swallow. Semisolid foods like pudding and hot cereal are easily swallowed. Use thickening agents as appropriate. 7. Maintain upright position for 30 to 45 minutes after feeding. use a right side-lying position after feeding to facilitate passage of stomach contents into the duodenum. NURSING CARE PLAN . 9. Liquids and thin foods like creamed soups are most difficult for patient with dysphagia. remove distracting stimuli during mealtimes. 10. The upright position facilitates the gravitational flow of food or fluid through the alimentary tract.on their sides. Use cushions or pillows to maintain position. whether in bed or in a chair or wheelchair. Cut foods into small pieces. 10. 9. Proper positioning of patients with swallowing difficulty is of primary importance during feeding or eating. 8. 8. Reference: Nursing Care Plan 5th edition by Gulanick and Myers pp 17-19. This facilitates concentration on chewing and swallowing. Position patient at 90 degree angle. 7. decrease the risk for aspiration. For patients with reduced cognitive abilities.

TAXONOMY: Cognitive-perceptual pattern CAUSE ANALYSIS: Unilateral neglect is the pattern lack of awareness of one side of the body. Approach the patient from the unaffected side when patient initially regains consciousness. This stimulates short-term memory of sensation. OBJECTIVES STO After 24 hours of effective nursing intervention. LTO After 5 days of giving effective nursing intervention. This will prevent any risk for injury to the patient. 4. This provides information on patient’s recognition of affected side. RATIONALE EXPECTED OUTCOME STO After 24 hours of giving effective nursing intervention. the patient will be able to verbalize cognitive awareness of the deficit.PROBLEM IDENTIFIED: Paralysis of one side of the body. 1. 6. Place all food in small quantities. NURSING DIAGNOSIS: Risk for unilateral neglect related to damage in the nondominant hemisphere of the brain secondary to stroke. . This decreases anxiety and fear while patient is unable to interpret whole environment. dress. The patient may forget that the affected side still exists. (Medical – Surgical Nursing By Joyce Black p 2131). the patient will be able to compensate for unilateral neglect as evidenced by being free from injury and demonstrating an increased awareness of the neglected body side. Small quantities make it easier to delineate foods because of the 3. 2. Ensure safe environment with call bell on patient’s unaffected side. and begin to wash. and eat with attention to both sides. CUES SUBJECTIVE • Client may report sensation of stimulus to one side of the body. the client is expected to begin touching the affected side during ADLs. 3. Provide tactile stimulation to affected side. resulting in the inability to respond to stimulus on the contralateral side of a cerebral infarction. 2. arranged simply on plate. 4. the client is expected to verbalize recognition of affected side. It is caused by damage to portions of the nondominant cerebral hemisphere. 6. 5. Observe patient’s performance of ADL (activities of daily living). Conduct sensory assessment. INTERVENTIONS INDEPENDENT 1. This determines the actual level of sensation for comparison with how the patient uses the senses on the affected side. LTO After 5 days of giving effective nursing intervention. 5. OBJECTIVE • Attend to one side of the body • Uses one extremity • Orient the head and eyes to one side • Inaccurate beliefs about the position of the limb in space or its existence. This approach diminishes spatial / visual deficits.

] 7. NURSING CARE PLAN . encourage the patient to hold and manipulate objects correctly. This helps develop fine motor skills and relearn spatial relationships. 8. 8.space between food items. Attach watch or bright bracelet to affected arm. This draws patient’s attention to the affected side. Practice drawing and copying figures with patient. Reference: Nursing Care Plan 5th edition by Gulanick and Myers pp 501-502 7.

BP.The upright position allows full lung excursion and enhance air exchange . -V/S T-37.140/100 Patient experienced adequate gas exchange as evidenced by absence of pallor. difficulty of breathing & hypoxia . P 1121). and monitor for side effects. breathing and relaxation technique to enhance breathing pattern b.Pace activities to the client’s tolerance and offer support during periods of respiratory distress or anxiety . cyanosis. .60 sec. 4 ed. inhalants. -Encouraged deep breathing exercise and coughing .Capillary refills 1. cyanosis. Bronchodilators relax bronchia smooth muscle facilitating air flow (Nursing Care Plans. antibiotics.Clients understanding of condition and preventive measures may facilitate necessary follow up care Patient understood & followed measures to relieved difficulty of breathing. supportive equipment e.P-98. Report significant change promptly. -Prompt recognition of deterioration of respiratory function can reduce potentially lethal outcomes -This minimize shortness of breathing and fatigue . patient will be able to experience maximal pulmonary ventilation and adequate gas exchange as evidenced by absence of pallor. medicine (bronchodilators). expectorants. client will be able to verbalize understanding of measures to be irritated as evidence by following measures given to him. CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION Subjective: ”Nahihirapan akong huminga kaya napkabit ako ng oxygen” as verbalized by the patient STO: -After 1-2 hours of nursing interventions.Positioned the patient in semi or high fowler’s position as indicated. Reference: Nursing Care Plans.This helps maintain a patent airway .RR 32. difficulty of breathing .Promote ventilation depth and clear air passage for adequate gas exchange. 4th ed. (Nursing Care Plan). LTO: -After 3 days of implementing nursing. reportable s/s Dependent: -Administered prescribed therapies such as water. Objective: -with oxygen inhalation at 36 / min .Provided instruction about a.4. hypoxia . th . activities allowed d.pallor / use of accessory muscle . medications c.PROBLEM: Difficulty in Breathing NURSING DIAGNOSIS: Impaired gas exchange related to decreased oxygen perfusion and ventilation secondary to Chronic heart failure TAXONOMY: Activity-Exercise Pattern CAUSE ANALYSIS: There is partial airway collapse that would cause the work of breathing to increase because there is less functional lung tissue to exchange water and carbon dioxide and increased ventilatory dead space that do not participate in gas or blood change that would led to decreased oxygen perfusion ventilation.).irritable tachypriec RR-32 .Independent: -Regularly monitored the patient’s respiratory rate pattern and manifestation of hypoxia or hypercapnia.

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