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NURSING CARE PLAN ASSESSMENT Subjective: Nahihirapan akong kumain as verbalized by the patient.

Objective: Body weight: 20 % below BMI Pale mucus membrane Poor muscle tone Decrease appetite. Weight: 49 kgs. Height: 54 NURSING DIAGNOSIS Imbalance Nutrition: Less than body requirement related to inability to ingest foods. SCIENTIFIC EXPLANATION PLANNING After 2 months of nursing intervention the client will: 1. Progressively gain weight towards desired goals. 2. Weight within normal range for height and weight. 3. Consume adequate nourishment. 4. Be free of signs of malnutrition. INTEVENTION Monitor vital signs. Determine the ability to chew, swallow and tolerate food. Assess weight, age, and body build. Note total daily intake. Assist in developing individualized regimen. Provide diet modifications. (moderate protein, increase calories) RATIONALE For baseline data. EVALUATION

Provides comparative baseline. To reveal changes that should be made in clients dietary intake. To correct and control underlying factors.

ASSESSMENT Subjective: Hirap akong huminga as verbalized by the patient. Objective: Dyspnea. Cyanosis. RR=24 cpm Capillary refill= 3 secs With 02 inhalation via nasal cannula 2 LPM. Easy fatigability. Use of accessory muscles for breathing.

NURSING DIAGNOSIS Ineffective airway clearance related to decreased ability to cough and swallow secondary to muscle weakness.

SCIENTIFIC EXPLANATION

PLANNING After 1 hour of nursing intervention the client will be able to:

INTEVENTION

RATIONALE

EVALUATION

Monitor vital signs. For baseline data. Assess for airway obstruction. Monitor respiratory patterns. 1. Maintain in patent Position the client airway at all to optimized times. respiration. 2. Identify and avoid Elevate the head of To take advantage specific factors the bed or change of gravity that inhibit position every 2 decreasing effective airway hours. pressure on the clearance. Encourage deepdiaphragm. breathing and coughing exercises. Give expectorants/ bronchodilators as ordered. Observe signs of To assess changes respiratory distress. and to note complications.

ASSESSMENT Subjective: Nanghihina ako, konting galaw o lakad lang mdali akong mpagod as verbalized by the patient. Objective: Limited range of motion. Limited ability to perform gross fine/ motor skills. Difficulty turning. Slow and uncoordinated movement. Muscle strength=2/5

NURSING DIAGNOSIS Impaired Physical Mobility related to neuromuscular impairment.

SCIENTIFIC EXPLANATION

PLANNING After 2 months of nursing intervention the client will be able to: 1. Perform activity independently in ADLs such as: Grooming Feeding Ambulating Communicating Toileting. 2. Demonstrate techniques that enable resumption of activities. 3. Maintain position of function and skin integrity. 4. Maintain in normal or increase strength.

INTEVENTION Monitor vital signs. Determine degree of immobility. Assist client to reposition self every 2 hours. Assist in doing passive assistive range of motion exercises to all extremities. Schedule activities with adequate rest periods during the day. Assist client to learn safety measures. Keep side rails up and bed in low position.

RATIONALE For baseline data. To assess functional ability. To promote optimal level of function and prevent complications. To reduce fatigue.

EVALUATION

ASSESSMENT Subjective: Nahihirapan akong ngumuya at lumunok as verbalized by the patient. Objective: Dysphagia. Difficulty of chewing. Unable to consume the meal served. Record current weight.

NURSING DIAGNOSIS Impaired swallowing related to neuromuscular impairment.

SCIENTIFIC EXPLANATION

PLANNING After 2 months of nursing intervention the client will be able to: 1.

INTEVENTION Monitor vital signs. Assess sensoryperceptual status.

RATIONALE For baseline data. To assess contributing factors and degree of impairment.

EVALUATION

Evaluate ability to swallow using crushed ice or small sips of water. Identify individual factors that can precipitate aspiration. Raise head to 90 degree angle with head in anatomic alignment and slightly flexed forward during feeding. Position patient on the unaffected side when feeding. Encourage rest To minimize period before fatigue. meals. Allow ample time for eating.