NURSING PROBLEM EXPLANATION GOAL INTERVENTION RATIONALE EVALUATION

Subjective: Bleeding Patient would be able to Independent: - Patient is stil uses ngt
Volume limiting pass food and fluid safely for feeding but has
from mouth to stomach. - Provide oral care - Optimal oral care orders for sipping
Objective: before feeding. Clean promotes appetite and small amounts of
- Dry mucous Patient would be able to and insert dentures eating. water with the use of
membranes maintain adequate before each meal. straw.
- Choking Damaged tissue hydration as evidenced by
- Decreased gag good skin turgor, moist - Determine ability to - Weak suck results in - Patient has good skin
reflex mucous membranes, and initiate/sustain inefficient nippling, turgor, still has dry
- Excursion of individually appropriate effective suck. suggesting ineffective mucous membranes
muscles or urine output. movement of tongue and has appropriate
decreased and mouth muscles, urine output.
strength involved Achieve and/or maintain impairing ability to
in mastication Hemisensory desired body weight. swallow. - Patient is maintaining
Nursing Diagnosis: defects,dysphagia 1,900 kcal/day in 6
Impaired - Auscultate breath - To evaluate the presence serviings.
swallowing sounds. of aspiration.
related to
muscle paralysis Dependent:
and perceptual - Prepare/assist with - To help determine and
impairment as diagnostic testing of evaluate status.
swallowing activity.
evidenced by
NGT.
Collaborative:
- Refer to - For
gastroenterologist/ne treatment/interventions
urologist as indicated. that may result in
improved swallowing.

Community:
- Encourage - To maintain/improve
continuation of facial muscle strength.
exercise program