Name: Abigael P.

Cunanan Group: N42-VI

Date: 10-05-22 CI: Mrs. Myrna de Chavez Fesalboni, RN

NURSING CARE PLAN 2

Name of Client: Patient E
Age/Sex: 28 y/o – Female

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective data: Imbalanced Short-term: Independent Short-term:

Nutrition: Less
“Maglisod nana sya’g Than Body Within 1 hour of 1. Approach the client in a 1. A calm, caring, After 1 hour of
tulon, ma’am, di na Requirements nursing intervention, the calm, nonjudgmental manner nonjudgmental approach nursing intervention, the
pud kastorya og related to patient will be able to: with open posture, good eye helps to promote trust. patient was able to:
tarong. Way kaon og inability to contact and a matter of-fact
inom tubig, kay di na ingest food - Obtain voice tone. - Obtained
niya makaya ang secondary to understanding of 2. If aspirated, little or no understanding of
kasakit sa iyang dysphagia as food options to 2. Assess ability to swallow a harm to the patient occurs. food options to
tutunlan.” As evidenced by support nutrition small amount of water. support nutrition
verbalized by the verbalization of supplementation. 3. Cognitive deficits can supplementation.
caregiver. inadequate 3. Determine patient’s result in aspiration even if
caloric intake. Long-term: readiness to drink. Patient able to swallow adequately. GOAL MET.
Objective data: needs to be alert, able to follow
• Spitting of Within 3 days of nursing instructions, hold head erect, Long-term:
saliva intervention, the patient and able to move tongue in
• Drooling will be able to: mouth. After 3 days of nursing
• Restlessness intervention, the patient
• Facial - Have tolerable 4. Instruct the patient to drink in 4. at a 90-degree angle with was able to:
grimacing swallowing an upright position and not to the head flexed forward at a
• Coughing capacity and tilt head back when drinking. 45-degree angle allows the - Have tolerable
improve trachea to close and swallowing
nutrition. esophagus to open, which capacity and
makes swallowing easier and improved
reduces the risk of aspiration. nutrition.

5. Instruct to avoid constant 5. To avoid trigger of pain. October 5, 2022

conversation. 3:30 PM
6. Encourage the patient to 6. Good oral hygiene
perform oral hygiene three enhances appetite; the
times a day. condition of the oral mucosa
is critical to the ability to eat. A.CUNANAN,FSUU/SN

7. Explain nutrition and the 7. Understanding the

patient's personal nutritional importance of maintaining
needs. proper nutrition will
encourage the patient to
become proactive in adhering
Dependent to the treatment plan.

8. Administer medications as 8. Patients receive

prescribed. medications appropriate to
their clinical needs.
Collaborative

9. Watch for signs of 9. Clients with dysphagia are

malnutrition and dehydration at serious risk for
and keep a record of food malnutrition and dehydration
intake.

10. Educate patient, family, and 10. It is common for family

all caregivers about rationales members to disregard
for food consistency and necessary dietary restrictions
choices. and give patient inappropriate
foods that predispose to
aspiration.