NCP 3.
Self-care Deficit: Feeding
DATA
ve findings:
ard for me to feed myself
my shoulder hurts when I
y hand “
ed by the patient
ve findings:
s assistance with self-care
ding ability limited
oss
Nursing Dx: (PE/S)
e Deficit in feeding related
der injury
EXPLANATION OF THE
PROBLEM
Decrease oxygen carrying
capacity of haemoglobin—
decreased nutrition in cells—
decreased ATP production
since oxygen is needed for
oxidation of CHO/gliucose—
decreased energy or muscle
weakness—self care deficit.
GOALS/ Expected outcomes ACTION/ NURSING RATIONALE RESPONSE&
INTERVENTIONS EVALUATION
STG: within 3 hour/s of NI the patient Dxtc: After 3 hr/s of NI, the pat
will be able to: able to
name available resources to continue to 1. Vital signs taking -serves as baseline data name available resources t
improve building independence. and recording -Speech therapy can continue to improve buildi
2. Inquire about a assess the patient’s ability independence
As evidenced/manifested by: swallow screen and to swallow different types
verbalize understanding of the evaluation before of liquids and foods and As evidenced/manifested
condition feeding the patient. also different consistency. verbalized understanding
-Patients are much more condition
inclined to eat the food
3. Ask the patient they like. Nutrition is a
about food vital part of healing
preferences process. STG is fully MET.
-This increases
LTG: after 24 hrs of NI the patient independence in ADLs
will be able to: performance After 24 hr/s of NI, the pa
feed himself on his own recognizing 4. Assess patients was able to
when he needs assistance need for assistive feed himself on his own re
devices -Proper positioning can when he needs assistance
As evidenced/manifested by: make the task easier
Weight gain Txc: while also reducing the As evidenced/manifested
Self-feeding ability with little 1. Place the patient in risk for aspiration. Weight gain
assistance a comfortable -These things expand Self-feeding ability with li
position for feeding possibilities of success. assistance
2. Provide patient
with proper -It is possible that the
utensils to aid in dominant hand will also LTG is fully MET.
self-feeding. be the affected hand if
3. Allow the patient to there is upper extremity
feed himself as soon involvement.
as possible. Assist
with set-up as -Deficits may be
needed. exaggerated if other
4. Ensure the patient senses or strengths are
wears dentures and not functioning optimally.
 eyeglasses if
required.
-Proper body mechanics
Edx: during eating is safer for
1. Educate the patient the patient. It helps
the use of proper prevent food from
body alignment and entering the wrong place.
mechanics -When assisting with
feeding, it is crucial to
adjust to the patients
2. Instruct the patient pace. If the patient feels
to allow enough rushed or senses that you
time between bites are in a hurry, it is more
likely for the patient not
to chew his or her food
properly.
-This demonstrated
caring and concern but
does not interfere with
3. Teach family and patients effort to achieve
caregivers to foster independence.
independence and
to intervene if the
patients become
fatigued, is unable
to perform task or
become excessively
frustrated.