ASSESSMENT SUBJECT: “Nahihirapan akong lumumod” As verbalized by the patient OBJECTIVE:  With trismus  with of presence of oral mucous

secretions  With presence of dysphagia

DIAGNOSIS Risk for aspirations related to impaired swallowing

PLANNING After continuous nursing intervention patient will be able to demonstrate techniques to prevent aspiration

INTERVENTION Assess factors that might lead to aspiration ( presence of dysphagia) Assess amount and consistency of secretions Maintatin operational suction equipment at bedside Suction as needed to clear secretions Elevate head of bed when providing fluids

RATIONALE To know causative or contributing factor

EVALUATION Expected Outcome: Goal met >seen patient in elevated positiona

To assist in correcting factors that can lead to aspiration To clear secretions To facilitate clearing airway

Avoid nonstimulating To and quiet pRevent stimulation environment

 Provide warm or liquid very cold  To activates temp receptors in the mouth that helps to stimulate swallowing  For exercise that may strengthen muscles to enhance swalowing To promote wellness  Refer to speech therapist Encouraged to strictly adhere to treatment regimen .

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 To divert the attention of the patient while in pain  To provide non pharmacological pain management  Administer .ASSESSMENT Subjective: “sumasakit ang panga ko” As verbalized by the patient Objective:  With facial grimace  with pain score of 5 out of 10 >slightly irritated  Slightly diaphoretic >With trismus noted  with abdominal rigidity DIAGNOSIS Acute Pain related to uncontrolled muscle spasm and involuntary muscle contraction PLANNING After 2 hours of nursing intervention patient’s pain Will be relieved and controlled. INTERVENTION  Assess predisposing factors to pain RATIONALE  To know the etiology of pain EVALUATION Patients pain score 0f 5 decreased to 2 ( moderate to mild pain) seenS patient comfortably sleeping  Monitor vital signs  Usually altered in acute pain  Ask the patient to describe the pain  Encourage verbalization of feelings  Encourage to have diversional activities  Adviced to have comfort measures sucha s back rub  To determine how in pain the patient is.

Patient was able to maintain adequate airway patency as avidenced by stabilized Respiratory rate of 21 bpm  Monitor respirations and breath sounds  Position the patient by elevating the bed  Insert oral airway in severe cases as ordered  To assess changes and note complications  To maintain anatomic position of tongue and natural airway .35bpm >with oral mucous secretions DIAGNOSIS ineffective Airway Clearance related to airway spasm and neuromuscular dysfunction PLANNING After 2 hours of nursing intervention.ASSESSMENT SUBJ: “nahihirapan akong huminga” as verbalized by the patient. OBJ: With difficulty vocalizing words >with trismus noted occassionally >Slighly cyanotic >with rapid and shallow breathing >Fast breathing. patient will be able to maintain airway patency INTERVENTION  Position the client appropriately by elevating of head bed  encourage deep breathing exercise RATIONALE  For maximum lung expansion  To maximize effort and mobilized secretions EVALUATION Goal met.

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