NURSING CARE PLAN FORM

Patient’s Name (Initials): C. M. G. Postoperative Diagnosis: 1. Cystic Hygroma Left 2. Nodular Colloid Goiter Right Non Toxic
Age: 30 years old Sex: Female Physician (Initials): Dr. M. A. L.
Diet: Nothing by Mouth

SUBJECTIV OBJECTIV NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EVALUATION

E E DIAGNOSI ANALYSIS
S
Impaired Decreased, Short term goal: Independent: 1. Hoarseness and sore  The patient
verbal delayed, or absent  The patient will 1. Assess throat may occur was able to
communicat ability to receive, communicate speech secondary to tissue communicate
ion may be process, transmit, through eye periodically; edema or surgical through eye
related to and use a system contact, facial encourage damage to recurrent contact, facial
physiologic of symbols. expressions, voice rest. laryngeal nerve and may expressions,
condition as and other last several days. and other
evidenced Source: nonverbal 2. Provide Permanent nerve nonverbal
by total Doenges, M.E., et gestures within alternative damage can occur (rare) gestures within
absence of al. Nurse’s Pocket 1 month. methods of that causes paralysis of 1 month.
language Guide Edition 15.  The patient will communicati vocal cords and/or  The patient
F.A. Davis attempt to use on as compression of the was able to
Company. language and appropriate, trachea. use language
Philadelphia, begin to e.g., slate and begin to
Pennsylvania. communicate board, 2. Assistive devices such as communicate
2008 with words letter/picture text-to-speech, TTY or with words
within 5 to 6 board. Place TDD assists those with within 5 to 6
months. IV line to speech impairments. months.
 The patient will minimize Picture boards and other  The patient
have increase interference apps can help children was able to
language skills with written communicate. It learn language
needed for communicati facilitates expression of skills needed
social and on. needs. for social and
 emotional 3. Sign emotional
reciprocal language. 3. Nurses can implement reciprocal
interactions important words and interactions
within 6 to 8 4. Use an phrases into their within 6 to 8
months. interpreter. profession to months.
 The patient will communicate with  The patient
use language or patients. Commonly used was able to
5. Pay attention phrases in the hospital
gestures to use language
to nonverbal such as “pain” “bathroom”
identify self, or gestures to
cues and or “water” can be useful
others, objects, identify self,
gestures. to learn.
feelings, needs, others,
plans, and objects,
desires within 6. Display 4. An interpreter should feelings,
12 months proper always be used when needs, plans,
speech communicating with a and desires
Long term goal: etiquette. patient who does not within 12
 The patient will speak the nurse’s months.
communicate to language.
significant 7. Involve the  The patient
other/caregiver family. 5. Patients may have was able to
and peers at specific gestures or cues communicate
least four basic 8. Keep they use to communicate. to significant
needs (hunger, communicati It may take time for the other/caregiver
thirst, fatigue, on simple; nurse to learn what these and peers at
pain), verbally ask yes/no are, but should be least four basic
and/or through questions. respected and needs (hunger,
gestures and reciprocated. thirst, fatigue,
body language. pain), verbally
9. Anticipate and/or through
needs as 6. Never speak loudly at a
gestures and
possible. Visit speech-impaired person
body
patient unless they are hard of
language.
frequently. hearing. Maintain eye
contact and allow the
 10. Continue patient to see your
speaking to mouth, do not turn away
the patient when speaking. Give the
even if they patient plenty of time to
can’t respond.
respond.

11. Post notice of 7. Family members often

patient’s know how to best
voice communicate with the
limitations at patient and can teach the
central nurse what the patient is
station and trying to say. Though the
answer call nurse should always
bell promptly. speak directly to the
patient, they can ask the
family for assistance to
12. Hang clarify information.
signage and
document
accordingly. 8. Patients who have
difficulty forming words or
who are aphasic may
13. Maintain require longer to process
quiet speech and respond. Try
environment. sticking to shorter
questions and allow
Collaborative: plenty of time to respond.
Do not ask multiple
14. Incorporate questions together.
speech- Asking questions that
language only require a “yes” or
therapy and “no” answer may be best
support
services. when possible.

9. Reduces anxiety and

patient’s need to
communicate.

10. Patients with a

tracheostomy or physical
barrier or who have
dysphagia or dementia
should still be spoken to
as a person.

11. Prevents patient from

straining voice to make
needs known/summon
assistance.

12. Once the best form(s) of

communication have
been discovered,
document in the chart
and hang signage so
other staff members are
aware of how to best
communicate with the
patient.
13. Enhances ability to hear
whispered
communication and
reduces necessity for
patient to raise/strain
 voice to be heard.

14. Speech-language
therapists can assist by
using language and
articulation activities for
children. They can teach
exercises to strengthen
the mouth and tongue
muscles and breathing
exercises to help with
resonance issues.