Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

Vigan City, Ilocos Sur
College of Nursing
NURSING CARE PLAN
Name of Patient: Roger B. Briales Name of Student: Czarina Joy F. Ramirez
Age and Gender: 48-year-old, Male Room: Ward G
Diagnosis: Cerebrovascular Accident Hemorrhagic Date: April 18, 2023
SCIENTIFIC NURSING NURSING
ASSESSMENT NURSING DIAGNOSIS BACKGROUND OBJECTIVES INTERVENTION RATIONALE EVALUATION
Subjective Data: Impaired swallowing Cerebrovascular Date: April 18, 2023 Independent: Date: April 18, 2023
“Haan na kaya as evidenced by Accident Time: 8 am 1. Review individual 1.Assess the patient’s Time: 1 pm
agtilmon,” as muscle paralysis and pathology and ability ability to swallow as
verbalized by his perceptual impairment. After 5 hours of to swallow, noting the soon as possible. After 5 hours of
significant other. Muscle paralysis & nursing intervention, extent of the paralysis: nursing intervention,
perceptual impairment the patient will clarity of speech, the patient was able to
Objective Data: maintain adequate tongue involvement, maintain adequate
• Incomplete lip hydration as evidenced ability to protect the hydration as evidenced
closure. Impaired swallowing by: airway, episodes of by:
• Coughing. coughing, presence of
• Inefficient sucking. • Good skin turgor adventitious breath • Good skin turgor
• Vomitus on pillow. Reference: • Moist mucus sounds. • Moist mucus
Doenges, M.
E., Moorhouse, F., &
membranes membranes
Murr, A. C. (2019). • Pass food and fluid 2. Maintain accurate 2. Alternative feeding • Pass food and fluid
NURSES'S POCKET GUIDE safely into the I&O. method such as NGT safely into the
Diagnoses, Prioritized feeding may be used if
Interventions, and Rationales
stomach. stomach.
(15th ed.). F.A. DAVIS are not sufficient to
COMPANY. meet fluid and “Goal Met”
nutritional needs.

3. Raise head of the 3. To reduce risk of

bed as upright as regurgitation or
possible and head aspiration.
slightly flexed forward
during feeding and
after feeding.
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Vigan City, Ilocos Sur
College of Nursing
NURSING CARE PLAN
4. Keep head of bed 4. To reduce risk of
elevated for 30 regurgitation or
minutes to 1 hour after aspiration.
feeding.

5. Have suction 5. Timely intervention

equipment available at may limit the untoward
the bedside, especially effects of aspiration.
during early feedings.

Dependent:
1.Administer tube 1.It is necessary for
feedings; 1600k/cal fluid replacement and
Osterized feeding nutrition when patient
is unable to take
anything orally.