The document outlines a nursing care plan for a patient with impaired swallowing leading to less than body requirements nutrition. The short term goal is for the patient to gain 2 pounds per week for 3 weeks. Interventions include collaborating with a dietician to determine calorie needs, weighing the patient daily, and providing small, frequent feedings including a bedtime snack. The long term goal is for the patient to exhibit no signs of malnutrition by discharge through ensuring adequate nutrition and fluid intake.
The document outlines a nursing care plan for a patient with impaired swallowing leading to less than body requirements nutrition. The short term goal is for the patient to gain 2 pounds per week for 3 weeks. Interventions include collaborating with a dietician to determine calorie needs, weighing the patient daily, and providing small, frequent feedings including a bedtime snack. The long term goal is for the patient to exhibit no signs of malnutrition by discharge through ensuring adequate nutrition and fluid intake.
The document outlines a nursing care plan for a patient with impaired swallowing leading to less than body requirements nutrition. The short term goal is for the patient to gain 2 pounds per week for 3 weeks. Interventions include collaborating with a dietician to determine calorie needs, weighing the patient daily, and providing small, frequent feedings including a bedtime snack. The long term goal is for the patient to exhibit no signs of malnutrition by discharge through ensuring adequate nutrition and fluid intake.
The document outlines a nursing care plan for a patient with impaired swallowing leading to less than body requirements nutrition. The short term goal is for the patient to gain 2 pounds per week for 3 weeks. Interventions include collaborating with a dietician to determine calorie needs, weighing the patient daily, and providing small, frequent feedings including a bedtime snack. The long term goal is for the patient to exhibit no signs of malnutrition by discharge through ensuring adequate nutrition and fluid intake.
∆ Ineffective airway Short term: Monitor respiratory status Short Term:
clearance related to and ability to cough and neuromuscular Ater 4 hours of nursirg deep breathe adequately. After 4 hours of nursing impairment as evidenced intervention the patient intervention the patient by difficult in swallowing, can be able to express Monitor vital signs verbalized in decrease of breathing and aspirations decrease in difficult difficulty in swallowing and swallowing and be Auscultate breath sounds was ventilated to relieve ventilated Determine the food aspiration. preference of the patient Long Term: Long term: Massage the sides of trachea and neck gently After 2 days of nursing After 2 days patient can be Monitor the patients pulse intervention, the patient able to maintain stable oximetry was able to maintain respiratory status stable respiratory status Encourage deep breathing with a 16bpm respiratory exercise and administer rate and normal breath oxygen if needed sounds by doing deep breathing exercise and oxygen therapy Diagnosis Plan of care Intervention Evaluation
∆ Impaired physical Short Term: •Assess patient's ability to Short Term:
mobility related to reduced perform ADLs effectively neuromuscular function as After 4 hours of nursing and safely on a daily basis After 4 hours of nursing evidenced by decrease in interventions, the patient interventions, the patient muscle endurance, will be able to demonstrate •Assess for developing was able to demonstrate strength, and control measures to increase thrombophlebitis Evaluate measures to increase mobility and perform need for assistive devices mobility by performing activities independently ROM exercises and •Encourageappropriate perform activities Long Term: use of assistive devices in independently with use of the home setting assistive devices After 2 days of nursing interventions, the patient •Allow patient to perform Long Term: will be free from immobility tasks at his or her own complications and use rate. Do not rush patient. After 2 days of nursing safety measures interventions, the patient •Encourage independent will be free from immobility activity as able and safe complications as evidence by free of •Perform passive or active thrombophlebitis, and use assistive ROM exercises safety measures with use Diagnosis Goals Intervention Evaluation
∆ Risk for Injury related to Short Term: • Assess patient for Short Term: impaired sensory function degree of visual secondary to diplopia as After 2 hours of nursing impairment Ascertain After 2 hours of nursing evidence by patient interventions, the patient knowledge of safety interventions, the patient reporting he is seeing will be able to verbalize needs/ injury prevention was able to identify factors double. understanding of individual and motivation that increase risk for injury factors that contribute to possibility of injury •Ensure the room Long Term: environment is safe with Long Term: adequate lighting and After 2 days of nursing furniture moved toward the interventions, the was free After 2 days of nursing walls from injury using safety interventions, the patient measures such as using will be able to protect self •Assess client's mucsle handrails and be free from injuries strength, gross, and fine motor coordination Instruct patient regarding safe lighting
•Train patient on safe
ambulation Diagnosis Plan of care Intervention Evaluation
Imbalanced Nutrition: Less Short-Term Goal Collaborate to the dietician Client has shown a slow, than Body to determine the number of progressive weight gain Requirementsrelated to Client will gain 2 pounds calories required. during hospitalization. difficulty swallowing. per week for the next 3 weeks. Weigh client daily. Client is able to verbalize importance of adequate Long-Term Goal Ensure that client receives nutrition and fluid intake. small, frequent feedings, Client will exhibit no signs including a bedtime snack, or symptoms of rather than three larger malnutrition by time of meals. discharge from treatment Stay with client during meals
Explain the importance of
adequate nutrition
Determine client's likes and
dislikes, and collaborate with dietitian to provide
