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  • Nursing Care Plan

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    Sheng Gosep
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    The document contains 4 nursing care plan assessments for different patients: 1. A patient who is having difficulty eating and is underweight. The nursing diagnosis is imbalance nutrition. Interventions include monitoring vitals, assessing diet, and providing diet modifications. 2. A patient having difficulty breathing. The nursing diagnosis is ineffective airway clearance. Interventions include monitoring vitals, positioning, and breathing exercises. 3. A patient feeling weak from minimal movement. The nursing diagnosis is impaired physical mobility. Interventions include range of motion exercises, assisting with ADLs, and safety measures. 4. A patient having difficulty chewing and swallowing. The nursing diagnosis is impaired swallowing. Interventions include assessing swallowing

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    NCP

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    The document contains 4 nursing care plan assessments for different patients: 1. A patient who is having difficulty eating and is underweight. The nursing diagnosis is imbalance nutrition. Interventions include monitoring vitals, assessing diet, and providing diet modifications. 2. A patient having difficulty breathing. The nursing diagnosis is ineffective airway clearance. Interventions include monitoring vitals, positioning, and breathing exercises. 3. A patient feeling weak from minimal movement. The nursing diagnosis is impaired physical mobility. Interventions include range of motion exercises, assisting with ADLs, and safety measures. 4. A patient having difficulty chewing and swallowing. The nursing diagnosis is impaired swallowing. Interventions include assessing swallowing

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    Download as DOCX, PDF, TXT or read online from Scribd
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    226 views4 pages

    Nursing Care Plan

    Uploaded by

    Sheng Gosep
    The document contains 4 nursing care plan assessments for different patients: 1. A patient who is having difficulty eating and is underweight. The nursing diagnosis is imbalance nutrition. Interventions include monitoring vitals, assessing diet, and providing diet modifications. 2. A patient having difficulty breathing. The nursing diagnosis is ineffective airway clearance. Interventions include monitoring vitals, positioning, and breathing exercises. 3. A patient feeling weak from minimal movement. The nursing diagnosis is impaired physical mobility. Interventions include range of motion exercises, assisting with ADLs, and safety measures. 4. A patient having difficulty chewing and swallowing. The nursing diagnosis is impaired swallowing. Interventions include assessing swallowing

    Copyright:

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    of 4

    NURSING CARE PLAN ASSESSMENT Subjective: Nahihirapan akong kumain as verbalized by the patient.

    Objective: Body weight: 20 % below BMI Pale mucus membrane Poor muscle tone Decrease appetite. Weight: 49 kgs. Height: 54 NURSING DIAGNOSIS Imbalance Nutrition: Less than body requirement related to inability to ingest foods. SCIENTIFIC EXPLANATION PLANNING After 2 months of nursing intervention the client will: 1. Progressively gain weight towards desired goals. 2. Weight within normal range for height and weight. 3. Consume adequate nourishment. 4. Be free of signs of malnutrition. INTEVENTION Monitor vital signs. Determine the ability to chew, swallow and tolerate food. Assess weight, age, and body build. Note total daily intake. Assist in developing individualized regimen. Provide diet modifications. (moderate protein, increase calories) RATIONALE For baseline data. EVALUATION

    Provides comparative baseline. To reveal changes that should be made in clients dietary intake. To correct and control underlying factors.

    ASSESSMENT Subjective: Hirap akong huminga as verbalized by the patient. Objective: Dyspnea. Cyanosis. RR=24 cpm Capillary refill= 3 secs With 02 inhalation via nasal cannula 2 LPM. Easy fatigability. Use of accessory muscles for breathing.

    NURSING DIAGNOSIS Ineffective airway clearance related to decreased ability to cough and swallow secondary to muscle weakness.

    SCIENTIFIC EXPLANATION

    PLANNING After 1 hour of nursing intervention the client will be able to:

    INTEVENTION

    RATIONALE

    EVALUATION

    Monitor vital signs. For baseline data. Assess for airway obstruction. Monitor respiratory patterns. 1. Maintain in patent Position the client airway at all to optimized times. respiration. 2. Identify and avoid Elevate the head of To take advantage specific factors the bed or change of gravity that inhibit position every 2 decreasing effective airway hours. pressure on the clearance. Encourage deepdiaphragm. breathing and coughing exercises. Give expectorants/ bronchodilators as ordered. Observe signs of To assess changes respiratory distress. and to note complications.

    ASSESSMENT Subjective: Nanghihina ako, konting galaw o lakad lang mdali akong mpagod as verbalized by the patient. Objective: Limited range of motion. Limited ability to perform gross fine/ motor skills. Difficulty turning. Slow and uncoordinated movement. Muscle strength=2/5

    NURSING DIAGNOSIS Impaired Physical Mobility related to neuromuscular impairment.

    SCIENTIFIC EXPLANATION

    PLANNING After 2 months of nursing intervention the client will be able to: 1. Perform activity independently in ADLs such as: Grooming Feeding Ambulating Communicating Toileting. 2. Demonstrate techniques that enable resumption of activities. 3. Maintain position of function and skin integrity. 4. Maintain in normal or increase strength.

    INTEVENTION Monitor vital signs. Determine degree of immobility. Assist client to reposition self every 2 hours. Assist in doing passive assistive range of motion exercises to all extremities. Schedule activities with adequate rest periods during the day. Assist client to learn safety measures. Keep side rails up and bed in low position.

    RATIONALE For baseline data. To assess functional ability. To promote optimal level of function and prevent complications. To reduce fatigue.

    EVALUATION

    ASSESSMENT Subjective: Nahihirapan akong ngumuya at lumunok as verbalized by the patient. Objective: Dysphagia. Difficulty of chewing. Unable to consume the meal served. Record current weight.

    NURSING DIAGNOSIS Impaired swallowing related to neuromuscular impairment.

    SCIENTIFIC EXPLANATION

    PLANNING After 2 months of nursing intervention the client will be able to: 1.

    INTEVENTION Monitor vital signs. Assess sensoryperceptual status.

    RATIONALE For baseline data. To assess contributing factors and degree of impairment.

    EVALUATION

    Evaluate ability to swallow using crushed ice or small sips of water. Identify individual factors that can precipitate aspiration. Raise head to 90 degree angle with head in anatomic alignment and slightly flexed forward during feeding. Position patient on the unaffected side when feeding. Encourage rest To minimize period before fatigue. meals. Allow ample time for eating.

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