NURSING CARE PLAN

PROBLEM IDENTIFIED: difficulty of swallowing

NURSING DIAGNOSIS: Risk for Altered Nutrition: Less than body requirements related to inability to swallow secondary to stroke.
TAXONOMY: Nutritional – Metabolic Pattern
CAUSE ANALYSIS: Swallowing is a complex process that requires the function of several cranial nerves. The mouth must open, the lips must close, and the tongue
must move. The mouth must sense the quantity and quality of the food bolus and must send messages to the swallowing center. A stroke in the territory of the
vertibrobasilar system causes dysphagia (the difficulty of swallowing). (Medical Surgical Nursing by Joyce Black p 2114).
CUES OBJECTIVES INTERVENTIONS RATIONALE EXPECTED OUTCOME
SUBJECTIVE STO INDEPENDENT STO

• Client may report After 24 hours of giving
difficulty of nursing intervention, the
swallowing. client will be able to verbalize
• Client may and demonstrate selection of
verbalize decreased food or meals that will
sense of taste. achieve a cessation of weight
loss.
OBJECTIVE
LTO
• Loss of appetite
• 10% to 20% below After 3 days of giving nursing
ideal body weight intervention, the client will be
able to demonstrate
• documented
manifestations of adequate
inadequate caloric
nutrition as evidenced by
intake.
maintenance of stable
weight, intake equaling
output, and consumption of
adequate calories for age,
height and weight.
1. Carefully assess the client’s
diet to ensure adequate nutrition.
Assess total intake.
2. Provide companionship during
mealtime.
3. Discourage beverages that are
caffeinated or carbonated.
4. If the patient has limited or no
voluntary head control, placing a
hand on the forehead may help.
5. Have the client in an upright
position, as close to 90 degrees as
possible, either in bed or in a
chair.
6. If the client does not open the
mouth, lightly touch both lips with
1. Many psychological,
psychosocial, and cultural LTO
factor determine the type,
amount, and appropriateness
of the food consumed.
2. Attention to the social aspects
of eating is important in both
the hospital and home setting.
3. These may decrease appetite
and lead to early satiety.
4. Remind the client not to throw
the head back to propel food
because this can lead to
aspiration.
5. Support the client’s head to
counteract hyper extension.
6. Stroking the muscle under the
chin, without crossing the
midline, also stimulates mouth
 the tip of a spoon. If this does not opening.
work, apply light pressure with a
finger to the chin just below the
lower lip.
7. Stroking the lips will stimulate
7. If a client does not close the lip closure.
lips, swallowing is more difficult.
Stroke the lips with a finger or ice
or by applying gentle pressure
just above the upper lip with your
thumb or forefinger.
8. Semisolid foods like pudding
8. Offer foods with consistency and hot cereal are easily
that patient can swallow. Use swallowed. Liquids and thin
thickening agents as appropriate. foods like creamed soups are
Cut foods into small pieces. most difficult for patient with
dysphagia.

COLLABORATIVE
1. Dietitians have a greater
1. Consult dietitian for further understanding of the
assessment and nutritional value of foods.
recommendations regarding food
preferences and nutritional
support.

Reference: Medical Surgical Nursing 7th Edition by Joyce Black pp 2124 – 2125.
Nursing Care Plans 5th Edition by Gulanick and Myers pp 113 – 114.

NURSING CARE PLAN

PROBLEM IDENTIFIED: Decreased level of consciousness
NURSING DIAGNOSIS: Risk for aspiration related to depressed cough and gag reflex secondary to stroke.
TAXONOMY: Activty – Exercise Pattern
CAUSE ANALYSIS: Clients with stroke are at high risk for aspiration. Aspiration is most common in early period and is related to loss of pharyngeal sensation, loss of
oropharyngeal motor control, and decreased level of consciousness. (Medical Surgical Nursing by Joyce Black p 2122).

CUES OBJECTIVES INTERVENTIONS RATIONALE EXPECTED OUTCOME

SUBJECTIVE STO INDEPENDENT STO

• Client may report After 24 hours of giving
altered sensing the nursing intervention, the
quantity and quality patient will be able to
of food. demonstrate the different
ways on preventing the risk
OBJECTIVE for aspiration.
• Difficulty in
swallowing – in LTO
opening the mouth,
closing the lips, After 3 days of giving nursing
moving the tongue intervention, the patient will
• Choking be able to maintain patent
• Coughing airway as evidenced by easily
managing saliva, no choking
• Presence of
or coughing while eating, no
crackles or rhonchi.
fever and no crackles or
rhonchi.
1. Monitor level of consciousness.
2. Assess cough and gag reflex.
3. Monitor swallowing ability:
• Assess for coughing or
clearing of throat after a swallow.
• Assess for regurgitation
of food or fluid through nares.
• Monitor for choking
during eating and drinking.
4. Auscultate bowel sounds to
evaluate bowel motility.
1. Decreased level of
consciousness is a prime risk LTO
factor for aspiration.
2. A depressed cough or gag
reflex increases the risk for
aspiration.
3. Pockets of food can be easily
aspirated at a later time;
choking indicates aspiration.
4. Decreased gastrointestinal
motility increases the risk of
aspiration because foods or
fluids accumulate in the
stomach.

5. Keep suction setup available 5. This is necessary to maintain

and use as needed. patent airway.
6. Position patient who have 6. This protects the airway.
decreased level of consciousness Proper positioning can
 on their sides.
7. Offer foods with consistency
that patient can swallow. Use
thickening agents as appropriate.
Cut foods into small pieces.
8. For patients with reduced
cognitive abilities, remove
distracting stimuli during
mealtimes.
9. Position patient at 90 degree
angle, whether in bed or in a chair
or wheelchair. Use cushions or
pillows to maintain position.
10. Maintain upright
position for 30 to 45 minutes after
feeding.
Reference: Nursing Care Plan 5th edition by Gulanick and Myers pp 17-19.
NURSING CARE PLAN
decrease the risk for
aspiration.
7. Semisolid foods like pudding
and hot cereal are easily
swallowed. Liquids and thin
foods like creamed soups are
most difficult for patient with
dysphagia.
8. This facilitates concentration
on chewing and swallowing.
9. Proper positioning of patients
with swallowing difficulty is of
primary importance during
feeding or eating.
10. The upright position facilitates
the gravitational flow of food
or fluid through the alimentary
tract. If the head of the bed
cannot be elevated because of
the patient’s condition, use a
right side-lying position after
feeding to facilitate passage of
stomach contents into the
duodenum.
PROBLEM IDENTIFIED: Paralysis of one side of the body.
NURSING DIAGNOSIS: Risk for unilateral neglect related to damage in the nondominant hemisphere of the brain secondary to stroke.
TAXONOMY: Cognitive-perceptual pattern
CAUSE ANALYSIS: Unilateral neglect is the pattern lack of awareness of one side of the body. It is caused by damage to portions of the nondominant cerebral
hemisphere, resulting in the inability to respond to stimulus on the contralateral side of a cerebral infarction. (Medical – Surgical Nursing By Joyce Black p 2131).

CUES OBJECTIVES INTERVENTIONS RATIONALE EXPECTED OUTCOME

SUBJECTIVE STO INDEPENDENT STO

• Client may report After 24 hours of effective 1. Conduct sensory assessment. 1. This determines the actual After 24 hours of giving
sensation of stimulus nursing intervention, the level of sensation for effective nursing
to one side of the patient will be able to comparison with how the intervention, the client is
body. verbalize cognitive patient uses the senses on the expected to verbalize
awareness of the deficit. affected side. recognition of affected side.
2. Observe patient’s performance
OBJECTIVE LTO of ADL (activities of daily living). 2. This provides information on
patient’s recognition of LTO
• Attend to one side After 5 days of giving affected side. The patient
of the body effective nursing may forget that the affected After 5 days of giving
• Uses one intervention, the patient will side still exists. effective nursing
extremity be able to compensate for 3. Approach the patient from the intervention, the client is
• Orient the head unilateral neglect as unaffected side when patient 3. This decreases anxiety and expected to begin touching
and eyes to one side evidenced by being free from initially regains consciousness. fear while patient is unable to the affected side during
injury and demonstrating an interpret whole environment. ADLs, and begin to wash,
• Inaccurate beliefs
increased awareness of the 4. Ensure safe environment with dress, and eat with
about the position of
neglected body side. call bell on patient’s unaffected 4. This will prevent any risk for attention to both sides.
the limb in space or
side. injury to the patient.
its existence.
5. Provide tactile stimulation to 5. This stimulates short-term
affected side. memory of sensation.

6. Place all food in small 6. This approach diminishes

quantities, arranged simply on spatial / visual deficits. Small
plate. quantities make it easier to
delineate foods because of the
 space between food items.]

7. This draws patient’s attention

7. Attach watch or bright bracelet to the affected side.
to affected arm; encourage the
patient to hold and manipulate
objects correctly.
8. This helps develop fine motor
8. Practice drawing and copying skills and relearn spatial
figures with patient. relationships.

Reference: Nursing Care Plan 5th edition by Gulanick and Myers pp 501-502

NURSING CARE PLAN

PROBLEM: Difficulty in Breathing
NURSING DIAGNOSIS: Impaired gas exchange related to decreased oxygen perfusion and ventilation secondary to Chronic heart failure
TAXONOMY: Activity-Exercise Pattern
CAUSE ANALYSIS: There is partial airway collapse that would cause the work of breathing to increase because there is less functional lung tissue to exchange water and
carbon dioxide and increased ventilatory dead space that do not participate in gas or blood change that would led to decreased oxygen perfusion ventilation. (Nursing Care
Plan).
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective: STO: .Independent:

”Nahihirapan akong
huminga kaya napkabit
ako ng oxygen” as
verbalized by the patient
Objective:
-with oxygen inhalation
at 36 / min
- irritable
tachypriec RR-32
- pallor / use of accessory
muscle
- Capillary refills 1.60
sec.
-V/S T-37.4,P-98,RR 32,
BP- 140/100
-After 1-2 hours of nursing
interventions, client will be
able to verbalize
understanding of measures
to be irritated as evidence
by following measures
given to him.
LTO:
-After 3 days of
implementing nursing,
patient will be able to
experience maximal
pulmonary ventilation and
adequate gas exchange as
evidenced by absence of
pallor, cyanosis, difficulty of
breathing ; hypoxia
-Regularly monitored the patient’s respiratory -Prompt recognition of Patient understood &
rate pattern and manifestation of hypoxia or deterioration of respiratory followed measures to
hypercapnia. Report significant change function can reduce potentially relieved difficulty of
promptly. lethal outcomes breathing.
-This minimize shortness of
- Pace activities to the client’s tolerance and breathing and fatigue
offer support during periods of respiratory
distress or anxiety - The upright position allows full
- Positioned the patient in semi or high fowler’s lung excursion and enhance air
position as indicated. exchange
- This helps maintain a patent Patient experienced
-Encouraged deep breathing exercise and airway adequate gas exchange as
coughing - Clients understanding of evidenced by absence of
- Provided instruction about condition and preventive pallor, cyanosis, difficulty
a. breathing and relaxation technique to measures may facilitate of breathing & hypoxia
enhance breathing pattern necessary follow up care
b. medications
c. activities allowed
d. supportive equipment
e. reportable s/s

Dependent: - Promote ventilation depth and

-Administered prescribed therapies such as clear air passage for adequate
water, medicine (bronchodilators), inhalants, gas exchange. Bronchodilators
expectorants, antibiotics, and monitor for side relax bronchia smooth muscle
effects. facilitating air flow

(Nursing Care Plans, 4th ed.).

th
Reference: Nursing Care Plans, 4 ed. P 1121).