FORTIS COLLEGE

PATIENT-CENTERED CARE PLAN

Student's Name

Brittany Barnes

Patient's Name
Age
86

M. Ford

Room No.

ER 1

Sex

Admitting __ER _____

Surgical Dx. N/A

Medical Dx. CVA

ASSESSMENT

ANALYSIS

PLAN

IMPLEMENTATION

Data Collection
Subjective & Objective

Nursing
Diagnosis
NANDA

Patient-centered
Goals With
Measurable
Outcome

Nursing Orders/Action
Include Rationale & References

O- 86 year old
Impaired
O-Night Incontinence
swallowing r/t
O- Very drowsy
O- Difficulty rousing
O- Difficulty
swallowing

neuromuscular
dysfunction

1. Client will
demonstrate
effective
swallowing
without signs
of aspiration
before
08/31/2015.
2. Client will
remain free
from
aspiration
(e.g. lungs
clear,
temperature
within normal
range) by
08/31/2015.

The Fortis College Student Nurse

will for all intervention will:
1.1 Manage impaired swallowing by
using a dysphagia team
comprised of a rehabilitation
nurse, speech pathologist,
dietician, physician, and
radiologist. Rationale: The
dysphagia team can help the
client learn to swallow safely
and maintain a good
nutritional status. (Wieseke,
Bantz,& Siktberg 2008).
1.2 Watch for signs of malnutrition
and dehydration and keep a
record of food intake. Rationale:
Malnutrition is common in
dysphagic clients. Clients with
dysphagia are at serious risk
for malnutrition and
dehydration which can lead to
aspiration pneumonia

EVALUATION
Evaluate Each Outcome
Criterion and Make
Recommendations
1. Goal was met. With
plans from the clients
dysphagia team, the
client was able to
demonstrate effective
swallowing without signs
of aspiration upon
discharge date of
08/31/2015.
2. Goal was partially met,
the client was able to
remain free from
aspiration, but the
clients temperature was
slightly elevated past the
normal range at 100.7
and patient was given a
dose of Tylenol.
Recommendation:

resulting froma depressed

immune function and
weakness, lethargy, and
decreased cough. (Wieseke,
Bantz,& Siktberg 2008).
1.3 Check the oral cavity from
proper emptying after the client
swallows and after the client
finishes the meal. Provide oral
care at the end of the meal. It
may be necessary to manually
remove food from the clients
mouth. If this is the case, use
gloves and keep the clients
teeth apart with a padded tongue
blade. Rationale: Food may
become pocketed on the
affected side and cause
stomatitis, tooth decay, and
possible later aspiration.
(Ackley 795).
2 Follow general aspiration
precautions which include sitting
90 degrees for all oral feedings,
take small bites/sips, slow rates,
and no straws. Rationale: An
upright posture after eating
has been associated with a
decreased incidence of
pneumonia aspiration.
(Coleman, 2004).
If signs of aspiration or
pneumonia are present,
auscultate lung sounds after

Client should continue therapy

with the use of rehabilitation
nurse, speech pathologist,
dietician, physician, and
radiologist to enhance
swallowing ability and enhance
compensatory strategies.
Discharge Teaching:
Teach the client and family
exercises prescribed by the
dysphagia team.
Teach the family how to monitor
the client to prevent and detect
aspiration during eating.

feeding. Note new onset of

crackles or wheezing, and note
elevated temperature.
Rationale: Auscultation of
bronchial lung sounds was
shown to be specific in
identifying clients at risk for
aspirating (Shaw et al, 2004).
Keep the client in an upright
position for 45 minutes to an hour
after a meal. Rationale: A study
demonstrated that the number
of elderly clients developing a
fever was significantly
reduced when clients were
kept sitting upright after eating
(Matsui et al, 2002).