NURSING CARE PLAN: NUTRITION

Name of Patient: Enchanted Kingdom

Age: 51 years old
Chief Complaint: Pain in swallowing for 2 days
Diagnosis: Acute Exudative Pharyngitis

NURSING ANALYSIS/HEALTH GOAL AND NURSING

CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS

INTERACTION Imbalanced IMMEDIATE CAUSE GOAL

“Noong Lunes, Nutrition less Inability to ingest At the end of 8 hour
kumain kami ng than body foods shift of independent
porkchop eh requirements nursing intervention
parang nalunok ko related to INTERMEDIATE and collaborative
ata ung buto. inability to CAUSE nursing
Tapos ayun, ingest foods Biological factors intervention, the
parang may (pain in swallowing client will be able to
gumuhit sa due to swelling of ingest foods
bangdang the pharynx) without pain or
lalamunan ko tapos discomfort in order
nagsusuka na ako, ROOT CAUSE to restore optimum
hindi ko na nga Presence of nutritional status, to
matapos ang hyperemic exudates meet the body
pagkain ko” in the pharynx requirements and
“Simula niyon, to promote health
hindi na ako HEALTH
makakain, kahit IMPLICATION OBJECTIVES
tubig ayaw kong An individual’s
uminom kasi health status greatly 1. Assess a. Determine and Factors that can EFFECTIVENESS
masakit talaga siya affects eating habits causative/ evaluate ability to affect ingestion 1. Was the client able
“Masakit siya and nutritional contributing factors chew, swallow and and/or digestion to be assessed the
kapag lumulunok status. Difficulty in taste by using of nutrients causative/’
ako kaya lugaw at swallowing crushed ice or (Nurse’s Pocket contributing? factors
tubig lang ang (dysphagia) due to small sips of water Guide by __yes __no why?
kinakain ko pero painfully inflamed Doenges,
minsan kahit un na throat or a stricture Moorhouse and
ang kinakain ko, of the esophagus Gessler-Murr, 9th
masakit pa rin.” can prevent a edition page
“Masakit siya sa person from 348)
 NURSING ANALYSIS/HEALTH GOAL AND NURSING
CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
lahat ng oras at obtaining adequate b. Ascertain To determine
nahihirapan din nourishment. understanding of what information
akong magsalita at (Fundamentals of individual nutritional to provide
lumunok” Nursing by Kozier, needs client/SO
7th edition, page (Nurse’s Pocket
OBSERVATION 1178). Increased Guide by
=Patient is pale susceptibility to Doenges,
and weak common illnesses, Moorhouse and
=Swelling in the chronic diseases, Gessler-Murr, 9th
pharynx and complications is edition page
=Difficulty in often a consequence 348)
swallowing and of inadequate
talking nutrition 2. Establish a a. Provide diet The soft diet is 2. Was the client able
=Hyperemic (Fundamentals of nutritional plan that modification as easily chewed to establish a
exudates on the Nursing by Craven meets individual indicated and digested. It nutritional plan that
pharynx and Hirnle, 4th needs =small feeding with is often ordered meets his individual
=Positive deep edition, page 963). snacks for clients who needs?
neck tenderness Inadequate nutrition =mechanical soft or have difficulty __yes __no why?
is associated with blenderized feedings chewing and
MEASUREMENT marked weight loss, =soft/ liquid diet swallowing. The
Blood Pressure: generalized pureed diet is a
120/80 mmHg weakness, altered modification of
Pulse Rate: functional abilities, the soft diet.
70 beats per delayed wound Liquid diet may
minute healing, increased be added to the
Respiratory Rate: susceptibility to food, which is
22 breaths per infection, decreased then blended to
minute immunocompetence, a semi-solid
Temperature: impaired pulmonary consistency
37.6° C function, and (Fundamentals
prolonged length of of Nursing by
hospitalization Kozier, 7th
(Fundamentals of edition, page
Nursing by Kozier, 1202).
7th edition, page
1190). b. Limit fiber/bulk if Because it may
indicated lead to early
satiety
(Nurse’s Pocket
Guide by
 NURSING ANALYSIS/HEALTH GOAL AND NURSING
CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
Doenges,
Moorhouse and
Gessler-Murr, 9th
edition page
350)

c. Promote Limiting fluids 1

adequate/timely fluid hour prior to
intake meal decreases
possibility of
early satiety
(Nurse’s Pocket
Guide by
Doenges,
Moorhouse and
Gessler-Murr, 9th
edition page
350)

3. Enhance a. Provide cognitive To enhance 3. Was the client able

swallowing ability to cues (e.g remind concentration to enhance his
meet fluid and client to and performance swallowing ability to
caloric body chew/swallow as of swallowing meet fluid and caloric
requirements indicated) sequence body requirements?
(Nurse’s Pocket __yes __no why?
Guide by
Doenges,
Moorhouse and
Gessler-Murr, 9th
edition page
513)

b. Encourage rest To minimize

period before meals fatigue (Nurse’s
Pocket Guide by
Doenges,
Moorhouse and
Gessler-Murr, 9th
edition page
513)
 NURSING ANALYSIS/HEALTH GOAL AND NURSING
CUES RATIONALE EVALUATION
DIAGNOSIS IMPLICATION OBJECTIVES INTERVENTIONS
c. Provide Which may be EFFICIENCY
analgesics prior to distracting during Was the interventions
feeding/swallowing feeding (Nurse’s done within the time
activity and Pocket Guide by frame?
decreasing Doenges, _yes __no why?
environmental Moorhouse and
stimuli Gessler-Murr, 9th APPROPRIATENESS
edition page Were the interventions
513) suitable to the client?
__yes __no why?
ACCESSIBILITY
Were the interventions
acceptable to the
client?
__yes __no why