Nursing Care Plan 2

Assessment
Subjective cues:
Incomprehensible
Objective cues:
Lack of chewing
Food refusal
Inability to clear oral
cavity

Needs
Gordons
functional
health
pattern
( nutritionalmetabolic
pattern

Diagnosis
Risk for
aspiration r/t
impaired
swallowing.

Planning
That within 24 hours
the patient will be
able
establish/demonstrat
e feeding methods
appropriate to his
situation.

Intervention
Assess for
age- related
risk factors
potentiating
risk of
aspiration
( e.g.,
elderly
infirm).
Rationale:
aspiration
pneumonia
is more
common in
extremely
young or
old patients
and
commonly
occurs in
individuals
with
chronically
impaired
airway
defense
mechanism

Evaluation
After the
nursing
interventions
the patient is
able to establish
/demonstrate
appropriate
feeding
methods for his
situation as
evidenced by:
Clear
breath
sounds.

.
Maintain
operational
suction
equipment
at bedside.
Rationale:
to clear
secretions
while
reducing
potential
aspirations
of
secretions.
Assist
patient with
oral
hygiene
after eating.
Rationale:
to ensure
that food
particles do
not remain
in mouth.
Elevate
patient to
highest
best

possible
position.
Rationale:
to decrease
risk of
aspiration.
Feed slowly
using small
bites.
Rationale:
to reduce
risk of
aspiration.

Nursing Care Plan 3

Assessment
Subjective cues:
Incomprehensible
Objective cues:
Disruption of
skin( epidermis)
(+) Skin lesion
Reddening of
affected area

Needs
Gordons
functional
health
pattern
(nutritionalmetabolic
pattern).

Diagnosis
Impaired skin
integrity r/t
physical
immobilization.

Planning
That within 24 hours
of nursing
interventions, the
patient will be able
to:
Participate in
prevention
measures
and
treatment.

Implementation
Independent
Inspect skin
in daily
basis,
describing
lesions and
changes
observed.
Rationale:
to monitor
progress of
wound
healing.
Keep the
area clean
and dry
through

Evaluation
After 24 hours
of nursing
interventions
the patient
was able to
participate in
prevention
measures and
treatment as
evidenced by:
Fast
healing
promoti
on of
lesion.

changing the
diaper.
Rationale:
to assist
bodys
natural
process of
repair.
Apply skinprotective
agents to
affected
area.
Rationale :
-promote
healing and
to keep it
clean and
dry.
-to protect
the lesion
and/or
surrounding
tissues.
Avoid use of
plastic
material and
remove wet
linens
promptly.

Rationale :
-to reduce
pressure on/
enhance
circulation to
compromise
d tissues.
-moisture
potentiates
skin
breakdown.
Turn the
patient to the
other side
every 2
hours.
Rationale:
-to promote
circulation
and to avoid
further lesion
complication
.

Nursing care Plan 1

Assessment

Needs

Subjective cues:
Incomprehensible

Gordon
s
function
al health
patterns
( activity
exercise
pattern).

Objective cues:
Diminished /
adventitious
breath sounds
( e.g., crackles).
Reversible and
Productive cough.

Diagnosi
s
Ineffectiv
e airway
clearance
r/t
chronic
obstructiv
e
pulmonar
y
disease.

Planning
That within 24 hours
of nursing
intervention the
patient will be able
to:
Maintain
airway
patency.
Demonstrate
reduction of
congestion
with breath

Intervention

Monitor vital signs.

Rationale: for
baseline data for
evaluation.
Monitor
respirations
and breath
sounds, noting
rate and
sounds( e.g.,
crackles).
Rationale :
indicative of

Evaluation
After 24 hours of
nursing
intervention the
patient was able
to maintain
airway patency
and demonstrate
reduction of
congestion as
evidenced by:
Clear
breath

sounding
clear, and
improved
oxygen
exchange.
( e.g., pulse
oximetry
results within
clients norms.

respiratory
distress and /
or
accumulation
of secretion.

Position head
appropriate for age
and condition.
Rationale :
To open or maintain
open airway in an atrest or compromised
individual.
Administer
medications( e.g.,
bronchodilators) and
oxygen as ordered.
Rationale: to relax
smooth respiratory
musculature, and
mobilize secretions.
Increased oral fluid
intake.
Rationale: hydration
can help prevent
accumulation of
viscous secretions
and improve
secretion clearance.

sounds.
Improved
oxygen
exchange(
oxygen
saturation
of 95%).