NURSING CARE PLAN: NUTRITION

Name of Patient: Enchanted KingdomAge: 51 years oldChief Complaint: Pain in swallowing for 2 daysDiagnosis: Acute Exudative Pharyngitis

CUESNURSING

DIAGNOSISANALYSIS/HEALTH

IMPLICATIONGOAL AND

OBJECTIVESNURSING

INTERVENTIONSRATIONALE EVALUATION

INTERACTION“Noong Lunes, kumain kami ng porkchop eh parang nalunok ko ata ung buto. Tapos ayun, parang may gumuhit sa bangdang lalamunan ko tapos nagsusuka na ako, hindi ko na nga matapos ang pagkain ko”“Simula niyon, hindi na ako makakain, kahit tubig ayaw kong uminom kasi masakit talaga siya“Masakit siya kapag lumulunok ako kaya lugaw at tubig lang ang kinakain ko pero minsan kahit un na ang kinakain ko, masakit pa rin.”

Imbalanced Nutrition less than body requirements related to inability to ingest foods

IMMEDIATE CAUSE Inability to ingest foods

INTERMEDIATE CAUSEBiological factors (pain in swallowing due to swelling of the pharynx)

ROOT CAUSEPresence of hyperemic exudates in the pharynx

HEALTH IMPLICATIONAn individual’s health status greatly affects eating habits and nutritional status. Difficulty in swallowing (dysphagia) due to painfully inflamed throat or a stricture of the esophagus can prevent a

GOALAt the end of 8 hour shift of independent nursing intervention and collaborative nursing intervention, the client will be able to ingest foods without pain or discomfort in order to restore optimum nutritional status, to meet the body requirements and to promote health

OBJECTIVES

1. Assess causative/ contributing factors

a. Determine and evaluate ability to chew, swallow and taste by using crushed ice or small sips of water

Factors that can affect ingestion and/or digestion of nutrients(Nurse’s Pocket Guide by Doenges, Moorhouse and Gessler-Murr, 9th

edition page

EFFECTIVENESS1. Was the client able to be assessed the causative/’ contributing? factors __yes __no why?

CUESNURSING

DIAGNOSISANALYSIS/HEALTH

IMPLICATIONGOAL AND

OBJECTIVESNURSING

INTERVENTIONSRATIONALE EVALUATION

“Masakit siya sa lahat ng oras at nahihirapan din akong magsalita at lumunok”

OBSERVATION=Patient is pale and weak=Swelling in the pharynx=Difficulty in swallowing and talking=Hyperemic exudates on the pharynx=Positive deep neck tenderness

MEASUREMENT Blood Pressure:120/80 mmHgPulse Rate:70 beats per minuteRespiratory Rate: 22 breaths per minuteTemperature: 37.6° C

person from obtaining adequate nourishment. (Fundamentals of Nursing by Kozier, 7th edition, page 1178). Increased susceptibility to common illnesses, chronic diseases, and complications is often a consequence of inadequate nutrition (Fundamentals of Nursing by Craven and Hirnle, 4th edition, page 963). Inadequate nutrition is associated with marked weight loss, generalized weakness, altered functional abilities, delayed wound healing, increased susceptibility to infection, decreased immunocompetence, impaired pulmonary function, and prolonged length of hospitalization (Fundamentals of Nursing by Kozier, 7th edition, page 1190).

2. Establish a nutritional plan that meets individual needs

b. Ascertain understanding of individual nutritional needs

a. Provide diet modification as indicated=small feeding with snacks=mechanical soft or blenderized feedings=soft/ liquid diet

b. Limit fiber/bulk if indicated

348)To determine what information to provide client/SO(Nurse’s Pocket Guide by Doenges, Moorhouse and Gessler-Murr, 9th

edition page 348)

The soft diet is easily chewed and digested. It is often ordered for clients who have difficulty chewing and swallowing. The pureed diet is a modification of the soft diet. Liquid diet may be added to the food, which is then blended to a semi-solid consistency(Fundamentals of Nursing by Kozier, 7th edition, page 1202).

Because it may lead to early satiety(Nurse’s Pocket

2. Was the client able to establish a nutritional plan that meets his individual needs?__yes __no why?

CUESNURSING

DIAGNOSISANALYSIS/HEALTH

IMPLICATIONGOAL AND

OBJECTIVESNURSING

INTERVENTIONSRATIONALE EVALUATION

3. Enhance swallowing ability to meet fluid and caloric body requirements

c. Promote adequate/timely fluid intake

a. Provide cognitive cues (e.g remind client to chew/swallow as indicated)

b. Encourage rest period before meals

Guide by Doenges, Moorhouse and Gessler-Murr, 9th

edition page 350)

Limiting fluids 1 hour prior to meal decreases possibility of early satiety (Nurse’s Pocket Guide by Doenges, Moorhouse and Gessler-Murr, 9th

edition page 350)

To enhance concentration and performance of swallowing sequence (Nurse’s Pocket Guide by Doenges, Moorhouse and Gessler-Murr, 9th

edition page 513)

To minimize fatigue (Nurse’s Pocket Guide by Doenges, Moorhouse and Gessler-Murr, 9th

edition page

3. Was the client able to enhance his swallowing ability to meet fluid and caloric body requirements?__yes __no why?

CUESNURSING

DIAGNOSISANALYSIS/HEALTH

IMPLICATIONGOAL AND

OBJECTIVESNURSING

INTERVENTIONSRATIONALE EVALUATION

c. Provide analgesics prior to feeding/swallowing activity and decreasing environmental stimuli

513)Which may be distracting during feeding (Nurse’s Pocket Guide by Doenges, Moorhouse and Gessler-Murr, 9th

edition page 513)

EFFICIENCYWas the interventions done within the time frame? _ yes __no why?

APPROPRIATENESSWere the interventions suitable to the client?__yes __no why?ACCESSIBILITYWere the interventions acceptable to the client?__yes __no why