NURSING CARE PLANNURSING CARE PLAN

PROBLEM #1: Risk for AspirationPROBLEM #1: Risk for AspirationSubjective:Subjective: The patient’s son said that his father is having The patient’s son said that his father is having

a difficulty in swallowing.a difficulty in swallowing.

ObjectiveObjective:: Observed that the patient is drooling when in a Observed that the patient is drooling when in a

side lying position.side lying position. Observed that the patient is having a hard time Observed that the patient is having a hard time

swallowing.swallowing. The patient has inability to chew or masticate.The patient has inability to chew or masticate.

NURSING DIAGNOSIS:NURSING DIAGNOSIS: Risk for aspiration r/t Risk for aspiration r/t ineffective swallowing mechanism. ineffective swallowing mechanism.

RATIONALE: RATIONALE: Patients with stroke are at high Patients with stroke are at high risk for aspiration pneumonia, it is r/t loss of risk for aspiration pneumonia, it is r/t loss of pharyngeal sensation, loss of oropharyngeal pharyngeal sensation, loss of oropharyngeal motor control and LOC.( Black & motor control and LOC.( Black & Hawk:2005:212)Hawk:2005:212)

GOALS AND OBJECTIVE: GOALS AND OBJECTIVE: After 1 hour of After 1 hour of nursing intervention, a decrease or no risk for nursing intervention, a decrease or no risk for aspiration.aspiration.

NURSING INTERVENTIONS:NURSING INTERVENTIONS:

Independent:Independent:

1.1. Monitor and record vital signsMonitor and record vital signs

Rationale: To detect signs of aspiration or Rationale: To detect signs of aspiration or impaired gas exchange due to impaired gas exchange due to respiration. (Sparks & Taylor: respiration. (Sparks & Taylor: 2005:38)2005:38)

2. Explain treatment to the patient and 2. Explain treatment to the patient and significant others. (Sparks & significant others. (Sparks &

Taylor:2005:38) Taylor:2005:38)

Rationale: To encourage compliance. Rationale: To encourage compliance. (Ackley, et al: 2002:291)(Ackley, et al: 2002:291)

3. Stop feeding STAT if you suspected 3. Stop feeding STAT if you suspected aspiration then apply suction aspiration then apply suction

PRN PRN and turn and turn patient on side.patient on side.

Rationale: To prevent aspiration. (Sparks & Rationale: To prevent aspiration. (Sparks & Taylor: 2005:38)Taylor: 2005:38)

4. Elevated head of bed 90° when feeding 4. Elevated head of bed 90° when feeding patient.patient.

Rationale: To decrease the risk of Rationale: To decrease the risk of aspiration. aspiration. (Sparks & Taylor: 2005:38)(Sparks & Taylor: 2005:38)

5. Keep suction equipment at bed side.5. Keep suction equipment at bed side.

Rationale: To remove aspirated food as Rationale: To remove aspirated food as necessary. (Sparks & Taylor: necessary. (Sparks & Taylor: 2005:38)2005:38)

EVALUATION: EVALUATION: Goal met. After 1 hour of Goal met. After 1 hour of nursing intervention, patient was able to have a nursing intervention, patient was able to have a decrease risk of aspiration as evidenced by no decrease risk of aspiration as evidenced by no choking or coughing while eating.choking or coughing while eating.

PROBLEM #2: Decrease cerebral PROBLEM #2: Decrease cerebral blood flowblood flow

Subjective:Subjective: Patient’s son said that his father sometimes Patient’s son said that his father sometimes

couldn’t recognize his wife.couldn’t recognize his wife.

Objective:Objective: Observed changes in pupillary reactions.Observed changes in pupillary reactions. Difficulty in swallowing.Difficulty in swallowing. Changes in motor response; extremity Changes in motor response; extremity

weakness and paralysisweakness and paralysis Altered mental status: speech abnormalitiesAltered mental status: speech abnormalities

NURSING DIAGNOSIS: NURSING DIAGNOSIS: Ineffective tissue Ineffective tissue perfusion: cerebral r/t interruption to blood perfusion: cerebral r/t interruption to blood flowflow

RATIONALERATIONALE: : As a vessels become narrow and As a vessels become narrow and become obstructed, distal tissues receive less become obstructed, distal tissues receive less blood, oxygen and circulation which leads to blood, oxygen and circulation which leads to ineffective tissue perfusion (Kozier ineffective tissue perfusion (Kozier et.al:2004:1340)et.al:2004:1340)

GOALS AND OBJECTIVE: GOALS AND OBJECTIVE: After 1-2 days of After 1-2 days of nursing intervention patient will be able to nursing intervention patient will be able to demonstrate behaviours/lifestyle changes to demonstrate behaviours/lifestyle changes to improve circulation such as relaxation improve circulation such as relaxation techniques, exercise/ dietary programtechniques, exercise/ dietary program

NURSING INTERVENTION:NURSING INTERVENTION:IndependentIndependent1. Elevate head of board and maintain head/neck in 1. Elevate head of board and maintain head/neck in

midline or neutral positionmidline or neutral positionRationale: To promote circulation/venous drainage Rationale: To promote circulation/venous drainage

(Smeltzer:2004:539)(Smeltzer:2004:539)

2. Keep environment and patient quiet. Space nursing 2. Keep environment and patient quiet. Space nursing actionsactions

Rationale: This measures reduce Intracranial Pressure Rationale: This measures reduce Intracranial Pressure (Ackley:2002:328)(Ackley:2002:328)

3. Maintain adequate nutrition3. Maintain adequate nutrition

Rationale: To promote tissue healing, Rationale: To promote tissue healing, oxygenation and metabolism (Sparks&Taylor: oxygenation and metabolism (Sparks&Taylor: 2005:336)2005:336)

DependentDependent

4. Administer diuretics such as Mannitol as 4. Administer diuretics such as Mannitol as orderedordered

Rationale: Mobilizes excess fluid oliguric renal Rationale: Mobilizes excess fluid oliguric renal failure or edema and prevents increase ICP failure or edema and prevents increase ICP (Deglin&Vallerand:2005:638-639)(Deglin&Vallerand:2005:638-639)

CollaborativeCollaborative

5. Administer supplemental oxygen as indicated5. Administer supplemental oxygen as indicated

Rationale: reduces hypoxia, which can cause Rationale: reduces hypoxia, which can cause cerebral vasodilation and increase pressure/ cerebral vasodilation and increase pressure/ edema formation (Sparks&Taylor:2005:336) edema formation (Sparks&Taylor:2005:336)

EVALUATION: EVALUATION: Goal Met. Patient was able to Goal Met. Patient was able to demonstrate improved circulation such simple demonstrate improved circulation such simple exercises and improved dietary regimen.exercises and improved dietary regimen.

PROBLEM #3. FeverPROBLEM #3. FeverSubjective:Subjective: Patient’s son said that his father is very warmPatient’s son said that his father is very warm Patient’s son said that his father complaint of headache.Patient’s son said that his father complaint of headache.

ObjectiveObjective FebrileFebrile Skin warm to touchSkin warm to touch Temp: 38.4 °C (normal range: 36.5-37.5 °C)Temp: 38.4 °C (normal range: 36.5-37.5 °C) RR: 30 bpm (normal range: 12-20 bpm)RR: 30 bpm (normal range: 12-20 bpm) Flushed skinFlushed skin

NURSING DIAGNOSIS:NURSING DIAGNOSIS: Hyperthermia r/t Hyperthermia r/t edema of the edema of the hypothalamushypothalamus

RATIONALE: Bleeding or edema of the hypothalamus can RATIONALE: Bleeding or edema of the hypothalamus can lead to ischemia of the thermoregulatory center of the brain lead to ischemia of the thermoregulatory center of the brain which causes hyperthermia. (Black&Hawk:2005:2126)which causes hyperthermia. (Black&Hawk:2005:2126)

GOALS AND OBJECTIVE:GOALS AND OBJECTIVE: After 1 hour of nursing After 1 hour of nursing intervention patients temperature will decrease to normal intervention patients temperature will decrease to normal temperature of 37.5 °C from the previous temperature of temperature of 37.5 °C from the previous temperature of 38.4°C.38.4°C.

NURSING INTERVENTION:NURSING INTERVENTION:Independent:Independent:1. .Take temperature every 1-4 hours1. .Take temperature every 1-4 hoursRationale: To obtain an accurate core temperature Rationale: To obtain an accurate core temperature

(Ignatavacious:2006:516)(Ignatavacious:2006:516)

2. use non-pharmacologic measures to reduce excessive 2. use non-pharmacologic measures to reduce excessive fever such as sponging with tipid waterfever such as sponging with tipid water

Rationale: Non-pharmacologic measures lowers body Rationale: Non-pharmacologic measures lowers body temperature and promote comfort. Tipid water is used temperature and promote comfort. Tipid water is used in sponging because cold water increases shivering. in sponging because cold water increases shivering. (Sparks&Taylor:2005:148)(Sparks&Taylor:2005:148)

3. monitor vital signs 3. monitor vital signs Rationale: to evaluate effectiveness or interventions and Rationale: to evaluate effectiveness or interventions and

monitor for complications (Sparks&Taylor:2005:149)monitor for complications (Sparks&Taylor:2005:149)

4. determine patient’s preferences for oral fluid and 4. determine patient’s preferences for oral fluid and encourage patient to drink as much as possible, unless encourage patient to drink as much as possible, unless contraindicated. Monitor I&O and administer IV fluid contraindicated. Monitor I&O and administer IV fluid if indicated.if indicated.

Rationale: Insensible fluid loss increase by 10% for Rationale: Insensible fluid loss increase by 10% for every 1.8 °F, increase in temperature patient must every 1.8 °F, increase in temperature patient must increase fluid intake to prevent fluid dehydration. increase fluid intake to prevent fluid dehydration. (Sparks&Taylor:2005:148)(Sparks&Taylor:2005:148)

DependentDependent

5. Administer paracetamol 500mg PO and record 5. Administer paracetamol 500mg PO and record effectivenesseffectiveness

Rationale: Inhibits synthesis of prostaglandins that may serve Rationale: Inhibits synthesis of prostaglandins that may serve as mediators of pain and fever primarily in the CNS. as mediators of pain and fever primarily in the CNS. Antipyretic and for pain. (Deglin&Vallerand:2006:7)Antipyretic and for pain. (Deglin&Vallerand:2006:7)

EVALUATION:EVALUATION: Goal Met. After 1 hour of nursing Goal Met. After 1 hour of nursing intervention patient’s temperature has lowered to 37.3 °C intervention patient’s temperature has lowered to 37.3 °C from previous 38.4 °C.from previous 38.4 °C.

PROBLEM #4. Slurred speechPROBLEM #4. Slurred speechSubjective:Subjective: The wife of the patient verbalized “hindi The wife of the patient verbalized “hindi

maintindihan ang salita nya na para ba siyang bulol”maintindihan ang salita nya na para ba siyang bulol”

ObjectiveObjective Speaks or verbalizes with difficultySpeaks or verbalizes with difficulty SlurringSlurring Difficulty in comprehending and maintaining the Difficulty in comprehending and maintaining the

usual communication patternusual communication pattern

Inability to modulate speechInability to modulate speech

NURSING DIAGNOSIS:NURSING DIAGNOSIS: Impaired verbal Impaired verbal communication r/t cranial nerve disfunctioncommunication r/t cranial nerve disfunction

RATIONALE:RATIONALE: Cranial nerve disfunction from a Cranial nerve disfunction from a stoke in the vertrobasilar artery or its other branches stoke in the vertrobasilar artery or its other branches may result from weakness or paralysis of the muscle may result from weakness or paralysis of the muscle of the lips, tongue and larynx which cause difficulty of the lips, tongue and larynx which cause difficulty in speaking, chewing, swallowing due to poor in speaking, chewing, swallowing due to poor muscle control. (Black&Hawk:2005:2114)muscle control. (Black&Hawk:2005:2114)

GOALS AND OBJECTIVE:GOALS AND OBJECTIVE: At the end of At the end of the shift patient will establish a method of the shift patient will establish a method of communication in which his needs can be communication in which his needs can be expressed.expressed.

NURSING INTERVENTION:NURSING INTERVENTION:IndependentIndependent1. Facilitate hearing and vision examinations, 1. Facilitate hearing and vision examinations,

obtaining necessary aidsobtaining necessary aidsRationale: When needed/desired for improving Rationale: When needed/desired for improving

communication. (Ackley:2002:398)communication. (Ackley:2002:398)

2. .Use nonverbal methods of communications2. .Use nonverbal methods of communicationsRationale: To reinforce your Rationale: To reinforce your

words(Sparks&Taylor:2005:)words(Sparks&Taylor:2005:)

3. Take temperature every 1-4hrs 3. Take temperature every 1-4hrs Rationale: To obtain an accurate core Rationale: To obtain an accurate core

temperature (Sparks&Taylor:2005:51)temperature (Sparks&Taylor:2005:51)

4. Use non-pharmacologic measure to reduce 4. Use non-pharmacologic measure to reduce excessive fever such as sponging with tepid excessive fever such as sponging with tepid waterwater

Rationale: Non-pharmacologic measures lower Rationale: Non-pharmacologic measures lower body temperature and promote comfort. Tepid body temperature and promote comfort. Tepid water is used in sponging because cold water water is used in sponging because cold water increases shivering (Sparks&Taylor:2005:51)increases shivering (Sparks&Taylor:2005:51)

DependentDependent

5. Administer paracetamol and record 5. Administer paracetamol and record effectivenesseffectiveness

Rationale: Inhibits sythesis of prostaglandins Rationale: Inhibits sythesis of prostaglandins that may serve as mediators of pain and fever, that may serve as mediators of pain and fever, primarily in the CNS. Antipyretic. primarily in the CNS. Antipyretic. (Deglin&Valerand:2006:7)(Deglin&Valerand:2006:7)

EVALUATION:EVALUATION: Goal Met. Patient was able to Goal Met. Patient was able to establish a method of communication in which establish a method of communication in which his needs was expressed.his needs was expressed.

PROBLEM #5. Body WeaknessPROBLEM #5. Body Weakness

SubjectiveSubjective Patient’s son said that his father is Patient’s son said that his father is

experiencing right sided body weakness.experiencing right sided body weakness. Patient’s son also verbalized that his father Patient’s son also verbalized that his father

complains of not being able to move his right complains of not being able to move his right legleg

ObjectiveObjective Difficulty of movingDifficulty of moving

Limited ROMLimited ROM Slowed movementSlowed movement Decrease reaction timeDecrease reaction time Uncoordinated movementsUncoordinated movements

NURSING DIAGNOSIS:NURSING DIAGNOSIS: Activity intolerance r/t right sided Activity intolerance r/t right sided body weaknessbody weakness

RATIONALE:RATIONALE: Almost all client have some degree of Almost all client have some degree of immobility after a stroke. Stroke’s causing hemiparesis or immobility after a stroke. Stroke’s causing hemiparesis or hemiplegia are usually caused by a stroke in the anterior or hemiplegia are usually caused by a stroke in the anterior or middle cerebral artery, leading to an infarction in the motor middle cerebral artery, leading to an infarction in the motor strip of the frontal cortex. (Black&Hawk:2005:2111)strip of the frontal cortex. (Black&Hawk:2005:2111)

GOALS AND OBJECTIVE:GOALS AND OBJECTIVE: After 3 days of nursing After 3 days of nursing intervention patient will have an improved physical intervention patient will have an improved physical mobility within the limitations imposed by the stroke.mobility within the limitations imposed by the stroke.

NURSING INTERVENTION:NURSING INTERVENTION:IndependentIndependent1. Encourage bed exercises1. Encourage bed exercisesRationale: prepares patient for late activities but also Rationale: prepares patient for late activities but also

offers hope and ascends of optimism about recovery. offers hope and ascends of optimism about recovery. (Black&Hawk:2005:2125)(Black&Hawk:2005:2125)

2. Provide emotional support and encouragement 2. Provide emotional support and encouragement Rationale: To help improve patient’s self concept Rationale: To help improve patient’s self concept

and motivation to perform ADL.and motivation to perform ADL.(Black&Hawk:2005:2125)(Black&Hawk:2005:2125)

3. Turn and position patient at least every 2 hours. 3. Turn and position patient at least every 2 hours. Establish turning schedules for dependent patients Establish turning schedules for dependent patients monitor frequencymonitor frequency

Rationale: Turning helps prevent skin breakdown by Rationale: Turning helps prevent skin breakdown by relieving pressure.(Black&Hawk:2005:2125)relieving pressure.(Black&Hawk:2005:2125)

4. Assess patient’s level of functioning using the functional 4. Assess patient’s level of functioning using the functional mobility scalemobility scale

Rationale: To determine patients’ capabilities. Rationale: To determine patients’ capabilities. (Black&Hawk:2005:2125)(Black&Hawk:2005:2125)

5. Involve patient in care related planning and decision making5. Involve patient in care related planning and decision makingRationale: To improve compliance. (Black&Hawk:2005:2125)Rationale: To improve compliance. (Black&Hawk:2005:2125)

EVALUATION:EVALUATION: Goal Partially Met. There was an improved Goal Partially Met. There was an improved mobility of right arm but still paralyzed right leg.mobility of right arm but still paralyzed right leg.

PROBLEM #6. Inability to PROBLEM #6. Inability to perform ADLsperform ADLs

Subjective:Subjective: Patient said that his son or relatives are the Patient said that his son or relatives are the

ones who takes care of him.ones who takes care of him.

ObjectiveObjective Inability to manipulate food in mouth: chew Inability to manipulate food in mouth: chew

and swallow foodand swallow food Inability to pick up a cup or glassInability to pick up a cup or glass

Inability to handout utensils and bring food from a Inability to handout utensils and bring food from a receptacle to the mouth.receptacle to the mouth.

Inability to perform self dressing/groomingInability to perform self dressing/grooming Inability to do self toiletingInability to do self toileting

NURSING DIAGNOSIS:NURSING DIAGNOSIS: Self care deficit r/t decreased Self care deficit r/t decreased strengthstrength

RATIONALE: Clients with complete paralyzes and cognitive RATIONALE: Clients with complete paralyzes and cognitive deficits may not be able to perform self care. Patient with deficits may not be able to perform self care. Patient with CVA has decreases sensorium thus having decreased CVA has decreases sensorium thus having decreased strength in performing self care.(Black&Hawk:2005:2128)strength in performing self care.(Black&Hawk:2005:2128)

GOALS AND OBJECTIVE:GOALS AND OBJECTIVE: After 3 days of After 3 days of nursing intervention patient will perform as many nursing intervention patient will perform as many ADLs as tolerated.ADLs as tolerated.

NURSING INTERVENTION:NURSING INTERVENTION:IndependentIndependent1. Observe, document and report patients functional 1. Observe, document and report patients functional

and perceptual or cognitive ability dailyand perceptual or cognitive ability dailyRationale: Careful observation helps you adjust Rationale: Careful observation helps you adjust

nursing actions to meet patients need. nursing actions to meet patients need. (Ignativacius:2006:1041)(Ignativacius:2006:1041)

2. Perform the prescribed treatment for the 2. Perform the prescribed treatment for the underlying condition. Monitor patients underlying condition. Monitor patients progress and report favorable and adverse progress and report favorable and adverse responses. responses.

Rationale: Applying therapy consistently aids Rationale: Applying therapy consistently aids patients independence. patients independence. (Ignativacius:2006:1041)(Ignativacius:2006:1041)

3. Provide assistive devices at each meal as 3. Provide assistive devices at each meal as needed. needed.

Rationale: This allow patient to do as much as Rationale: This allow patient to do as much as possible for self. possible for self.

((Ignativacius:2006:1043)Ignativacius:2006:1043)

4. Encourage patient to do as much for self as possible, 4. Encourage patient to do as much for self as possible, giving simple instructions one at a timegiving simple instructions one at a time

Rationale: To aid comprehension. (Ignativacius:2006:1043)Rationale: To aid comprehension. (Ignativacius:2006:1043)

CollaborativeCollaborative

5. .Consult with physician with physical/occupational 5. .Consult with physician with physical/occupational therapisttherapist

Rationale: Provides expert assistive for developing a Rationale: Provides expert assistive for developing a

therapy plan and identifying special equipment needstherapy plan and identifying special equipment needs..(Ignativacius:2006:1042)(Ignativacius:2006:1042)

EVALUATION:EVALUATION: Goal Partially Met. Because Goal Partially Met. Because the patient was non compliance with regards to the patient was non compliance with regards to performing as many ADLs as tolerated.performing as many ADLs as tolerated.

PROBLEM #7. Risk for InjuryPROBLEM #7. Risk for InjuryObjectiveObjective Weakness of right side of bodyWeakness of right side of body Motor impairmentsMotor impairments Decrease sensoriumDecrease sensorium

NURSING DIAGNOSIS:NURSING DIAGNOSIS: Risk for injury r/t Risk for injury r/t right sided body weaknessright sided body weakness

RATIONALERATIONALE: Factors that increase the risk for : Factors that increase the risk for injury include decrease LOC, weakness, injury include decrease LOC, weakness, flacidity, spasticity, altered thought processes, flacidity, spasticity, altered thought processes, motor, visual, and spatial perceptual motor, visual, and spatial perceptual impairments. (Black&Hawk:2005:2128)impairments. (Black&Hawk:2005:2128)

GOALS AND OBJECTIVE:GOALS AND OBJECTIVE: After 1-2 hours After 1-2 hours patient will be able to help identify and apply patient will be able to help identify and apply safety measures to prevent injury.safety measures to prevent injury.

NURSING INTERVENTION:NURSING INTERVENTION:IndependentIndependent1. Identify interventions/safety devices.1. Identify interventions/safety devices.

Rationale: To promote physical environment and Rationale: To promote physical environment and individual safety. (Sparks&Taylor:2005:173) individual safety. (Sparks&Taylor:2005:173)

2. Keep side rails or bed raised for clients with 2. Keep side rails or bed raised for clients with hemiplegia and hemiparesishemiplegia and hemiparesis

Rationale: To protect patient from rolling out of bed. Rationale: To protect patient from rolling out of bed. (Sparks&Taylor:2005:173)(Sparks&Taylor:2005:173)

3. Evaluate individuals response to violence in 3. Evaluate individuals response to violence in surroundingssurroundings

Rationale: May enhance regard for own/others safety. Rationale: May enhance regard for own/others safety. (Sparks&Taylor:2005:173)(Sparks&Taylor:2005:173)

4. Observe for factors that may cause or contribute to 4. Observe for factors that may cause or contribute to injuryinjury

Rationale: To increase awareness of patient/family Rationale: To increase awareness of patient/family members and caregivers. (Sparks&Taylor:2005:173)members and caregivers. (Sparks&Taylor:2005:173)

5. Test heating pads and bath water before using, 5. Test heating pads and bath water before using, assess extremities daily for injuryassess extremities daily for injury

Rationale: To assist patient with decreased Rationale: To assist patient with decreased tactile sensitivity. (Sparks&Taylor:2005:174)tactile sensitivity. (Sparks&Taylor:2005:174)

EVALUATION:EVALUATION: Goal Met. After 1-2 hours Goal Met. After 1-2 hours patient was able to identify and apply safety patient was able to identify and apply safety measures to prevent injury.measures to prevent injury.

PROBLEM #8. Difficulty of PROBLEM #8. Difficulty of swallowingswallowing

Subjective:Subjective: Patients son said that his father does not finish the Patients son said that his father does not finish the

food given to him.food given to him.

ObjectiveObjective Poor muscle tonePoor muscle tone Weakness of muscle for swallowing or masticationWeakness of muscle for swallowing or mastication Loss of weight with inadequate food intakeLoss of weight with inadequate food intake

Decreased I&ODecreased I&O

NURSING DIAGNOSIS: NURSING DIAGNOSIS: Risk for altered nutrition: Risk for altered nutrition: Less than body requirements r/t inability to swallowLess than body requirements r/t inability to swallow

RATIONALE:RATIONALE: Swallowing is a complex process that Swallowing is a complex process that requires the functions of several cranial nerves. A requires the functions of several cranial nerves. A stroke in the territory of the vertebrobasilar system stroke in the territory of the vertebrobasilar system cause dysphagia. (Black&Hawk:2005:2114)cause dysphagia. (Black&Hawk:2005:2114)

GOALS AND OBJECTIVE:GOALS AND OBJECTIVE: After 3-4 days of After 3-4 days of nursing intervention patient would be able to nursing intervention patient would be able to increase the required amount of input as tolerated.increase the required amount of input as tolerated.

NURSING INTERVENTION:NURSING INTERVENTION:IndependentIndependent1. Monitor fluid I&O 1. Monitor fluid I&O Rationale: Because body weight may decrease as a Rationale: Because body weight may decrease as a

result of fluid loss. (Sparks&Taylor:2005:317)result of fluid loss. (Sparks&Taylor:2005:317)

2. Provide a diet prescribed for patients specific 2. Provide a diet prescribed for patients specific conditioncondition

Rationale: To improve patients nutritional status Rationale: To improve patients nutritional status and increase weight. and increase weight. (Sparks&Taylor:2005:317)(Sparks&Taylor:2005:317)

3. Teach the principle of good nutrition for 3. Teach the principle of good nutrition for patients specific conditionpatients specific condition

Rationale: This encourages patient and family Rationale: This encourages patient and family members to participate in patients care. members to participate in patients care. (Sparks&Taylor:2005:317)(Sparks&Taylor:2005:317)

4. Involve family members in meal planning 4. Involve family members in meal planning

Rationale: To encourage them to help patient to Rationale: To encourage them to help patient to comply with the diet regimen after discharge. comply with the diet regimen after discharge. (Sparks&Taylor:2005:317)(Sparks&Taylor:2005:317)

5. Elevate head of bed 90° during meal times 5. Elevate head of bed 90° during meal times and for 30 minutes after the completion of and for 30 minutes after the completion of meals.meals.

Rationale: To decrease the risk of aspirationRationale: To decrease the risk of aspiration . . (Sparks&Taylor:2005:317)(Sparks&Taylor:2005:317)

CollaborativeCollaborative6. Administer IV fluids or tube feedings6. Administer IV fluids or tube feedingsRationale: May be necessary for fluid Rationale: May be necessary for fluid

replacement and nutrition if patient is unable replacement and nutrition if patient is unable to take anything orally. to take anything orally. (Ignativacius:2006:2128)(Ignativacius:2006:2128)

EVALUATION:EVALUATION: Goal Met. Patient was able to Goal Met. Patient was able to increase the amount of intake as tolerated.increase the amount of intake as tolerated.