CUES SUBJECTIVE: y

NURSING DIAGNOSIS Impaired R/T

OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION LONG TERM:

OBJECTIVE: y

Swallowing LONG TERM: INDEPENDENT: At the end of hours of effective y Instruct the SO to: nursing interventions, the patient y Give will be able to: liquids/feedings y Maintain adequate with thickened hydration as evidenced consistency. by good skin turgor, moist mucous y Avoid foods which membranes, and may thicken individually appropriate secretions such as urine output. milk products and chocolate. y Feed one consistency of food at a time. y Place food on the unaffected side of the mouth during feedings. SHORT TERM: At the end of hours of effective nursing interventions, the patient s SO will be able to: y Identify interventions and actions to promote intake and prevent aspiration. Demonstrate feeding techniques that best fits the patient s needs. Verbalize the importance of allowing ample time for eating or feeding. y Assisting the patient in flexing the neck when swallowing.

Feedings with a thicker consistency are more tolerable for patients with difficulty in swallowing. To prevent accumulation of thick secretions that contributes to swallowing difficulties. To prevent aspiration.

y y

Demonstrate to the SO the correct position for feeding to prevent aspiration like elevating the head of the bed to semi-fowlers position, keeping the head in neutral/midline position. Offer sips of water using a straw. Create with the SO a proper

y y

For the patient to be able to have more control in moving the food to swallowing position. To facilitate the closing of the epiglottis thus preventing accidental entry of food/liquids to the trachea. To enhance the SOs knowledge and independence in feeding the patient and reduce the risk of regurgitation/ aspiration. To avoid posterior head tilting while drinking. To allow ample time for eating/feeding thus not

SHORT TERM: Goals were fully met because was not able to aspirate and the SO was able to demonstrate the correct feeding techniques.

schedule for feeding.

Observe oral cavity for remaining food and remove food that the patient is unable to swallow. Provide oral hygiene following each feeding.

interfering with patient s other ADLs and gives time for rest every after feeding. To prevent the patient from choking on unswallowed food and prevent cavities.

DEPENDENT: y Follow the prescribed diet for the patient. Consider tube feedings or parenteral solutions as indicated. y To be able to sustain patient s dietary needs accordingly. To be able to monitor the input and output of the patient correctly and accurately