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Student:__Jay Crawford________________Client Initials:___WF______________Age:__71______ Medical Diagnosis/ History:________________________________________________________________________________________ Nursing Diagnosis Literature Rationale for Nursing Diagnosis Client Situation Client Goal(s) 1. Risk for aspiration R/T dysphagia 20 There is risk that the patient could have Client had a barium swallow Client will not aspirate during feeding. CVA. secretions, food, or fluids bypass the epiglottis where the dysphagia team Client Outcomes and enter the thracheobronchial passages determined that he could Client will not show evidence of aspiration (temperature (Carpenito-Moyet, 2008). This is a result of swallow small amounts of spike) 30 minutes after feeding. the patient having difficulty swallowing. An honey thickened liquids or unsuccessful swallow can allow food to get pudding but that anything Client swallowing will improve with practice so that a barium past the epiglottis and into the trachea. The thinner such as water or juice swallow after one month will show a more effective CVA has left this patient with reduced would likely result in swallowing pattern. sensation and motor control on his right side aspiration. The client would so there is potential for this to occur on that prefer to load his spoon himself side of his throat. and take larger bites than is recommended and at shorter intervals. The Doctors order is that he get teaspoon sized bites with extended time between for swallowing and that his throat be checked for pocketing food on the right side. P. Hawley 2001/ reformatted F.LeBlanc 2006. Nursing Diagnosis Literature Rationale for Nursing Diagnosis Client Situation Client Goal(s) 2. Risk for imbalanced nutrition less than This applies to a non NPO patient who is This client is uncomfortable Client Goal(s) body requirements R/T dysphagia 20 at risk for weight loss due to insufficient with needing this level of Client will not lose more than 10% of body weight. CVA intake or processing of nutrients to meet care and frequently becomes Client Outcomes metabolic needs (Carpenito-Moyet, 2008). uncooperative with attempts Clients weight will drop less than 1 pound with each weekly This is a result of this clients dysphagia to feed him. He also does weighing. requiring feeding assistance and his not seem to care for the distaste for his allowed diet. vanilla flavored ensure pudding that is the best form of nutrition for his status. P. Hawley 2001/ reformatted F.LeBlanc 2006. Nursing Diagnosis Literature Rationale for Nursing Diagnosis Client Situation Client Goal(s) 3. Self care deficit syndrome: Feeding According to Carpenito-Moyet (2008), this This client has right side Client will attain strategies to assist in his care. (3), Bathing (2), diagnosis arises when a client has paralysis, dysphagia, and Client will participate in feeding, dressing, toileting, and Dressing/Grooming (2), Toileting cognitive or motor function impaired to aphasia. He is bathing activities. (1), Instrumental (1), 20 CVA the point where the five self-care activities uncomfortable in the hospital Client Outcomes AMB right side paralysis, aphasia, are difficult or impossible for him to setting and wants to go Client will demonstrate the ability to wash his face and shave. dysphagia and incontinence perform independently. This clients CVA home. Overcoming these Client will feed himself with cuing to go slow and take small bites. has left him incontinent with a foley deficits will help the client catheter. He has dysphagia, aphasia, and achieve this. right sided paralysis as a result of neurological damage from his brain injury (Day et al. 2009). P. Hawley 2001/ reformatted F.LeBlanc 2006. Client Interventions Nursing Interventions Literature based Rationale for Evaluation Interventions Client will indicate preferred flavor of Nurse will place patient in high fowlers Clients with dysphagia The client did not show signs of aspiration 30 minutes after ensure pudding. position or geri chair for feeding. should be fed at a minimum feeding. So in our limited time (one feeding) the in the semi-fowlers position interventions appear to have been effective. This client will Nurse will monitor feedings to insure (Day, Paul, Williams, have to show some improvement before another swallowing small bites with adequate time between Smeltzer, and Bare 2009). evaluation. We did not have the extra flavors of pudding on hand to do the client intervention but this can make a big for swallowing using cues. difference in a clients desire to eat. I would work harder to Miller and Carding (2007) make this happen if I had this client again. Nurse will clean clients mouth with advise modifying diet suction toothbrush after feeding. patterns for smaller bites and time between as a Nurse will take clients temperature 30 management technique for minutes after feeding. dysphagia. Day et al. (2009) recommend teaching the client to use suction after eating but at this stage in the clients recovery, the nurse will do it. Day et al. (2009) list temperature monitoring as a means to detect aspiration. P. Hawley 2001/ reformatted F.LeBlanc 2006. Client Interventions Nursing Interventions Literature based Rationale for Evaluation Interventions Eliminate offensive odours. Odours, either external or This client initially showed no interest whatsoever in the within the mouth, can decrease thickened liquid diet which was presented to him. The most Maintain oral hygiene. appetite (Carpenito-Moyet effective intervention for getting him to eat was the 2008). reintroduction of food because he ate later. He also Assess for pain before meals. responded better when his wife was feeding him. I was Pain can also decrease appetite unable to find serum albumin levels in his lab work and this (Carpenito-Moyet 2008). was a bit surprising. This client was hard to assess for pain Check lab results for serum Albumin also but he was not entirely comfortable in the geri chair. and prealbumin levels. Serum albumin and prealbumin levels are valid tests for Collaborate with dysphagia team. nutritional screening (Perry & Potter, 2006). Encourage and promote feeding. The dysphagia team can Reintroduce food frequently. perform videofluoroscopy tests to evaluate swallowing and Weigh client daily. possibly upgrade the clients diet (Miller & Carding, 2007). Assess food intake. Appetite is often poor and family involvement can help (Day et al., 2009) Daily weighing and feeding assessments help evaluate patients nutritional status (day et al., 2009) P. Hawley 2001/ reformatted F.LeBlanc 2006. Client Interventions Nursing Interventions Literature based Rationale for Interventions Evaluation Client will wash his face. Assess hygiene Enhancing self care by having client practice We did have the client wash his own face. His wife fed him activities he can do with one hand (shaving with and I forgot to instruct her to load the spoon and have him Client will shave with an Bathe client in areas where he and electric razor, self feeding and self bathing feed himself until he was done eating but she was told that electric razor. can’t. are important factors to improve quality of life this was a better way. I shaved the client but I think he may in a post stroke client (Day et al. 2009). have been dissatisfied with my effort. I didn’t think about his ability to do this until later. Client will feed himself. Educate about hygiene Patient and family education is critical for rehabilitation (Day et al. 2009). Change pad and clean client after a bowel movement. Urinary and bowel incontinence or constipation are common after a stroke and Educate family to provide cueing care is important to maintain skin integrity and assistance with feeding. (Day et al. (2009). Position client PT provides ROM for affected side and exercises for standing. These are important Collaborate with PT to assess to maintain and strengthen muscles and progress and get their desired reestablish coordination (Day et al. 2009). interventions. Combing hair is an activity that can be Dress client and comb his hair. achieved with one hand (Day et al. 2009). Assess clients ability to comb his Client might be able to dress himself with hair. modified clothing (Velcro fasteners) (Day et al. 2009). P. Hawley 2001/ reformatted F.LeBlanc 2006.
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