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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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posted:10/18/2011
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