NURSING CARE PLAN FORMAT

Name:_________________________________ Medical Diagnosis: Myasthenia Gravis Date :

_________________
Nursing Assessment Nursing Interventions
Subjective Objective Interventions Rationale
Axial and limb Difficulty in swallowing 1. Monitor vital signs. To note changes and possible signs of
weakness food complication and serve as baseline data.
Hypotonicity of 3/5.
3. Assess patient’s cognitive and Sensory awareness, orientation,
sensory-perceptual status concentration, motor coordination affects
desire and ability to swallow safely and
effectively.
5. Auscultate breath sounds To evaluate the presence of aspiration

Nursing Diagnosis 7. Determine food preferences of the To incorporate as possible, enhancing

Impaired swallowing patient. intake.
Problem
9. Massage the laryngopharyngeal Toi stimulate swallowing.
related to neuromuscular musculature (sides of trachea and neck)
Related gently.
impairment
factor
11. Encourage continuation of facial To maintain or improve muscle strength.
as evidenced by difficulty in exercise program
Defining swallowing
characteri 13. Maintain the patient in high-Fowler’s to reduce risk of regurgitation or aspiration.
stics position with head flexed slightly forward
during meals.
Nursing Inference 15. Manage size of bites. Use a teaspoon To encourage smaller bites.
Due to neuromuscular impairment will affect or small spoon
the muscles and direct to nervous system 17. Encourage a rest period before and To minimize fatigue.
control which can cause varying degrees of after meals
skeletal muscle weakness which result in 18. Incorporate eating style and pace To avoid fatigue and frustration with
double vision, drooping eyelids, and trouble when feeding process.
talking.
 After 24 hrs of nursing interventions, the patients will be able to demonstrate effective swallowing after fluid
Nursing Plan/Goal intake.

After 24 hrs of nursing interventions, goal is partially met, the patient has able to swallow after fluid intake.
Nursing
Evaluation
Prof. AltroyVanAgtang