Cues Nursing Background Knowledge Goal and Objectives Nursing Evaluation

Diagnosis Interventions
and Rationale
Objective: Risk for Risk for aspiration was defined by the North American NOC: Aspiration NIC: Aspiration
aspiration Nursing Diagnosis Association as a state in which an Prevention Precautions
 The doctor related to individual is at risk for entry of gastric secretions,
ordered NGT tube feeding. oropharyngeal secretions, solids, or fluids into the Goal: The patient will
insertion. tracheobronchial passage. be free from foreign
 Intubated body that may
 Extubated but Aspiration can lead to many complications that can obstruct his airways
still with NGT jeopardized the health of the patient. Aspiration can increase and be knowledgeable
risk of the patient of bacterial pneumonia, pulmonary edema, on preventing
acute respiratory failure, etc,. Thus, prevention is the key to aspiration after
avoid complications. discharge.

https://medical-
dictionary.thefreedictionary.com/risk+for+aspiration Objectives:
The nurse will be
After nursing able to:
interventions, the client
will be able to:

1. Demonstrate Discuss to the

awareness of the client and his s/o
risk for the factors that
aspiration. can increase the
risk for
aspiration. To
 provide
awareness and
help the client to
avoid doing
things that may
cause aspiration.

2. Be Demonstrate and
knowledgeable explain to the
on how to client and his s/o
administer food the proper ways
through the tube of NGT feeding.
properly with To provide
the help of adequate
family member. nutrition to the
client without
compromising his
health.

3. Maintain proper Educate s/o of the

position and be client the
comfortable importance of
during feeding. proper
positioning while
feeding and after
feeding (at least
30- degrees
during continuous
feedings. Keep
the bed’s backrest
elevated to at
 least 30 degrees
during
intermittent
feedings and for
at least an hour
afterward)
Elevated position
while feeding
decrease the risk
for aspiration.

4. Enumerate sign Inform the client

and symptoms and his s/o the
of aspiration. manifestations of
aspiration. This
helps them to
assess high-risk
situation and to
call for
emergency.

5. Maintain proper Discuss and

placement of instruct to the s/o
NGT. the importance of
auscultating the
abdomen before
feeding to ensure
the placement of
the NGT tube. To
secure proper
placement.
6. Decrease level
 of discomfort Encourage the s/o
while sleeping of the client to
and. observe
frequently when
he is asleep. To
be aware if the
tube is displaced.

https://hign.org/consultgeri/try-this-series/preventing-aspiration-older-adults-dysphagia

https://brooksidepress.org/giu/lessons/lesson-1-nursing-care-related-to-the-gastrointestinal-system/section-iv-gastrointestinal-intubation/1-39-nursing-care-of-the-patient-with-a-nasogastric-
tube/

https://nursinganswers.net/essays/managing-nasogastric-tube-feeding-and-maintaining-nutrition-health-essay.php

Cues Nursing Background Knowledge Goal and Objectives Nursing Evaluation

Diagnosis Interventions
and Rationale
Subjective: Impaired NOC: Joint NIC: Exercise
physical movement: Active therapy: Joint
 The client mobility movement
complains Goal: The patient will
numbness of be able to restore and
the limbs maintain his muscle
 Body strength as well as
weakness mobility functions
after discharged.

Objectives:

After nursing The nurse will be

interventions, the client able to:
will be able to:

1. Identify the Assess the

compatible rom client’s functional
exercise for his level of mobility.
condition. To determine the
best possible
exercise for the
client.

2. Be in a Encourage the s/o

comfortable of the client to
position every change his
time. position every 2
hours and put a
padding to bony
parts of his body.
To promote
relaxation and
avoid the
 development of
pressure ulcer.

3. Demonstrate Instruct exercises

understanding of with low
the exercises to repetitions such
restore his as cyclical
mobility. (walking
) exercise,
resistance
exercise, and
balancing
activities. To help
the client
improve his
ability to walk
and balance
himself.

4. Perform exercise
without Encourage the
experiencing client to avoid
muscle fatigue. strenuous
exercise and have
adequate rest
periods between
exercises. To
avoid muscle
fatigue and
muscle damage.

5. Verbalized
 understanding of Discuss to the
the importance client and his s/o
of recognizing the importance of
own limits. recognizing
body's signals
when the limit of
exercise for that
session is
reached.

6. Show proper use

of assistive Teach the client
device if needed. the proper way of
using selected
assistive device.
Assistive device
help the client to
improve
independent
functioning
ability.
https://eujournal.org/index.php/esj/article/view/10174/9705