NURSING CARE PLAN

Assessment Nursing Inference Planning Intervention Rationale Evaluation

Diagnosis

Subjective Impaired Dysphagia Short Term Objective INDEPENDENT: Short Term Objective
Cues
swallowing
related to Dry oral mucosa After 1-3 hours, the • Establish rapport. • To develop trust and After 1-3 hours, the client
“nahihirapan po client will be able to: cooperation with the client. was able to:
ako nurse dysphagia
Reduced capacity to
lumunok, secondary to swallow liquid and • Demonstrate the • Determine the client’s potential for • • Demonstrated the
Swallowing disorders are
nakakaramdam dry oral food correct feeding swallowing problems, noting age and especially common in the correct feeding
ako ng pain kahit mucosa techniques and medical conditions. techniques and
elderly due to the
sa pag inom ko Impaired swallowing swallowing exercises swallowing
coexistence of a variety of
lang ng tubig ” as • Understand the exercises
neurological,
verbalized by the purpose of nursing • Understand the
neuromuscular, or other
patient. Reference: intervention. purpose of nursing
conditions.
Wayne, G. (2021). intervention.
Objective
Cues Impaired • Review the history of the patient's • To determine if any
Swallowing. medication. medications are one of the
Long Term Objective FULLY MET
• The patient Nurseslabs. factors that cause impaired
is showing Retrieved from: swallowing, such as
After 1-2 weeks of
discomfort https://nursestudy.ne benzodiapines, nsaids,
nursing interventions,
when t/dysphagia- serostomia, etc.
the client will be able to:
drinking impaired-swallowing-
water. nursing-review/ • Monitor the client's feeding and • To determine the ability of
• Demonstrate
improved swallowing swallowing activities. the client to swallow. Long Term Objective
ability as evidenced
by the absence of • Assess what the client can safely eat • To provide the client with a After 1-2 weeks of nursing
discomfort when and drink. consistency of food and interventions, the client
swallowing food or fluid that is most easily was able to:
fluids, no evidence swallowed.
of aspiration, and • Demonstrated
the ability to ingest • If oral intake is not possible, initiate • The client must have improved
fluids and foods. alternative feedings such as NGT. optimal nutrition. swallowing ability
as evidenced by
• Encourage the client to have a rest • To minimize fatigue or the absence of
period before swallowing food or pain. discomfort when
drink. swallowing food
or fluids, no
• Massage the laryngopharyngeal • To help stimulate evidence of
musculature (sides of trachea and swallowing. aspiration, and
neck) gently. the ability to
ingest fluids and
• Use a glass with a nose cut-out to • To refrain from pouring foods.
avoid posterior head tilting while liquid into the mouth or
client's drinking. "washing food down" with PARTIALLY MET
liquid.

• Teach the client and/or SO (s) to learn • To enhance the ability of

specific feeding techniques and the client to swallow food
swallowing exercises. or liquid.

• Encourage the client to continuation of • To maintain or improve

facial exercise program. muscle strength. Muscle
strengthening can facilitate
greater swallowing ability.

• In the event of choking, instruct the • To prevent aspiration or

client and/or SO(s) on emergency more serious
measures. complications.

• Observe for any signs of aspiration • To provide immediate

during swallowing of food or fluid. intervention that could
prevent complications for
the patient.

• Provide oral hygiene to the client at • Frequent oral hygiene may

least four hours as needed. help to alleviate the client's
feeling of dry mouth and
improve their ability to
swallow.
COLLABORATIVE:
 • To determine appropriate
• Collaborate to surgeon, nursing intervention for the
gastroenterologist, or neurologist as client that will help in
indicated for treatment (e.g., improving swallowing
reconstructive facial surgery, ability.
esophageal dilatation) that may result
in improved swallowing.

• Collaborate with a speech-language • To identify specific

pathologist.
techniques to enhance
client efforts and safety
measures.

• Consult with dysphagia specialist or • To determine appropriate

rehabilitation team, as indicated. nursing intervention for the
client that will help in
improving swallowing
ability.
• Consult with nutritionist. • To establish optimum
dietary.