Diagnosis Plan of care
∆ Ineffective airway
clearance related to
neuromuscular
impairment as evidenced
by difficult in swallowing,
breathing and aspirations
Intervention Evaluation
Short term: Monitor respiratory status Short Term:
and ability to cough and
Ater 4 hours of nursirg deep breathe adequately. After 4 hours of nursing
intervention the patient intervention the patient
can be able to express Monitor vital signs verbalized in decrease of
decrease in difficult difficulty in swallowing and
swallowing and be Auscultate breath sounds was ventilated to relieve
ventilated Determine the food aspiration.
preference of the patient
Long Term:
Long term: Massage the sides of
trachea and neck gently After 2 days of nursing
After 2 days patient can be Monitor the patients pulse intervention, the patient
able to maintain stable oximetry was able to maintain
respiratory status stable respiratory status
Encourage deep breathing with a 16bpm respiratory
exercise and administer rate and normal breath
oxygen if needed sounds by doing deep
breathing exercise and
oxygen therapy
 Diagnosis
∆ Impaired physical
mobility related to reduced
neuromuscular function as
evidenced by decrease in
muscle endurance,
strength, and control
Plan of care Intervention
Short Term: •Assess patient's ability to
perform ADLs effectively
After 4 hours of nursing and safely on a daily basis
interventions, the patient
will be able to demonstrate •Assess for developing
measures to increase thrombophlebitis Evaluate
mobility and perform need for assistive devices
activities independently
•Encourageappropriate
Long Term: use of assistive devices in
the home setting
After 2 days of nursing
interventions, the patient •Allow patient to perform
will be free from immobility tasks at his or her own
complications and use rate. Do not rush patient.
safety measures
•Encourage independent
activity as able and safe
•Perform passive or active
assistive ROM exercises
Evaluation
Short Term:
After 4 hours of nursing
interventions, the patient
was able to demonstrate
measures to increase
mobility by performing
ROM exercises and
perform activities
independently with use of
assistive devices
Long Term:
After 2 days of nursing
interventions, the patient
will be free from immobility
complications as evidence
by free of
thrombophlebitis, and use
safety measures with use
 Diagnosis Goals Intervention Evaluation

∆ Risk for Injury related to
impaired sensory function
secondary to diplopia as
evidence by patient
reporting he is seeing
double.
Short Term: • Assess patient for
degree of visual
After 2 hours of nursing impairment Ascertain
interventions, the patient knowledge of safety
will be able to verbalize needs/ injury prevention
understanding of individual and motivation
factors that contribute to
possibility of injury •Ensure the room
environment is safe with
Long Term: adequate lighting and
furniture moved toward the
After 2 days of nursing walls
interventions, the patient
will be able to protect self •Assess client's mucsle
and be free from injuries strength, gross, and fine
motor coordination Instruct
patient regarding safe
lighting
Short Term:
After 2 hours of nursing
interventions, the patient
was able to identify factors
that increase risk for injury
Long Term:
After 2 days of nursing
interventions, the was free
from injury using safety
measures such as using
handrails

•Train patient on safe

ambulation
 Diagnosis Plan of care
Imbalanced Nutrition: Less Short-Term Goal
than Body
Requirementsrelated to Client will gain 2 pounds
difficulty swallowing. per week for the next 3
weeks.
Long-Term Goal
Client will exhibit no signs
or symptoms of
malnutrition by time of
discharge from treatment
Intervention Evaluation
Collaborate to the dietician Client has shown a slow,
to determine the number of progressive weight gain
calories required. during hospitalization.
Weigh client daily. Client is able to verbalize
importance of adequate
Ensure that client receives nutrition and fluid intake.
small, frequent feedings,
including a bedtime snack,
rather than three larger
meals.
Stay with client during
meals
Explain the importance of
adequate nutrition
Determine client's likes and
dislikes, and collaborate
with dietitian to provide