NURSING CARE PLAN

Nursing Analysis Goals and Nursing Rationale Evaluation

Cues Diagnosis Objectives Interventions

Subjective: Risk for Scientific LONG TERM: INDEPENDENT INDEPENDENT OUTCOME:

● The aspiration Analysis: Within 8 hours, a) Assess the a) To immediately Within 8 hours,
patient related to Risk for the patient and causative signs of resolve the the patient was
verbalized feeding aspiration is patient’s mother aspiration to symptoms that can able to have
that she is alteration with generally shall be able to prevent worsening lead to swallowing
willngly bottled- regarded to of feeding trouble problems and Demonstrate
ready to formula include factors 1. Demonstrate such as: aspiration which effective feeding
temporaril such as effective feeding - Mild fever may compromise with bottled-
y feed her intermittent with bottled- after eating respiratory function formula through
baby with feeding of formula through - Choking or in breathing. absence of
a bottled- delivery absence of coughing cough, choking
formula methods, cough, choking - Wheezing or other signs of
intubation and/or or other signs of or voice trouble in
Further cues are feeding tubes, trouble in that sounds feeding.
not applicable for and disorder feeding. dry __ Goal Met
a risk problem regarding - Faster or __ Goal
since it is only respiratory 2. Maintain slower Partially Met
potential. functions or patent airway breathing __ Goal Unmet
deficient upon sucking during Why?
nutrients for from the feeding
regulatory blottled-formula - Sucking Maintain patent
mechanisms of during meals weakly airway upon
the body. For the b.) Proper sucking from the
relative factors in 3. Observe and b) Instruct the positioning of blottled-formula
feeding, usage of demonstrate the patient’s mother bottle feeding is the during meals
bottled formula safety about the proper vital key in __ Goal Met
for infants are in precautions of bottled-formula by preventing __ Goal
great risk of bottled-formula tilting the patient’s aspiration since it Partially Met
aspiration due to upon sterile head with the neck, focuses on having a __ Goal Unmet
the conditions of making and and supporting it patent entry of the Why?
the possibility of consumption. over the shoulder. formula milk in the
the milk as a mouth that Observe and
foreign material decreases the demonstrate the
to enter in the likelihood of safety
lungs, since directing into lungs precautions of
gastric contents instead of in the bottled-formula
disrupts stomach. upon sterile
structural lung c) Encourage the making and
abnormalities. patient’s mother to consumption.
have resting c) Monitoring the __ Goal Met
Situational periods with the baby’s __ Goal
Analysis: patients during manifestation Partially Met
Feeding an infant meals and observe whether in body __ Goal Unmet
with a bottled feeding cues that movement and/or Why?
formula is manifest as facial expression
presumed to be fullness, allows immediate
easier than specifically prevention of the
breastfeeding burping. symptoms of
since it does not aspiration.
require such d) Assess rate and
establishing good depth of d) Tachypnea,
attachment, and respirations and shallow
generally known chest movement. respirations, and
to be easier in Monitor for signs asymmetric chest
consumption for of respiratory movement are
feeding. failure such severe frequently present
However, bottled tachypnea. because of
feeding also compromised
causes aspiration airway in the lungs.
when the milk When aspiration
directly goes into occurs,
the lungs instead the patient may
in the stomach require
which may endotracheal
compromise intubation and
chest infections. mechanical
Through clinical e) Evaluate cough, ventilation to keep
symptoms of swallow, and gag airways clear.
feeding trouble, reflexes movement
primarily frequently. Notify e) Frequent
choking and health care evaluation of
coughing, which providers if absent. reflexes is needed
can be to prevent
accompanied by aspiration
watery eyes, red associated with
face complexion DEPENDENT respiratory
due to lack of a) Evaluate the problems.
airway need for enteral
obstruction,weak feeding, if needed
sucking, and as doctor’s order,
other signs once impaired DEPENDENT
indicating swallowing a) Further actions
difficulty in function or no for pharmacologic
feeding. movement of air therapy be SHORT
SHORT has occurred. considered as an TERM:
The patient’s TERM: invasive procedure Within 4 hours
condition Within 4 hours for a baby should the patient was
indicates the patient shall be significantly able to
temporary be able to evaluated and
bottled feeding consider its
that also suffers traumatic risk Perform proper
from nutrient 1. Perform b) Administer factors into the positioning of
deficiency. This proper medications, as mouth and bottled-feeding
shows relative positioning of indicated, for pharynx. at least 3 times
demand for bottled-feeding example, after
effective feeding at least 3 times mucolytics, demonstration
towards the after expectorants, b) Aids in __ Goal Met
patient to meet demonstration bronchodilators, reduction of __ Goal
the metabolic and analgesics, as bronchospasm and Partially Met
needs concerning 2. Display good ordered by the mobilization of __ Goal Unmet
poor nutritional “latch”without physician. slung expansion. Why?
status and immediate Analgesics are
potential withdrawal given to improve Display good
inflammation. cough effort by “latch”without
3. Verbalize reducing immediate
REFERENCE: understanding discomfort but withdrawal
Doenges, M.E., about the should be used __ Goal Met
Moorhouse, causative effects cautiously because __ Goal
M.F., Murr, A.C. of being at risk they can decrease Partially Met
(2014). Nursing of aspiration. COLLABORATIV cough effort and __ Goal Unmet
Care Plans: E depress respirations Why?
guidelines for a) Perform
individualizing assistive treatments Verbalize
client care across such as feeding COLLABORATIV understanding
the life span 9th tubes if prescribed E about the
edition. Davis by the doctor. a) Coordination of causative effects
Company: treatments, of being at risk
Philadelphia, PA. schedules, and oral of aspiration.
ISBN 978-0- intake reduces __ Goal Met
8036-3041-3 likelihood of __ Goal
compromising the Partially Met
Udan-Quiambao, b) Follow up nutrition status of __ Goal Unmet
J. (2007). monitoring of serial the client and its Why?
Medical-Surgical chest x-rays, effect on organ
Nursing: ABGs, and pulse metabolism.
Concepts and oximetry readings,
Clinical as well as b) Follows
 Application 2nd laboratory results. progress and
edition. effects of
Educational respiratory
publishing functions and
house: Manila, therapeutic
Ph. ISBN 978- c) Provide teaching regimen and
971-513-268-8 based on the needs facilitates
of the patient and necessary
the relatives alterations in
regarding the: therapy
• Illness and its
possible
complication c) Reduces anxiety
• Procedures and for a stressful
related nursing care situation that the
client’s relative is
facing by starting
appropriate
planning.
assists the family in
dealing with the
health-care system
on the client’s
critical condition.

References:
Doenges, M., Moorhouse, M. F., & Murr, A. (2019).Nurse’s Pocket Guide.(15th ed.). F.A. Davis.

Cox, H. C., & Newfield, S. A. M. (2007). Cox's clinical applications of nursing diagnosis: Adult, child, women's, mental health,
gerontic, and home health considerations (5th ed.). Philadelphia: F.A. Davis Company.

Udan, J.Q. (2009). Medical Surgical Nursing: Concepts and Application 2nd ed. Ermita, Manila: Giuani Prints Houes, Educational
Publishing House.