Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation

(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
Rationale for interventions & progress toward achieving
goals & outcomes)
Subjective: • Pt will demonstrate  Determine the • Pt demonstrated
effective swallowing client's readiness to effective
Impaired without choking or eat. The client needs swallowing
Swallowing r/t coughing during to be alert, able to without choking or
esophageal defects meals on this follow instructions, coughing during
aeb hx of reflux student’s shift able to hold the head all meals
and aspiration of erect, and able to • Pt remained free
Objective: food • Pt will remain free move the tongue in from aspiration
from aspiration aeb the mouth. • Pt was able to
Swallowing clear lungs clear, return
precautions on temp WNL during  Watch for demonstrate
Kardex hospital stay uncoordinated understanding of
chewing or appropriate
• Pt will return swallowing; coughing swallowing
demonstrate immediately after techniques after
understanding of eating or delayed teaching session
appropriate coughing, which may
swallowing indicate silent
techniques after aspiration; pocketing
teaching session of food; wet-
sounding voice;
sneezing when
eating; delay of more
than 1 second in
swallowing; or a
change in respiratory
patterns. If any of
these signs is
present, put on
gloves, remove all
food from the oral
cavity, stop feedings,
and consult with a
 speech and language
pathologist and a
dysphagia team if
available. These are
signs of impaired
swallowing and
possible aspiration

 Crush all medications

(as appropriate) and
mix in pudding or
applesauce

 Keep pt in upright
position during meal
and for to 20 min.
after eating

 Instruct pt to take
small bits, double
swallow, and eat
slowly

 Have suction
equipment available
during feeding.

 Watch for signs of

aspiration and
pneumonia.
Auscultate lung
sounds after feeding.
Note new crackles or
wheezing, and note
elevated
temperature. Notify
 the physician as
needed. The
presence of new
crackles or
wheezing, an
elevated
temperature or white
blood cell count, and
a change in sputum
could indicate
aspiration of food . It
could also indicate
the presence of
pneumonia. Clients
with dysphagia are
at serious risk for
aspiration
pneumonia

 Watch for signs of

malnutrition and
dehydration. Keep a
record of food intake.
Malnutrition is
common in
dysphagic clients. A
food intake record
will allow the nurse,
speech and language
pathologist, and
dietitian to
determine the
adequacy of
nutritional intake.

 Provide oral care

 after each meal

Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation
(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
Rationale for interventions & progress toward achieving
goals & outcomes)
Subjective: • Pt will regain  Monitor site of skin
integrity of skin impairment Q 4hours
surface by end of for color changes,
hospital stay redness, swelling,
• Pt will report any warmth, pain, or • Pt regained
Objective: Impaired skin altered sensation or other signs of integrity of skin
integrity r/t pain at site of skin infection. Determine surface aeb
inflamed tissue aeb impairment whether the pt is resolution of
redness, pain, • Pt will demonstrate experiencing cellulitis
edema, and loss of understanding of changes in sensation
function plan to heal skin and or pain. • Pt did not report
prevent re-injury any altered
after teaching  Individualize plan sensation or pain
session according to the at site of skin
• Pt will describe client's skin impairment
measures to protect condition, needs, and
and heal the skin and preferences. Avoid • Pt could not
to care for any skin harsh cleansing demonstrate
lesion after teaching agents, hot water, understanding of
extreme friction or plan to heal skin
force, or cleansing and prevent re-
too frequently injury after
teaching session;
 Minimize exposure re-teaching
of skin impairment recommended
and other areas to
moisture from • Pt described
incontinence, measures to
perspiration, or protect and heal
wound drainage. If the skin and to
the client is care for any skin
incontinent, lesion
implement an
incontinence plan to
prevent exposure to
chemicals in urine
 and stool that can
strip or erode the
skin.

 For pts with limited

mobility, use a risk-
assessment tool to
systematically assess
immobility-related
risk factors .A
validated risk-
assessment tool
such as the Norton
or Braden scale
should be used to
identify clients at
risk for immobility-
related skin
breakdown

 Do not position pt on
site of skin
impairment. Turn
and position pt at
least every 2 hours.
Transfer pt with care
to protect against
the adverse effects
of external
mechanical forces
such as pressure,
friction, and shear.

 Evaluate for use of

specialty mattresses,
 beds, or devices as
appropriate If the
goal of care is to
keep a client (e.g., a
terminally ill client)
comfortable, turning
and repositioning
may not be
appropriate.
Maintain head of the
bed at the lowest
possible degree of
elevation to reduce
shear and friction,
and use lift devices,
pillows, foam
wedges, and
pressure-reducing
devices in the bed.
Evaluate for use of
specialty mattresses
or beds as
appropriate

 Implement a written
treatment plan for
topical treatment of
the site of skin
impairment. A
written plan ensures
consistency in care
and documentation

 Select a topical
treatment that will
maintain a moist
 wound-healing
environment and
that is balanced with
the need to absorb
exudate. Caution
should always be
taken not to dry out
the wound.

 Avoid massaging
around the site of
skin impairment and
over bony
prominences.
Research suggests
that massage may
lead to deep-tissue
trauma

 Assess the client's

nutritional status.
Refer for a nutritional
consult, and/or
institute dietary
supplements as
necessary.
Optimizing
nutritional intake,
including calories,
fatty acids, protein,
and vitamins, is
needed to promote
wound healing
 Assessment Nursing Diagnosis Goals & Expected Outcomes Nursing Interventions Evaluation
(Supporting data) (NANDA diagnostic statement) (Realistic, timed, measurable) (Strategies or actions for care) (Client’s response to nursing actions
Rationale for interventions & progress toward achieving
goals & outcomes)
Subjective:  Assess pt’s feelings,
values, and reasons
• Pt will discuss fear for not following the • Pt refused to
Ineffective Health of or blocks to prescribed plan of discuss fear of or
maintenance r/t care.
implementing blocks to
Objective: chronic substance
use aeb
health regimen implementing
 Assess for family
dysfunctional organ with this student patterns, economic
health regimen
DX of hepatic and
renal failure systems during shift issues, and cultural with this student
secondary to ETOH • Pt will create goals patterns that • Pt created
abuse for health care influence compliance several goals for
maintenance with with a given medical health care
student nurse to regimen. maintenance to
 implement after d/c implement after
• Pt will follow  Help pt determine d/c
mutually agreed how to arrange a
upon health care daily schedule that
incorporates the new
maintenance plan
health care regimen
after d/c (e.g., taking pills
before meals).

 Refer pt to social
services for financial
assistance if needed.

 Identify support
groups related to the
disease process (AA,
NA, etc.)

 Obtain or design
educational material
that is appropriate
for pt; use pictures if
possible.

 Ensure that follow-up

appointments are
scheduled before the
client is discharged;
discuss a way to
ensure that
appointments are
kept

 Assess sensory
deficits and
 psychomotor skills in
terms of the pt’s
ability to comply with
a health program.

 Recognize resistance
to change in lifelong
patterns of personal
health care.

 Discuss with pt
realistic goals for
changes in health
maintenance.

 Have pt and family

demonstrate at least
twice any procedures
to be done at home