URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

NURSING CARE PLAN (NCP)

Name of Student: DOMINGO, MA. ALMIRA S. Year Level and Group: Level IV- Blk. 4

Affiliating Agency/Area: ___________________________________________ Month/Year of Exposure: April 26, 2022

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

(at least 10)

Subjective: Problem, Etiology, Signs Short Term Goal: Independent: Short Term Goal Evaluation
(P.E.S.) format S.M.A.R.T. + Evidence  Assessment Goal met
“Parang naninigas After 5 hours of  Assess the patient’s Impairment in cognitive or After 5 hours of rendering
po yung panga ko Impaired swallowing cognitive and sensory- sensory-perceptual status affects
kaya po pag related to
rendering nursing perceptual status. the patient’s desire and ability to
nursing intervention, the
kumakain ako neuromascular intervention, the patient swallow safely and effectively. patient was able to:
medyo impairment secondary will:  Showed no signs of
nabubulunan po to Parki’son's Disease aspiration after meals
ako” as verbalized as evidenced by  Assess ability to swallow Ask client to swallow; feel larynx (such as coughing,
 Show no signs of
by the patient chooking, drooling, by positioning examiner's elevate. Ask client to cough; test for a crackles in the lungs, or
aspiration after
coughing, muscle thumb and index finger gag reflex on both sides of posterior chooking).
meals (such as
rigidity, and aspiration on client's laryngeal pharyngeal wall (lingual surface) with a  Remained free from
coughing, crackles tongue blade. Do not rely on presence
in the lungs, or protuberance. aspiration (e.g., lungs
of gag reflex to determine when to clear, temperature within
chooking) feed.
 Remains free from normal range).
aspiration (e.g.,  Mastificate food everytime
lungs clear,  Therapeutic he ate
To monitor for aspiration
temperature within  Auscultate breath sounds  Decreased the urge to
pneumonia.
normal range) droll
 Be able to Client needs to be alert, able to
mastificate every  Determine client's
follow instructions, hold head
food he ate. readiness to eat.
erect, and able to move tongue in
 Decrease the urge mouth.
to droll Placing food in the functioning
 Place the food in the
side of the patients mouth allows
functioning side of the
for sensory stimulation and taste
patients mouth.
and may trigger swallowing
reflexes.
 Weigh client weekly to help
evaluate nutritional status.
Objective: INFERENCE Long Term Goal: Clients with swallowing Long term Goal Evaluation
(at least 5) Scientific Explanation S.M.A.R.T.+ Evidence  Educative impairments often take two to Goal met
 (+) muscle (Diagram Form) After 2 days of  Ensure that there is four times longer than others to After 2 days of rendering
rigidity Patient is diagnosed with adequate time for client eat, if being fed. Often, food is
 Coughing Parkinson’s disease
rendering nursing to eat. offered rapidly to speed up the
nursing intervention, the
while intervention, the patient task, and this can increase the patient was able to:
swallowing will be able to: chance of aspiration.  Demonstrated
 Continuous
drolling  Demonstrate aspiration precaution
 (+) food Rigid muscle due to aspiration Praise reinforces behavior and  Reported and showed
pocketing difficulty of muscle to relax precaution sets up a positive atmosphere in manifestations of
every after  Praise client for which learning takes place.
bite  Report and show successfully following swallowing without
 Difficulty in manifestations of directions and swallowing coughing, chooking,
mastification swallowing appropriately. drooling and food
of food Difficulty to mastificate It is common for family members
 Double food because of muscle without to disregard necessary dietary pocketing
swallowing rigidity coughing,  Educate client, family, restrictions and give client  Freed from
 Watery eyes chooking, and all caregivers about inappropriate foods that complications such as
 Unable to rationales for food predispose to aspiration.
move the drooling and food consistency and choices. aspiration pneumonia,
food to the Coughing while swallowing pocketing malnutrition and
back of the  Free from dehydration
pharynx Dependent: Swallowing difficulties and
 Hoarness complications choking are common in  Ingested an adequate
 Rapid and such as aspiration  Assess the cause and the parkinson’s disease. Producing amount of nutrients and
shallow Continuos drooling degree of impairment by baseline data will help in
pneumonia, maintain the ideal body
breathing using dysphagia assessing in the future if the
 Crackles malnutrition and screening test patient’s disorder in regressing or weight
sound upon dehydration progressing.  Met with a speech
auscultation  Ingest an pathologist and develop
Vs as follow:
Bp: 130/100 Food pocketing every after adequate amount a discharge plan.
Pr: 97 bpm bite of nutrients and Determine infection by observing
Rr: 22 cpm  Review laboratory results the trends in the blood test.
maintain the
Temp: 36.7 C
O2 Sat: 99% ideal body weight
Unable to move food to  Meet with a To achieve adequate nutritional
the back of the pharynx  Administer tube feeding, intake, and prevent malnutrition
speech parenteral nutrition, or and dehydration.
pathologist and hydration as ordered.
develop a
Swallowing impairement Suctioning may be necessary if the
discharge plan.  Have suction equipment client is choking on food and could
available during feeding. If aspirate.
choking occurs and
suctioning is necessary,
discontinue oral feeding until
client is safely assessed with
a videofluoroscopic swallow
 study and fiberoptic
endoscopic evaluation of
swallowing (FEES),
whichever client can safely
tolerate.

Interdependent/Collaborative Referral to a specialist will let the

patient learn specific techniques
 Refer to Ent or speech to enhance efforts and safety.
pathologist.

The dysphagia team can help the

 For impaired swallowing, client learn to swallow safely and
use a dysphagia team maintain a good nutritional
composed of a status.
rehabilitation nurse,
speech pathologist,
dietitian, physician, and
radiologist who work
together.

Swallowing exercises can improve

 Work with client on the client's ability to swallow.
swallowing exercises Exercises need to be done at
prescribed by dysphagia intervals necessitating nursing
team. involvement.

Checked by: Edward Reiner Palaganas, RN Date: April 26, 2022

Clinical Instructor’s Name and Signature