Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders and Rationale
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*I
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Evaluation
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Subjective
Pt daughter states that her mother has been struggling with swallowing and seems
to choke a lot since her stroke.
Objective
Diagnosis of stroke and right sided paralysis
Pt exhibits difficulty swallowing without choking.
Orders to have a speech therapy consult
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Problem
Risk for aspiration
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Long Term:
Pt will maintain a patent airway and clear lung sounds by discharge.
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*Monitor respiratory rate, depth, and effort.
Rationale: “Signs of aspiration should be detected
as soon as possible to prevent further aspiration and to initiate treatment that
can be lifesaving” (Ackley & Ladwig, 2008, p. 149).
*Auscultate lung sounds frequently.
Rationale: “Bronchial auscultation of lung sounds was shown to be specific in identifying
clients at risk for aspiration” (Ackley & Ladwig, 2008, p. 149).
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ü
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R/T
Impaired swallowing secondary to stroke
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Short Term:
Pt will swallow and digest NG tube medications and ice chips PO without aspiration
throughout this shift, by 1900.
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*Measure and record the length of the tube that is outside of the body at defined
interval to help ensure correct placement.
Rationale: “As part of maintaining correct placement, it is helpful to note the
length of the tube outside of the body; it is possible for a tube to slide out and
be in the esophagus, without obvious disruption of the tape” (Ackley & Ladwig,
2008, p. 149).
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ü
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