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Natividad, Michael John F.

BSN IV

Nursing Care Plan


ASSESSMENT Subjective: >Nahihirapan akong matulog sa gabi e, as verbalized by the patient DIAGNOSIS Disturbed sleep pattern related to interruptions secondary to hospital monitoring procedures and unfamiliar sleep surroundings PLANNING INTERVENTION RATIONALE
To mimic usual pre-sleep routines;thus, enhancing ease to sleep

EVALUATION After 1 hour of nursing interventions, the client was able to identify individually appropriate interventions to promote sleep

Allow client to continue usual sleep practices After 1 hour (e.g. presleep routines such as reading, watching of nursing television, listening to music, and meditating) interventions, whenever possible

Objective: >Change in normal sleep pattern (Awake at night, while asleep during daytime >Weakness on daytime, feeling of not well rested >Client is hospitalized

the client will identify individually appropriate interventions to promote sleep

Satisfy basic needs such as comfort and warmth before sleep Reduce environmental distractions such as: >close door to client's room and put a "Vital signs only during hours" sign >use night light rather than overhead light whenever possible; >keep staff conversations at a low level and away from client's room; >close curtains between clients in a semi-private room or ward; >keep beepers and alarms on low volume; >provide client with "white noise" such as a fan, soft music, or tape-recorded sounds of the ocean or rain; have sleep mask and earplugs available for client if needed

Comfort enhances sleep

To avoid interruptions, thus, increasing sleeping time

Natividad, Michael John F. BSN IV

Nursing Care Plan


ASSESSMENT Subjective: >Nahihirapan ako lumunok kaya nga hindi pa ako madischarge, as verbalized by the patient DIAGNOSIS Impaired swallowing related to neuromuscular impairment: decreased gag reflex PLANNING After 1 hour of nursing interventions, the client will be able to identify individually appropriate interventions or actions to promote intake and prevent aspiration INTERVENTION Verify proper fit of dentures if present During feeding, raise head of bed as upright as possible with head in anatomical alignment and slightly flexed forward. Keep head of bed elevated for 30-45 minutes after feeding, if possible Frequently assess breath sounds Massage the laryngopharyngeal musculature gently Assist patient in learning specific feeding techniques and swallowing exercises RATIONALE To avoid accidental dislodgement and aspiration of dentures To reduce risk of regurgitation or aspiration EVALUATION

Objective: >Inability to push food down completely through swallowing > choking before a swallow >repetitive swallowing >hyperextension of head during trial meal

To evaluate presence of aspiration

After 1 hour of nursing interventions, the client was able to identify individually appropriate interventions or actions to promote intake and prevent aspiration

To stimulate swallowing

To promote enhancement of swallowing reflex

Natividad, Michael John F. BSN IV

Nursing Care Plan


ASSESSMENT Subjective: >Pasensya ka na, nahihirapan ako kumilos eh, as verbalized by the patient DIAGNOSIS Impaired bed mobility related to neuromuscular impairment INTERVENTION Inform the client and After 30 Significant Others (SOs) minutes of about the importance of nursing proper positioning and interventions, the client and frequent repositioning. significant Instruct to turn the others will dependent client frequently, verbalize willingness utilizing bed and mattress to participate positioning settings to assist in movements; reposition in repositioning good body alignment, using program. appropriate support Instruct client and SOs in methods of moving client relative to specific situations and mobility needs Inform the SOs to assist the patient with activities of hygiene, toileting, feeding, as indicated PLANNING RATIONALE To facilitate learning and increase their willingness by augmenting their awareness of the procedure EVALUATION After 30 minutes of nursing interventions, the client and significant others verbalized willingness to participate in repositioning program.

Objective: > Inability to turn side to side; move from supine to sitting or reposition self in bed >Generalized weakness >Slow bodily movements

To facilitate timely, appropriate and proper repositioning of the patient by the caregivers while preventing strains and unnecessary discomforts

To ensure repositioning is appropriate with its need

To achieve patients daily need with collaborative support and through the help of proper positioning