ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

ANALYSIS
Subjective Data: Impaired Abnormal Long-Term Goal: Independent: -With impaired -Patient displays
Nahihirapan siyang swallowing functioning of After 3-4 months of -Have suction swallowing improved
maka-hinga at maka- related to the swallowing nursing equipment reflexes, swallowing, as
ubo, hindi niya rin neuromuscular mechanism interventions, the available and secretions can evidenced by
kayang kumain mag- impairment. associated with patient will be able functioning rapidly absence of
isa. as verbalized by deficits in oral, to: properly. accumulate in the aspiration, no
patients wife. pharyngeal, or posterior pharynx evidence of
esophageal -Display improved and upper coughing or
Objective Data: structure or swallowing, as trachea, choking during
function. evidenced by increasing the risk eating/drinking,
-Difficulty of Impaired absence aspiration of aspiration. no stasis of food
swallowing swallowing and the risk of in oral cavity after
-Drooling involves more aspiration is -Monitor the -These signs may eating, ability to
-Stasis of mucus time and effort decreased as patient for indicate ingest
secretions in oral to transfer food manifested by coughing, regurgitation/ foods/fluids.
cavity or liquid from reduced stasis of gagging, aspiration.
-Gagging the mouth to mucus secretions, wheezing and -Patient
-Wheezing the stomach. It chances of gagging, difficulty of determines
-Rapid breathing occurs when the drooling and breathing. different
muscles and abnormally rapid emergency
Vital signs: nerves that help breathing. -Teach the -Because the tip measures when
the food patient and the of ngt may be signs of aspiration
BP: 110/70 through the family on how to dislodged from occurs.
Pulse: 85 bpm throat and monitor for signs the stomach and
Respiration: 30 cpm esophagus are of aspiration lead to aspiration.
Temperature: 36.5C not working especially during
02 SAT: 99% right. It can be a ngt feeding.
temporary or -Because
permanent -Monitor the alteration may
complication patients vital indicate
that can be sign. complications like
fatal. aspiration.
-Encourage deep -To promote lung
breathing and expansion and
coughing initiates the
exercises. coughing reflex,
which facilitates
expectoration of
mucus secretion.

-Keep the patient -To prevent

in an upright aspiration due to
position for more backflow of
than 30 minutes osteorized food.
after a meal.

-Position the -To promote

patient correctly airway clearance
with the head due to stasis of
facing to the side mucus and to
or on a semi/high promote
fowlers. oxygenation via
maximum chest
expansion.

-Provide oral care - Good oral and

before feeding. dental hygiene
can help prevent
bad breath, tooth
decay and gum
disease
Dependent:
-Administer N- -To Decrease
Acetylcysteine as viscosity of the
ordered by the mucus secretions
doctor. for easy removal.

-Suction -To clear the

secretions as airway due to
ordered by the obstruction by
doctor. the mucus
secretions.

Collaborative:

-Refer to -To liquefy mucus

Respiratory secretion for easy
Therapist for expulsion.
Nebulization.

-Refer to -For indirect

Respiratory removal of mucus
Therapist for to breathe more
Chest freely.
physiotherapy.

-Consult with -Evaluating gag

speech therapist reflex decreases
to evaluate gag the risk for
reflexes. aspiration.
-Refer to -The dysphagia
dysphagia team team can help the
composed of a patient learn to
rehabilitation swallow safely
nurse, speech and maintain a
pathologist, good nutritional
dietitian, status.
physician, and
radiologist who
work together.