NURSING CARE PLAN Nursing Diagnosis #6: Imbalanced nutritional status: Less than body requirements related to inability

to ingest food as evidenced by nahihirapan siyang ubusin yung pagkain as verbalized by the significant other Goal: To promote nutrition Expected outcome: At the end of 8 hours nursing interventions, the client will able to: Increase food intake Tolerate feeding Nursing Interventions Identified factors that contribute to imbalance nutrition: less than body requirements Rationale: to determine if specific interventions may be required Assessed clients tolerance to feeding nahihirapan siyang ubusin yung pagkain as verbalized by the significant other The nasogastric feeding tube is in proper position as confirmed by the bedside nurse Tube feeding 1800kcal/day 1.5cal/ml divided into 6 equal feeding + 1 can of ensure Rationale: to determine if specific interventions may be required Confirmed the placement of nasogastric feeding tube Rationale: misplacement may result in aspiration of enteral feeding Provided diet modifications as ordered Rationale: to ensure ongoing nutritional needs are being met as condition/situation changes Outcome The client has ulcer in oral cavity with denuded surface and has difficulty in swallowing

NURSING CARE PLAN

NURSING CARE PLAN Nursing Diagnosis #8: Risk for aspiration related to denudedto muscular as evidenced by Nursing Diagnosis #7: Impaired physical mobility related oral cavity as evidenced by nasogastric tube feeding decreased muscular strength Goal: ToTo promote mobility of aspiration Goal: prevent occurrence Expected outcome: At At the end ofhours nursing interventions, thethe client will able to: Expected outcome: the end of 8 8 hours nursing interventions, client will able to: Manifest negative signsby himself. (cyanosis, coughing and shortness of breath) Manage to do ROM of aspiration Maintainable to do exercise as tolerated. To be clear airway Nursing Interventions Noted clients level of consciousness and Nursing Interventions mental status degree of immobility Determined Rationale: impairments in this areas has Rationale: to determine specific higher risk of aspiration interventions required Assessed clients ability to swallow and Identified factors/complications that strength of gag reflex contributes to immobility Rationale: to determine presence or Rationale: to determine specific effectiveness of protective mechanism interventions required Confirmed the placement of nasogastric Performed ROM exercise to the client feeding tube Rationale: promotes mobility and Rationale: misplacement may result in circulation of the blood aspiration of enteral feeding Provided safety measures Rationale: to promote safe environment Suction as indicated Rationale: to clearthe family/significant other Encouraged secretions while reducing potential support and assistsecretions to for aspiration of in the positioning Elevated client (frequent shifting of of the the bed into semi to high fowlers position before and after feeding weight) Outcome Patient is conscious and coherent with Outcome mental status of intermittent confusion The client requires help from another person in order to move The client has difficulty in body The client has generalized swallowing and has depressed gag muscle and presence of weakness, flaccid reflex pain due to decubitus ulcer The nasogastric feeding tube isin the ROM exercise was performed in proper position as confirmed by the bedside nurse morning Side rails up Suctioning done by the nurse before Frequent positioning was done by the feeding. other. significant No aspiration was noted during the shift

Rationale: toto reduce pressure ulcer feeding Rationale: facilitate gravity flow of and reduces risk of aspiration Observed for any signs of cyanosis, shortness of breath and coughing Rationale: indication occurrence of aspiration No cyanosis noted

NURSING CARE PLAN Nursing Diagnosis #9: Disturbed thought processes related by medication overdose as evidenced by visual and auditory hallucinations Goal: to Maintain usual reality orientation Expected outcome: At the end of 8 hours nursing interventions, the client will able to: Recognize changes in thinking/behavior Maintain usual reality orientation Nursing Interventions Assessed degree of disorientation Outcome Reports visual hallucination like seeing a cup of taho falling from curtain and side rails of clients bed and auditory hallucination like hearing that he is being called. Oriented client to the surroundings and procedures to be done Rationale: to decrease alienation to the environment and to increase trust from the client Determine medications taken Methylprednisolone, zynapse capsule, seroquel The client was oriented with the surroundings and explanation of the procedures was done before performing it to him.

Rationale: to determine the amount of reorientation and intervention required to the client

Rationale:to identify medication that can contribute to disturbed thought processes

NURSING CARE PLAN

Nursing Diagnosis #10: Anxiety related to prolonged hospitalization secondary to multiple health diseases as evidenced by Goal: To reduce level of anxiety Expected outcome: At the end of 8 hours nursing interventions, the client will able to: Appear relaxed Report anxiety is reduced Identify ways to deal with and express anxiety Nursing Interventions Assessed signs of anxiety

Outcome (+) restlessness (+) facial grimace

Rationale: to determine level of anxiety Reassured that the client is not alone in dealing with problems Rationale: presence of support person will help reduce anxiety level Provided comfort measures

The client has significant others

Calm and quiet environment was provided.

Rationale: to reduce sensory stimuli