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Nursing Diagnosis and Plan of Care
Nursing Diagnosis #1: Risk for Aspiration related to impaired swallowing.
Nursing Goal/ Expected Outcome: The patient will tolerate tube feedings throughout the nurse’s shift, 0700-
1930, without any episodes of nausea, vomiting, or aspiration.
Intervention #1: During tube feedings, the nurse will assess the patient’s respiratory rate, depth, and
effort, making sure to make any signs of aspiration (coughing, dyspnea, cyanosis, wheezing, or
hoarseness).
Rationale: “Signs of aspiration should be detected as soon as possible to prevent further aspiration and to
initiate treatment that can be lifesaving. Because of laryngeal pooling and residue in clients with
dysphagia, silent aspiration (i.e., not manifested by choking or coughing) may occur” (Ackley &
Ladwig, 2011, p.152).
Evaluation: Patient did not experience any aspiration
Nursing Diagnosis #2 A decrease in the cardiac output which is related to the increase in peripheral vascular
resistance secondary as a result of hypertension
Goal/outcome. The patient will verbalize, demonstrate knowledge of, and participate in a minimum of two
activities for stress management and rest by 1600 after all of the patient’s scheduled therapies.
Interventions and rationale. The patient will attempt to rest in a calm environment with minimal environmental
noise and activity to help promote relaxation and reduce stimulants. The patient will schedule blocked periods
of uninterrupted rest to lessen physical and emotional stressors which may cause an increase in BP, affecting the
diagnosis of hypertension. The patient will participate in relaxation techniques such as guided imagery to reduce
stressful stimuli and calm the patient, therefore reducing the BP.
Evaluation. The patient was able to successfully demonstrate and verbalize knowledge of three methods
of stress management and reduction
Conclusion
