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    Father Saturnino Urios University: San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines

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    ROGEN KATE AZARCON
    The patient is at risk for aspiration due to stroke and nasogastric feeding. The nursing care plan includes monitoring vital signs, input/output, consciousness level, and providing feeding and medications as prescribed. Turning the patient and encouraging deep breathing exercises will help prevent aspiration and pneumonia. The goal is for the patient to avoid aspiration from 10am to 2pm as evaluated by clear lung sounds and stable vital signs.

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    Father Saturnino Urios University: San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines

    Uploaded by

    ROGEN KATE AZARCON
    24 views2 pages
    The patient is at risk for aspiration due to stroke and nasogastric feeding. The nursing care plan includes monitoring vital signs, input/output, consciousness level, and providing feeding and medications as prescribed. Turning the patient and encouraging deep breathing exercises will help prevent aspiration and pneumonia. The goal is for the patient to avoid aspiration from 10am to 2pm as evaluated by clear lung sounds and stable vital signs.

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    The patient is at risk for aspiration due to stroke and nasogastric feeding. The nursing care plan includes monitoring vital signs, input/output, consciousness level, and providing feeding and medications as prescribed. Turning the patient and encouraging deep breathing exercises will help prevent aspiration and pneumonia. The goal is for the patient to avoid aspiration from 10am to 2pm as evaluated by clear lung sounds and stable vital signs.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    24 views2 pages

    Father Saturnino Urios University: San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines

    Uploaded by

    ROGEN KATE AZARCON
    The patient is at risk for aspiration due to stroke and nasogastric feeding. The nursing care plan includes monitoring vital signs, input/output, consciousness level, and providing feeding and medications as prescribed. Turning the patient and encouraging deep breathing exercises will help prevent aspiration and pneumonia. The goal is for the patient to avoid aspiration from 10am to 2pm as evaluated by clear lung sounds and stable vital signs.

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    FATHER SATURNINO URIOS UNIVERSITY

    San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines

    Nursing Program
    Name: Rizza Aubrey Miles Monta
    Date: March 7, 2023

    NURSING CARE PLAN

    Assessment Nursing Planning Nursing Intervention Rationale Evaluation


    Diagnosis

    Risk for Within 4 hours of 1. monitor Vital signs of 1. to monitor any signs of alterations and After 4 hours of
    Subjective Cues: Aspiration nursing interventions, nursing
    patient report it to staff nurse for further
    No statement related to the patient will not be interventions, the
    verbalized by the stroke as able to: 2. measure and record management patient was not
    patient evidenced by able to:
    Input and output 2. to determine signs of dehydration of
    Osteorized Experience aspiration
    feeding via fr 10 am to 2 pm as 3. Instruct the watcher lf patient Experience
    Nasogastric observed by clear lung aspiration fr 10
    patient to do the TSB 3. to provide hygiene to patient and to
    Objective Cues: Tube sounds, unlabored am to 2 pm as
    breathing, and oxygen 4. Assess the level of prevent from any infections observed by clear
    - With NGT , Intact saturation within lung sounds,
    consciousness using 4. this is to determine the level of
    normal range (96% to unlabored
    -With FBC , 100%) GCS consciousness of the patient by scoring breathing, and
    draining well oxygen saturation
    5. Give osteorized feeding through GCS. and still the GCS of patient
    within normal
    - incomprehensible at 10 am is 9 range (96% to
    sounds 100%)
    6. Turn the patient side to 5. As prescribed by the doctor of the
    -limited ROM side hourly patient - Goal Met
    noted
    7. monitor respiratory rate 6. to promote decreasing of pain of the
    R.A.M.Monta ,
    - CRT >2 seconds , depth and effort pressure ulcer and to decrease also the FSUU/SN
    - awake, with IFV 8. Administer due level of pressure ulcer
    #7 PNSS 1L @
    20gtts/min hooked medication with osteorized 7. to determine any unusualities that may
    at Left metacarpal
    feedig develop signs of pneumonia as the
    vein
    9. moderate high back rest patient may also risk for having
    of patient pneumonia
    Initial V/s: 10.encourage deep 8. as prescribed by the physician at 2 pm
    breathing exercise to in the afternoon
    patient 9. Whether self-feeding, assisting with
    T- 36.8
    feeding, administering medications or
    P- 82 tube feedings, the head of the bed should
    R- 18 remain elevated for 30 min-1 hour after.
    10. To facilitate proper breathing exercise
    Bp- 120/80
    and determine any unusual sounds of the
    O2 - 97% lungs

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