Example Nursing Diagnosis and Careplan Potential for Injury (Apsiration)
Assessment Data Related to Nursing Diagnosis
What Objective and Subjective Data lead you to this one diagnosis.
Objective:
CVA with Left Sided Paralysis
Diminished Gag Reflex
Difficulty Swallowing Liquids
Subjective (from patient or family)
” Mom chokes every time she eats”.
Nursing Diagnosis
Potential for Injury (Aspiration) related to dimminshed gag reflex and impaired swallowing ability
Goal
Goal (Should be broad statements which solve the Problem part of the Nursing Diagnosis Statement. )
Patient will not have injury related to aspiration (10/20/95 2-10pm)
Outcome Criteria
Specific and observable things which allow an observer to determine if the patient met the goal
1. Patient will have no choking episodes while eating.
2. Patient color will remain cyanotic
3. Patient lung sounds will remain clear
4. Patient CXR will show no signs of aspiration
Nursing Interventions
Interventions should be things that you do (either independently or dependently) to assist the patient in reaching the goal. They should be focused on addressing the cause of the problem (the related to part of the nursing diagnosis statement)
Place patient on side or with HOB to avoid aspiration of mucous.
Feed patient liquids which have been thickened, as thin liquids are more likely to cause aspiration.
Monitor lung sounds for signs of aspiration
Monitor Lab and X-ray data for signs of aspiration.
Evaluation
Evaluate based on the patients progress towards each of the outcome Criteria
1. Patient did not have problems with choking during my shift.
2. Patient color was pink.
3. Patient lung sounds remained clear.
4. You may or may not have lab/X-ray data to report, depending on the day and what tests have been ordered.
Goal Met, Continue Plan.
ALSO INCLUDE
Was this an appropriate Nursing Dx for THIS PATIENT? It may turn out that after you care for the patient, you discover a higher priority nursing diagnosis.