What could be 1 nursing diagnosis with 1 outcome/smart goal

What could be 1 nursing diagnosis with 1 outcome/smart goal, 5 interventions, 5 rationales, 5 evaluations for a patient who is 67 years old and is diagnosed with Dysphagia 2. The patient is in risk of ineffective airway clearance RIT neurological dysfunction evidenced by the patient's CVA dysphagia present. History of present illness: The patient was brought to the hospital for generalized edema. Past medical and surgical history: Hypothyroidism, rheumatoid arthritis."

Dysphagia, Specific Perimeters, Actions, Reasons, Checks for a Nursing Care Plan on a Particular Client

 Patient Profile:

 Age: 67 years old

 Diagnosis: Hear burn, risk for impaired gas exchange associated with CVA resulting in neurological changes.

 History: Swelling throughout ,low thyroid hormone, Rheumatoid arthritis.

 Nursing Diagnosis:

 Immobility and potential for chronic medical condition that adds risk for Ineffective Airway Clearance due to dysphagia and neurological dysfunction.

 SMART Goal:

 Specific: The patient will have success in clearance of the airway.

 Measurable: The patient will not exhibit aspiration (coughing, choking during meals) and will show signs of better swallowing.

 Achievable: Depending on the necessary and sufficient intercessions and evaluations.

 Relevant: Critical to avoiding such conditions such as aspiration pneumonia.

 Time-bound: In 1 week of performing the care plan.

 Interventions:

 You should screen the patient’s swallowing function before each meal.

 Rationale: Assessing swallowing function is done to determine challenges that are usually present prior to meals and directs the correct diet and feeding techniques that should not result to aspiration.

 Evaluation: Patient presentation indicate that the patient has a better swallowing function since there was no coughing or choking during feeding time.

 Consult with an SLP for the administration of swallowing therapy plan as this would be used for all patients undergoing a swallowing therapy.

 Rationale: Therefore, SLPs can adjust therapy and perform exercises to help enhance swallowing mechanisms that will prevent aspiration.

 Evaluation: The patient of swallowing therapy- The SLP evaluation and the recommendations of the patient progress in swallowing.

 Teach the patient and the family member about the correct methods of feeding and the symptoms of aspiration.

 Rationale: Education therefore enables the patient as well as the family to understand what gives cause for aspiration principally and when they are likely to encounter difficulties.

 Evaluation: Patient and family clearly show correct technique for feeding and stated knowledge of how to identify signs of aspiration.

 Use of aspiration precautions including, offer of thickened liquids and use of a modified diet according to SLP advice.

 Rationale: Liquid diets are thickened special for minimizing aspiration possibilities in patients with dysphagia.

 Evaluation: The patient enjoys meals with no aspiration identified they also report improved comfort during meal time.

 Respiratory status those should be assessed frequently and oxygen saturation levels as well.

 Rationale: Self-assessment enables identification of any violation of the normal process of airway clearance or any aspiration related complication.

 Evaluation: As for respiratory status and oxygen saturation: Airway patency is maintained and patients’ breathing is adequate or improved.

 Evaluation:

 Patient has negative history of aspiration during meals the patient did not choked or cough during the meals.

 Measure: A observation of the students during their meal time.

 The patient shows enhanced swallowing abilities as observed the patient and other health care staff of the health facility.

 Measure: Monthly clinician and nursing staff follow-up by the SLP.

 The patient and family are able to identify appropriate techniques of feeding as well as identifying signs of aspiration.

 Measure: Teaching aids and handling during educative sessions.

 Simple changes in food and fluid consistency help in lowering aspiration because incidents of difficulty during meal taking were reduced.

 Measure: Collection on the changes in food intake and the patients’ feedback.

 Although the subjects presented a few episodes of abnormal breathing accompanied by C/S rales, the respiratory status and oxygen saturation levels are within normal values suggesting adequate clearance of the airways.

 Measure: Follow-up of preformed care plan charting of assessments of respiratory rate and oxygen saturation.

 The interventions of this effective and systematic care plan relate to the patient’s potential for compromised airway clearance because of dysphagia and neurological issues.