CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Impaired Swallowing LONG TERM: INDEPENDENT: LONG TERM:

R/T At the end of hours of effective
 nursing interventions, the patient  Instruct the SO to:
will be able to:  Give  Feedings with a thicker
liquids/feedings consistency are more
 Maintain adequate with thickened tolerable for patients
hydration as evidenced consistency. with difficulty in
by good skin turgor, swallowing.
moist mucous  Avoid foods which  To prevent
membranes, and may thicken accumulation of thick
individually appropriate secretions such as secretions that
urine output. milk products and contributes to
OBJECTIVE: chocolate. swallowing difficulties.
 Feed one  To prevent aspiration.

consistency of food
at a time.
 Place food on the  For the patient to be
unaffected side of able to have more
the mouth during control in moving the
feedings. food to swallowing
position.
SHORT TERM:
 Assisting the patient  To facilitate the closing SHORT TERM:
At the end of hours of effective
in flexing the neck of the epiglottis thus Goals were fully met
nursing interventions, the
when swallowing. preventing accidental because was not able to
patient’s SO will be able to:
entry of food/liquids to aspirate and the SO was
 Identify interventions the trachea. able to demonstrate the
and actions to promote  Demonstrate to the SO the  To enhance the SOs correct feeding techniques.
intake and prevent correct position for feeding knowledge and
aspiration. to prevent aspiration like independence in
 Demonstrate feeding elevating the head of the feeding the patient and
techniques that best fits bed to semi-fowlers reduce the risk of
the patient’s needs. position, keeping the head in regurgitation/
 Verbalize the importance neutral/midline position. aspiration.
of allowing ample time  Offer sips of water using a  To avoid posterior head
for eating or feeding. straw. tilting while drinking.
 Create with the SO a proper  To allow ample time for
eating/feeding thus not
 schedule for feeding.
 Observe oral cavity for
remaining food and remove
food that the patient is
unable to swallow. Provide
oral hygiene following each
feeding.
DEPENDENT:
 Follow the prescribed diet
for the patient.
 Consider tube feedings or
parenteral solutions as
indicated.
interfering with
patient’s other ADLs
and gives time for rest
every after feeding.
 To prevent the patient
from choking on
unswallowed food and
prevent cavities.
 To be able to sustain
patient’s dietary needs
accordingly.
 To be able to monitor
the input and output of
the patient correctly
and accurately