Student Nursing Care Plan Template
Client: _______________________________________________
Care Plan initiated by: __________________________________
Date: _______________________________________________
Assessment Nursing Diagnosis Goals and Outcomes Nursing Interventions Rationale Implementation Evaluation
Risk Factors : Risk of Aspiration After 72 hours of nursing 1. Take vital signs 1. Assess vital sign at 1. Taking vital signs
- Daughter of client as evidenced by intervention, the client will be frequently, noting frequent intervals to frequently, noting Subjective data :
states that patient has impaired able to maintain a patent onset of a fever, assess physiological onset of a fever,
increased 1. The client said that he
been struggling with swallowing, airways and risk for aspiration increased respiratory evidence of aspiration
swallowing and respiratory rate, and feels comfortable when
depressed cough and will be decreased as rate, and increased 2. Signs of aspiration increased heart rate
seems to choke a lot he chews and swallows
since her stroke. gag reflexes evidenced by : heart rate should be detected as EA : Vital sign when he is fed slowly
- Client said he had secondary to stroke - Daughter of client states 2. Monitor respiratory soon as possible to Temperature : 36.5
that patient did not rate, depth, and prevent further aspiration C 3. The client said he
depressed cough
- Crackles noted upon struggling with swallowing effort. and to initiate treatment RR: 23 feels comfortable
auscultation and did not seems to choke 3. Before initiating oral that can be lifesaving breaths/minute because adjust the
- Client exhibits PR : 110 position when eating and
a lot since her stroke feeding, check 3. If client is having
difficulty swallowing beats/minute
- Client said he did not had client’s gag reflex problems swallowing, BP: 150/95 mmHg after eating
without choking and
gag reflexes depressed cough and ability to see nursing interventions 2. Monitoring 4. When the client wants
secondary to stroke - Crackles are not noted on swallow by feeling for Impaired respiratory rate, to be given oral feeding
auscultation the laryngeal Swallowing. depth, and effort. the client said he wants
Vital Signs : - Client not exhibits prominence as the 4. With decreased Note any signs of to vomit
difficulty swallowing client attempts to symptoms of pneumonia, aspiration such as
TEMP: 36.5 C
without choking and gag swallow an increased respiratory dyspnea, cough,
RR: 23 breaths/minute Objective data :
reflexes secondary to stroke 4. Auscultate lung rate and/or crackles may cyanosis, wheezing,
sounds frequently be the first sign of 1. Temperature within
PR: 120 beats/minute hoarseness, foul-
Vital signs and before and after pneumonia normals limit is 36,5 C
smelling sputum, or
BP: 110/70 mmHg Temp : 36,5-37,5 C feedings, note any 5. Slowed feeding allows fever. If new onset 2. The pulse within
RR :16-20 cpm new onset of crackles time for more deliberate of symptoms, normal limit is 110
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PR : 80-100 cpm or wheezing. swallowing, reducing perform oral beats/minute
BP : 120/80 – 139/90 mmHg 5. If client needs to be aspiration suction and notify 4. Respiratory Rates
fed, feed slowly and 6. A client with aspiration provider within normals limit is 23
allow adequate time needs immediate immediately breaths/minute
for chewing and suctioning and may need EA : Wheezing in
5. The blood pressure
swallowing. further lifesaving the client does not
within normals limit is
6. Have suction interventions such as decrease
machine available intubation and 3. Before initiating 150/95 mmhg
when feeding high- mechanical ventilation oral feeding, 6. The client looks
risk clients. If 7. Decreased gastric reflux checking client’s wheezing does not
aspiration does occurs at both 30- and gag reflex and decrease
occur, suction 45-degree HOB ability to swallow
immediately. elevation. by feeling the
7. Keep the head of the laryngeal Assessment
bed (HOB) elevated prominence as the Risk for Aspiration as
at 30 to 45 degrees, client attempts to evidence by impaired
preferably with the swallow
swallowing, depressed
client sitting up in a EA : When the
cough and gag reflexes
chair at 90 degrees client wants to be
when feeding. Keep given oral feeding secondary to stroke is
head elevated for an the client said he partially met
hour after eating wants to vomit
4. If client needs to be Plan : Continue
fed, feeding slowly intervention
and allow adequate 1. Taking vital signs
time for chewing frequently, noting onset
and swallowing. of a fever, increased
EA : When the
respiratory rate, and
client is fed slowly,
increased heart rate
the client said
2. Monitoring respiratory
comfortable
chewing and rate, depth, and effort.
swallowing Note any signs of
For a guide to nursing care plans, visit: h ttps://nurseslabs.com/nursing-care-plans/
5. Keeping the head of aspiration such as
the bed (HOB) dyspnea, cough,
elevated at 30 to 45 cyanosis, wheezing,
degrees, preferably hoarseness, foul-
with the client
smelling sputum, or
sitting up in a chair
fever. If new onset of
at 90 degrees when
feeding. Keep head symptoms, perform oral
elevated for an hour suction and notify
after eating provider immediately
EA : The client said 3. Before initiating oral
comfortable feeding, checking client’s
because adjusts the gag reflex and ability to
position when swallow by feeling the
eating and after laryngeal prominence as
eating the client attempts to
swallow
For a guide to nursing care plans, visit: h ttps://nurseslabs.com/nursing-care-plans/
