Nursing Prioritization Date Identified 1.

March 2, 2012 Cues Objective: Uncontrolled chewing Use of anti-psychotic medications Protrusion of the tongue Impaired dentition Diagnosis Risk for aspiration related to swallowing disorder secondary to use of anti-psychotic medication as manifested by protrusion of the tongue. Justification Aspiration of food content in the lungs is a serious complication that may result in dyspnea, cyanosis, or even death. It can occur when the protective airway reflexes are blocked or decrease from a variety of factors. Prevention is the primary goal when caring for patients at risk for aspiration. (Aspiration): Brunner & Suddarths Medical Surgical Nursing [Page-563] Because according to Orems theory nursing; self-care, safe-care deficit and nursing system is a related concepts. Self-care deficits result when there is inadequacy to meet the known selfcare demand. And also, it may lead to skin disorder that may cause unwanted effect on the patient.

2. March 2, 2012

Objective: Poor dental health care Dry mouth Halitosis Presence of skin lesions Presence of lice Oil hair Not neat in appearance Cognitive impairment

Self-care deficit (bathing, hygiene,) related to inadequate self-care hygienic materials/environment as manifested by presence of skin lesion.

3. March 05, 2012

Objective: Tremors on the hand and feet Decreased lower extremity strength.

(Orems general theory of nursing) Fundamentals of Nursing:Kozier [Page-44] Risk for falls related to uncontrolled As nurses, we should be concerned tremors at the extremities secondary to about the prevention of accidents and use of anti-psychotic medication as injury to the patient. according to manifested by slow movement. maslows hierarchy of needs, second

 Impaired balance Use of anti-psychotic drugs. Slow movement Tremors while holding edges of furniture

level involves safety and security needs which includes protection, security and freedom of harm. Accident can be prevented with proper intervention (Safety) Fundamentals of Nursing:Kozier [Page-710]

Nursing Care Plan Prioritization #1 ASSESSMENT Objective: Uncontrolled chewing Use of antipsychotic medications Protrusion of the tongue Impaired dentition NURSING DIAGNOSIS Risk for aspiration related to swallowing disorder secondary to use of anti-psychotic medication as manifested by protrusion of the tongue. BACKGROUND KNOWLEDGE Side effect of antipsychotic medication Protrusion of the tongue Improper placement of food Difficulty in swallowing Risk for aspiration After 4 days: practice implemented methods to prevent aspiration on her own. Long term goal: After 3 week of nursing intervention patient will be able to perform on her own the appropriated feeding method to prevent aspiration. PLANNING Short term goal: After 2 days: verbalize her knowledge about prevention of aspiration. After 3 days: demonstrate participation in preventing aspiration. IMPLEMENTATION Independent: 1. Provide soft foods that stick together. 2. Vary placement of food in patients mouth. 3. Provide a rest period prior to feeding time. 4. Feed slowly, using small bites, instructing the patient to chew slowly and thoroughly. 5. Allow sufficient time for client to finish eating. Dependent: Review medication regime. RATIONALE To aid swallowing efforts. To facilitate proper swallowing of food.

EVALUATION Outcome: Partially Goal met Short term goal: After 2 days: verbalize her knowledge about prevention of aspiration. After 3 days: demonstrate participation in preventing aspiration. After 4 days: practice implemented methods to prevent aspiration on her own. Long term goal: After 3 week of nursing

To properly chew the food Encourage patient to build on success.

intervention patient will be able to perform on her own the appropriated feeding method to prevent aspiration.

Prioritization # 2 NURSING DIAGNOSIS Objective: Self-care deficit (bathing, hygiene,) Poor dental related to inadequate health care self-care hygienic Dry mouth materials/environment Halitosis Presence of skin as manifested by presence of skin lesion lesions Presence of lice Oily hair Not neat in appearance Cognitive impairment ASSESSMENT BACKGROUND KNOWLEDGE Environment Low prioritized institution Low financial support Insufficient availability of hygienic materials Self-care deficit (bathing/hygiene) PLANNING IMPLEMENTATION Independent: 1. Asses memory/intellectu al functioning 2. Determine individual strength and skills of the patient 3. Assist clients needs for personal care assistance 4. Explain to patient the importance of health care RATIONALE

EVALUATION

Short term goal: After 2 days: verbalize her knowledge about of health care practices. After 3 days: demonstrate participation in using alternative method and

Outcome: To note Goal met developmenta l level to Short term goal: which client After 2 days: has verbalize her progressed knowledge about of health care Promote safe practices. care independence After 3 days: demonstrate participation in using alternative

hygiene kit. After 4 days: practice alternative method for hygiene care on her own Long term goal: After 1 week of nursing intervention patient will be able to lessen the skin problems that are present.

practices. 5. Instruct patient about appropriate hygienic practice and alternative methods. 6. Demonstrate use of alternative resources. 7. Allow sufficient time for client to accomplished task to fullest extent. Dependent: Assist with medication regime as necessary.

method and hygiene kit. After 4 days: practice alternative method for hygiene care on her own Long term goal: Encourage patient to build on success. After 1 week of nursing intervention patient will be able to lessen the skin problems that are present.

Prioritization # 3 ASSESSMENT Objective: Tremors on the hand and feet Decreased lower extremity strength. Impaired balance Use of antipsychotic drugs. Slow movement Tremors while edges of furniture NURSING DIAGNOSIS Risk for falls related to uncontrolled tremors at the extremities secondary to use of antipsychotic medication as manifested by tremors on hand and feet. BACKGROUND KNOWLEDGE PLANNING IMPLEMENTATION Independent: 1. Assess for potential personal cause of falls. (Cognitive change). 2. Identify environmental hazards in the environment. 3. Demonstrate safety practices appropriate to environment. 4. Assist the patient in ambulation 5. Giving instruction on how to properly use furniture. 6. Provide educational resources (direction for proper use) Dependent: Review medication regime and how it affects the client. RATIONALE EVALUATION Outcome: Goal met Short term: After 1 week: verbalized her knowledge on how to prevent falls After 2 week: Verbalized techniques on how to minimize risk for falls. After 3 weeks: demonstrated techniques on how to prevent falls. Long term: After 2 weeks of nursing intervention, patient demonstrated lifestyle changes to reduce risks

Uncontrolled tremors at extremities Short term: After 1 week: Unsteady balance at verbalize her the feet knowledge on how to prevent Decrease grasp falls capability After 2 week: Risk for falls. Verbalize techniques on how to minimize risk for falls. After 3 weeks: demonstrate techniques on how to prevent falls. Long term: After 2 weeks of nursing intervention, patient demonstrates lifestyle changes to

To assess for

development and baseline data. For prevention and modification of environment.

to ensure safety enforcement of learning

reduce risks factors and protect self from injury.

factors and protect self from injury.