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.

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

(Aspiration): Brunner & Suddarths Medical Surgical Nursing [Page-563] Self-care deficit (bathing, hygiene,) Because according to Orems theory related to inadequate self-care nursing; self-care, safe-care deficit hygienic materials/environment as and nursing system is a related manifested by presence of skin lesion. concepts. Self-care deficits result when there is inadequacy to meet the known self-care demand. And also, it may lead to skin disorder that may cause unwanted effect on the patient. (Orems general theory of nursing) Fundamentals of Nursing:Kozier [Page-44] As nurses, we should be concerned about the prevention of accidents and injury to the patient. according to maslows hierarchy of needs, second

3. March 05, 2012

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

Risk for falls related to uncontrolled tremors at the extremities secondary to use of anti-psychotic medication as manifested by slow movement.

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 PLANNING IMPLEMENTATION RATIONALE To aid swallowing efforts. To facilitate proper swallowing of food. To properly chew the food Encourage patient to build on success. 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

Independent: Short term goal: 1. Provide soft After 2 days: verbalize foods that stick her knowledge about together. prevention of 2. Vary placement aspiration. of food in patients mouth. After 3 days: 3. Provide a rest demonstrate period prior to participation in feeding time. preventing aspiration. 4. Feed slowly, using small After 4 days: practice bites, instructing implemented methods the patient to to prevent aspiration chew slowly and on her own. thoroughly. 5. Allow sufficient Long term goal: time for client to After 3 week of finish eating. nursing intervention patient will be able to Dependent: perform on her own Review the appropriated medication feeding method to regime. prevent aspiration.

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

Prioritization # 2 ASSESSMENT Objective: Poor dental health care Dry mouth Halitosis Presence of skin lesions Presence of lice Oily hair Not neat in appearance Cognitive impairment NURSING DIAGNOSIS Self-care deficit (bathing, hygiene,) related to inadequate self-care hygienic materials/environment as manifested by presence of skin lesion BACKGROUND KNOWLEDGE Environment Low prioritized institution Low financial support Insufficient availability of hygienic materials Self-care deficit PLANNING IMPLEMENTATION RATIONALE To note development al level to which client has progressed EVALUATION Outcome: Goal met Short term goal: After 2 days: verbalize her knowledge about of health care practices.

Independent: 1. Asses memory/intellectu al functioning 2. Determine individual strength and skills of the patient 3. Assist clients After 3 days: needs for personal demonstrate care assistance participation in 4. Explain to patient using alternative the importance of Short term goal: After 2 days: verbalize her knowledge about of health care practices.

Promote safe care independence After 3 days: demonstrate participation in

(bathing/hygiene)

method and 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.

health care 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.

using alternative method and hygiene kit. After 4 days: practice alternative method for hygiene care on her own Encourage patient to build on success. Long term goal: 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 Uncontrolled tremors at extremities Unsteady balance at the feet Decrease grasp capability Risk for falls. 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,

Short term: After 1 week: verbalize her knowledge on how to prevent falls After 2 week: 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

To assess for development and baseline data. For prevention and modification of environment.

to ensure safety enforcement of learning

lifestyle changes to reduce risks factors and protect self from injury.

patient demonstrated lifestyle changes to reduce risks factors and protect self from injury.