Clinical Concept Map

Key Key Key

Problem/Nursing Dx: Problem/Nursing Dx: Problem/Nursing Dx:
Potential for Aspiration Pain Risk for Falls

Priority: #1 Priority: #2 Priority: #3

Supporting Data: Supporting Data: Supporting Data:

Recent stroke with Pt reported pain 7/10 IV established
deficits, decreased ability
Grimaces Weakness
to speak
Anxious Confusion
Decreased gag reflex

Reason for needing Health Care (Medical Dx/Surgical Procedure):

CVA, complications during surgery

Plan of Care
Complete this section for the highest priority problem
List the goal for the problem that is the top priority. As you are making the goal,
think about what nursing care/interventions you will provide to fix the problem.
Assess and monitor vital signs, respiratory status, and labs q1 (WBC). Monitor for signs
of aspiration (tachypnea, cough, rales, wheezing, cyanosis, fever) q1.
Nursing Interventions (List 4 specific)
These interventions might be specific medications, treatments, and activities that
would fix the problem.

1. Assess and monitor pt’s ability to swallow

Monitor ability to swallow so as to increase oral intake as appropriate while

monitoring for aspiration
2. Raise HOB 90 to eat
decreases risk for aspiration
3. Supervise pt during oral intake
be available to suction/clear airway if necessary.
4. Record carb count as ordered
ensure pt is getting adequate nutrition
5. Encourage pt to take small bites
Smaller bites are easier to swallow and less likely to occlude the airway
6. Provide thick liquids to drink
thick liquids are less likely to be aspirated

Intervention Rationale
See above