Nursing Care Plan For Risk For Aspiration

SHARE:



RISK FOR ASPIRATION
Definition:
                At risk for entry of gastrointestinal secretions, oropharyngeal secretions, or [exogenous food] solids or fluids into tracheobronchial passages [due to dysfunction or absence of normal protective mechanisms]
Risk factors:
  •  Decreased GI motility
  •  Delayed gastric emptying
  •  Depressed cough and gag reflexes
  •  Feeding or GI tubes
  •  Impaired swallowing
  •  Incompetent lower esophageal sphincter
  •  Increased gastric residual or intragastric pressure
  •  Medication administration
  •  Reduced level of consciousness (LOC)
  •  Situations hindering elevation of upper body
  •  Surgery or trauma to face, mouth, or neck
  •  Tracheotomy or endotracheal tube
  •  Wired jaws
Expected outcomes:
The patients will
  •  Have clear breath sounds on auscultation.
  •  Have normal bowel sounds.
  • Maintain patent airway.
  •  Breathe easily, cough effectively, and show no signs of respiratory distress or infection.
  • Demonstrate measures to prevent aspiration.
  • Maintain respiratory rate within normal limits for age.
  • Describe plan for home care.
Interventions and Rationales:
       Determine:
                  Assess for gag and swallowing reflexes. Impaired reflexes may cause aspiration.
                  Assess respiratory status at least every 4 hr or according to established standards; begin cardiopulmonary monitoring to detect signs of possible aspiration (increased respiratory rate, cough, sputum production, and diminished breath sounds).
                  Auscultate bowel sounds every 4 hr and report changes. Delayed gastric emptying may cause regurgitation of stomach contents.
                  Elevate the head of the bed or place the patient in Fowler’s position to aid breathing.
                  Recognize the progression of airway compromise and report your findings to detect complications early.
         Perform:
                   Help patient turn, cough, and deep breathe every 2–4 hr. Perform postural drainage, percussion, and vibration every 4 hr, or as ordered. Suction, as needed, to stimulate cough and clear upper and lower airways. These measures promote drainage of secretions and full expansion of lungs.
                   Perform chest physiotherapy before feeding to decrease the risk of emesis leading to aspiration.
                   Elevate patient during feeding, and use an upright position after feeding. Such positioning uses gravity to prevent regurgitation of stomach contents and promotes lung expansion.
                   Place patient in the lateral or prone position and change position at least every 2 hr to reduce the potential for aspiration by allowing secretions to drain.
            Inform:
                      Instruct patient and family members in home care plan. They must demonstrate the ability to carry out measures to prevent or respond to aspiration events to ensure adequate home care before discharge.
            Attend:
                      Encourage fluids within prescribed restrictions. Provide humidification, as ordered (such as a nebulizer). Fluids and humidification liquefy secretions.
Reference:
 Thoyre, S. M., et al. (2005, May–June). The early feeding skills assessment for preterm infants. Neonatal Network, 24(3), 7–16.

COMMENTS

Name

anaphysio,3,ASEPSIS AND INFECTION CONTROL,9,audio,1,biochemistry,2,blog,1,BSN Notes: Assessment in Psychiatry,6,BSN Notes: Burns,11,BSN Notes: Care of Terminally Ill Patients,6,BSN Notes: Childhood and Developmental Disorders,6,BSN Notes: Common Behavioural and Social Problems,4,BSN Notes: Common Childhood Diseases,7,BSN Notes: Common Signs And Symptoms,32,BSN Notes: Community Mental Health Nursing,12,BSN Notes: Critical Care,12,BSN Notes: Disaster and Emergency,15,BSN Notes: ENT,8,BSN Notes: Eye,25,BSN Notes: History and Assessment,24,BSN Notes: Introduction of Psychiatry,27,BSN Notes: Legal Issues In Psychiatry,4,BSN Notes: Medication Administration,24,BSN Notes: Neuritic_Stress related and Somatization Disorders,10,BSN Notes: Neurology,6,BSN Notes: Oncological Nursing,8,BSN Notes: Organic Brain Disorders,1,BSN Notes: Oxygenation,3,BSN Notes: Personality_Sexual and Eating Disorders,5,BSN Notes: Principles and Concepts of Psychiatry Nursing,2,BSN Notes: Psych-pharmacology and Other Treatment Modalities,30,BSN Notes: Psychiatry Emergencies and Crisis Intervention,4,BSN Notes: Psychosocial Needs,5,BSN Notes: Schizophrenia and othe Psychotic Disorders,4,BSN Notes: The healthy child,5,BSN Notes: TNPR,9,BSN Notes: Urinary Elimination,14,chn,41,clinicalkannada,4,clinicals1,35,clinicals2,10,clinicals3,26,clinicals4,11,Code of Ethics,3,community,7,Critical thinking,7,drugs,3,Equipment & Linen,9,Equipments & Linen,1,Etics and Legal,1,exa,1,exam,11,featured,19,fon,141,fon3,141,fun,1,geriatric,1,graphic,1,Growth and Development,5,he,93,hotspot,6,kannada,54,language,1,Machinery,10,Medications,1,Memory Tools,9,mhn,126,microbiology,3,misc,2,mnemonics,48,msn,137,NCLEX,13,ncp,27,news,4,obg,28,OBG Medications,1,Peri- operative Nursing,2,pharma,29,Physical Examination and Assessment,9,Psychology,2,Pulse,7,resources,1,Respiration,4,Transitional care,1,Ventilators,5,voice,2,
ltr
item
notes.nursium.com: Nursing Care Plan For Risk For Aspiration
Nursing Care Plan For Risk For Aspiration
notes.nursium.com
https://notes.nursium.com/2017/02/nursing-care-plan-for-risk-for.html
https://notes.nursium.com/
https://notes.nursium.com/
https://notes.nursium.com/2017/02/nursing-care-plan-for-risk-for.html
true
3454605208880343795
UTF-8
Loaded All Posts Not found any posts VIEW ALL Readmore Reply Cancel reply Delete By Home PAGES POSTS View All RECOMMENDED FOR YOU LABEL ARCHIVE SEARCH ALL POSTS Not found any post match with your request Back Home Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sun Mon Tue Wed Thu Fri Sat January February March April May June July August September October November December Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec just now 1 minute ago $$1$$ minutes ago 1 hour ago $$1$$ hours ago Yesterday $$1$$ days ago $$1$$ weeks ago more than 5 weeks ago Followers Follow THIS CONTENT IS PREMIUM Please share to unlock Copy All Code Select All Code All codes were copied to your clipboard Can not copy the codes / texts, please press [CTRL]+[C] (or CMD+C with Mac) to copy