Student Slides Nursing Diagnosis Risk for Aspiration rt

Student Slides

Nursing Diagnosis Risk for Aspiration r/t impaired swallowing Outcome: Patient will maintain patent airway and clear lung sounds. Nursing Interventions 1. Monitor for s/s of difficulty in swallowing 1. Cough during eating; change in voice tone or quality after swallowing; abnormal movements of the mouth, tongue, or lips; and slow, weak, imprecise, or uncoordinated speech. 2. Abnormal gag, delayed swallowing, incomplete oral clearance or pocketing, regurgitation, pharyngeal pooling, delayed or absent trigger or swallow, and inability to speak consistently Page 1010 8

Nursing Diagnosis Risk for Aspiration r/t impaired swallowing 1. 2. 3. 4. 5. Monitor Respiratory rate, depth, and effort Auscultate lung sounds q 4 hrs Monitor bowel sounds q 4 hrs Take VS q 4 hrs, esp. temp Feed slowly with small bites and allow time for chewing and swallowing 6. Place food on strong side of mouth 7. Have patient sit upright when eating and keep HOB 30 -45 degrees for an hour after eating 8. Encourage patient to use chin tuck when swallowing 9. Provide rest periods 10. Consult HCP for speech consult for swallow study 3

Nursing Diagnosis Imbalanced Nutrition: less than body requirements r/t poor appetite Outcome: Patient will eat 50% of breakfast, lunch and dinner. Nursing Interventions 1. Monitor food intake; recorded percentages of served food that is eaten 2. Monitor patient ability to eat (time involved, motor skills, visual acuity, and ability to swallow) 3. Offer small frequent meals 4. Assist with ordering meals, encouraging familiar foods 5. Avoid interruptions during mealtimes 4

Nursing Diagnosis Imbalanced Nutrition: less than body requirements r/t poor appetite 1. Provide a calm, peaceful, pain free, odor free environment 2. Provide social interaction by encouraging family to visit during meal times. 3. Encourage or provide oral care prior to meal time 4. Provide rest periods before meals 5. Consult with HCP for a Dietary consult 6. Teach the importance of having good nutrition during the time of an illness. 5

Nursing Diagnosis Risk for Aspiration r/t NGT feeding Outcome: Patient will maintain patent airway and clear lung sounds. Nursing Interventions 1. Determine if patient is at high risk for aspiration: coughing, hx of GERD, nasotracheal suction, an artificial airway, decreased LOC, and lying flat. 2. Keep HOB up to 30 -45 degrees at all times 3. Measure gastric residual volumes every 4 -6 hrs. 1. 250 ml or more on 2 consecutive assessments: delayed gastric emptying or if 500 ml on assessment 2. Discuss follow up with HCP 6

Nursing Diagnosis Risk for Aspiration r/t NGT feeding 1. Stop feedings if aspiration occurs 2. Administer metoclopramide (Reglan) if ordered 3. Monitor for nausea, vomiting, cramping and diarrhea and tube occlusion. 4. Increase rate per order 7