RISK FOR ASPIRATION Nursing Care Plan

Mr. Chong, 52 years old, had a history of heart attack 3 months ago. He was now recovered from the incident and have been doing precautionary measures to prevent occurrence. Unfortunately, the morning after the Christmas Eve, Mr. Chong experienced chest pain and went unconscious. His relatives immediately called for help and saved Mr. Chong's life. The nurse found out that Mr. Chong forgot to take his maintenance medicine on the night of Christmas Eve and Mr. Chong drunk and eat a lot. The nurse noted that Mr. Chong is using oral dentures. Below is a sample of nursing care plan about risk for aspiration of Mr. Chong.

ASSESSMENT

Subjective:
(for the risk for aspiration, we don't have any subjective data as we assume that the patient is unconscious.)
Objective:
The patient is sleepy, unconscious and coherent. His/her eyes are only respond to painful stimuli. The client utters inappropriate words and no body movements. I used Gaslow's Coma scale and the result of my observation is 5, eye response 2, verbal response 3, and motor response 0.

DIAGNOSIS

Risk for aspiration related to unconsciousness as manifested by GCS of 5.

PLANNING

After an hour of nursing intervention, risk for aspiration will be managed.

INTERVENTION

- Identify Mr. Chong, the patient's risk according to condition or disease process to determine when observation and interventions may be required. Note his level of consciousness, awareness of surroundings, and cognitive function, as impairments in these areas increase his risk of aspiration. Determine presence of his neuromuscular disorders, noting muscle groups involved, degree of impairment, and whether they are of an acute or progressive nature such as stroke, Parkinson's disease, Guillain-Barre syndrome, or amyotropic lateral sclerosis.

- Assess the Mr. Chong's ability to swallow and strength of gag reflex and evaluate amount/consistency of secretions to determine presence/effectiveness of his protective mechanisms. Observe for his neck and facial edema particularly risk for airway obstruction and inability to handle secretions. Remove his oral dentures to prevent foreign aspiration. Suction as needed but avoid triggering of gag mechanic.

- Note administration of enteral feedings because of potential for regurgitation and misplacement of the tube. Ascertain lifestyle habits for example, use of alcohol, tobacco, and other CNS-suppresants which can affect awareness and muscles of gag and swallow. Assist with diagnostic studies such as fiber optic endoscopy which may be done to assess for presence or degree of secretions. Assist in postural drainage to mobilize thickened secretions that may interfere with swallowing

- Monitor use of oxygen masks in patient at risk for vomiting. Refrain from using oxygen masks for him. Keep wire cutters with Mr. Chong at all times when jaws are wired or banded to facilitate clearing airway in emergency situations. Maintain operational suction equipment at his bedside or his  chair side. Avoid keeping Mr. Chong supine when he is on mechanical ventilation especially when also receiving enteral feedings. Supine positioning and enteral feedings have been shown to be independent risk factors for the development of aspiration pneumonia. Ascultate lung sounds frequently, especially when Mr. Chong is coughing frequently or not coughing at all, or when he is on ventilator being tube-fed, to determine presence of secretions. Elevate the patient to highest or best possible position or sitting upright position in chair for eating and drinking and during the feedings. Provide a rest period prior to feeding time. The rested patient may have less difficulty with swallowing.

EVALUATION

After an hour of nursing intervention, the risk for aspiration had managed.

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