RISK FOR ASPIRATION Nursing Care Plan

Aspiration is the medical term for inhaling small particles of food or drops of liquid into the lungs which is commonly caused by depressed level of conciousness. Here is an example of nursing care plan for patients with risk for aspiration.

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 unconciousness as manifested by GCS of 5.

PLANNING
 - After an hour of nursing intervention, risk for aspiration will be gone.

INTERVENTION

Identify at risk client according to condition or disease process to determine when observation and interventions may be required. Note client's level of consciousness, awareness of surroundings, and cognitive function, as impairments in these areas increase client's risk of aspiration. Determine presence of 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 client's ability to swallow and strength of gag reflex and evaluate amount/consistency of secretions to determine presence/effectiveness of protective mechanisms. Observe for neck and facial edema particularly risk for airway obstruction and inability to handle secretions. Remove 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 clients at risk for vomiting. Refrain from using oxygen masks for comatose individuals. Keep wire cutters with client at all times when jaws are wired or banded to facilitate clearing airway in emergency situations. Maintain operational suction equipment at bedside or chair side. Avoid keeping client supine when 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 in client who is coughing frequently or not coughing at all, or in client on ventilator being tube-fed, to determine presence of secretions. Elevate client 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 client may have less difficulty with swallowing. 

EVALUATION

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

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