Mr. Chong, 52 years old,
had a history of heart attack 3 months ago. He was now recovered from the
incident and has 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 eyes are only responding
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 amyotrophic 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-suppressants 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. Auscultate 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.
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
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