People with difficulty
of swallowing often are at risk for aspiration. Risk for aspiration is a
clinically useful diagnosis for people at high risk for aspiration because of
reduced level of consciousness, structural deficits, mechanical devices, and
neurologic and gastrointestinal disorders. The diagnosis risk for aspiration
should be used to describe people who require nursing interventions to prevent
aspiration. This is a nursing care plan sample about risk for aspiration of Mr.
Daliso, 45 years old, former actor on former TV Channel, post-operated, awake
but still under influence of anesthesia.
Assessment:
Objective:
- Agitated
- Inconsolable
- Restless
- Unaware of the
surroundings
- Lack of eye contact
- Lack of communication
- Slurred speech
- Low level of consciousness
Diagnosis:
Risks for aspiration
related to his reduce level of consciousness secondary to anesthesia.
Planning:
After 4 hours of nursing
intervention, the patient will not experience aspiration and as the effect of
anesthesia wear off; the patient will relate measures to prevent aspiration and
will name foods of fluids that are high risk for causing aspiration.
Interventions:
- Assess causative
factors to risk of aspiration.
- Reduce the risk of aspiration in patient with decreased sensorium by
maintaining a side-lying position if not contraindicated by injury. If the
patient cannot be position of the side, open the oropharyngeal airway by
lifting the mandible up and forward and tilting the head backward. Assess for
position of the tongue by ensuring it has not dropped backward, occluding the
airway. Keep the head of the bed elevated, if not contraindicated by
hypotension or injury. Maintain side-lying position after feedings.
- Maintain good oral hygiene by cleaning the teeth and mouthwash on cotton
swab; apply petroleum jelly to lips; removing encrustations gently. Clear the secretions
from the mouth and throat with a tissue or gentle suction. Reassess frequently
for obstructive material in mouth and throat. Reevaluate frequently for good
anatomic positioning.
- If the patient is
under tracheostomy or endotracheal tubes, inflate cuff only during continuous
mechanical ventilation, during and after eating, during an hour after tube
feedings and during intermittent positive-pressure breathing
treatments. Suction every 1 to 2 hours and if needed and provide oral
care. Confirm that tube placement has been verified by radiography or
aspiration of greenish fluid but ensure that you check the
hospital/organizational policy for preferred method. Confirm that tube
position has not changed since it was inserted and verified. Then elevate the
head of the bed for 30 to 45 minutes during feeding periods and 1 hour after to
prevent reflux by use of reverse gravity. Aspirate for residual contents before
each feeding for tubes positioned gastrically. Then administer intermittently
feeding if residual contents are less than 150 mL, or administer feeding if
residual is no greater than 150 mL at 10% to 20% of hourly rate and must be
continuous. Regulate gastric feedings using an intermittent schedule,
allowing periods for stomach emptying between feeding intervals.
- Initiate health
teaching and referrals, as indicated. Instruct the client and family on
causes and prevention of aspiration. Maintain oral hygiene to prevent pneumonia
related to oral bacteria aspiration. Have the family demonstrate tube-feeding
technique. Refer the family to a community nursing agency for assistance at
home. Teach the client about the danger of eating when under the influence of
alcohol. Teach the Heimlich or abdominal thrust maneuver to remove aspirated
foreign bodies.
Evaluation:
After 4 hours of nursing
intervention, the patient did not experience aspiration and as the effect of
anesthesia wear off, the patient related measures to prevent aspiration and
named foods of fluids that are high risk for causing aspiration.
For more samples of nursing care plan you are free to check it
out in our NCP LIST page.
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