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INEFFECTIVE BREATHING PATTERN Nursing Care Plan

Stuart, 23 years old, diagnosed with pneumonia 3 months ago. Because of having not enough money for hospitalization. His state got worse day...

RISK FOR ASPIRATION Nursing Care Plan

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.

 

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