Nursing DX Client Outcomes Interventions
Risk for Aspiration for Client will swallow and 1. Monitor respiratory rate
entry of gastrointestinal digest oral, nasogastric or (normal respiratory rate for
secretions, gastric feedings without pediatrics are 20 to 30/min.),
oropharyngeal aspiration during meal depth, and effort. Note any
secretions, solids, or times 3-5 times daily. signs of aspiration such as
fluids into the dyspnea, cough, cyanosis,
tracheobronchial wheezing, or fever (normal
passages r/t impaired temperature for pediatrics is
swallowing and 36 to 38 degrees Celsius or
reduced LOC. 96.8 to 100.4 degrees
Fahrenheit).
Objectively: Client has
difficulty swallowing 2. When feeding client,
and chewing solids and watch for signs of impaired
drinking fluids. All swallowing or aspiration
food and fluids are including coughing, choking,
thickened before spitting foods, or excessive
serving to client. drooling.
3. Have a suction machine
available when feeding high
risk clients.
4. Keep head of bed
elevated or client ambulated
in wheelchair when feeding
and for at least an hour
afterward.
Rationales Evaluations
1. Signs of aspiration Client will keep receiving thickened
should be detected as soon food and fluids during meals. All
as possible to prevent precautions will be repeated during the
further aspiration and to process of meal times and at least an
initiate treatment that can hour afterward. Client has responded
be lifesaving. Because of well to interventions and has shown no
laryngeal pooling and new signs of aspiration with
residue in clients with implementing new precautions.
dysphagia, silent aspiration
can occur.
2. Clients who aspirate
will show early signs of
difficulty in swallowing.
3. A client with aspiration
needs immediate
suctioning and may need
further lifesaving
interventions such as
intubation.
4. Maintaining a sitting
position after meals can
help decrease aspiration
pneumonia.
 Nursing DX Patient Outcomes Interventions
Risk for impaired skin Staff members of the 1. Monitor skin condition at
integrity r/t client being health care system will least once a day for color or
immobile due to brain check once a day and texture changes,
traumatic injury at 17 report any altered tissue, dermatological conditions, or
months of age. lesions, or skin integrity. lesions. Determine whether
the client is experiencing loss
of sensation or pain.
Objectively: Client is 2. Implement an
unable to move body incontinence management
and is 100% dependent plan to prevent exposure to
on staff to be mobilized chemicals in urine and stool
in all daily tasks. that can strip or erode the
skin. (Health care team will
check client’s diapers every
2 hours for urine or stools.)
3. Turn and position client
every 2 hours. Transfer the
client with care to protect
against the adverse effects of
external mechanical forces.
(pressure, friction, or shear)
Rationales Evaluations
1. Systematic inspection Client skin has been moist with no
can identify impending breakdown of skin or lesions
problems early in an breakdown present. Health care team
immobile client. will keep repeating interventions of
mobilization and monitoring of skin
2. Implementing an and incontinence plans.
incontinence prevention
plan with the use of a skin
protectant or a cleanser
protectant can significantly
decrease skin breakdown
3. Turning the client,
mobilizing, and taking
precautions will keep skin
integrity intact and have
less breakdown.
 Nursing DX Patient Outcomes Interventions Rationales Evaluations
Risk for Falls r/t client Client will remain free 1. . Make sure side rails of 1. Client will need side Client has remained free from falls
being immobile due to from falls daily and in an bed are kept up and locked to rails of bed up and locked with implementing preventions of falll
brain traumatic injury environment to minimize keep from client falling from into place to keep from risks. Health care team will keep
at the age of 17 the incidence of falls. the bed. falling out of bed implementing procedures and will
months. identify in the future any new
2. Be careful when 2. A very important procedures that should be performed
Objectively: Client is ambulating a client who is preventive measure to will taking care of the client.
unable to move body immobile. Be sure to lock reduce the risk of injurious
and is 100% dependent the wheels on the bed and the falls for nonambulatory
on staff to be mobilized wheelchair, have sufficient clients involves increasing
in all daily tasks. She personnel to protect the safety measures while
does not have any client from falls. transferring, including
control over extremities careful locking of
or ability to keep from equipment such as
falling if left 3. When ambulating client wheelchairs and beds
unattended in a risk into the wheelchair make before moves.
area. sure client is properly .
strapped into the char with 3. Immobile client with
all belts clasped together. To traumatic brain injury
help protect client against should be properly
falling from wheelchair. strapped into a wheelchair
to sustain free from falling
and injuries.