Assessment Explanation of Objective Intervention Rationale Evaluation

the problem /Expected outcome

S:Non Short term TX: TX: Goals met if

Patient with After 20 mint of  Signs of aspiration should be
O: multiple sclerosis nursing  Monitor respiratory identified as soon as possible to Short term After 20
difficulty in have a high risk intervention: rate, depth, and prevent further aspiration and to mint of nursing
chewing and of aspiration both effort. Note any initiate treatment that can be life- intervention:
swallowing chewing and  The patient is signs of aspiration saving.
swallowing free of signs of such as dyspnea,  The patient is
A: require a number aspiration and cough, cyanosis,  The primary risk factor of free of signs of
Risk of of muscles in the the risk of wheezing, or fever. aspiration is decreased level of aspiration and
aspiration mouth and throat aspiration is consciousness. the risk of
related to to work in a decreased.  Assess the level of aspiration is
impaired coordinated way. consciousness.  Nausea or vomiting places decreased.
swallowing In MS, the nerves patients at great risk for
that control these Long term  Assess for presence aspiration, especially if the level
muscles can After1days Of of nausea or of consciousness is Goals met if
become damaged nursing vomiting compromised. Antiemetics may
causing weakness intervention: be required to prevent aspiration Long term
and of regurgitated gastric contents. After1days Of
incoordination nursing intervention:
that can provoke  The patient DX: DX:
swallowing swallows and  Auscultate bowel  Reduced gastrointestinal motility  The patient
problems. digests oral, sounds to assess for increases the risk of aspiration as swallows and
nasogastric, or gastrointestinal fluids and food build up in the digests oral,
gastric feeding motility. stomach. Further, elderly patients nasogastric, or
without have a decrease in esophageal gastric feeding
aspiration. motility, which delays without
 Position patients esophageal emptying. When aspiration.
with a decreased combined with the weaker gag
level of reflex of older patients, aspiration
 consciousness on is at higher risk.
their side.
 secretions out of the mouth
instead of down the pharynx,
 Keep head of the where they could be aspirated.
bed elevated when
feeding and for at  Maintaining a sitting position
least a half-hour after meals may help decrease
afterward. aspiration pneumonia in the
elderly

EDX: EDX:

 Encourage patients  Oral care before meals reduces

to Provide oral care bacterial counts in the oral cavity.
before and after Oral care after eating removes
meals. residual food that could be
aspirated at a later time.
 Instruct the patient
to have liquids after  Ingesting food and fluids together
food is eaten. increases swallowing difficulties