Natividad, Michael John F.

Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis
S= Not Applicable Risk for SHORT TERM:  Monitor level of A decreased level of SHORT TERM:
aspiration r/t After 1 hour of consciousness. consciousness is a prime After 1 hour of
O=The patient decreased level Nursing risk factor for aspiration. Nursing
manifested the ff: of Interventions, the Interventions, the
 Diagnosis of consciousness patient’s significant  Assess cough A depressed cough or gag patient’s significant
stroke and other will verbalize and gag reflexes. reflex increases the risk of other verbalized
right sided understanding of aspiration understanding of
paralysis importance of importance of
 Lethargy elevating head of  Auscultate bowel Decreased gastrointestinal elevating head of
 decreased bed to prevent sounds to motility increases the risk bed to prevent
level of aspiration. evaluate bowel of aspiration because food aspiration.
consciousness motility. or fluids accumulate in the
(GCS 3 LONG TERM: stomach. LONG TERM:
E1V1M1) After 7 days of After 7 days of
 depressed Nursing  Assess Aspiration of small Nursing
cough reflex Interventions, the pulmonary status amounts can occur without Interventions, the
 difficulty patient will remain for clinical coughing or sudden onset patient remained
swallowing free from aspiration evidence of of respiratory distress, free from aspiration
without as evidenced by aspiration. especially in patients with as evidenced by
choking absence of dyspnea, Auscultate breath decreased levels of absence of dyspnea,
normal vital signs, sounds for consciousness. normal vital signs,
and absence of development of and absence of
crackles. crackles and/or crackles.
rhonchi.
This is necessary to
 Keep suction maintain a patent airway.
setup available
and use as
needed. Early intervention protects
the patient’s airway and
 Notify the prevents aspiration.
 physician or
other health care
provider
immediately of
noted decrease in
cough and/or gag
reflexes or
difficulty in This protects the airway.
swallowing. Proper positioning can
 Position patients decrease the risk of
who have a aspiration. Comatose
decreased level patients need frequent
of consciousness turning to facilitate
on their sides. drainage of secretions.

A displaced tube may

erroneously deliver tube
 Check placement feeding into the airway.
of NGT before
feeding. High amounts of residual
 Check residuals (>50% of previous hour’s
before feeding. intake) indicate delayed
Hold feedings if gastric emptying and can
residuals are high cause distention of the
and notify the stomach leading to reflux
physician. emesis.

Promotes cooperation

 Explain
importance of
elevating HOB to The upright position
SO. facilitates the gravitational
 Maintain upright flow of food or fluid
position for 30 to through the alimentary
45 minutes after tract.
feeding.
Mobilizes thickened
 Assist with secretions.
postural
drainage.