Scribd
Upload
26 views

Assessment Nursing Diagnosis Inference Planning Interventions Rationale Evaluation

The patient has a Glasgow coma score of 7 and is in a coma. They have an NGT in place for feeding. The significant others have expressed not properly elevating the head of the bed or following correct NGT feeding procedures. The nursing diagnosis is risk for aspiration related to improper feeding techniques. The plan is to educate the significant others on proper NGT feeding, maintaining head elevation above 30 degrees, monitoring for signs of aspiration, and seeking immediate medical help if aspiration is suspected. This is to prevent aspiration pneumonia within the next 8 hours.

Uploaded by

Nicole Marin-Ching
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
26 views

Assessment Nursing Diagnosis Inference Planning Interventions Rationale Evaluation

The patient has a Glasgow coma score of 7 and is in a coma. They have an NGT in place for feeding. The significant others have expressed not properly elevating the head of the bed or following correct NGT feeding procedures. The nursing diagnosis is risk for aspiration related to improper feeding techniques. The plan is to educate the significant others on proper NGT feeding, maintaining head elevation above 30 degrees, monitoring for signs of aspiration, and seeking immediate medical help if aspiration is suspected. This is to prevent aspiration pneumonia within the next 8 hours.

Uploaded by

Nicole Marin-Ching
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

Assessment Nursing

Diagnosis
Inference Planning Interventions Rationale Evaluation

Subjective:
Hindi naman
naming tinataas
yung kama.
Basta kung ano
lang yung
maabutan
tapospinapakain
na namin ganun
as verbalized by
the significant
other.




Objective:
Glasgow
coma
score of 7
LOC
coma
Presence
of NGT

Risk for aspiration
related to lack of
knowledge of the
significant others
in giving feedings

Decreased level of
consciousness of
patient

Presence of NGT
for feeding

Lack of previous
exposure of
significant others to
NGT

Improper way of
feeding the patient

Risk for aspiration

Within 8 hours of
nursing
interventions, the
patient will
experience no
aspiration as
evidenced by
noiseless
respirations, clear
breath sounds;
and clear,
odorless
secretions and
proper feeding
procedure of the
significant others.
Maintain head
of bed elevated
higher than 30
degrees.







Notify the
physician or
other health
care provider
immediately of
noted decrease
in cough and/or
gag reflexes, or
difficulty in
swallowing.
Confirm
placement at
least once
every shift of
NGT
Monitor
residual of
feeding tube at
least once
every shift
when the
patient is
receiving
continuous
Positioning the
patient with the
head of the bed
elevated has
been shown to be
an effective part
of the ventilator
bundle at
reducing
aspiration and
pneumonia.
Early intervention
protects the
patient's airways
and prevents
aspiration.





To assure correct
placement of
feeding tubes.

Monitors patient
tolerance of tube
feeding regimen.




Unelevated
bed
Misconcep-
tions








feeds and prior
to bolus feeds.
Teach
significant
others how to
properly feed
the patient


Provide mouth
care at least
every four
hours.

Educate
significant
others of
signs that
patient has
aspirated.

Educate
significant
others of
patient
symptoms of
complication
of aspiration
that indicate
the need to
seek
immediate
medical
attention.

Avoid
misconceptions





Secretions are a
source of
microaspiration.


To allow early
detection and
facilitate
appropriate
caregiver
response


To allow early
detection and
facilitate
appropriate
significant-others
response.

You might also like