Plan of Care For: A
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angela_sexton_8Plan of Care For: A
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angela_sexton_8Plan of Care for: a
Risk for Aspiration
Risk Factors Decreased gastrointestinal motility; delayed gastric emptying; depressed cough; depressed gag reflex; facial surgery; facial trauma; gastrointestinal tubes; incompetent lower esophageal sphincter; increased gastric residual; increased intragastric pressure; impaired swallowing; medication administration; neck trauma; neck surgery; oral surgery; oral trauma; presence of endotracheal tube; presence of tracheostomy tube; reduced level of consciousness; situations hindering elevation of upper body; tube feedings; wired jaws
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Outcomes Aspiration Prevention, Respiratory Status: Ventilation, Swallowing Status Client Outcomes Client Will (Specify Time Frame):
Maintain patent airway and clear lung sounds
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Intervention Aspiration Precautions Nursing Interventions and Rationales
Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, hoarseness, or fever. Signs of aspiration should be detected as soon as possible to prevent further aspiration and to initiate treatment that can be lifesaving. Because of laryngeal pooling and residue in clients with dysphagia, silent aspiration (i.e., not manifested by choking or coughing) may occur (Ramsey, Smithard, & Kalra, 2005; Guy & Smith, 2009). Auscultate lung sounds frequently and before and after feedings; note any new onset of crackles or wheezing. EB: Bronchial auscultation of lung sounds was shown to be specific in identifying clients at risk for aspirating (Shaw et al, 2004).
Take vital signs frequently, noting onset of a temperature, increased respiratory rate. Have suction machine available when feeding high-risk clients. If aspiration does occur, suction immediately. A client with aspiration needs immediate suctioning and may need further lifesaving interventions such as intubation. Keep head of bed elevated at 30 to 45 degrees, preferably sitting up in a chair at 90 degrees when feeding. Keep head elevated for an hour afterward. Maintaining a sitting position with and after meals can help decrease aspiration pneumonia (Guy & Smith, 2009). EB: A study demonstrated that the number of clients developing a fever was significantly reduced when kept sitting upright after eating (Matsui et al, 2002). Listen to bowel sounds frequently, noting if they are decreased, absent, or hyperactive. Decreased or absent bowel sounds can indicate an ileus with possible vomiting and aspiration; increased high-pitched bowel sounds can indicate a mechanical bowel obstruction with possible vomiting and aspiration (Fauci et al, 2008). Note new onset of abdominal distention or increased rigidity of abdomen. Abdominal distention or rigidity can be associated with paralytic or mechanical obstruction and an increased likelihood of vomiting and aspiration (Fauci et al, 2008).
