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Subjective
Pt stated that she was nauseous.
Objective
Pt vomited after eating breakfast
tray.
Pt coughed, wet cough, after each
attempt to swallow.
Pt took a long time to chew and swallow
food and continued to pocket food in cheeks even after attempting to swallow.
Pt needed assistance to chew food
and took about 5 minutes to chew and swallow each small bite of food provided for
her.
Regurgitation of gastric contents
with belching after dinner tray.
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Problem
Impaired swallowing
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Long Term:
Patient will remain free from aspiration
until the time of discharge.
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Assess
the patient’s ability to swallow using a bedside swallow screening because a screening
can show if the patient is at risk for aspiration and if the patient should be on
precautions such as thickened liquids.
It can also decrease the patient’s length of stay, shorten recovery time, and reduce
overall health costs. (Ackley
& Ladwig, 2008, p 812).
Watch for signs and symptoms of aspiration
and pneumonia. Auscultate lung sounds
after feeding and note any new lungs sounds such as crackles or wheezes because
new lung sounds in an increase in respiratory rate can indicated aspiration of food
or the onset of pneumonia (Ackley & Ladwig, 2008, p 813).
Keep the patient in an upright position
for more than 45 minutes after a meal to prevent aspiration in older adults (Ackley
& Ladwig, 2008, p 813).
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Goal still
in progress. Patient has not had any incidence of aspiration at the current time. No discharge orders are written and
goal still in progress of being evaluated.
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Continue
to assess bedside swallowing techniques and monitor for possible aspiration. Will be re-evaluated tomorrow at noon.
Lung sounds
will be continued to be assessed every shift as well as after each feeding to note
any new lung sounds. Will continue
until time of discharge.
Continue
to keep patient in an upright position after meals to prevent aspiration until the
time of discharge. Re-evaluate each
shift.
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R/T
neuromuscular disturbances
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Short Term:
Patient will demonstrate effective
swallowing techniques by the end of the shift and evaluated by a nurse or therapist.
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Watch for uncoordinated chewing or
swallowing, or coughing immediately after swallowing because it can indicate possible
silent aspiration and they are signs of possible aspiration and impaired swallowing
(Ackley & Ladwig, 2008, p 812).
Work with the patient on swallowing
exercises as described by the dysphagia team because swallowing exercises are both
motor and sensory and can improve the patient’s ability to swallow (Ackley &
Ladwig, 2008, p 813).
Have suction material ready at bedside
and during feeding in case chocking occurs and suctioning is necessary to clear
airway. If this is the case, need to
discontinue oral feedings until the client is assessed with a swallow study (Ackley
& Ladwig, 2008, p 813).
Praise the patient for successfully
following directions and swallowing appropriately because positive reinforcement
helps the patient want to learn (Ackley & Ladwig, 2008, p 813).
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Goal not met- will continue to work
with the speech therapist and dysphagia team to help patient learn ways to improve
swallowing. Will re-evaluate goal next shift. Need to have the results of swallow
test and need to have dysphagia team consult with patient.
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Will continue to watch for uncoordinated
swallowing to ensure that patient is not going to aspirate.
Continue to assess with each feeding and each shift.
Will continue to work with dysphagia
team to improve swallowing skills.
Will re-evaluate with dysphagia team next shift.
Will have suction material at bedside
until the time of discharge to have in case aspiration does occur.
Continue to use positive reinforcement
to help patient want to learn to swallow efficiently and without aspiration.
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