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Medical Diagnoses: Risk for Aspiration


Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale







Pt daughter states that her mother has been struggling with swallowing and seems to choke a lot since her stroke.





Diagnosis of stroke and right sided paralysis


Pt exhibits difficulty swallowing without choking.


Orders to have a speech therapy consult





Risk for aspiration







Long Term:


Pt will maintain a patent airway and clear lung sounds by discharge.


*Monitor respiratory rate, depth, and effort.


Rationale: “Signs of aspiration should be detected as soon as possible to prevent further aspiration and to initiate treatment that can be lifesaving” (Ackley & Ladwig, 2008, p. 149).


*Auscultate lung sounds frequently.


Rationale: “Bronchial auscultation of lung sounds was shown to be specific in identifying clients at risk for aspiration” (Ackley & Ladwig, 2008, p. 149).
















Impaired swallowing  secondary to stroke






Short Term:


Pt will swallow and digest NG tube medications and ice chips PO without aspiration throughout this shift, by 1900.


*Measure and record the length of the tube that is outside of the body at defined interval to help ensure correct placement.


Rationale: “As part of maintaining correct placement, it is helpful to note the length of the tube outside of the body; it is possible for a tube to slide out and be in the esophagus, without obvious disruption of the tape” (Ackley & Ladwig, 2008, p. 149).




















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*I = Implementation.  Check those interventions/actions/orders that were implemented.






Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.

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