Nursing Care Plan for Risk for Aspiration

Nursing Care Plan

Medical Diagnoses: Risk for Aspiration

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

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

Objective

Diagnosis of stroke and right sided paralysis

Pt exhibits difficulty swallowing without choking.

Orders to have a speech therapy consult

Problem

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).

ü

R/T

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).

ü

AEB

N/A

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

References

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

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Assessment	Nursing DX/Clinical Problem	Client Goals/Desired Outcomes/Objectives	Nursing Interventions/Actions/Orders and Rationale	*I	Evaluation
					Goals	Interventions
Subjective Pt daughter states that her mother has been struggling with swallowing and seems to choke a lot since her stroke. Objective Diagnosis of stroke and right sided paralysis Pt exhibits difficulty swallowing without choking. Orders to have a speech therapy consult	Problem 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).	ü
	R/T 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).	ü
	AEB N/A