Risk for aspiration can occur when there is loss of protective airway reflexes such as seen in pt. Who are unconscious from drug, alcohol, stroke or cardiac arrest. After 3-6 hrs. Of N.I the SO will be able to identify causative factors. Evaluate presence of neuromuscular weakness and degree of impairment. Maintain safety measure. Note administration of enteral feeding, being aware of potential for regurgitation and misplacement of.
Risk for aspiration can occur when there is loss of protective airway reflexes such as seen in pt. Who are unconscious from drug, alcohol, stroke or cardiac arrest. After 3-6 hrs. Of N.I the SO will be able to identify causative factors. Evaluate presence of neuromuscular weakness and degree of impairment. Maintain safety measure. Note administration of enteral feeding, being aware of potential for regurgitation and misplacement of.
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Risk for aspiration can occur when there is loss of protective airway reflexes such as seen in pt. Who are unconscious from drug, alcohol, stroke or cardiac arrest. After 3-6 hrs. Of N.I the SO will be able to identify causative factors. Evaluate presence of neuromuscular weakness and degree of impairment. Maintain safety measure. Note administration of enteral feeding, being aware of potential for regurgitation and misplacement of.
Copyright:
Attribution Non-Commercial (BY-NC)
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Download as DOCX, PDF, TXT or read online from Scribd
Subjective: Risk aspiration Risk for aspiration Plan:
related to can occur when decreased level of there is loss of After the provision Establish rapport. To build trusting consciousness. protective airway of nursing care, the relationship. Objective: pt. risk for reflexes such as seen in pt. who are aspiration will be Received pt. on unconscious from reduce as lying position on To have baseline drug, alcohol, stroke manifested by: Monitor and Short Term: bed, unconscious , data. with ongoing or cardiac arrest or record V/S. Short Term: After 2 hrs. of PNSS 1L in instances when a N.I the patient/ regulated @ 10-15 non-functioning After 3-6 hrs. of N.I relative shall gtts./min. (KVO) nasogastric tube the SO will be able be able to 200 ml. level allows gastric to identify causative avoid factors infusing well @ left content to drain factors. that may cause hand. around the tube and Evaluate presence Note level of aspiration. cause silent ➢ (+) difficulty aspiration. of neuromuscular consciousness To assess in speaking weakness and and awareness of contributing factor. ➢ (+) degree of surrounding. weakness impairment. ➢ (+) Note headache administration of To avoid lung Maintain safety ➢ (+) enteral feeding, aspiration. measure. dizziness being aware of ➢ (+) blurred vision potential for ➢ (+)Paralysi regurgitation and s on right misplacement of part of the tube. Provide body information about ➢ With NGT the effect of inserted aspiration in the ➢ With Foley catheter lung. inserted To provide Instruct in safety knowledge about Vital Sign: concerns when tube feeding. BP: 140/100 feeding oral or NGT. To prevent regurgitation of Elevate client food or fluid. highest or best possible position for eating and drinking and during the It may slow feeding. digestion and Instruct the family increase risk for to avoid/ limit regurgitation. Long Term: activities that Long Term: increase intra- After 2 day of N.I abdominal After 2 days of the SO will pressure. N.I the pt. shall demonstrate be able to techniques to experience no prevent and aspiration as correct aspiration. To prevent evidence by overfeeding. noiseless Maintain correct respiration, tube/ oral feeding. Ascertain that clear breath feeding is in sounds, clear correct position. odorless Measure secretions. residuals when appropriate. To identify regurgitation. Add food coloring. To avoid aspiration. Feed slowly instruct the pt. to chew slowly and thoroughly. To decrease risk for aspiration and Give semi-solid aid swallowing foods, avoid effort. pureed foods and mucus- production foods (milk). Use soft foods that sticks NGT may enter together/ form the lung and may bolus. lead to serious lung damage.
Monitor if the NGT is correctly intact. And maintain suction equipment by bedside.