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Nursing Care Plan

(Risk for Aspiration)

Cues Nursing Scientific Objective/ Implementation Rationale Expected


Diagnosis Explanation Planning Outcome

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.

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