Name of Patient: G.L.

O
Age: 82 years old

Clustered Cues
07/08/14
9:00 AM

Ward/Bed Number: MMSW no. 2

Nursing Diagnosis
Risk for Aspiration
related to oral
trauma.; advanced age
because of possible
cough and glottis
reflexes and
nutritional depletion.

Rationale
At risk for entry of
gastrointestinal
secretions,
oropharyngeal
secretions, or solids or
fluids into
tracheobronchial
passages
Pathophysiology:
A full stomach
contains solid
particles of food. If
these are aspirated,
the problem then
becomes one of
mechanical blockage
of the airways and
secondary infection.
During periods of
fasting,
the stomach contains
acidic gastric juice,
which, if aspirated,
may
be very destructive
to the alveoli and

Outcome Criteria
The patient will
demonstrate
techniques to prevent
aspiration after 2
hours of nursing
interventions.

Attending Physician: Dr. M.

Impression / Diagnosis: Focal seizure with dyscognitive
features; hypertensive cardiovascular
disease
Nursing
Interventions

Rationale

1. Assess for and

report signs
and symptoms
of aspiration
of secretions
or foods/fluids
(e.g. rhonchi,
cough,
tachypnea,
tachycardia,
dyspnea).

1. To establish
baseline data.

2. Maintain
client in high
Fowler's
position
during and for
at least 30
minutes after
meals and
snacks unless
contraindicate

2. Because upper
airway
patency is
facilitated by
upright
position.

Evaluation
07/08/14
11:00 AM
Goal met.
The patient
demonstrated
techniques that
prevent aspiration
after 2 hours of
nursing interventions.

capillaries.
Aspiration of gastric
contents causes
a chemical burn of
the tracheobronchial
tree and pulmonary.
An inflammatory
response occurs.
This results in the
destruction of
alveolarcapillary
endothelial
cells, with a
consequent
outpouring of
protein-rich fluids
into the
interstitial and intraalveolar spaces. As a
result, surfactant is
lost,
which in turn causes
the airways to close
and the alveoli to
collapse.
Finally, the impaired
exchange of oxygen
and carbon dioxide
causes respiratory
failure.
The pathologic
process involves an
acute inflammatory
response to bacteria
and bacterial
products.
Aspiration is likely to
occur if the patient
cannot adequately
coordinate
protective glottic,
laryngeal, and cough

d.

3. Give semisolid foods or

use soft foods
that stick
together/form
a bolus.

4. Provide very
warm or very
cold liquids.

3. To aid in
swallowing
effort.

4. Activates
temperature
receptors in
the mouth that
help to
stimulate
swallowing.

5. Assist client
with oral
hygiene after
eating.

5. To ensure that
food particles
do not remain
in mouth.

6. Instruct family
member to
avoid or limit
activities that
may increase

6. It may slow
digestion/
increase risk
of
regurgitation.

reflexes. This
hazard is increased if
the patient has a
distended abdomen,
is in
a supine position,
has the upper
extremities
immobilized by
intravenous
infusions or hand
restraints, receives
local anesthetics
to the oropharyngeal
or laryngeal area for
diagnostic
procedures,
has been sedated, or
has had long-term
intubation.

Students Name: __________________________________________

Clinical Instructor: _________________________________________

intraabdominal
pressure (E.g.
straining or
tight/constricti
ve clothing).