ASSESSMENT S> the patients wife verbalized, Simula nang na admit siya, nilagyan na siya ng endotracheal tube.

Para raw makahinga siya ng mabuti at hindi mahirapan. O> Patient cant ambulate nor sit. After client do active range of motion, RR=34, PR=97 bpm and BP=140/100. T=37.7C

NURSING DIAGNOSIS Risk for aspiration r/t presence of endotracheal tube and reduced level of consciousnes s.

SCIENTIFIC RATIONALE Both acute and chronic conditions can place patients at risk for aspiration. Acute conditions, such as postanesthesia effects from surgery or diagnostic tests, occur predominantly in the acute care setting. Chronic conditions, including altered consciousness from head injury, spinal cord injury, neuromuscular weakness, hemiplegia and

PLANNING After 8 hours of nursing intervention, the patients risk of aspiration will decrease as a result of ongoing assessment and early intervention.

NURSING INTERVENTIONS Independent Monitor level of consciousness

RATIONALE

EVALUATION

Auscultate breath sounds for development of crackles and/or rhonchi.

After 8 hours of nursing intervention, A decreased level the patients risk of of consciousness is aspiration was a prime risk factor decreased as a result for aspiration. of ongoing assessment and early intervention. Aspiration of small amounts can occur without coughing or sudden onset of respiratory distress, especially in patients with decreased levels of consciousness. To prevent aspiration of secretions and maintain open airway.

Position patient who have a decreased level of consciousness on their sides. Keep suction machine available for use.

dysphagia from stroke, use of tube feedings for nutrition, endotracheal intubation, or mechanical ventilation may be encountered in the home, rehabilitative, or hospital settings. Elderly and cognitively impaired patients are at high risk. Aspiration is a common cause of death in comatose patients. Reference: http://www1.us .elsevierhealth. com/MERLIN/ Gulanick/Cons

Explain to the relative the need for proper positioning. Collaborative Collaborate with the respiratory therapist to determine the effectiveness of the cuff of the ET tube. Dependent Perform suctioning as ordered by the physician.

To clear secretions and provide patent airway. Reference: http://www1.us.els evierhealth.com/M ERLIN/Gulanick/ Constructor/index. cfm?plan=04

tructor/index.cf m?plan=04