Nursing Care Plan


Return to Care Plan Listing
 






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

 

 

 

 

 

 

7,800 Patho review flash cards, download now and ace your exams

*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 (8th ed.). St. Louis: Mosby Elsevier.






Return to Table of Contents