Nursing Care Plan2 Cva

Nursing Care Plan (Risk for Aspiration) Cues Subjective:

Objective: Received pt. on lying position on bed, unconscious , with ongoing PNSS 1L regulated @ 10-15 gtts./min. (KVO) 200 ml. level infusing well @ left hand. ➢ (+) difficulty in speaking ➢ (+) weakness ➢ (+) headache ➢ (+) dizziness ➢ (+) blurred vision ➢ (+)Paralysi s on right

Nursing Diagnosis

Scientific Explanation

Risk aspiration related to decreased level of consciousness.

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 or in instances when a non-functioning nasogastric tube allows gastric content to drain around the tube and cause silent aspiration.

Objective/ Planning

Implementation

Rationale

Expected Outcome

Plan: After the provision Establish rapport. of nursing care, the pt. risk for aspiration will be reduce as manifested by: Monitor and record V/S. Short Term:

To build trusting relationship.

To have baseline data.

After 2 hrs. of N.I the patient/ relative shall be able to avoid factors that may cause aspiration.

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 level of consciousness and awareness of surrounding. Note administration of enteral feeding, being aware of potential for regurgitation and misplacement of

Short Term:

To assess contributing factor.

To avoid lung aspiration.

part of the body ➢ With NGT inserted ➢ With Foley catheter inserted

tube. Provide information about the effect of aspiration in the lung. Instruct in safety concerns when feeding oral or NGT.

Vital Sign: BP: 140/100

Elevate client highest or best possible position for eating and drinking and during the feeding.

Long Term: After 2 day of N.I the SO will demonstrate techniques to prevent and correct aspiration. Maintain correct tube/ oral feeding.

Instruct the family to avoid/ limit activities that increase intraabdominal pressure.

To provide knowledge about tube feeding. To prevent regurgitation of food or fluid.

It may slow digestion and increase risk for regurgitation. Long Term:

To prevent overfeeding. Ascertain that feeding is in correct position.

After 2 days of N.I the pt. shall be able to experience no aspiration as evidence by noiseless respiration, clear breath sounds, clear odorless

Measure residuals when appropriate.

secretions. To identify regurgitation.

Add food coloring. To avoid aspiration. Feed slowly instruct the pt. to chew slowly and thoroughly.

Give semi-solid foods, avoid pureed foods and mucusproduction foods (milk). Use soft foods that sticks together/ form bolus.

Monitor if the NGT is correctly intact. And maintain suction equipment by bedside.

To decrease risk for aspiration and aid swallowing effort.

NGT may enter the lung and may lead to serious lung damage.