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    Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation Short Term: Short Term

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    Chi Sabbaluca
    The patient was at risk for aspiration due to decreased level of consciousness from a stroke. Short term nursing interventions included monitoring consciousness level, assessing cough and gag reflexes, auscultating bowel sounds, and positioning the patient on their side. Long term goals included remaining free from aspiration as evidenced by absence of dyspnea and crackles after one week of nursing interventions.

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    Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation Short Term: Short Term

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    Chi Sabbaluca
    99 views3 pages
    The patient was at risk for aspiration due to decreased level of consciousness from a stroke. Short term nursing interventions included monitoring consciousness level, assessing cough and gag reflexes, auscultating bowel sounds, and positioning the patient on their side. Long term goals included remaining free from aspiration as evidenced by absence of dyspnea and crackles after one week of nursing interventions.

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    167704558-Ncp-Stroke copy

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    The patient was at risk for aspiration due to decreased level of consciousness from a stroke. Short term nursing interventions included monitoring consciousness level, assessing cough and gag reflexes, auscultating bowel sounds, and positioning the patient on their side. Long term goals included remaining free from aspiration as evidenced by absence of dyspnea and crackles after one week of nursing interventions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    99 views3 pages

    Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation Short Term: Short Term

    Uploaded by

    Chi Sabbaluca
    The patient was at risk for aspiration due to decreased level of consciousness from a stroke. Short term nursing interventions included monitoring consciousness level, assessing cough and gag reflexes, auscultating bowel sounds, and positioning the patient on their side. Long term goals included remaining free from aspiration as evidenced by absence of dyspnea and crackles after one week of nursing interventions.

    Copyright:

    © All Rights Reserved
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    Download as docx, pdf, or txt
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    Natividad, Michael John F.

    Assessment Nursing Planning Interventions Rationale Evaluation


    Diagnosis
    S= Not Applicable Risk for SHORT TERM:  Monitor level of A decreased level of SHORT TERM:
    aspiration r/t After 1 hour of consciousness. consciousness is a prime After 1 hour of
    O=The patient decreased level Nursing risk factor for aspiration. Nursing
    manifested the ff: of Interventions, the Interventions, the
     Diagnosis of consciousness patient’s significant  Assess cough A depressed cough or gag patient’s significant
    stroke and other will verbalize and gag reflexes. reflex increases the risk of other verbalized
    right sided understanding of aspiration understanding of
    paralysis importance of importance of
     Lethargy elevating head of  Auscultate bowel Decreased gastrointestinal elevating head of
     decreased bed to prevent sounds to motility increases the risk bed to prevent
    level of aspiration. evaluate bowel of aspiration because food aspiration.
    consciousness motility. or fluids accumulate in the
    (GCS 3 LONG TERM: stomach. LONG TERM:
    E1V1M1) After 7 days of After 7 days of
     depressed Nursing  Assess Aspiration of small Nursing
    cough reflex Interventions, the pulmonary status amounts can occur without Interventions, the
     difficulty patient will remain for clinical coughing or sudden onset patient remained
    swallowing free from aspiration evidence of of respiratory distress, free from aspiration
    without as evidenced by aspiration. especially in patients with as evidenced by
    choking absence of dyspnea, Auscultate breath decreased levels of absence of dyspnea,
    normal vital signs, sounds for consciousness. normal vital signs,
    and absence of development of and absence of
    crackles. crackles and/or crackles.
    rhonchi.
    This is necessary to
     Keep suction maintain a patent airway.
    setup available
    and use as
    needed. Early intervention protects
    the patient’s airway and
     Notify the prevents aspiration.
    physician or
    other health care
    provider
    immediately of
    noted decrease in
    cough and/or gag
    reflexes or
    difficulty in This protects the airway.
    swallowing. Proper positioning can
     Position patients decrease the risk of
    who have a aspiration. Comatose
    decreased level patients need frequent
    of consciousness turning to facilitate
    on their sides. drainage of secretions.

    A displaced tube may


    erroneously deliver tube
     Check placement feeding into the airway.
    of NGT before
    feeding. High amounts of residual
     Check residuals (>50% of previous hour’s
    before feeding. intake) indicate delayed
    Hold feedings if gastric emptying and can
    residuals are high cause distention of the
    and notify the stomach leading to reflux
    physician. emesis.

    Promotes cooperation

     Explain
    importance of
    elevating HOB to The upright position
    SO. facilitates the gravitational
     Maintain upright flow of food or fluid
    position for 30 to through the alimentary
    45 minutes after tract.
    feeding.
    Mobilizes thickened
     Assist with secretions.
    postural
    drainage.

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