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ANGELA RAWSON

Pediatric Nursing Care Plan

Priority Nursing Diagnosis: Risk for aspiration related to increased gastric reflux.

Goal: Client will not aspirate gastric contents.


Outcome Criteria
1. Swallows and digests oral,
nasogastric, or gastric
feeding without aspiration
during hospital stay

Interventions
1. Monitor client's gag reflex and
ability to swallow by feeling the
laryngeal prominence as the client
attempts to swallow every feeding.

Scientific Rationale
1. It is important to check
client's ability to swallow
before feeding. A client
can aspirate even with an
intact gag reflex.

Evaluation
1. Client was still refluxing
formula/breastmilk when laying
down, but did not aspirate any
contents.

2. Patients respiratory rate


will remain within
parameters 25-50 breaths
per minute during hospital
stay.

2. Monitor for signs of aspiration by


assessing respiratory rate, depth,
and effort every feeding.

2. Signs of aspiration should


be detected as soon as
possible to prevent
further aspiration and to
initiate treatment that
can be lifesaving.
Aspirated contents can
cause further
complications such as
pneumonia.

2. Clients respiratory rate, depth, and


effort acceptable during feedings at
28 breaths per minute, and did not
appear to be in any distress.

3. Clients lungs will remain


clear of crackles and
wheezes during hospital
stay.

3. Assess pulmonary status by


auscultating breath sounds for
development of crackles/or wheezes
every shift.

3. Aspiration of small
amounts can occur
without coughing or
sudden onset of
respiratory distress.

3. Clients lung sounds were clear in all


fields and free from crackles and
wheezes throughout hospital stay.

4. Clients risk for aspiration


will decrease by proper
positioning by discharge.

4. Position client supine on their side


every day when laying down to
sleep.

4. This positioning (rescue


positioning) decreases the
risk for aspiration by
promoting the drainage of
secretions out of the
mouth instead of down
the pharynx, where they
could be aspirated.

4. Clients mother positioned client on


side when trying to lay him down with
the head of the bed elevated.
However, client still had reflux and
mother was scared to lay baby down.
Most of the time, mother held child
while sleeping and kept upright most
of the day out of fear.

5.

5. Keep suction setup available at


bedside and use as needed during
hospital stay and to take home
when discharged.

5. Suctioning may be
necessary to maintain a
patent airway in clients at
high risk for aspiration.
Secretions can rapidly
accumulate in the
posterior pharynx and
upper trachea, increasing
the risk for aspiration.

5. Clients mother asked for a bulb


syringe to keep airway patent and
used properly when needed.

6. Clients reflux will decrease


by maintaining upright
position after feedings
during hospital stay.

6. Maintain the client in an upright


position for 30-45 minutes after
each feeding.

6. The upright position


facilitates the
gravitational flow of the
food or fluid through the
alimentary tract.

6. Clients mother did very well holding


client for an extended period before
laying down to change his diaper, or
trying to lay down for naps.

7. Client will not aspirate due


to vomiting during hospital
stay.

7. Monitor for presence of any nausea,


or vomiting every shift.

7. Nausea or vomiting places


patients at great risk for
aspiration. Antiemetics
may be required to
prevent aspiration of
regurgitated gastric
contents.

7. Client did not present with any


vomiting, or nausea symptoms during
hospital stay.

Client will remain free of


excess oral excretions by
use of bulb syringe during
hospital stay.

8. Client will be able to


swallow secretions without
difficulty during hospital
stay.

8. Consult a speech pathologist to


obtain a swallow evaluation before
being discharged home.

8. A speech pathologist can


be consulted to perform a
dysphagia assessment
that helps determine the
need for videofluroscopy
or modified barium
swallow and to establish
specific techniques to
prevent aspiration in
clients with impaired
swallowing.

8. Client did have a swallow evaluation


done during hospital stay and had a
normal result and did not appear to
have any difficulty swallowing.

9. Clients chest X-ray will


remain clear during hospital
stay.

9. Obtain a chest x-ray upon


admission.

9. Pulmonary infiltrates on
chest x-ray films indicate
some level of aspiration
that may have already
occurred.

9. Clients chest x-ray was


unremarkable.

10. Family will demonstrate


effective learning by
demonstrating proper
feeding techniques by
discharge.

10. Instruct parents in proper feeding


techniques during hospital stay and
upon discharge.

10. Both the patient and


caregivers need to be
active participants in
implementing the
treatment plan to
optimize safe nutritional
intake.

10. Both mother and father were


instructed and demonstrated back
proper feeding techniques.

11. Family will demonstrate


effective learning by
demonstrating proper
suctioning techniques by
discharge.

11. Instruct parents and caregivers


proper suctioning techniques during
hospital stay and before discharging
home.

11. Suctioning reduces the


volume of secretions and
reduces aspiration risk.

11. Mother demonstrated proper use of a


bulb syringe to suction clients oral
and nasal cavity.

12. Family will demonstrate


effective learning by
verbalizing understanding of
aspiration signs and
symptoms by discharge.

12. Instruct parents and caregivers to


recognize signs and symptoms of
aspiration during hospital stay and
before discharging home.

12. Information aids in


appropriate assessment
of when to call for further
evaluation.

12. Mother is very attentive to clients


needs and knew exactly how to
resolve choking episodes. Even
though mother was scared she used
correct techniques to maintain an
open airway for client.

13. Family will demonstrate


effective learning by
verbalizing how to react in
an emergency by discharge.

13. Demonstrate to the parents and


caregivers what should be done if
the patient aspirates during hospital
stay and before discharging home.

13. Respiratory aspiration


requires immediate
action by the caregiver to
maintain the airway and
promote effective
breathing and gas
exchange. Being prepared
for an emergency helps
prevent further
complications.

13. Mother is very attentive to clients


needs and knew exactly how to
resolve choking episodes. Even
though mother was scared she used
correct techniques to maintain an
open airway for client.

14. Family will demonstrate


effective learning by
demonstrating proper
positioning of client by
discharge.

14. Explain to the parents and caregiver


the need for proper positioning
during hospital stay and before
discharging home.

14.

Upright positioning
decreases the risk for
aspiration.

14. Mother demonstrated understanding


of correct positioning and kept the
clients head of the bed elevated
when changing diaper, or laying down
for naps.

15. Client will tolerate reflux


medications well during
hospital stay.

15. Administer acid reflux medication


per doctors orders during hospital
stay.

15. Antacids and reflux


medications decrease
symptoms of
gastroesophageal reflux,
which can put client at
increased risk for
aspiration.

15. Client received Axid three times a day


as ordered by physician. It seemed to
have helped decrease the reflux
symptoms, but did not resolve the
reflux.