Sie sind auf Seite 1von 4


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

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.

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

2. Patients respiratory rate

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

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

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

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

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. 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

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

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

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

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

9. Obtain a chest x-ray upon


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

9. Clients chest x-ray was


10. Family will demonstrate

effective learning by
demonstrating proper
feeding techniques by

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

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

11. Instruct parents and caregivers

proper suctioning techniques during
hospital stay and before discharging

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

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

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

14. Explain to the parents and caregiver

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


Upright positioning
decreases the risk for

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

15. Antacids and reflux

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

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