Risk for Aspiration

- At risk for entry of GI secretions, oropharyngeal secretions, or solids or fluids into

tracheobronchial passages.

Risk factors:
- Reduced LOC
- Depressed cough/gag reflex
- Impaired swallowing
- Facial/oral/neck surgery or trauma; wired jaws
- Situation hindering elevation of upper body
- Delayed gastric emptying; decreased GI motility; increased intragastric pressure;
increased gastric residual
- Presence pf tracheostomy or ET tube
- GI tubes; tube feedings; medication administration
Objectives
- Experience no aspiration as evidenced by noiseless respirations; clear breath
sounds; clear, odorless secretions
- Identify causative/risk factors
- Demonstrate techniques to prevent and/or correct aspiration
Nursing interventions
1. To assess causative/contributing factors:
- Note clients LOC, awareness of surrounding, and cognitive function
- Determine presence of neuromuscular disorders, noting muscle groups involved,
degree of impairment, and whether they are of an acute or progressive nature
- Assess clients ability to swallow and strength of gag/cough reflex and evaluate
amount/consistency of secretions
- Observe for neck and facial edema
- Note administration of enteral feedings because of potential for regurgitation
and/or misplacement of tube
- Ascertain lifestyle habits
2. To assist in correcting factors that can lead to aspiration:
- Monitor use of oxygen masks in clients at risk for vomiting. Refrain from using
oxygen masks in clients at risk for vomiting
- Keep wire cutters/scissors with client at all times when jaws are wired banded.
- Maintain operational suction equipment at bedside/chairside
- Suction as needed
- Assist with postural drainage to mobilize thickened secretions that may interfere
with swallowing
- Auscultate lung sounds frequently
- Elevate client to highest or best possible position
- Provide soft foods that stick together
- Offer very warm or very cold liquids to stimulate swallowing
- Avoid washing solids down with liquids
- Ascertain that feeding tube is in correct position
Impaired Gas Exchange

- Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveoli-

capillary membrane

Related factors:
- Ventilation perfusion imbalance (altered blood flow)
- Alveolar-capillary membrane changes
- Altered oxygen supply
- Altered oxygen-carrying capacity of blood
Subjective:
- Dyspnea
- Sense of impending doom
Objective:
- Confusion
- Restlessness
- Irritability
- Somnolence
- Hypoxia
- Hypercapnia
- Cyanosis
- Tachycardia
- Polycythemia
Objectives:
- Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs
within clients normal limits and absence of symptoms of respiratory distress
- Verbalize understanding of causative factors and appropriate interventions
- Participate in treatment regimen
Nursing interventions:
1. To assess causative/contributing factors
- Note presence of factors listen in related factors
2. To evaluate degree of compromise
- Note RR, depth, use of accessory muscles, pursed-lip breathing; and areas of
pallor/cyanosis; for example, peripheral versus central or general duskiness
- Auscultate breath sounds, note areas of decreased/adventitious breath sounds
as well as fremitus
- Assess LOC and mentation changes. Note somnolence, restlessness, reports of
headache on arising
- Monitor vital signs and cardiac rhythm
- Evaluate pulse oximetry to determine oxygenation; evaluate lung volumes and
forced vital capacity to assess for respiratory insufficiency
- Review other pertinent laboratory data; chest xrays
- Assess energy level ad activity tolerance
- Note effect of illness on self-esteem/body image
3. To correct/improve existing deficiencies
 - Elevate head of bed/position client appropriately, provide airway adjuncts and
suction, as indicated, to maintain airway.
- Encourage frequent position changes and deep breathing/coughing exercises.
Use incentive spirometer, chest physiotherapy, IPPB, and so forth, as indicated.
Promotes optimal chest expansion and drainage secretions.
- Provide supplemental oxygen at lowest concentration indicated by laboratory
results and client symptoms/situation.
- Maintain adequate I&O for mobilization of secretions, but avoid fluid overload
- Use sedation judiciously to avoid depressant effects on respiratory functioning
- Encourage adequate rest and limit activities to within client tolerance. Promote
calm/restful environment.
- Provide psychological support, active listen questions/concerns to reduce anxiety
- Administer medications, as indicated
- Monitor/instruct client in therapeutic and adverse effects as well as interactions of
drug therapy
- Assist with procedures and individually indicated
- Monitor/adjust ventilator setting
- Keep environment allergen/pollutant free
4. To promote wellness
- Review risk factors, particularly environmental/employment-related
- Discuss implications of smoking related to the illness/condition
- Encourage client and SOs to stop smoking, attend cessation programs, as
necessary
- Discuss reasons for allergy testing when indicated. Review individual drug
regimen and ways of dealing with side effects
- Instruct in the use of relaxation, stress reduction techniques, as appropriate
- Reinforce need for adequate rest, while encouraging activity and exercise
- Review job description/work activities
- Discuss home oxygen therapy and safety measures, as indicated, when home
oxygen implemented.

Ineffective/Altered Tissue Perfusion

- Decrease in oxygen resulting in the failure to nourish the tissues at the capillary
level.
Etiology
- Interruption of flow-arterial, venous
- Exchange problem
- Hypervolemia, hypovolemia
Subjective:
- Claudification
- Angina pain
- Palpitation
Objective
- Diminished/absent arterial pulsations
 - Skin color. Pale on elevation, color does not return on lowering leg; dependent,
blue or purple
- Skin temperature: cold extremities
- Skin quality: shining, lack of lanugo
- Blood pressure changes in extremities
- Bruits
- Slow-growing, dry, thick brittle nails
- Slow healing of lesions
- Round scars covered with atrophied skin
- Gangrene
- Delayed capillary refill
Nursing Interventions:
1. Assess causative/contributing factors
- Determine factors related to individual situations
- Monitor changes mentation, vital signs, postural BPs, signs of electrolyte
imbalances
- Evaluate for signs of infections especially when immune system is compromised
- Observe for signs of pulmonary emboli: sudden onset of chest pain, cyanosis,
respiratory distress, hemoptysis, diaphoresis, hypoxia, anxiety, restlessness
2. Note for degree of impairment/organ involvement:
Gastrointestinal:
- Note complaints of nausea, vomiting, location/type of pain
- Auscultate bowel sounds, measure for increase abdominal girth, changes in
stool/presence of blood
- Note symptoms of peritonitis, ischemic colitis, abdominal angina
Cardiac:
- Assess baseline ABGs, electrolytes, BUN, creatinine and cardiac enzymes
- Measure cardiac rhythm, document dysrthmia
- Investigate complaints of chest pain/angina, note precipitating factors, changes in
characteristics of pain episodes
Peripheral:
- Check for calf tenderness (Homans signs), swelling and redness which may
indicate thrombus formation
- Monitor clotting time, Hgb/hct
- Observe for signs of shock/sepsis, note presence of bleeding or signs of DIC
- Auscultate for systolic/continuous bruits below obstruction in extremities
3. Minimize/correct causative factors: Maximize tissue perfusion
Gastrointestinal:
- Maintain gastric/intestinal decompression and monitor output
- Provide small/easy digested food/fluids when tolerated
- Encourage rest after meals to maximize blood flow to stomach
- Prepare patient for surgery if indicated
Cardiac:
- Monitor VS, hemodynamics, heart sounds
- Encourage quiet, restful atmosphere
- Caution patient to avoid activities that increase cardiac workload
 - Review ways of avoiding constipation
- Administer medications
- Note signs of ischemia secondary to drug effects
Peripheral:
- Do assistive active ROM exercises
- Encourage early ambulation if possible
- Discourage sitting/standing for long periods of time, constricting clothings and
crossing legs
- Elevate the legs when sitting but avoid sharp angulation of the hips or knees
- Avoid use of knee gatch on bed; elevate entire food as indicated
- Place foot cradle on bed as needed
- Apply thromboembolic/ace bandages to lower extremities before arising from bed
to enhance venous return and help prevent venous stasis
- Exercise caution in use of hot water bottles or heating pads: tissue may have
decrease sensitivity due to ischemia
- Monitor for signs of bleeding during use of fibrinolytic agents
- Encourage patient to limit quit smoking
- Elevate head of bed at night to increase gravitational blood flow
- Monitor closely for signs of shock when sympathectomy is done
- Use paper tapes instead of adhesive
- Administer medications
- Avoid massaging the legs when at risk for embolus
- Monitor circulation above/below casts: use ice and elevate limb to reduce edema
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Bowel Incontinence

- Change in normal bowel habits characterized by involuntary passage of stool

- Objective manifestation: involuntary passage of stools

Goals
- Verbalizes understanding of causative/contributing factors and appropriate
interventions
- Participates therapeutic regimen to control incontinence
- Establishes near to normal pattern of bowel functioning as possible
Interventions:
1. Assess causative contributing factors:
- Identify pathophysiologic factors present
- Note times of occurrence preceding/precipitating events
 - Check for impaction which may be a contributing factors
- Auscultate bowel sounds
- Note color, odor, consistency, amount and frequency of stool
- Encourage patient to record times at which incontinence occurs
- Auscultate abdomen for presence, location, and characteristics of bowel sounds
- Palpate for distention
- Compare with previous bowel patterns
2. Promote control/management of incontinence
- Assess in treatment of causative/contributing factors
- Establish bowel program: regular time for defacation (usually 30 mins after
eating)
- Take patient to the bathroom/place on commode or bedpan at specialized
interval, taking into considerations individual needs and incontinence pattern
- Encourage diet high in bulk, fiber, ad adequate fluids (minimum of 2000-2400 mL
per day)
- Give stool softeners/bulk formers as indicated
- Provide pericare to avoid excoriation of the area
- Promote exercise program, to increase muscle tone/strength, including perineal
muscles
-

Diarrhea
- Passage of loose, unformed stool

Related factors
- High stress level; anxiety
- Laxative use
- Alcohol use
- Toxins
- Contaminants
- Adverse effects of medications; radiation
Subjective
- Abdominal pain
- Urgency, cramping
Objective
- Hyperactive bowel sounds
- At least 3 loose liquids stools per day
Objectives:
- Reestablish and maintain normal pattern of bowel functioning
- Verbalize understanding of causative factors and rationale for treatment regimen
- Demonstrate appropriate behavior to assist with resolution of causative factors
Nursing interventions:
1. To assess causative factors/etiology
- Note reports of abdominal or rectal pain associated with episodes
- Auscultate abdomen for presence, location and characteristics of bowel sounds
 - Observe for presence of associated factors, such as fever/chills, abdominal
pain/cramping, bloody stools, emotional upset, physical exertion, and so forth
- Evaluate diet history and note nutritional/fluid and electrolyte status
- Determine recent exposure to different/foreign environments, change in drinking
water/food intake, similar illness of others
2. To eliminate causative factors
- Restrict solid food intake, as indicated
- Provide for changes in dietary intake to avoid foods/substances that precipitate
diarrhea
- Limits caffeine and high fiber foods; avoid milk and fruits, as appropriate
3. To maintain hydration/electrolyte balance
- Review laboratory studies for abnormalities
- Administer antidiarrheal medications, as indicated, to decrease GI motility and
minimize fluid losses
- Encourage oral intake of fluids containing electrolytes
- Administer enteral and IV fluids, as indicated
4. To maintain skin integrity
- Assist, as needed, with pericare after each bowel movement
- Apply lotion/ointment as skin barrier, as needed
- Provide dry linen, as necessary
- Expose perineum/buttocks to air; use heat lamp with caution, if needed to keep
area dry
5. To promote return to normal bowel functioning
- Increase oral fluid intake and return to normal diet, as tolerated
- Encourage intake of nonirritating liquids
- Recommend products such as natural fiber, plain natural yogurt, Lactinex to
restore normal bowel flora
- Administer medications, as ordered
6. To promote wellness
- Review causative factors and appropriate interventions to prevent recurrence
- Evaluate/identify individual stress factors and coping behaviors
- Review food preparation, emphasizing adequate cooking time and proper
refrigeration/storage
- Discuss possibility of dehydration and the importance of proper fluid replacement

Nutrition: Altered Less Than Body Requirements

- The state in which an individual experiences an intake of nutrients insufficient to

meet metabolic needs
Related factors:
- Inability to ingest or digest food or absorb nutrients due to biologic, psychological
or economic factors
Objective
- Underweight of 20% or more of the IBW
- Loss of weight with adequate food intake
- Poor muscle tone
 - Weakness of muscles required for swallowing or mastication
- Sore, inflamed buccal cavity
- Capillary fragility
- Hyperactive bowel sounds
- Diarrhea or steatorrhea
- Pale conjunctiva & mucous membranes
- Excessive weight loss of hair
- Decreased subcutaneous fat
- Cessation of menses
Goals
- Demonstrate progressive weight gain towards the goal
- Displays normalization of laboratory values and free of signs of malnutrition
reflected in defining characteristics
- Verbalize understanding of causative factors when known and necessary
interventions
- Demonstrates behaviors, life style changes to regain or maintain appropriate
weight
Nursing Interventions:
1. Assess causative/contributing factors
- Review factors that may prevent ingestion or digestion of nutrients. Assess ability
to chew, swallow, taste, denture fit, mechanical barriers and so forth
- Note food tolerance/aversions
- Assess drug interactions, disease effects, allergies, use of laxatives, diuretics
- Determine psychological factors, cultural desires/influences
- Auscultate bowel sounds
- Do psychological assessment, assessing body image
- Note occurrence of amenorrhea, tooth decay, swollen salivary glands etc.
2. Evaluate degree of deficit
- Assess weight, age, body build, strength, activity/rest level, and so forth
- Note total daily calorie intake. Maintain dietary intake, times and patterns of
eating
- Calculate basal energy expenditure (BEE) using Harris-Benedict formula, and
estimate energy and protein requirements
- Measure/calculate subcutaneous fat and muscle mass via triceps skin fold and
midarm muscle circumference
- Review laboratory data indicated
- Assist with diagnostic procedures
- Identify patients at risk for malnutrition
3. Establish a diet plan that meets individual needs
- Assist regimen to corrects/control underlying causative factors (cancer,
malabsorption syndrome, anorexia)
- Provide diet modification as indicated
- Administer pharmaceutical agents as indicated
- Consult dietician/nutritional team as indicated
- Determine whether patient prefer/tolerated more calories in the AM meal
- Use flavouring agents if salt is restricted
- Encourage use of sugar/ honey in beverages if carbohydrate are tolerated well
- Encourage patient to choose foods that are appealing
- Avoid foods that cause intolerances/increase gastric motility according to
individual needs
- Limit fiber/bulk, which may lead to early satiety
- Promote pleasant, relaxing environment, including socialization when possible
- Prevent/minimize unpleasant odors/sight that may have a negative effect on
appetite/eating
- Provide oral care before/after meals and prn
- Encourage use of lozenges and so forth to stimulate salivation when dryness is a
factor
- Promote adequate fluid intake
- Weight weekly and prn
- Develop individual strategies when problem is mechanical or paralysis
- Consult occupational therapist for assistive devices as necessary
- Develop controlled program of nutrition therapy
- Develop behavior modification program with patient involvement appropriate to
specific needs
4. Promote wellness
- Stress importance of well balanced nutritious intake
- Develop consistent, realistic weight gain goal
- Weigh weekly and document results
- Consult with dietician/nutritional support team as necessary
- Develop regular exercise/ stress reduction program
- Review drug regimen, side effects, and potential interactions with other
medical/OTC drugs
- Review medical regimen and provide information/assistance as necessary
- Assist patient to identify/obtain resources such as foods stamps, budget
counseling
- Refer to dental hygiene/professional care counseling etc.
- Provide/reinforce patient teaching when surgery is planned regarding
preoperative and postoperative dietary needs
- Assist patient/SO to learn how to blend food and do tube feeding
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