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Assessment Nursing Diagnosis Scientific Rationale Objectives Interventions Rationale Evaluation

Subjective: Risk for aspiration Aspiration occurs After an hour of nursing 1. Keep suction 1. This is to After an hour of nursing
Objective: related to impaired because the protective intervention, the client machine possible interventions, the client
 Advanced age swallowing secondary airway reflexes (e.g., will be free from signs available during decrease the was seen to be free of
 Patient’s level of to cerebrovascular gag, cough) are missing of aspiration and the feeding. If amount any signs of aspiration
consciousness is accident. or blunted by risk of aspiration is aspiration does aspirated which and the risk of
reduced: anesthesia. It could lead decreased as evidenced occur, suction would reduce aspiration was
lethargic to aspiration by: immediately. the risk for lung decreased and was seen
 Patient is pneumonia resulting  No signs of injury. not in distress and of
undergoing from aspiration of distress 2. Keep head of bed 2. This is to normal respiratory
therapy for materials or chemicals  Normal O2 sat elevated when prevent the functioning.
dysphagia foreign to the and respiratory feeding and for upward flow of
 Patient is taking tracheobronchial tree functioning at least a half feeding into the
a CNS from above (e.g., hour afterward. esophagus into
depressant: aspiration of colonized the trachea.
 Patient has tube oropharyngeal 3. Position patient 3. Since the LOC is
feedings materials) or from on their side. reduced, this
 Left sided below (e.g., aspiration position
weakness could of gastroesophageal promotes
hinder the contents). drainage of
elevation of the secretions out of
patient’s upper
George T. Vaida and Sudheer K. Jain,
Chapter 6 - ANESTHETIC the mouth where
body.
COMPLICATIONS IN UROLOGIC
SURGERY, In Complications of
it could be easily
Urologic Surgery (Fourth Edition), suctioned.
edited by Samir S. Taneja,, W.B.
Saunders, Philadelphia, 2010, Pages 4. Feed thicker 4. This consistency
57-82, ISBN 9781416045724.
food would be less
Eulalia R.Y. Cheng, Aspiration
Pneumonia, In Pediatric Clinical Advisor
likely to be
(Second Edition), edited by Lynn C. aspirated.
Garfunkel, Jeffrey M. Kaczorowski and
Cynthia Christy, Mosby, Philadelphia, 5. When patient 5. This promotes
2007, Pages 56-57, ISBN
9780323035064, would be better chewing
https://doi.org/10.1016/B978-
032303506-4.10032-X.
graduating to and lessens the
oral food, place risk for
food and aspiration
medication on
strong side of
mouth.
6. When eating, the 6. Massaging the
nurse can unaffected side
massage the of the throat
unaffected side promotes
of the throat. swallowing of
the patient
7. Provide oral care 7. Oral care
reduces that
amount of
bacteria in the
mouth that could
be aspirated
along with
residual food
that could be left
in the mouth.
8. Educate 8. Since after being
caretaker on the discharged, the
importance of patient would
positioning then have less
supervision by
the nurse in the
event of a
complication.
W/c is why the
relatives need to
be prepared and
understand the
complexities of
the case.
9. Educate 9. To be able to
caretaker on determine
signs on whether to refer
Aspiration immediately to
the physicians.
10. Encourage the 10. Rehab will be
patient and able to restore
family to comply the normal
with functions of the
rehabilitation patient.

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