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Date Assessment Data Nursing Expected Nursing Interventions Rationale Evaluation

Diagnosis Outcomes Criteria


08/01/2018 Pattern of Health Risk for Short term:  Monitor level  A decreased Short term:
Perception and aspiration After 8 hours of of level of After 8 hours of
Health related to rendering consciousness consciousnes rendering
Maintenance depressed effective nursing . s is a prime effective nursing
cough/gag intervention the risk factor for intervention the
reflexes and patient will be aspiration. patient was able
impaired able to maintain  A depressed to maintain a
swallowing a patent airway  Assess cough cough or gag patent airway
with clear breath and gag reflex with clear breath
sounds and will reflex. increases the sounds and
expectorate clear risk of expectorated
secretions and aspiration. clear secretions
be free of  To maintain a and was free of
aspiration.  Keep suction patent airway. aspiration.
setup
Long term: available (in Long term:
After 24 hours both hospital After 24 hours
of rendering and home of rendering
effective nursing setting) and effective nursing
intervention, the use as needed.  Early intervention the
patient will be  Notify the intervention patient was free
free of signs of physician or protects the of signs of
aspiration and other health patient's aspiration and
the risk of care provider airways and the risk of
aspiration is immediately prevents aspiration was
decreased. of noted aspiration. decreased.
decrease in
cough and/or
gag reflexes,
or difficulty in
swallowing.  The upright
 Maintain position
upright facilitates the
position for 30 gravitational
to 45 minutes flow of food
after feeding. or fluid
through the
alimentary
tract.