NURSING CARE PLAN

Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation
Objective: Risk for Aspiration of stomach After 4 hours of Nursing  Identify at risk  To determine After 4 hour of nursing
 DAT with Aspiration contents into the Intervention the client will: client according when intervention goal was met
SAP lungs is a serious  Experience no to condition or observation as evidence by:
 Cleft lip complication that can aspiration as disease process and/or  Experienced no
Palate cause pneumonia evidence by as listed in risk interventions aspiration as
 Cough and result in the noiseless factors. may be evidence by
following clinical respirations; clear required. noiseless
picture: tachycardia, breath sounds;  Assess for age- respirations; clear
dyspnea, central clear, odorless related risk  Aspiration breath sounds;
cyanosis,hypotension secretions. factors pneumonia is clear, odorless
, and finally death. It  Identify causative potentiating risk more common secretions.
can occur when the risk factors. of aspiration (e.g. in extremely  Identified
protective airway  Demonstrate Premature infant, young or old causative risk
reflexes is absent or techniques to elderly infirm) patients and factors.
decreased due to prevent and/or commonly  Demonstrated
medical conditions correct aspiration. occurs in techniques and
like cleft lip and  Patient is free from individuals prevented and/or
palate and use of any signs of with showed correct
devices like aspiration and the chronically aspiration.
endotracheal risk of aspiration is impaired air  The Patient has
intubation. In addition decreased.  Note client’s level way defense no signs of
to this, oropharyngeal of mechanism. aspiration and the
secretions, or solids consciousness, risk of aspiration
or fluids could also awareness of  As was decreased
enter surroundings and impairments in
tracheobronchial cognitive these disease
passages due to function. increase
decreased coughing client’s risk of
gag, and epiglottis aspiration
reflexes. Prevention owing to the
is the primary goal inability to
when caring for cough or
aspiration. Evidence swallow well
confirms that one of and/or the
the main preventive presence of an
measures for  Determine the artificial
aspiration is placing presence of airway,
at risk patients in a neuromuscular mechanical
semi recumbent disorders, noting ventilation,
position. Other muscles groups and/or tube
measures are involved degree feeding.
compensating for of impairment
absent reflexes, and whether they  Helps to
assessing feeding are of an acute or determine
tube placement, progressive effectiveness
identifying delayed nature. of protective
stomach emptying. mechanisms.
And managing effects  Assess client’s
of prolonged ability to swallow
intubation. and strength of
gag reflex or
cough reflex.
Evaluate
amount/consisten
cy of secret  Client with a
Observe for neck head/neck
and facial surgery or a
edema. tracheal/bronc
hial injury is at
 Note particular risk
administration of for airway
enteral feeding obstruction
and an
inability to
handle
secretions.