Proper NCP 2 “Risk for Aspiraton”

CUES EXPLANATION OF THE GOALS AND OBJECTIVES INTERVENTIONS RATIONALE CRITERIA FOR ACTUAL EVALUATION
PROBLEM EVALUATION
Subjective cues: Goal:  Assess initial VS  To serve as baseline Fully met if the Partially met because
Client Watcher verbalized Aspiration is common, even in The client will be able to data and to evaluate client demonstrated the client demonstrated
“Medyo nagwworry ako healthy patients, it can have a be free of signs of degree of compromise minimal clear minimal clear breath
na baka mag hanggad sya significant morbidity and aspiration and the risk of breath sounds, sounds, resonant
(RR)
tuwing nagseizure” mortality in certain aspiration is decreased. resonant percussion percussion over the
 Assess level of  The primary risk
circumstances. And since over the lungs are lungs are noted. There is
Objective cues: according to the case of the Long Term Objective: consciousness factor of aspiration is noted. There is absence of cough and
 Difficulty swallowing patient who had 10-20 Within 3 days of nursing decreased level of absence of cough the vital signs are
episodes of seizures per day intervention, risk for consciousness and the vital signs within normal limits.
 Crackles noted upon before admission which is aspiration will be are within normal And will be able to
auscultation why it lead to the possibility of decreased as evidenced limits. And will be demonstrate measures
the patient having a risk of by:  Assess for gag  Impaired swallowing able to demonstrate to prevent aspiration.
 Stiff Contraction aspiration.  expectorates clear reflex and may cause aspiration. measures to prevent
secretions and is free swallowing. aspiration.
 Irritability of aspiration
Risk for Aspiration is defined  Nausea or vomiting Partially met if the
as a vulnerable to entry of  Assess for client demonstrated
 With vital signs of: presence places patients at
gastrointestinal secretions, minimal clear
BP: 110/80
oropharyngeal secretions,  maintains a patent of nausea or great risk for breath sounds,
CR: 75 bpm airway with normal aspiration, especially
solids or fluid into the vomiting. resonant percussion
RR: 16 cpm breath sounds if the level of
tracheobronchial passages, over the lungs are
T: 36.5 oC
which may compromise consciousness is noted. There is
SpO2: 97%
health. compromised. absence of cough
Nsg. Dx: Risk for  swallows and digests Antiemetics may be and the vital signs
oral, nasogastric, or are within normal
aspiration related to required to prevent
gastric feeding limits. And will be
episodes of seizure. aspiration of able to demonstrate
without aspiration regurgitated gastric measures to prevent
contents. aspiration.
Short Term Objectives:  Evaluate
 To determine Not met if the client
 After 8 hours of amount/consiste
demonstrated
nursing intervention ncy of secretions presence/effectivenes
minimal clear
pt. will demonstrate s of protective breath sounds,
measures to prevent mechanisms resonant percussion
aspiration.  Keep head of bed  Maintaining a sitting over the lungs are
elevated when position after meals noted. There is
feeding and for may help decrease absence of cough
 Within 8 hours of at least a half aspiration pneumonia and the vital signs
nursing interventions, the hour afterward. are within normal
in the elderly. limits. And will be
client will show absence
of any signs or symptoms able to demonstrate
of further complications  Position patients  This positioning (resc measures to prevent
or worsening of condition with a decreased ue positioning) aspiration.
level of decreases the risk for
 Within 1 hour of aspiration by
nursing interventions, the consciousness on
client will verbalize their side. promoting the
understanding of drainage of secretions
condition, therapy of out of the mouth
regimen, side effects of instead of down the
medications, and when to pharynx, where they
contact health care  Encourage pt. to could be aspirated.
provider. drink fluids
when eating.  To prevent blockage
on the passage of
food.
 Instruct pt. to eat
with small
amount of food.  To prevent
obstruction on airway
 Provide oral care and aspiration.
before and after
meals.  Oral care before
meals reduces
bacterial counts in the
oral cavity. Oral care
after eating removes
residual food that
could be aspirated at a
later time.