Nursing Department

NURSING CARE PLAN

Patient: Giron, Peter Jay Dx: Aspiration Pneumonia Diet: NGT - MF @80 cc Q3h (strict aspiration precaution)
Age: 8 months Gender: Male HL (LL), VS Q4h, INO Qshift Medications: Oral meds

Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective Cues: Risk for Aspiration Short term: Independent: Independent: Short term:
related to depressed
The grandmother of cough or gag reflex After 2 hours of 1. Evaluate and 1. This allows the After 2 hours of
the patient has stated, nursing intervention, assess the nurse to level nursing intervention,
“Minsan, napapansin the client will be able ability of the and assess the goal has been
kong parang to: patient to what kind of partially met.
nahihirapan siya cough, diet is suitable
huminga at palagi siya 1. Slowly swallow, for the patient. Client is still having
naubo.” maintain a gurgle or suck. This is also to troubles in
clear airway. determine the maintaining a clear
“Maaga kase siya . level of airway, yet is slowly
pinanganak kaya 2. Slowly return effectiveness establishing normal
maliit,” as the patient’s the vital signs of protective vital signs. Caregiver
grandmother at normal mechanisms. has demonstrated
verbalized. levels. basic understanding
of the client’s
Objective Cues: After 2 hours of 2. Monitor vital 2. This provides condition.
intervention, the signs every 4 baseline data
Temp: 36.7 caregiver will be able hours. and monitors Long term:
PR: 121 to: whether there
RR: 36 are changes After 48 hours of
O₂ Sat: N/A 1. Understand within the intervention, the goal
BP: N/A the condition patient’s has been partially
of the client. condition that met.
- Pre-term are needed to
- Pigeon chest Long term: be treated or Client has
- No signs of looked upon. demonstrated slowly
cyanosis After 48 hours of acquiring normal vital
 Nursing Department
- Coughing with intervention, the 3. Make sure the 3. In milk signs. However, signs
sputum client will be able to: patient is feedings, of aspiration
production placed in a make sure the pneumonia like cough
- Wheezing 1. Demonstrate proper infant is in an and wheezing are still
- Irritable signs that the position. For upright present. The
vitals signs are patients with a position to caregiver of the client
normalizing. decreased eliminate has successfully
level of difficulties. explained the
2. Eliminate consciousness This is to condition of the client,
presence of , make sure to protect the their possible risks
sputum. turn their airway and to and has discussed
heads on their promote what signs and
3. Maintain a side. absence of symptoms aspiration
clear airway, aspiration. is accompanied with.
free from signs The caregiver has
of aspiration. 4. Monitor input 4. To identify also demonstrated
and output of whether the proper time and
After 48 hours of the client. patient is technique when it
intervention, the dehydrated or comes to milk feeding.
caregiver will be able is experiencing
to: edema.

1. Explain the
condition of 5. Keep 5. This is used in
the client suctioning case of
including its equipment on emergency
other risks. the bedside. since the
patient is
2. Demonstrate labeled to be
proper milk high risk for
feeding aspiration.
through
nasogastric 6. Educate the 6. This would
tube. caregiver further prevent
about the late diagnoses
3. See signs and condition the and to identify
symptoms of client has and earlier if there
 Nursing Department
aspiration instruct signs are any
when it arises. and symptoms changes with
of aspiration, the client’s
as well as the condition and
diagnosis of stability.
the client.

Dependent: Dependent:

1. Notify the 1. Early

physician or intervention
other health protects the
care provider patient's
immediately of airways and
noted prevents
decrease in aspiration.
cough and/or
gag reflexes,
or difficulty in
swallowing.

2. Implement 2. This would

feeding prevent
techniques as aspiration
prescribed by since the meal
the physician. will be
administered
through NGT.

3. Obtain 3. ABG monitors

laboratory blood gas and
tests such as oxygen
ABG and saturation,
blood-sputum CBC obtains
tests. white blood
cell count if
there are any
Nursing Department
suspected
infections
present and
blood-sputum
test may be
needed to
make sure the
patient is
receiving the
right antibiotic
therapy if
needed.

4. Administer oral 4. Administration

medications as of the right
prescribed by drug can
the physician. alleviate
coughing,
infection, pain
or cough out
sputum.

5. Intubate if 5. Patients with a

necessary. large amount
of secretions
or who cannot
clear them
themselves
may require
frequent
suctioning.

Collaboration: Collaboration:

1. Provide foods 1. To avoid

with chances of
consistency aspiration,
 Nursing Department
that the client NGT feeding is
can swallow advised.
as per the Gravity is used
dietician’s in order for the
order. In this milk to slide
case, the through the
patient can tube and
only be fed plunger can be
through NGT used if the
milk feeding. tube is
blocked.

PASSED BY: PRODIGALIDAD, Zxiakira C.

NUR215
2nd year - BS Nursing
2 PM - 6 PM shift