Date Cues Nursing Scientific Basis

Diagnosis
02/04/2020 Subjecive: “mura Risk for aspiration - risk for aspiration
man ko mahadlok related to is a state in which
matuk.an siya mura Nasogastric Tube an individual is at
man sya mu Feeding. risk for entry of
aksyon og suka” as gastric secretions,
verbalized by oropharyngeal
patient’s mother. secretions or
  exogenous food or
Objective: fluids into
> with O2 tracheobrachial
inhalation 2L/min passages caused
> with nasogastric by dysfuntion of
tube absence of normal
  protective
meachanism.
 Date Cues Nursing Diagnosis Scientific Basis
02/04/2020 > frequent The defining
movement when characteristics are
feeding the presence of risk
> doesn’t like to sit factors including
down when feeding reduced level of
> abnormal breaths consciousness,
sounds heard over depressed cough
auscultation. and gag reflexes
  and the presence
of tracheostomy or
endotracheal tube,
an overinflated
tracheostomy
endotracheal cuff,
inadequate inflation
of a tracheostomy
or endotracheal
tube cuff,
 Date Cues Nursing Scientific Basis
Diagnosis
02/04/2020 gastrointestinal tubes
and bolus tube feeding
or medication
administration. Other
risk factors are
situations hindering
elevation of the of the
upper body, increased
intragastric pressure,
increase gastric residual
, decreased
gastrointestinal motility,
delaying gastric
emptying, impaired
swallowing, wired jaws
and facial, oral, and
neck surgery or trauma.
 
MOSBYS Medical
Nursing and Allied
Health; Dictionary fourth
edition (page 133)
 Goal Of Care Nursing Rationale Evaluation
Intervention
After 30 minutes of Independent:   After 30 minutes of
nursing intervention - monitor vital signs - serves as baseline nursing intervention
the patient will be   data the patient is able to:
able to: - confirm placement - misplacement of  
  of nasogastric tube. nasogastric tube may >be free of signs of
> be free of signs of Determine feeding result to aspiration of aspiration as
aspiration position in stomach enteral formula. evidenced by no
> decrease risk of by auscultating Injecting air abnormal breath
aspiration injected air before determines proper sound
> maintain a patent intermittent feedings. placement of ngt. > tolerate feeding
airway with normal - keep head of bed  
breath sounds elevated at 30 to 45 - reduces risk of
> swallows and degrees during regurgitation
digest nasogastric feeding and at least 1  
feeding without hour after feeing  
aspiration.     
   
 
 
 
Goal Of Care Nursing Rationale Evaluation
Intervention
- monitor gastric - presence of large
residuals between or gastric residuals may
before feeding potentiate an
  incompetent
  esophageal sphincter,
  leading to vomiting
  and aspiration.
 - investigate - signs and symptoms
development of reflection respiratory
dyspnea, cough, distress suggests
tachypnea, and aspiration.
cyanosis. Auscultate  
breath sounds
 
Goal Of Care Nursing Rationale Evaluation
Intervention
- investigate - may require
development of considerations of
dyspnea, cough, surgically placed feeding
tachypnea, and tube, percutaneous
cyanosis. Auscultate endoscopic gastrostomy
breath sounds (peg) or jejustomy for
- note indicators of NG client safety and
tube intolerance, such consistency of formula
as absence of gag feeding.
reflex, high risk of - to create immediate
aspiration, and frequent care plan
removal of NG tubes.  
- encourage mother of  - confirmation of
the patient to report placement of gastric
immediately any feeding tube should be
abnormal symptoms. obtained by x-ray
 
Collaborative:
- review abdominal x-ray
if performed