University:
West Coast University
Course:
NURS 103 | Fundamentals of Nursing
Academic year:

2021
Views:

41

Pages:

2
Author:

Galaffi133

ASSESSMEN T CUES Subjective: No verbal cues Objective: HR: 104 bpm RR: assisted BP: 80/40 O2 sat: 91% GCS: 4 (E1V2M1) >Unresponsive >With ET tube NURSING DIAGNOSIS OUTCOME IDENTIFICATION Risk for aspiration r/t presence of endotracheal tube and altered level of consciousness After 3 hours of nursing intervention the patient will be able to: Scientific Basis: Reduce levels of consciousness’ compromises the cough reflex and the normal swallow process. Thus patients with a reduced level of consciousness may be predisposed to aspirate and have a reduced ability to clear aspirated material from the lungs. Maintain patent airway as evidenced by oxygen saturation of 96% Reference: Hibberd, J., Fraser, J., Chapman, C., McQueen, H., & Wilson, A. (2013). Can we use influencing factors to predict aspiration pneumonia in the United Kingdom?. Multidisciplinary respiratory medicine, 8(1), 39. https://doi.org/10.1186/20496958-8-39 PLANNING NURSING INTEVENTIONS RATIONALE (with references) Independent: The primary risk factor of Assess level of aspiration is decreased consciousness. level of consciousness (Doenges, M. et al. 2016). INTERVENTIONS Auscultate breath sounds for development of crackles and/or rhonchi. Remain free of aspiration with no adventitious breath sounds noted and reduce the risk of recurrence Monitor the effectiveness of the endotracheal tube cuff/ . Position on sides. Aspiration of small amounts can occur without coughing or sudden onset of respiratory distress, especially in patients with decreased levels of consciousness. Crackle and rhonchi that occur suddenly could be an indicator of a small amount of aspiration. (Doenges, M. et al. 2016). An ineffective cuff can increase the risk of aspiration. Work together with the respiratory therapist, as necessary, to verify cuff pressure. (Doenges, M. et al. 2016). To prevent aspirations of secretions and maintain EVALUATION After 3 hours of nursing intervention the patient was able to: Maintain patent airway as evidenced by oxygen saturation of 96% Remain free of aspiration with no adventitious breath sounds noted and reduce the risk of recurrence Perform oral suctioning. Inform the physician or other health care provider instantly of noted decrease in cough/gag reflexes or difficulty in swallowing. Educate the family for the need for proper positioning. open airways. (Doenges, M. et al. 2016). Suctioning reduces the volume of oropharyngeal secretions and reduces aspiration risk (Doenges, M. et al. 2016). Early intervention protects the patient’s airway and prevents aspiration. Anyone identified as being at high risk for aspiration should be kept NPO (nothing by mouth) until further evaluation is completed. (Doenges, M. et al. 2016). Upright positioning decreases the risk for aspiration(Doenges, M. et al. 2016).