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    2 NCP Impaired Swallowing Edited

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    Zharm May
    -Encourage fluid -To prevent intake as dehydration and ordered. promote mucus clearance. -Feed the patient -To meet the small frequent patient's meals as nutritional needs ordered. safely. -Monitor intake -To monitor and output. hydration status and identify signs of aspiration. -Weigh the -To monitor patient daily. nutritional status. -Provide oral -To prevent oral hygiene after infections and each meal. promote comfort. -Turn and -To prevent position every 2 pressure ulcers hours. and promote

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    2 NCP Impaired Swallowing Edited

    Uploaded by

    Zharm May
    1K views4 pages
    -Encourage fluid -To prevent intake as dehydration and ordered. promote mucus clearance. -Feed the patient -To meet the small frequent patient's meals as nutritional needs ordered. safely. -Monitor intake -To monitor and output. hydration status and identify signs of aspiration. -Weigh the -To monitor patient daily. nutritional status. -Provide oral -To prevent oral hygiene after infections and each meal. promote comfort. -Turn and -To prevent position every 2 pressure ulcers hours. and promote

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    -Encourage fluid -To prevent intake as dehydration and ordered. promote mucus clearance. -Feed the patient -To meet the small frequent patient's meals as nutritional needs ordered. safely. -Monitor intake -To monitor and output. hydration status and identify signs of aspiration. -Weigh the -To monitor patient daily. nutritional status. -Provide oral -To prevent oral hygiene after infections and each meal. promote comfort. -Turn and -To prevent position every 2 pressure ulcers hours. and promote

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views4 pages

    2 NCP Impaired Swallowing Edited

    Uploaded by

    Zharm May
    -Encourage fluid -To prevent intake as dehydration and ordered. promote mucus clearance. -Feed the patient -To meet the small frequent patient's meals as nutritional needs ordered. safely. -Monitor intake -To monitor and output. hydration status and identify signs of aspiration. -Weigh the -To monitor patient daily. nutritional status. -Provide oral -To prevent oral hygiene after infections and each meal. promote comfort. -Turn and -To prevent position every 2 pressure ulcers hours. and promote

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    © All Rights Reserved
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    The key takeaways are that impaired swallowing can be caused by neuromuscular impairment and can lead to complications like aspiration if not properly managed. Nursing interventions aim to improve swallowing and prevent aspiration.

    Signs and symptoms of impaired swallowing include difficulty swallowing, drooling, stasis of mucus in the oral cavity, gagging, wheezing, and rapid breathing.

    Nursing interventions for impaired swallowing include positioning the patient correctly, providing oral care before feeding, encouraging deep breathing and coughing exercises, keeping the patient upright for 30 minutes after meals, and monitoring for signs of aspiration.

    ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

    ANALYSIS
    Subjective Data: Impaired Abnormal Long-Term Goal: Independent: -With impaired -Patient displays
    “Nahihirapan siyang swallowing functioning of After 3-4 months of -Have suction swallowing improved
    maka-hinga at related to the swallowing nursing equipment reflexes, swallowing, as
    maka-ubo, hindi niya neuromuscular mechanism interventions, the available and secretions can evidenced by
    rin kayang kumain impairment. associated with patient will be able functioning rapidly absence of
    mag-isa.” as deficits in oral, to: properly. accumulate in the aspiration, no
    verbalized by pharyngeal, or posterior pharynx evidence of
    patient’s wife. esophageal -Display improved and upper coughing or
    structure or swallowing, as trachea, choking during
    Objective Data: function. evidenced by increasing the risk eating/drinking,
    Impaired absence aspiration of aspiration. no stasis of food
    -Difficulty of swallowing and the risk of in oral cavity after
    swallowing involves more aspiration is -Monitor the -These signs may eating, ability to
    -Drooling time and effort decreased as patient for indicate ingest
    -Stasis of mucus to transfer food manifested by coughing, regurgitation/ foods/fluids.
    secretions in oral or liquid from reduced stasis of gagging, aspiration.
    cavity the mouth to mucus secretions, wheezing and -Patient
    -Gagging the stomach. It chances of gagging, difficulty of determines
    -Wheezing occurs when the drooling and breathing. different
    -Rapid breathing muscles and abnormally rapid emergency
    nerves that help breathing. -Teach the -Because the tip measures when
    Vital signs: the food patient and the of ngt may be signs of aspiration
    through the family on how to dislodged from occurs.
    BP: 110/70 throat and monitor for signs the stomach and
    Pulse: 85 bpm esophagus are of aspiration lead to aspiration.
    Respiration: 30 cpm not working especially during
    Temperature: 36.5C right. It can be a ngt feeding.
    02 SAT: 99% temporary or -Because
    permanent -Monitor the alteration may
    complication patients’ vital indicate
    that can be sign. complications like
    fatal. aspiration.
    -Encourage deep -To promote lung
    breathing and expansion and
    coughing initiates the
    exercises. coughing reflex,
    which facilitates
    expectoration of
    mucus secretion.

    -Keep the patient -To prevent


    in an upright aspiration due to
    position for more backflow of
    than 30 minutes osteorized food.
    after a meal.

    -Position the -To promote


    patient correctly airway clearance
    with the head due to stasis of
    facing to the side mucus and to
    or on a semi/high promote
    fowlers. oxygenation via
    maximum chest
    expansion.

    -Provide oral care - Good oral and


    before feeding. dental hygiene
    can help prevent
    bad breath, tooth
    decay and gum
    disease
    Dependent:
    -Administer N- -To Decrease
    Acetylcysteine as viscosity of the
    ordered by the mucus secretions
    doctor. for easy removal.

    -Suction -To clear the


    secretions as airway due to
    ordered by the obstruction by
    doctor. the mucus
    secretions.

    Collaborative:

    -Refer to -To liquefy mucus


    Respiratory secretion for easy
    Therapist for expulsion.
    Nebulization.

    -Refer to -For indirect


    Respiratory removal of mucus
    Therapist for to breathe more
    Chest freely.
    physiotherapy.

    -Consult with -Evaluating gag


    speech therapist reflex decreases
    to evaluate gag the risk for
    reflexes. aspiration.
    -Refer to -The dysphagia
    dysphagia team team can help the
    composed of a patient learn to
    rehabilitation swallow safely
    nurse, speech and maintain a
    pathologist, good nutritional
    dietitian, status.
    physician, and
    radiologist who
    work together.

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