Risk For Aspiration

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UNIVERSITY OF CEBU at PARDO & TALISAY

BULACAO, CEBU CITY


272-8475 / 272-298

NURSING CARE PLAN


Name: Erica Marie H. Fabrigas
NCP#1: Risk for Aspiration R/T Depressed Cough and Gag Reflex

Assessment Nursing Planning Intervention Rationale Evaluation


Diagnosis

Subjective: Risk for Aspiration Short term: • Assess for gag reflex • Impaired swallowing Goal met; as
 Maglisod koa R/T Depressed After 30 minutes of nursing and swallowing. may cause aspiration. evidenced by patient/
og tulon sa Cough and Gag interventions the patient will be SO was able to
foods Reflex able to: • Elevate the head of the • To aid breathing and demonstrate and
 Patient will demonstrate bed or Upright position promotes lung verbalize
Objective: measures to prevent when eating. expansion. understanding of
 RR 22 cpm aspiration. cause and therapeutic
 Restlessness Long term: • Place pt. on lateral • Reduces the risk of management regimen
 Hoarseness of After 1-2 hours of nursing position or change the aspiration by allowing and patient was able
voice noted intervention patient/significant position. secretions to drain. to maintain a patent
 Productive other will be able to: airway
cough with  Significant other will bed • Encourage pt. to drink • To prevent blockage
mucus demonstrate and verbalize fluids when eating. on the passage of food.
secretion color understanding of cause
yellow and therapeutic
management regimen • Instruct pt. to eat with • To prevent obstruction
maintain airway patency small amount of food. on airway and
and maintain normal aspiration.
breathing pattern

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