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Nursing Diagnosis Aspiration Related to Impaired Protective Reflexes Secondary to Neck Trauma
(Chemotherapy and radiation therapy)
3. Nursing interventions and corresponding rationale
(Number each intervention and its corresponding scientific rational)
2. Assessment Data Pertinent to above Nursing
Dx
a. Subjective Assessment
Pt Coughing
Pt stating Ў§have not been able to swallow since my CancerЎЁ
b. Objective Assessment
PcX-ray resulting in mild to moderate Infiltration in basilar lobes of lungs
Swallowing Study resulting in Silent Aspiration
Nothing by mouth/use of G tube
3a. Interventions
Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, or fever
Before initiating oral feeding, check clients gag reflex and ability to swallow by feeling the laryngeal prominence as the client attempts to swallow.
Have suction machine available when feeding high-risk clients. If aspiration does occur, suction immediately
Keep head of bed elevated when feeding and for at least an hour afterward.
Check to make sure initial nasogastric feeding tube placement was confirmed by x-ray, especially if a small-bore feeding tube is used. If unable to use x-ray for verification, check the pH of the aspirate. If pH reading is 4 or less, the tube is probably in the stomach. Also check bilirubin level of aspirate if possible.
Determine placement of feeding tube before each feeding or every 4 hours if client is on continuous feeding. Check pH of aspirate and note characteristic appearance of aspirate; do not rely on air insufflations method
Check for gastric residual every 4 hours during continuous feedings or before feedings; if residual is greater than 100 ml for gastrostomy feedings or greater than 200 ml for nasogastric tube feedings hold feedings following institutional protocol
During Enteral feedings, position client with head of bed elevated 30 to 40 degrees; maintain for 30 to 45 minutes after feeding
Stop continual feeding temporarily when turning or moving client
Have a speech and occupational therapist assess clients swallowing ability and other physiological factors and recommend strategies for working with client in the home (e.g., pureeing foods served to client
Encourage pt to chew thoroughly and eat slowly during meals. Instruct pt not to talk while eating.
While swallowing pt will place chin onto his chest and demonstrate proper swallowing techniques throughout meal.
3b. Scientific Rationale
Signs of aspiration should be detected as soon as possible to prevent further aspiration and to initiate treatment that can be lifesaving. Because of laryngeal pooling and residue in clients with Dysphagia, silent aspiration may occur.
It is important to check clients ability to swallow before feeding. A client can aspirate even with an intact gag reflex (Baker, 1993).
A client with aspiration needs immediate suctioning and will need further lifesaving interventions such as intubations (Fater, 1995).
4Maintaining a sitting position after meals may help decrease aspiration pneumonia in the elderly (Sasaki et al, 1997).
X-ray verification of placement remains the gold standard for determining