Nursing Diagnosis Aspiration Related to Impaired Protective Reflexes Secondary to Neck Trauma

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 ÐŽ§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

1. Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, or fever

2. Before initiating oral feeding, check client's gag reflex and ability to swallow by feeling the laryngeal prominence as the client attempts to swallow.

3. Have suction machine available when feeding high-risk clients. If aspiration does occur, suction immediately

4. Keep head of bed elevated when feeding and for at least an hour afterward.

5. 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.

6. 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

7. 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

8. During Enteral feedings, position client with head of bed elevated 30 to 40 degrees; maintain for 30 to 45 minutes after feeding

9. Stop continual feeding temporarily when turning or moving client

10. Have a speech and occupational therapist assess client's swallowing ability and other physiological factors and recommend strategies for working with client in the home (e.g., pureeing foods served to client

11. Encourage pt to chew thoroughly and eat slowly during meals. Instruct pt not to talk while eating.

12. While swallowing pt will place chin onto his chest and demonstrate proper swallowing techniques throughout meal. 3b. Scientific Rationale

1. 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.

2. It is important to check client's ability to swallow before feeding. A client can aspirate even with an intact gag reflex (Baker, 1993).

3. A client with aspiration needs immediate suctioning and will need further lifesaving interventions such as intubations (Fater, 1995).

4. 4Maintaining a sitting position after meals may help decrease aspiration pneumonia in the elderly (Sasaki et al, 1997).

5. X-ray verification of placement remains the gold standard for determining safe placement of feeding tubes (Metheny et al, 1998). Nursing Research: Small-bore feeding tubes have been inadvertently placed in the respiratory tract, and clients did not demonstrate any signs of respiratory distress (Metheny et al, 1990a). Use of pH and bilirubin measurement has been found to be predictive of correct placement of feeding