Professional Documents
Culture Documents
DIAGNOSIS PLAN
SUBJECTIVE Risk for A state in which an After 1 day of 1. Assess to rule out After 1 day of
CUES: aspiration individual is at risk for nursing gastrointesti hypoactive peristalsis nursing
related to entry of gastric interventions, nal function and abdominal interventions,
nakukurian Neuromuscular secretions, oropharyngeal the patient will distension. the patient was
na hiya dysfunction secretions, or exogenous be able to have: 2. Position able to have:
pagtutulon food or fluids into patient with to prevent gastric
asya naka tracheobronchial Normal head of bed reflux through Normal
NGT hiya as passages because of breath elevated 30 gravity. If head breath
verbalized by dysfunction of normal sounds or degrees elevation is sounds or
the patients protective mechanisms. no change contraindicated, no change
watcher. in patients position patients in in
Aspiration(the baseline 3. Maintain right lateral decubitus patients
misdirection breath patency and position to facilitate baseline
OBJECTIVE of oropharyngeal sounds functioning passage of gastric breath
CUES: secretions or gastric of contents accross the sounds
contents into the larynx ABG values pylorus.
nasogastric
with NGT for and lower respiratory remain ABG
suction
feeding tract) is common in older within values
apparatus
history of adults with dysphagia and patients remain
to prevent
CVA can lead to aspiration baseline 4. Provide within
accumulation of
(January pneumonia. frequent and patients
No gastric contents.
2017) scrupulous baseline
The older adult with one evidence of mouth care
minimize gag
of these conditions is at gastric No
reflex
even greater risk for contents in 5. Ensure that to prevent evidence
Aspiration because The lung endotrachea colonization of the of gastric
dysphagia is secretions l/tracheosto oropharynx with contents
superimposed my cuff is bacteria and in lung
properly noculation of the secretions
inflated lower airways.
Goals met
6. Treat nausea
promptly;
collaborate to limit aspiration of
with oropharyngeal
physician on secretions.
an order for
antiemetic
to prevent vomiting
Additional and resultant
interventions for aspiration.
patients receiving
continuous or
intermittent enteral
tube feedings
1. Position
patients with
head of bed
elevated 45
degrees
3. Instill blue
food coloring
to feeding
solutions
Experience
Formation of blister healing of
Increase the
ulcer/regain
frequency of turning
skin integrity
(turning q2). Position To disperse
Rupture of blister (reduce size of
ulcer) the client to stay off pressure over
the ulcer. If there is time or
Reduce risk no turning surface decreasing
+ open wound for infection without a pressure the tissue
ulcer, use a pressure load
redistribution bed &
continue turning the
client
Dependent/Collaborative:
To prevent
malnutrition
& delayed
Ensure adequate
healing
dietary intake.
Review dieticians
recommendations.
To prevent
Prevent the ulcer contaminatio
from being exposed n/spread of
to urine & feces. Use infection
indwelling catheters,
bowel containment To promote
systems, & topical wound
creams or dressings. healing on
clients who
Supplement the diet do not have
with vitamins & adequate
minerals. Vitamins C calories.
and zinc are
commonly
prescribed.
Pressure
ulcers cannot
heal in clients
Provide oral with severe
supplementations, malnutrition.
tube-feedings or
hyperalimentation to
achieve positive
nitrogen balance.
To promote
Remove devitalized
faster healing
tissue from the
& reduce
wound bed, except in
infection
the avascular tissue
or on the heels.
Began by cleansing
the ulcer bed with
normal saline, then
use appropriate
technique for
debridement. Once
the ulcer is free of
devitalized tissue,
apply dressing the
keep the wound bed
moist & the
surrounding skin dry.
Do not use occlusive
dressings on ulcer.