Sample Care Plan Template Page 45
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51Nursing Diagnosis and Priority # 4:
Risk for aspiration R/T depressed cough, tube feedings, presence of endotracheal tube, decreased gastrointestinal motility, reduced
level of consciousness AEB patient intubated and on ventilator, NG tube placed with tube feeds, previous incident of aspiration, heavy
alcohol consumption, decreased LOC while sedated with medication, medical diagnosis of GERD and RASS of 2+ while on sedation
vacation.
General Goal:
The patient will not aspirate any secretions or gastric contents during the day of care.
Outcome Objective(s): (use SMART format)
1. The patient will maintain clear lung sounds upon auscultation q4hrs during the nursing shift.
2. The patient will digest tube feedings and will have less than 200 ml in stomach upon aspiration of NG tube q8hrs during the nursing
shift.
3. The nurse will perform oral care q2hrs and suctioning PRN to prevent aspiration of secretions in the oral cavity during the nursing
shift.
Patient Responses
Interventions with time frames/frequency
Rationale (for each intervention)
(subjective/objective data)
1) Monitor the patient’s respiratory rate, depth,
1) Signs of aspiration should be assessed as
1) The patient did not experience
and effort. The nurse should not any signs of
soon as possible so that lifesaving treatment
any signs of aspiration during the
aspiration such as dyspnea, cough, cyanosis,
is not delayed (Guy & Smith, 2009).
nursing shift. RR was set at 14 by
wheezing, hoarseness, or fever (Ackley &
the ventilator and depth was steady.
Ladwig, 2011).
2) Bronchial auscultation is a specific
intervention that has been proven to identify
2) The patient lung sounds were
2) The nurse should auscultate the patients lung
client at risk for or who have aspirated
auscultated q4hrs and not
sounds q4hrs for new onset adventitious sounds
(Shaw et al, 2004).
adventitious sounds were present.
indication aspiration (Ackley & Ladwig, 2011).
3) While the patient is receiving a continuous
3) Studies have shown that the elevation of
3) The patients HOB was
tube feed his he of bed should be elevated 30-45
the HOB at 30-45 degrees decreases
maintained at 30 degrees
degrees to decrease the risk of aspirating gastric
aspiration pneumonia and the onset of
throughout shift because patient is
contents.
fevers (Guy & Smith, 2009).
on a continuous tube feed at 55
ml/hr.
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan
12/17/2012
page 25
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