Risk for Aspiration Concept Map PDF

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Summary

risk for aspiration concept map...

Description

Medications Gabapentin, 600 mg, oral TID

Lab Data No pertinent lab data to diagnosis

Pathophysiology Dysphagia or swallowing difficulty is associated with the lack of a gag reflex, as occurs in degenerative neurological diseases and stroke. Dysphagia frequently begins with difficulty swallowing solid foods and progresses to the inability to swallow liquids. And individual may complain of feeling as though the food gets stuck, and frequent attempts to swallow are necessary for movement of food.

Nursing Diagnosis Risk for aspiration related to patients PEG tube as evidenced by esophageal dysphagia.

Medical History Patients medical history includes esophageal dysphagia, nausea and vomiting, gastroesophageal reflux disease, abdominal pain, and multiple sclerosis and seizures.

Physical Assessment 47 years old (S) PEG tube in left upper quadrant of abdomen (O) Intermittent feeding by PEG tube at 65 mL/hr Slurred speech (O)

Nursing Interventions

Education 1. Troy BSN Student will educate the patient on risks for aspiration. 2. Troy BSN Student will educate the patient on what to do if aspiration does occur. 3. Troy BSN student will educate the patient on the proper positioning to facilitate feedings and prevent spiration.

Coping / Family No family present. Nurse informed patient that husband would be calling soon. Plans were being made to transport the patient to rehab center.

1. Troy BSN Student will keep head of patients bed elevated at 30 degrees or higher during feedings. “Keep the head of the bed elevated while the patient is receiving a tube feeding or eating and for 30 minutes afterward, unless otherwise directed.” (Taylor et. al., 2021) 2. Troy BSN Student will check residual before resuming feedings. “Administer intermittent (bolus) tube feedings, as ordered. Assess for tolerance by checking for residual stomach contents, assessing for abdominal distention or firmness, or assessing for a feeling of fullness or nausea before each feeding.” (Taylor et. al., 2021) 3. Troy BSN Student will monitor patient for signs of aspiration, such as dyspnea, cyanosis, and coughing. “ Signs of aspiration should be identified as soon as possible to prevent further aspiration and to initiate treatment that can be lifesaving.” (Gil Wayne, 2017, chart 1) 4. Troy BSN Student will auscultate the patients bowel sounds to assess for gastrointestinal motility. “Reduced gastrointestinal motility increases the risk for aspiration as fluids and food build up in the stomach.” (Gil Wayne, 2017, chart 1) 5. Troy BSN Student will check placement of the PEG tube before feedings. “A displaced tube may erroneously deliver tube feeding into the airway. Chest x-ray verification of accurate tube placement is most reliable. Gastric aspirate is usually green, brown, clear, or colorless, with a pH between 1 and 5.” (Gil Wayne, 2017, chart 1)

Instructions: 1. For medications – list pertinent medications the patient is currently taking, including drug name, action, nursing implications, and evaluation of response to each medication. 2. Pathophysiology – include a brief description of the patho for each medical diagnosis contributing to this patient problem. 3. Medical History – include pertinent facts only 4. Physical assessment – include pertinent facts only 5. Nursing interventions – list interventions specific to this patient problem 6. Coping / Family – include an assessment of the patient’s coping mechanisms, and any family/significant others impact 7. Educational needs – identify pertinent educational needs related to this patient problem 8. Lab Data – include only lab data that is relevant to this patient problem Note: This information is to be very concise. You should ONLY include information related to this problem. If the patient has more than one problem, you will need additional maps, one for each problem....