Aplikasi Merah Putih

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Aplikasi Pulsa Gratis

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Nursing Diagnosis: Risk for Aspiration Application of NANDA, NOC, NIC

Nursing Diagnosis: Risk for Aspiration
Betty J. Ackley

NANDA Definition: At risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into the tracheobronchial passages

Related Factors: RISK FACTORS: Increased intragastric pressure; tube feedings; situations hindering elevation of upper body; reduced level of consciousness; presence of tracheostomy or endotracheal tube; medication administration; wired jaws; increased gastric residual; incomplete lower esophageal sphincter; impaired swallowing; gastrointestinal tubes; facial, oral, or neck surgery or trauma; depressed cough and gag reflexes; decreased gastrointestinal motility; delayed gastric emptying

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
·         Respiratory Status: Ventilation
·         Aspiration Control
·         Swallowing Status
Client Outcomes
·         Swallows and digests oral, nasogastric, or gastric feeding without aspiration
·         Maintains patent airway and clear lung sounds
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Aspiration Precautions
Nursing Interventions and Rationales
·         Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, or fever. 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 (i.e., not manifested by choking or coughing) may occur.
·         Auscultate lung sounds frequently and before and after feedings; note any new onset of crackles or wheezing.
·         Take vital signs q __ h(rs).
·         Before initiating oral feeding, check client's gag reflex and ability to swallow by feeling the laryngeal prominence as the client attempts to swallow. It is important to check client's ability to swallow before feeding. A client can aspirate even with an intact gag reflex (Baker, 1993).
·         When feeding client, watch for signs of impaired swallowing or aspiration, including coughing, choking, spitting food, or excessive drooling. If client is having problems swallowing, see Nursing Interventions for Impaired swallowing.
·         Have suction machine available when feeding high-risk clients. If aspiration does occur, suction immediately. A client with aspiration needs immediate suctioning and will need further lifesaving interventions such as intubation (Fater, 1995).
·         Keep head of bed elevated when feeding and for at least a half hour afterward. Maintaining a sitting position after meals may help decrease aspiration pneumonia in the elderly (Sasaki et al, 1997).
·         Note presence of any nausea, vomiting, or diarrhea. Treat nausea promptly with antiemetics.
·         Listen to bowel sounds qh, noting if they are decreased, absent, or hyperactive. Decreased or absent bowel sounds can indicate an ileus with possible vomiting and aspiration; increased high-pitched bowel sounds can indicate mechanical bowel obstruction with possible vomiting and aspiration.
·         Note new onset of abdominal distention or increased rigidity of abdomen. Abdominal distention or rigidity can be associated with paralytic or mechanical obstruction and an increased likelihood of vomiting and aspiration.
·         If client has a tracheostomy, ask for referral to speech pathologist for swallowing studies before attempting to feed. After evaluation, decision should be made to either have cuff inflated or deflated when client eats. The presence of a tracheostomy tube increases the incidence of aspiration. For some clients, inflating the cuff may help decrease aspiration; for other clients the inflated cuff will interfere with swallowing. This decision should be made following swallowing studies for the safety of the client's airway (Murray, Brzozowski, 1998).
·         Feed client only during formal rest periods from restraints.
·         If client shows symptoms of nausea and vomiting, position on side.
·         If client needs to be fed, feed slowly and allow adequate time for chewing and swallowing.
Enteral feedings
·         Check to make sure initial 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, tube is probably in the stomach. Also check bilirubin level of aspirate if possible X-ray verification of placement remains the gold standard for determining safe placement of feeding tubes (Metheny et al, 1998; Rakel et al, 1990). Small-bore feeding tubes have been inadvertently placed in the respiratory tract, and clients did not demonstrate any signs of respiratory distress (Fater, 1995). Use of pH and bilirubin measurement has been found to be predictive of correct placement of feeding tubes, both gastric and intestinal. Bilirubin testing is done using urinary bilirubin test strip and a developed visual bilirubin scale (Metheny, Smith, Stewart, 2000).
·         Keep nasogastric tube securely taped. Use pink tape to secure the tube. Use of pink tape as opposed to clear tape or butterfly tape increases the length of time a tube stays taped (Burns et al, 1995).
·         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 insufflation method. The auscultatory air insufflation method is often not reliable for differentiating between gastric or respiratory placement. Testing the pH generally predicts feeding tube position in the gastrointestinal tract, especially if combined with identification of appearance of aspirate (Metheny et al, 1993, 1998).
·         Check for gastric residual every 4 hours during continuous feedings or before feedings; if residual is (100 ml for gastrostomy feedings or (200 ml for nasogastric tube feedings (McClave et al, 1992), hold feedings following institutional protocol. Increased intragastric pressure from retained feeding can result in regurgitation and aspiration, but holding feeding unnecessarily can also result in an inadequate caloric intake (Edwards, Metheny, 2000).
·         If ordered by physician, put several drops of blue or green food coloring in tube feeding to help indicate aspiration. In addition, test the glucose in tracheobronchial secretions to detect aspiration of enteral feedings. Colored secretions suctioned or coughed from the respiratory tract indicate aspiration (Ackerman, 1993; Fater, 1995). However, this technique is not reliable and use of a multiple-use bottle may result in contamination of feedings and spread bacteria (Fellows et al, 2000). Tracheobronchial secretions that test positive for glucose can indicate aspiration of enteral feedings (Metheny, St John, Clouse, 1998).
·         During enteral feedings, position client with head of bed elevated 30 to 40 degrees; maintain for 30 to 45 minutes after feeding. Keeping client's head elevated helps keep food in stomach and decreases incidence of aspiration (Fater, 1995; Sasaki et al, 1997). A study of mechanically ventilated clients receiving enteral feedings demonstrated a decreased incidence of nosocomial pneumonia if the client was positioned at a 45-degree semirecumbent position as opposed to a supine position (Drakulovic et al, 1999).
·         Stop continual feeding temporarily when turning or moving client. When turning or moving a client, it is difficult to keep the head elevated to prevent regurgitation and possible aspiration.
·         Carefully check elderly client's gag reflex and ability to swallow before feeding. Laryngeal nerve endings are reduced in the elderly, which diminishes the gag reflex (Close, Woodson, 1989).
·         Watch for signs of aspiration pneumonia in the elderly with cerebrovascular accidents, even if there are no apparent signs of difficulty swallowing or of aspiration. Bedside evaluation for swallowing and aspiration can be inaccurate; silent aspiration can occur in this population (Smithard et al, 1998).
·         Use central nervous system depressants cautiously; elderly clients may have an increased incidence of aspiration with altered levels of consciousness. Elderly clients have altered metabolism, distribution, and excretion of drugs. Some medications can interfere with the swallowing reflex.
Home Care Interventions
·         For clients at high risk for aspiration, obtain complete information from the discharging institution regarding institutional management. Continuity of care can prevent unnecessary stress for the client and family and can facilitate successful management in the home setting.
·         Assess the client and family for willingness and cognitive ability to learn and cope with swallowing, feeding, and related disorders. Food and feeding habits may be strongly tied to family cultural values. Acknowledgment and/or adjustment to cultural values can facilitate compliance and successful family coping.
·         Establish emergency and contingency plans for care of client. Clinical safety of client between visits is a primary goal of home care nursing (Stanhope, Lancaster, 1996).
·         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; providing adaptive equipment for independence in eating). Successful strategies allow the client to remain part of the family.
·         Assess caregiver understanding and reinforce teaching regarding positioning and assessment of the client for possible aspiration.
·         Obtain suction equipment for the home as necessary.
·         Teach caregivers safe, effective use of suctioning devices. Inform client and family that only individuals instructed in suctioning should perform the procedure.
Client/Family Teaching
·         Teach client and family signs of aspiration and precautions to prevent aspiration.
·         Teach client and family how to safely administer tube feeding.

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ABC Medika mengatakan...

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