SAINT PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
NURSING CARE PLAN FORM

Patient’s Name (Initials): Admitting Diagnosis/Medical Diagnosis/CC:

Age: _ Sex: __ Physician (Initials):
Room No: Diet:

SUBJECTIVE OBJECTIVE NURSING SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EXPECTED

DIAGNOSIS OUTCOME

Risk for After 4-6hrs of nursing Keep suction machine A patient with aspiration After 4-6hrs
Aspiration: Pathophysiolo intervention the patient available when feeding needs immediate suctioning of nursing
At risk for gy will be high-risk patients. If and will need further intervention the
able to: patient is able to:
entry of aspiration does occur, lifesaving interventions such
Aspiration occurs
gastrointestin when something suction immediately. as intubation.
Be free of signs
al secretions, enters into the
 Patient is Early intervention protects of aspiration
oropharynge lungs that is not Inform the physician or
the patient’s airway and and the risk of
al secretion, air. This free of signs other health care
prevents aspiration. Anyone aspiration is
solids, or sometimes provider instantly of
of aspiration identified as being at high decreased.
fluids into causes aspiration noted decrease in
tracheobronc pneumonia, but and the risk cough/gag reflexes or risk for aspiration should be
hial not always. For of aspiration difficulty in swallowing. kept NPO (nothing by Patient expect
passages. example, the mouth) until further
is decreased. orates clear
patient has a gag evaluation is completed.
reflex, causing  Patient expe secretions and
coughing, or the is free of
cilia lining the ctorates Early intervention protects
lungs are able to Keep head of bed aspiration.
clear elevated when feeding the patient’s airway and
sweep out the prevents aspiration. Anyone
aspirated item. If secretions and for at least a half
identified as being at high Patient
the patient and is free hour afterward.
aspirates a risk for aspiration should be maintains a
secretion that has of kept NPO (nothing by
patent airway
a high bacterial aspiration. mouth) until further
count they will evaluation is completed. with normal
 Patient
likely get breath sounds.
 SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM

aspiration Position patients with a This positioning (rescue Patient

maintains a
pneumonia. decreased level of positioning) decreases the swallows and
patent consciousness on their risk for aspiration by digests oral,
airway with side. promoting the drainage of nasogastric, or
normal secretions out of the mouth gastric feeding
instead of down the without
breath pharynx, where they could aspiration
sounds. be aspirated.
 Patient
swallows Provide foods with Thickened semisolid foods
and digests consistency that the such as pudding and hot
patient can swallow. cereal are most easily
oral, swallowed and less likely to
Use thickening agents if
nasogastric, recommended by a be aspirated. Liquids and
speech pathologist or thin foods (e.g., creamed EVALUATION
or gastric
dietician. soups) are most difficult for
feeding patients with dysphagia.
without
aspiration. Well-masticated food is
Allow the patient to
chew thoroughly and eat easier to swallow, food cut
slowly during meals. into small pieces may also
be easier to swallow.

Note new onset of Abdominal distention or

abdominal distention or rigidity can be associated
increased rigidity of with paralytic or mechanical
abdomen. obstruction and an increased
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM

likelihood of vomiting and

aspiration.

Stop continual feeding When turning or moving a

temporarily when patient, it is difficult to keep
turning or moving the head elevated to prevent
patient. regurgitation and possible
aspiration.
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM
SAINT PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
NURSING CARE PLAN FORM