ASSESSMENT Nursing Diagnosis: Acute pain rlt swallowing S> Masakit kapag lumulunok ako.

Pain rated as 10/10 O Grimacing noted when swallowing Prefers soft foods and liquids Guarding behavior noted NGT insertion ordered Decrease interaction with people around Irritable

EXPLANATION OF THE PROBLEM The pain is due to anaplastic cancer of the thyroid.

GOALS & OBJECTIVES

INTERVENTIONS Dx: Monitor level of consciousness.

RATIONALE

EVALUATION

A decreased level of consciousness is a prime risk factor for aspiration. A depressed cough or gag reflex increases the risk of aspiration. Pockets of food can be easily aspirated at a later time. Choking indicates aspiration.

Assess cough and gag reflexes.

Monitor swallowing ability: o Assess for coughing or clearing of the throat after a swallow. o Assess for residual food in mouth after eating. o Assess for regurgitation of food or fluid through nares. o Monitor for choking during eating or drinking. Auscultate bowel sounds to evaluate bowel motility.

Decreased gastrointestinal motility increases the risk of aspiration because food or fluids accumulate in the stomach. Elderly patients have a decrease in esophageal motility, which delays esophageal emptying. When combined with

the weaker gag reflex of elderly patients, aspiration is a higher risk.

Auscultate breath sounds for development of crackles and/or rhonchi

Aspiration of small amounts can occur without coughing or sudden onset of respiratory distress, especially in patients with decreased levels of consciousness.

In patients with endotracheal or tracheostomy tubes, monitor the effectiveness of the cuff. Collaborate with the respiratory therapist, as needed, to determine cuff pressure. Tx: Keep suction setup available (in both hospital and home settings) and use as needed.

An ineffective cuff can increase the risk of aspiration.

This is necessary to maintain a patent airway.

Notify the physician or other health care provider immediately of noted decrease in

Early intervention protects the patients airway and prevents aspiration.

cough and/or gag reflexes or difficulty in swallowing.

Position patients who have a decreased level of consciousness on their sides

This protects the airway. Proper positioning can decrease the risk of aspiration. Comatose patients need frequent turning to facilitate drainage of secretions. This will help detect abnormalities early.

Supervise or assist patient with oral intake. Never give oral fluids to a comatose patient.

Offer foods with consistency that patient can swallow. Use thickening agents as appropriate. Cut foods into small pieces.

Semisolid foods like pudding and hot cereal are most easily swallowed. Liquids and thin foods like creamed soups are most difficult for patients with dysphagia.

Position patient at 90degree angle, whether in bed or in a chair or wheelchair. Use

Proper positioning of patients with swallowing difficulties is of primary

cushions or pillows to maintain position.

importance during feeding or eating.

Maintain upright position for 30 to 45 minutes after feeding.

The upright position facilitates the gravitational flow of food or fluid through the alimentary tract. If the head of the bed cannot be elevated because of the patients condition, use a right side-lying position after feedings to facilitate passage of stomach contents into the duodenum.

Provide oral care after meals.

This removes residuals and reduces pocketing of food that can be later aspirated. A displaced tube may erroneously deliver tube feeding into the airway.

In patients with nasogastric (NG) or gastrostomy tubes: o Check placement before feeding.

Use speech pathology consultation as appropriate.

A speech pathologist can be consulted to perform a dysphagia assessment that helps

determine the need for videofluoroscopy or modified barium swallow.

Edx: Explain to patient/caregiver the need for proper positioning.

This decreases the risk of aspiration.

Instruct on signs and symptoms of aspiration.

This aids in appropriately assessing high-risk situations and determining when to call for further evaluation.

Instruct on upperairway suctioning technique

To prevent accumulation of secretions in the oral cavity.