Assessment

Subjective Pt stated that she was nauseous.

Nursing DX/Clinical Problem Problem Impaired swallowing

Client Goals/Desired Outcomes/Objectives Long Term: Patient will remain free from aspiration until the time of discharge.

Objective Pt vomited after eating breakfast tray. Pt coughed, wet cough, after each attempt to swallow. Pt took a long time to chew and swallow food and continued to pocket food in cheeks even after attempting to swallow. Pt needed assistance to chew food and took about 5 minutes to chew and swallow each small bite of food provided

Nursing Interventions/Actions/Orders and Rationale Assess the patients ability to swallow using a bedside swallow screening because a screening can show if the patient is at risk for aspiration and if the patient should be on precautions such as thickened liquids. It can also decrease the patients length of stay, shorten recovery time, and reduce overall health costs. (Ackley & Ladwig, 2008, p 812). Watch for signs and symptoms of aspiration and pneumonia. Auscultate lung sounds after feeding and note any new lungs sounds such as crackles or wheezes because new lung sounds in an increase in respiratory rate can indicated aspiration of food or the onset of pneumonia (Ackley & Ladwig, 2008, p 813). Keep the patient in an upright position for more than 45 minutes after a meal to prevent aspiration in older adults (Ackley & Ladwig, 2008, p 813).

*I Goals

Evaluation Interventions Continue to assess bedside swallowing techniques and monitor for possible aspiration. Will be re-evaluated tomorrow at noon. Lung sounds will be continued to be assessed every shift as well as after each feeding to note any new lung sounds. Will continue until time of discharge. Continue to keep patient in an upright position after meals to prevent aspiration until the time of discharge. Re-evaluate each shift.

Goal still in progress. Patient has not had any incidence of aspiration at the current time. No discharge orders are written and goal still in progress of being evaluated.

R/T neuromuscular disturbances

Short Term: Patient will demonstrate effective swallowing techniques

Watch for uncoordinated chewing or swallowing, or coughing immediately after swallowing because it can

Goal not met- will continue to work with the speech therapist and

Will continue to watch for uncoordinated swallowing to

for her. Regurgitation of gastric contents with belching after dinner tray.

AEB difficulty eating, vomiting, pt took a long time to swallow foods, and coughing after swallowing.

by the end of the shift and evaluated by a nurse or therapist.

indicate possible silent aspiration and they are signs of possible aspiration and impaired swallowing (Ackley & Ladwig, 2008, p 812). Work with the patient on swallowing exercises as described by the dysphagia team because swallowing exercises are both motor and sensory and can improve the patients ability to swallow (Ackley & Ladwig, 2008, p 813). Have suction material ready at bedside and during feeding in case chocking occurs and suctioning is necessary to clear airway. If this is the case, need to discontinue oral feedings until the client is assessed with a swallow study (Ackley & Ladwig, 2008, p 813). Praise the patient for successfully following directions and swallowing appropriately because positive reinforcement helps the patient want to learn (Ackley & Ladwig, 2008, p 813).

dysphagia team to help patient learn ways to improve swallowing. Will reevaluate goal next shift. Need to have the results of swallow test and need to have dysphagia team consult with patient.

ensure that patient is not going to aspirate. Continue to assess with each feeding and each shift. Will continue to work with dysphagia team to improve swallowing skills. Will re-evaluate with dysphagia team next shift. Will have suction material at bedside until the time of discharge to have in case aspiration does occur. Continue to use positive reinforcement to help patient want to learn to swallow efficiently and without aspiration.