Assessment

  1. Assess the patient’s ability to swallow and control oral secretions.
  2. Monitor for signs and symptoms of aspiration, including coughing, choking, and difficulty breathing.

Nursing Diagnosis

  • Risk for aspiration related to presence of endotracheal tube and altered level of consciousness.

Planning

  1. The patient will maintain patent airway as evidenced by oxygen saturation of 96%.
  2. The patient will remain free of aspiration with no adventitious breath sounds noted and reduce the risk of recurrence.

Implementation

  1. Position the patient in an upright position during feeding and for at least 30 minutes after.
  2. Administer medication as ordered to decrease excessive oral secretions.
  3. Assess the patient’s level of consciousness and ability to follow commands before offering food or fluids.
  4. Offer small, frequent meals with a consistency appropriate for the patient’s level of swallowing ability.
  5. Provide thickened liquids or pureed foods as appropriate.
  6. Refer the patient to a speech therapist for a swallow evaluation and possible recommendations for swallowing strategies.
  7. Monitor the patient for signs of respiratory distress and respond quickly if they occur.
  8. Provide education to the patient and family about the signs and symptoms of aspiration and strategies to minimize the risk.

Evaluation

  1. Monitor the patient’s response to the interventions and adjust the care plan as necessary.
  2. Document the patient’s response to the interventions and communicate any changes to the interdisciplinary team.

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