NCP: Risk for Aspiration, Cerebro-vascular Accident (CVA)

Cerebro-vascular Accident (CVA)

Need
NUTRITIONAL-METABOLIC PATTERN

Nursing Diagnosis
Risk for aspiration related to poor coughing reflex secondary to COPD, CVA

Rationale:
Chronic conditions, including altered consciousness from head injury, spinal cord injury, neuromuscular weakness, hemiplegia and dysphagia from stroke, use of tube feedings for nutrition, endotracheal intubation, or mechanical ventilation may be encountered in the home, rehabilitative, or hospital settings. Elderly and cognitively impaired patients are at high risk. Aspiration is a common cause of death in comatose patients.

Sources:
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=04

Objective of Care
Within my 8 hours span of care my patient will be free from aspiration as evidenced by:

a. patent airway;
b. unlabored breathing.

Nursing Interventions
1. Monitor level of consciousness.
® A decreased level of consciousness is a prime risk factor for aspiration.
2. Assess cough and gag reflexes.
® A depressed cough or gag reflex increases the risk of aspiration.
3. 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.
4. Assess pulmonary status for clinical evidence of aspiration. 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.
5. In patients with endotracheal or tracheostomy tubes, monitor the effectiveness of the cuff.
® An ineffective cuff can increase the risk of aspiration.
6. Keep suction setup available and use as needed.
® This is necessary to maintain a patent airway.
7. Notify the physician or other health care provider immediately of noted decrease in cough and/or gag reflexes or difficulty in swallowing.
® Early intervention protects the patient’s airway and prevents aspiration.
8. 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.
9. Check placement of NGT before feeding.
® A displaced tube may erroneously deliver tube feeding into the airway.
10. Check residuals before feeding. Hold feedings if residuals are high and notify the physician.
® High amounts of residual (>50% of previous hour’s intake) indicate delayed gastric emptying and can cause distention of the stomach leading to reflux emesis.
11. 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 patient’s condition, use a right side-lying position after feedings to facilitate passage of stomach contents into the duodenum.
12. Assist with postural drainage.
® Mobilizes thickened secretions.