Assessment Objective: Noiseless Respiration

Nursing Diagnosis Risk for aspiration related to esophangeal disease affecting the stomach valve function

Goal After 8 hours of nursing intervention the patient will Stomach acid and experience no enzyme flow aspiration as back to evidenced by esophagus noiseless respirations; clear, odorless secretions. Stomach enzyme pass through the lungs

Inference GERD

Intervention Assess the clients ability to swallow and strength of gag reflex

Rationale Helps to determine presence/effectiveness of protective mechanism

Avoid keeping client supine / flat on bed

Supine positioning have shown to be independent risk for the development of aspiration

Evaluation After 8 hours of nursing intervention the patient had experience no aspiration as evidenced by noiseless respirations; clear, odorless secretions.

Auscultate lung sounds frequently Risk for Aspiration Elevate client to highest or best possible highest position Provide soft foods that stick together

To determine prensence of secretions

To prevent aspiration

To aid swallowing effort

Instruct family members to avoid/ limit activities after

Increase risk of regurgitation

eating that increase intaabdominal pressure