Assessment S= Not Applicable O=The patient manifested the ff:

Diagnosis of stroke and right sided paralysis Lethargy decreased level of consciousness (GCS 3 E1V1M1) depressed cough reflex difficulty swallowing without choking

Nursing Diagnosis Risk for aspiration r/t decreased level of consciousness

Planning SHORT TERM: After 1 hour of Nursing Interventions, the patients significant other will verbalize understanding of importance of elevating head of bed to prevent aspiration. LONG TERM: After 7 days of Nursing Interventions, the patient will remain free from aspiration as evidenced by absence of dyspnea, normal vital signs, and absence of crackles.

Interventions
Monitor level of consciousness.

Rationale
A decreased level of consciousness is a prime risk factor for aspiration. A depressed cough or gag reflex increases the risk of aspiration Decreased gastrointestinal motility increases the risk of aspiration because food or fluids accumulate in the stomach. Aspiration of small amounts can occur without coughing or sudden onset of respiratory distress, especially in patients with decreased levels of consciousness.

Evaluation SHORT TERM: After 1 hour of Nursing Interventions, the patients significant other verbalized understanding of importance of elevating head of bed to prevent aspiration. LONG TERM: After 7 days of Nursing Interventions, the patient remained free from aspiration as evidenced by absence of dyspnea, normal vital signs, and absence of crackles.

Assess cough and gag reflexes.

Auscultate bowel sounds to evaluate bowel motility.

Assess pulmonary status for clinical evidence of aspiration. Auscultate breath sounds for development of crackles and/or rhonchi. Keep suction setup available and use as needed. Notify the physician or other health care provider immediately of noted decrease in cough and/or gag

This is necessary to maintain a patent airway.

Early intervention protects the patients airway and prevents aspiration.

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. A displaced tube may erroneously deliver tube feeding into the airway. High amounts of residual (>50% of previous hours intake) indicate delayed gastric emptying and can cause distention of the stomach leading to reflux emesis. Promotes cooperation

Check placement of NGT before feeding. Check residuals before feeding. Hold feedings if residuals are high and notify the physician.

Explain importance of elevating HOB to SO. Maintain upright position for 30 to 45 minutes after feeding. Assist with postural drainage.

The upright position facilitates the gravitational flow of food or fluid through the alimentary tract. Mobilizes thickened secretions.