NURSING CARE PLAN | Prepared by: Karl Jade J.
Tulibas, BSN 2
ASSESSMENT
DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for aspiration Nasogastric tube Short term goal: Independent:
-No verbal cues. related to presence feeding is a strategy 1. Check placement of 1. To prevent
of nasogastric tube for temporary or -Pt will not NGT before feeding displacement of
Objective: with enteral feeding, long-term feeding experience through auscultation: the tube and
and impaired and for preventing aspiration during introducing air erroneously
-Pt. with nasogastric swallowing ability. aspiration enteral feeding through the tube and delivering the
tube for enteral pneumonia in listen for whoosh tube feeding into
feeding. patients with Pt. will: sounds. the airway of the
dysphagia. -Keep head of the pt.
-Impaired ability to bed at 30 degrees
swallow. Aspiration angle during and 2. Check residuals 2. Large amounts of
pneumonia is a 30mins to 1 hr after before feeding, or residuals indicate
common feedings. every 4 hours if delayed gastric
complication in feeding is continuous. emptying and
patients fitted with a -Maintain a clear Hold feedings if can cause
nasogastric tube. airway free of any amount of residuals is distention of the
obstructions. large, and notify the stomach, leading
Reference: physician. to reflux emesis.
Pubmed/NCBI
3. Keep head of bed 3. Maintaining a
elevated when sitting position
feeding and for at after meals may
least a half hour help decrease
afterward. aspiration
pneumonia in
the elderly.
4. Position patients with 4. This positioning
a decreased level of (side-lying
consciousness on positioning)
their side. decreases the
risk for aspiration
by promoting the
drainage of
secretions out of
the mouth
instead of down
the pharynx,
where they could
be aspirated.
5. During enteral 5. Keeping patient’s
feedings, position head elevated
patient with head of helps keep food
bed elevated 30 to 40 in stomach and
degrees; maintain for decreases
30 to 45 minutes after incidence of
feeding. aspiration.
6. Place whole or 6. Mixing pills with
crushed pills in soft food helps
foods (e.g., custard). reduce risk for
Verify with a aspiration.
pharmacist which pills
should not be
crushed.
7. Offer liquids before 7. Ingesting food
and after food during and fluids
feedings. together
increases
swallowing
difficulties.
