Topic: Gas Exchange and Risk for aspiration related to Dysphagia
Provide the expected outcomes for each of the following Nursing interventions:
Diagnosis: Risk for aspiration related to Dysphagia
Nursing Intervention, rationale and Expected outcome
1.Interventions: Position patient upright during feedings.
Rationale: The elevated head helps keep food in the stomach and reduces aspiration.
2.Intervention: Assist patient with oral intake
Rationale: Assisting helps the strategy for safe swallowing.
3. Intervention: Perform oral care before and after meal.
Rationale: Oral care after eating removes food residues that could cause aspiration at a later time.
4.Intervention: Patient placed on their side.
Rationale: This position decreases the risk for aspiration by promoting drainage of secretions out of the mouth instead of pharynx.
Diagnosis: risk for impaired Gas exchange related to patient’s history of smoking.
Nursing intervention/Rationale/Expected out
5.Intervention: Position client with head of bed elevated, in a semi-Fowler’s position as tolerated.
Rationale: Semi-Fowler’s position allows increased lung expansion because the abdominal contents are not crowding the lungs.
6.Intervention: Assess the patient’s nutritional status.
Rationale: Malnutrition can be lead to loss of muscle mass, this can affect breathing muscle.
7.Intervention: Monitor vital signs.
Rationale: With initial hypoxia and hypercapnia, blood pressure (BP), heart rate, and respiratory rate all rise.
8.Intervention: Assess skin color for development of cyanosis.
Rationale: To ensure that adequate amount of oxygen is supplied to tissues and organs.