Question

mr. Johnson, 68 year old was admitted to a sckilled nursing facility following hospitalization for a right cerebral stroke that resulted in paralysis on the left side and inability to move the arm or leg. he is unable to turn without assistance and requires assistance with dressing and groomimg. after several days of physical therapy he learned to transfer himself to a wheel chair with assistance and is learning to use his left hand for eating and daily activity. his gag refex is weakened. swalowing is delayed, and there is coughing after swallowing. he displays a frightened expression after each episode. he has a foley catheter draining light yellow urine, he smoked for 50yrs. feeding tube put in place, he always expresses his feelings of being dependent and concerns about ability to resume life as usual. he is married and lives in a community with his wife,

he denies pain b/p 140/80, R 24, P 88, t 99F

What care is of priority?

Perform a nursing school care plan. using aspiration

Answer 1

What care is of priority?

Mr. Johnson, admitted with right cerebral stroke and has paralysis and weakened limb movement.

He has weakened gag reflex, coughing after swallowing so there are chances of aspiration.

He has a foley catheter chances to develop urinary tract infection ( since his body temperature is slightly raised along with pulse)

Ambulation along with Physiotherapy to strength his muscle strength.

Perform a nursing school care plan. using aspiration

Risk for Aspiration:

• Advanced age
• Decreased gastrointestinal motility
• Delayed gastric emptying
• Depressed cough or gag reflex
• Impaired swallowing
• Increased gastric residual
• Presence of tube feeding

Goal-

• To ensure patient is free of signs of aspiration and the risk of aspiration is decreased
• Patient maintains a patent airway with normal breath sounds.
• Patient swallows and digests oral, nasogastric, or gastric feeding without aspiration.

Assessment

Assessment is required in order to distinguish possible problems that may have lead to aspiration

• Assess the level of consciousness
• Assess the Respiratory status, rate depth & effort and any signs of cyanosis. Assess pulmonary status for signs aspiration. Auscultate breath sounds for crackles and rhonchi. Monitor chest x-ray films.
• Assess the swallowing studies of the patient

Intervention-

Keep suction machine available when feeding high-risk patients. If aspiration does occur, suction immediately.

Notify other health person if they is a decreased gag reflex in the patient

Asses the position of the NG tube if it is present in the gastric cavity before feeding

Elevate the head end 30 to 45 degree of the patient when feeding and half hour after feeding

Identify any signs of abdominal distension

Allow the patient to chew thoroughly and eat slowly during meals.

Patients with a decreased level of consciousness place them on their side.

Perform oral hygiene before and after feeds

Teach family member to identify any signs of aspiration and suction the oral cavity. Always maintain 45 degree elevation of the head end .

Refer patient to a home health nurse or  rehabilitation specialist