Asymptomatic Aspiration Pneumonitis Nursing Diagnosis

beleanor · Nov 20, 2012

So, I've reworked my prioritized list, but I'd still be interested in feedback!

Imbalanced nutrition: less than body requirements r/t increased caloric and protein needs 2° to wound healing AEB low hemoglobin and low hematocrit, chronic anemia, very low albumin, low total protein, edema, low BMI, patient statement, "It's hard to make yourself eat if you don't feel like it. I'm trying to here - but I fill up quickly."
Ineffective airway clearance r/t immobility, stasis of secretions, absent cough 2° aspiration pneumonitis AEB chest xray showing bilateral infiltrate, tachypnea (respiratory rate between 24-28).
Impaired tissue integrity r/t the effects of pressure and immobility 2° to sensory and motor deficits AEB 3 decubitus ulcers.
Risk for falls

r/t fatigue 2° infection, malnutrition,
r/t impaired mobility 2° paraplegia.

[*]Risk for infection r/t anti-ulcer medication therapy 2° aspiration of neutralized gastric contents.

[*]Risk for complications of decreased cardiac output r/t septic shock. collaborative.

[*]Risk for complications of cardiac arrhythmias r/t sepsis or septic shock. collaborative

[*]Risk for complications of deep vein thrombosis r/t immobility, recent pelvic surgical history, advanced age and indwelling catheter, and thrombocytosis. collaborative.

[*]Activity intolerance

r/t compromised oxygen transport 2° to anemia AEB tachypnea, verbal report of "weakness."
r/t increased metabolic demands 2° sepsis and fever AEB tachypnea, verbal report of "weakness."

[*]Risk for bleeding r/t anticoagulation medication therapy.

[*]Adult failure to thrive r/t limited ability to adapt to effects of aging and loss of social relatedness AEB declining physical functioning, social withdrawal, weight loss, self-care deficit, apathy, and anorexia. Patient statements: "I don't want to wake up to take a pill if I feel fine," "it's hard to make yourself eat if you don't fee like it," "it's just me, so I don't worry about eating."

[*]Ineffective self health management r/t complexity of therapeutic regimen, mistrust of home healthcare personnel, and questions about benefits of regimen AEB verbalized desire to manage treatment and sequelae, verbalized difficulty with integration of regimens, acceleration of illness symptoms, verbalization that client specifically did not take action to include treatment regimens into daily life.

Thanks everyone and anyone!

Hi All,
I'm a brand new member here after months of reading others' posts! I'd greatly appreciate any help with this mess! Here's the situation:
I'm in the middle of writing a monster care plan - in my program we only have to fully develop 2 diagnoses per plan, but I do need to list, completely, all relevant nursing Dx, etiologies and defining characteristics. My patient is 73, septic, in isolation for MRSA, with a stage IV decubitus ulcer on the sacrum (w/ bilateral femoral osteomyelitis). He's severely protein malnourished, has co-morbid cardiovascular problems and is paraplegic from a much older occupational accident. He's TPN + oral intake and consumes a minimum of 2445 calories/day and 144 g protein/day - these figures represent only TPN and Ensure, not what he orders from the cafeteria, which is protein heavy. He eats small amounts, all day long and has moderate colostomy output and well functioning kidneys. His HOB is rarely above 30 degrees to reduce shearing forces and so he now also has bilateral lung infiltrate, and a med Dx of aspiration pneumonitis. I have at least 15 nursing diagnoses for him (though half are pulled out of "disuse syndrome.") I'm fairly comfortable with my prioritization and PES formatting, except for...

Can I use risk for aspiration? I feel this needs to be high priority (ABC's, maslow), especially considering that he's aspirating right now, not risk for, but actual. Even though he is asymptomatic right now, this situation could become so much worse - even more so because he's on IV pantoprazole, so while the aspirated contents would normally burn his bronchial tree, it's now neutralized and could allow for bacterial organisms. I can't figure out how to build this into my nursing care without making it a medical diagnosis - there is no "aspiration" dx for nursing. While it's probable that he does have impaired gas exchange, I did not hear crackles upon auscultation and his respiratory rate (24-28), could be the result of fever, sepsis, etc.

Also, I think part of my problem is that this man is dealing with paraplegia - something I can't do anything about, but that impacts his safety and care...

As I look at the list below, I feel like impaired mobility, impaired tissue perfusion are glaring holes, but I can't seem to figure out where to put them in....

this is quick look at my prioritized list:
1. Imbalanced Nutrition: less than body requirements r/t increased protein and vitamin requirements for wound healing secondary to stage IV decubitus ulcer
2. Impaired skin integrity r/t necrotic tissue secondary to peripheral vascular alterations and venous stasis
3. Risk for aspiration r/t prolonged recumbency secondary to pressure ulcer treatment
OR
4. Impaired respiratory function r/t bronchial inflammatory response secondary to aspiration pneumonitis AEB tachypnea, CXR shows bilateral infiltrates
5. risk for falls
6. risk for shock
7. risk for PE/DVT
8. risk for bleeding
9. disturbed sensory perception r/t loss of proprio/extero/cortical sensory loss secondary to paraplegia
10. activity intolerance r/t fatigue and increased oxygenation demands
11. bathing/toileting self care deficits
12. adult failure to thrive
13. ineffective self health management
14. readiness for enhanced self health management
15. social isolation

any ideas for tidying, elegant solutions, dove-tailing, better prioritizing and puzzle solving would be awesome!!!

Esme12, ASN, BSN, RN · Nov 20, 2012

Ineffective airway clearance r/t immobility, stasis of secretions, absent cough 2° aspiration pneumonitis AEB chest xray showing bilateral infiltrate, tachypnea (respiratory rate between 24-28).
Impaired tissue integrity r/t the effects of pressure and immobility 2° to sensory and motor deficits AEB 3 decubitus ulcers.
Imbalanced nutrition: less than body requirements r/t increased caloric and protein needs 2° to wound healing AEB low hemoglobin and low hematocrit, chronic anemia, very low albumin, low total protein, edema, low BMI, patient statement, “It’s hard to make yourself eat if you don’t feel like it. I’m trying to here - but I fill up quickly.”
Activity intolerance

r/t compromised oxygen transport 2° to anemia AEB tachypnea, verbal report of “weakness.”
r/t increased metabolic demands 2° sepsis and fever AEB tachypnea, verbal report of “weakness.”
[*]Adult failure to thrive r/t limited ability to adapt to effects of aging and loss of social relatedness AEB declining physical functioning, social withdrawal, weight loss, self-care deficit, apathy, and anorexia. Patient statements: “I don’t want to wake up to take a pill if I feel fine,” “it’s hard to make yourself eat if you don’t fee like it,” “it’s just me, so I don’t worry about eating.
[*]Ineffective self health management r/t complexity of therapeutic regimen, mistrust of home healthcare personnel, and questions about benefits of regimen AEB verbalized desire to manage treatment and sequelae, verbalized difficulty with integration of regimens, acceleration of illness symptoms, verbalization that client specifically did not take action to include treatment regimens into daily life.
[*]Risk for falls
r/t fatigue 2° infection, malnutrition,
r/t impaired mobility 2° paraplegia.
[*]Risk for infection r/t anti-ulcer medication therapy 2° aspiration of neutralized gastric contents.
[*]Risk for complications of decreased cardiac output r/t septic shock. collaborative.
[*]Risk for complications of cardiac arrhythmias r/t sepsis or septic shock. collaborative
[*]Risk for complications of deep vein thrombosis r/t immobility, recent pelvic surgical history, advanced age and indwelling catheter, and thrombocytosis. collaborative.
[*]Risk for bleeding r/t anticoagulation medication therapy
Good job! I've reworked your priority.....remember ABC's if they are breathing they are leaving. What semester are you?

beleanor · Nov 20, 2012

I'm in a one year, accelerated program - started in May and graduate May 2013. Re: prioritization - makes sense according to ABC's/Maslow, but my hesitancy is that no one seems to be paying attention to the med dx "aspiration/chemical pneumonitis." This patient is still allowed oral intake and there've been no mentions of nursing interventions regarding aspiration prevention in any care plan. It seems to me that his care team is prioritizing his "not progressing" nutritional status above this airway problem - which could be possible, I suppose, even though it flies in the face of ABC, he does have a BMI of 15, "non progressing status," and a granulating stage IV ulcer.

He is on diflucan, vanc and ertepenem. Is it possible that his care team is assuming the aspiration is "minimal"? Is it possible that they are assuming he's prophylactically covered by his antibiotics against the development of pneumonia? Is it possible they're calling it "aspiraiton pneumonitis," but really it's not (the CXR showed LLL infiltrate, not RML infiltrate as is commonly seen with aspiration pneumonia)?

I guess I just find it hard to believe that me, of all people/nursing students, could find something wrong with the care/prioritization of care for my patient...

Thanks for your help!!

Esme12, ASN, BSN, RN · Nov 20, 2012

This patient should be on aspiration precautions.....have a speech swallow eval consultation performed. He should be sat up for meals and eating. This would play into the risk for infection R/T aspiration pneumonia and ineffective airway clearance whether it is from secretions from pneumonia or food. Which places it at the top of the list as a priority. risks while they can be vvery important they are never more important than actual problems present.

Unfortunately.....this is where nursing school butts heads with the reality. They are focused on his wound and needing protein to heal said would for that is how they are probably being reimbursed. Sending this patient to a hospital for swallow eval might not be covered....or just not a priority to them....for whatever reason. Some facilities, and staff, just don't "see it" or just don't care.....sigh.

Great job on the care plan!

beleanor · Nov 20, 2012

thanks Esme12 for your feedback. I often find the most frustrating part of any formal training is knowing how best to enact your ideals in the real world. I'll keep the ABC prioritization and include my rationale...

Esme12, ASN, BSN, RN · Nov 20, 2012

You enact your practice to keep your patient and your license safe....the heck with the other guy. You practice the best practice for your patient regardless of the other guy.....sometimes this means there will be facilities that won't be a "good fit". But always be the best you you can be!