Care Plan Nursing Diagnosis: Aspiration, potential for

nurseprnRN, BSN, RN · Oct 8, 2012

I'm having trouble with the nursing diagnosis part of a care plan. It's for a patient who has a tracheostomy and a PEG tube, and as such they have a potential for aspiration. I'm just having some trouble...
This is what I have so far: Potential for aspiration related to PEG tube and tracheostomy use, manifested by...(insert S&S here)...
I have two questions:
(1) Is it ok to say potential for aspiration related to use of PEG tube and trach, or do I have to be more specific than that? Should I only use either PEG or trach in this diagnosis and not both?
(2) The only signs and symptoms that I have so far is that the client has difficulty breathing when she is lying completely flat, but does that relate to potential for aspiration?
I know that when a PEG tube is running that a client can't be lower than 35 degrees, so (2) would only apply when the PEG is not running because otherwise she wouldn't be flat... I'm not sure what signs and symptoms I should be using....
I would appreciate and help, suggestions, etc...
Thanks.

Two things to remember here:

1) You cannot make a nursing diagnosis by knowing only the medical diagnosis. Looks to me like you are trying to do that, and it's wrong. You make your nuring diagnosis by ASSESSING the PATIENT. So... what S&S did you observe? You can't just say "insert here" because to have made that diagnosis you have to have observed something. Data from a chart counts as observed data.

2) What do you find in your handy-dandy, completely indispensable NANDA-I 2012-2014, the definitive book on nursing diagnosis? Every student and a lot of nurses should have one; free two-day shipping for students from Amazon.com. Pulling mine down from the shelf (I use it all the time in my business) I find that there is no such thing as a nursing diagnosis for "potential for aspiration," but there is one for "risk for aspiration." A subtle difference, but one that might help you think about this.

If you go to the NANDA-I webpage (and I would strongly recommend that you do: FAQs at NANDA International Nursing Diagnosis Frequently Asked Questions, and all those questions answered, too) you'll learn that the dread "r/t and AEB" your faculty made you look up were for learning purposes and to teach you to observe, not just to pull a sexy-sounding diagnosis out of, um, the air. NANDA-I wants you to know why you are making a diagnosis, mostly because if you don't then you don't know what to do about it and how you know if what you did do is working, but they do not insist on either their exact language nor on the "AEB" in the hands of a working, knowledgeable nurse.

We are knowledgeable about so much more than "alterations in comfort" and "knowledge deficit," as experienced nurses know. I think since because staff nurses are some of the least-empowered people on the planet, and often mostly because they think that's so, that they don't realize the real power they hold, based by science, the law, and a long tradition of activism. If you were in my shoes, you'd love having that power as much as I do. You have it now. Use it.

Because I have a little extra time today and I want to convince you of the usefulness of this resource, I will give you what the Risk for Aspiration diagnosis page says:

Risk for Aspiration: At risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into the tracheobronchial passages (Domain 11: Safety/Protection, Class 2: Physical Injury)

Risk Factors:

Decreased gastrointestinal motility

delayed gastric emptying

depressed cough

depressed gag reflex

facial surgery

facial trauma

gastrointestinal tubes

impaired swallowing

incompetent lower esophageal sphincter

increased gastric residual

increased intragastric pressure

neck surgery

neck trauma

oral surgery

oral trauma

presence of endotracheal tube

presence of tracheostomy tube

reduced level of consciousness

situations hindering elevation of upper body

treatment - related side effects (e.g., pharmaceutical agents)

tube feedings

wired jaws

Now, doesn't that give you some good rationales for why your patient might be at risk for aspiration? Again, you can't just pull them out of a hat, you have to assess their absence or presence in THIS particular patient. If this person hasn't had aspiration, you can't say that their aspiration has been manifested by anything. Sometimes a "risk for..." nursing diagnosis is enough to document that you have assessed this person, recognized a bona fide risk, and then set about delineating how you will mitigate or eliminate it.

Hope that's helpful. Get the book.

Esme12, ASN, BSN, RN · Oct 8, 2012

Welcome to AN! The largest online nursing community!

ok...first......you are falling into the same hole that trips most new students. You find your diagnosis and then try to retrofit the patient into the diagnosis. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly. I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.