Help with care plan on aspiration

[juardsrn]

I'm having an awful time writing a care plan for my patient and any help/input would be more than helpful!

My nursing dx is: Potential for aspiration related to impaired swallowing as evidenced by excessive saliva production and presence of a G-tube

(I know NANDA only has a "risk for aspiration", but this semester, our teacher only wants us using "potential for" in our care plans. Should I change the nursing dx to ineffective airway clearance?)

Pt background: 24yo F with cerebral palsy, mental retardation, constipation, epilepsy, and also a quadriplegic. Pt also had a G-tube placed in 02/15.

Vitals: (0800) - 97.0 (axillary), 60, 20, 110/68, 94%

(1200) - 100.2 (axillary), 62, 18, 108/64 95%

Meds: Metoclopram 5mg

Baclofen 60 mg

Milk of Magnesia 30 mL

Docusate 50 mg

Depo provera 150 mg

When I noticed the spike in her temperature, I went to the pt's RN and discussed that I was scared she may have aspirated sometime after her tube feeding. Came to find out that she started her menstrual cycle and usually gets a temp on the first day (crisis averted, thankfully).

I guess I have 2 questions.

1.) Would it be okay to put "the patient will demonstrate effective coughing" as a goal? The pt will only do so many commands. I doubt if I explain deep breathing and coughing exercises, she'll understand. However, when I was assessing her oral membranes and asked her to open her mouth, she was able to do that. I suppose I won't truly know unless I try, right?

2.) The patient has a prescription for Baclofen (muscle relaxant). I know in my experience, my doctor gave me a muscle relaxant to help from coughing up so much mucous all the time. Would it be safe to say that Baclofen can produce the same effects as another muscle relaxer did for me?

The current nursing diagnosis book I'm using is: "Nursing Care Plans - Diagnoses, Interventions, and Outcomes" by Gulanick and Myers.

I feel like I'm falling into some kind of trap on this one and missing something!

The patient is at a risk for aspiration because of their excessive saliva and mucous production, their lungs sounds slightly like crackles, and they also have a presence of a g-tube.

Any help would be super awesome and graciously taken!!

[HouTx, BSN, MSN, EdD]

You're on the right track. It's great that you have incorporated goals that are actually realistic and within the range of her many limitations. You may want to expand on that in terms of interventions.... what specific actions can she perform that would help her clear secretions? e.g., the act of blowing requires a deep inspiration, so can she blow into a bubble wand? Blow on a feather?

[juardsrn]

Ahh that's a great idea! I think she might able to blow on a feather! I didn't think something like that could be used as an intervention.

I guess I was making it harder than it really is. I've just never had a patient who is quite like this one. And I'm positive it won't be my last haha

Thanks for the suggestion!

[Purple_roses]

If you can, I would advise changing some of the data in your OP. You listed some things that could make it easy to ID your patient.

[juardsrn]

Ah dang it! I tried to be as vague as I could, but still listing important info. What would I need to take out? I assumed that since there isn't a city, state, or facility everything would be okay.

[Xlorgguss]

This is so weird. I literally had the same patient a few weeks ago and I am using them for a care plan too.

[nursej22, MSN, RN]

There are also at least 2 interventions related to the g tube that you haven't listed.

[MMC.RN]

You could potentially take out her age, just say young female in her 20's or even just young female. In addition, state she had her g-tube placed in February, an exact date is unnecessary. I wouldn't necessarily say it would be easy to identify her, but better be safe than sorry!

I agree with the PP, you are on the right track, but are missing a few interventions related to the g-tube. In addition, research ways to assist with clearing secretions. Sometimes care plan books do not encompass everything.