Nursing Care Plan

[BANJ]

Hello! I need some help on my care plan. My patient admitting dx is ascites. One of my nursing dx is risk for injury (pulmonary aspiration) r/t nasogastric tube suction. I need four interventions. I only have two in mind which are -- Check placement of the tube and elevate head of bed 30 - 45 degrees. My patient is NPO except meds. If anyone can help, it would be greatly appreciated! :)

[gumby1411]

Is pulmonary aspiration considered "risk for injury?" It seems more appropriate to use ineffective breathing pattern r/t to increased abdominal girth (due to the ascites) or imbalanced nutrition r/t to suctioning and NPO order. You might already have these listed for this patient, so just disregard if you do.

For pulmonary aspiration, what are the most important interventions related to this patient? Think ABC's. Check the patient's respiratory rate, depth, and pattern of breathing. Note use of accessory muscles, nasal flaring, irritability, etc. since these can indicate respiratory difficulty. Monitor oxygen saturation. Administer oxygen as ordered. Etc. And, when in doubt, you can always use patient/family education as an intervention!

[AOX4RN, MSN, RN, NP]

do you have a care plan book? those are great for giving assessments, interventions, evaluations, and expected outcomes with rationales.