Nursing diagnosis

nurseprnRN, BSN, RN · May 5, 2015

I'm not sure I did my risk diagnosis & outcomes correctly ..
Risk for aspiration r/t presence of gastrointestinal tube secondary to GERD
possible s/Sx
1)Bolus tube feeding
2)gag reflex impairment
3)impaired physical mobility
Outcomes
1)Patient will maintain patent airway & continue to have clear breath sounds
2)Patient's mouth will be clean and free from any debris or mucous build-up
3)Patient will have less than 30 cc of residual throughout hospitalization.
4)Patient will be free of cough, tachypnea, and dyspnea

I'm looking at the nursing diagnosis for "risk for aspiration (page 381 in the current NANDA-I 2015-2017) and I'm not seeing what you have there. So I don't really know how you came up with that. Remember, you cannot use language that does not appear in the NANDA-I 2015-2017. This is really not negotiable. if you don't have the book, go to Amazon and get it right away.

Please search in AllNurses for very clear explanations about how you do not pick nursing diagnosis or choose a nursing diagnosis, you make a diagnosis based on specific criteria, called defining characteristics for many diagnoses, and called risk factors in risk diagnoses. Both esme and I have posted extensively on this.

Yes, it really is that simple. You look up in the book things that are potentially appropriate diagnoses, and you check the defining characteristics or risk factors(and approved related factors) to see if they allow you to make that diagnosis. You don't have to make up anything. You have to diagnose anything, and you certainly do not look for some sort of reference that says, "For medical diagnosis X, I picked nursing diagnosis Y." It doesn't work that way. Nursing diagnosis is based on your assessment.

Now, as to your specific question.

Risk for aspiration

Definition: Vulnerable to entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into the tracheobronchial passages, which may compromise health.

Risk factors

* barrier to elevating upper body

* decrease in G.I. motility

* decrease the level of consciousness

* delayed gastric emptying

* depressed gag reflex

* enteral feedings

* facial surgery

* facial trauma

* impaired ability to swallow

* incompetent lower esophageal sphincter

* increase in gastric residual

* increase in intragastric pressure

* ineffective cough

* neck surgery

* neck trauma

* oral surgery

* Oral trauma

* presence of oral/nasal tube (e.g., tracheal, feeding)

* treatment regimen

* wired jaw

Okay, you have a risk factor of "presence of the gastrointestinal tube" but I don't really know what that is. Is this a G-tube, J-tube? "Presence of a gastrointestinal tube" is not an approved risk factor to enable you to make this diagnosis. Could you clarify?

You have 3 things listed for possible signs and symptoms, but none of those are signs and symptoms of aspiration. However, if you look at your approved list of risk factors, it appears that at least 2 of them are approved risk factors.

Therefore, to document how you made your diagnosis, you would say, "Risk for aspiration related to enteral feedings and impaired gag reflex." Your individual assessment of this patient may have included other risk factors which you did not describe here, but maybe present and should be noted in your risk factors.

For outcomes, your first is perfect. No aspiration means there's no evidence of aspiration, so clear breath sounds would be a good thing to have happen. Not sure that patent airway is, per se, an outcome of no aspiration-- can you clarify?

The outcome of "no aspiration" is not "a clean mouth," although keeping the mouth clean may very well be a good intervention, depending on the risk factors you've identified in your assessment.

Having less than 30 mL of residual is not a result of no aspiration either, so you can't call it an outcome. However, since a risk factor for respiration is an increase in gastric residual, specifying measures to minimize the gastric residual would be a good intervention to prevent aspiration.

I hope this is helped to clarify the difference between an intervention and an outcome. An intervention is something that you do, or specify that others will do, to decrease the risk of, in this case, aspiration. An outcome is what you hope happens after these interventions are applied to prevent aspiration.

browneyedgirl21 · May 6, 2015

Thank you so much for your reply

I made several changes after reading your post

Risk for aspiration R/T gastrointestinal tube

Possible S/Sx

1) gag reflex impairment/ dysphagia

2) depressed cough, tachypnea, and dyspnea

3) decreased gastrointestinal motility

GOAL: Patient will not aspirate secretions, food/liquid during hospitalization

EXPECTED OUTCOMES:

1) Patient will maintain patent airway & continue to have clear breath sounds

2) Patient will be free of cough, tachypnea and dyspnea

3) Patient will swallow and digest gastric feeding without aspiration

ASSESS/MONITOR

1) Auscultate lung sounds before and after feedings; note any new onset of crackles or wheezing.

2) Assess for cough and gag reflex

3) Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, or fever

My patient can eat food but she doesn't like the food at the rehab center so she had a gastrointestinal tube placed for her nutrition needs. I chose risk for aspiration because my patient can no longer sit up w/o assistance & she no longer leaves her bed.

Thank you so much for all of your help