Risk for aspiration care plan

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Hi, need a little guidance!

My pt amongst other things has a gt tube (no swallowing reflex) I'm using Risk for Aspiration as my diagnsosis. As far as the care plan , rational and interventions, they are all related to the placement of, care of and what goes into the gt tube (medication, enternal feeding). This is correct??

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Specializes in Mental and Behavioral Health.

What about making certian there are bowel sounds, and positioning the pt upright before feeding? Monitoring lung sounds and temperature in case they do aspirate, and you don't catch it.

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Let me ask a question. I'm a beginning nursing student....the gt tube was already in place......would I include these steps in my care plan. I'm even thinking now...he had pulmacare going through 24hrs., I just inserted medications...so i start from there...right??? The positioning of pt and monitoring would be good! Thanks!

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Specializes in Telemetry, CCU.

The number one thing for any pt that is at risk of aspiration is to keep the HOB at 30 degrees at all times, not just feeding. This is an extremely important nursing diagnosis and one you will see and put into practice day after day in many settings.

Some key points are HOB 30 degrees, monitor stomach contents (gastric residual) every 4 hours or more (depending on what you find when you check), monitor bowel sounds, monitor oral secretions and suction prn, follow chest xray results, monitor temperature and follow WBC count for s/s of infection (as well as other signs of infection). These are just off the top of my head, what I do for my patients, memorized after a few years of those nursing care plans :) Trust me, they will teach you something!!!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

risk for aspiration is an anticipated problem. you must state what the risk factor is for the aspiration. with gastric tubes the risk of aspiration can be any or all of the following:

  • improperly administered tube feeding
  • improper placement of gastric tube
  • improper placement of the patient (before or after) a tube feeding
  • excessive gastric residual

the interventions for this kind of diagnosis are very restricted. they can only be:

  • strategies to prevent the problem and risk factor from happening in the first place
  • monitoring for the specific signs and symptoms of this problem
  • reporting any symptoms that do occur to the doctor or other concerned professional

there are webpages for this diagnosis on the internet with suggestions for interventions and goals:

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