NURSING DIAGNOSIS

Risk For Aspiration

Related to Reflux of
Gastric Contents
Defining characteristics:
Subjective Data:
I often have oral
regurgitations after meals,
as verbalized by the client.

GOALS
Short term goal:
Client will be able to
know the steps in
preventing aspiration
after 2 hours of nursing
interventions.

Long term goal:

Objective data:
During occasions:
(+) claims of sour taste
upon burping
(+) dyspnea
(+) coughing
(+) gagging
(+) palpitations
Occasional episodes
hematemesis

Client will be able to

fully understand and
implement the ways to
prevent regurgitation
and aspiration after 8
hours of nursing
interventions.

NURSING
INTERVENTIONS
Diagnostics:
1. assess usual ways after
meals
2. monitor/get/compute
clients weight and BMI
3. assess routine meal timing
and amount
Interventions:
1. offer high protein, low fat
diet
2. assist in elevating head of
bed during meals and/or keep
client on upright position 23hours after meals
3. administer antacids as
ordered
Educative:
1. instruct to take small
frequent feedings
2. instruct to take liberal
amount of fluids (warm)
during meals
3. encourage to never take
meals within 2 hours before
bed time
4. encourage on weight
reduction regimen
5. encourage deep breathing
every time feeling nauseated
and/or gagging
6. discourage the use of tightfitting clothes and pants

RATIONALE

EVALUATION

1. to know and possibly correct improper

ways that leads to regurgitations
2. to know and plan for necessary weight
reduction regimen
3. to make necessary adjustments

STO:
Goal met. Client never
had any episodes of oral
regurgitation 2 hours
after initiation of nursing
interventions.

1. to minimize episodes of heartburn

2. to facilitate movement of foods down
the lower GI organs, preventing
possibilities of backflow
3. to minimize gastric hyperacidity and
minimize episodes of regurgitations

1. to facilitate complete gastric emptying

2. to promote flushing of digested
materials down the alimentary canal
3. to make sure that gastric materials
passed through before lying down. This is
to prevent backflow of gastric materials
to the trachea
4. to minimize abdominal pressure from
excess fats (if present)
5. this helps relax muscles on tension
during forceful backing of gastric
materials
6. to minimize abdominal pressure

LTO:
Goal met. Client showed
full understanding on the
ways to prevent
occurrence of oral
regurgitations by
demonstration.