- Risk for Aspiration related to reduced level of consciousness and Impaired protective reflexes as evidenced by coughing, and decreased oxygen saturation
- Risk for Falls related to decreased lower extremity strength and unsafe, cluttered environment as evidenced by Environmental hazards and disorientation
- Risk for Injury related to Impaired mobility and Medication side effects as evidenced by kin breakdown and skin impairment
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Expresses coughing and breathing difficulty Objective Data: Oral/facial surgery or trauma Stroke/paralysis Presence of tracheostomy Tube feedings | Risk for Aspiration related to Reduced level of consciousness and Impaired protective reflexes as evidenced by coughing, and decreased oxygen saturation | Patient will not experience aspiration, as observed by clear lung sounds, unlabored breathing, absence of coughing, and oxygen saturation within normal limits. Patient and/or caregiver will demonstrate appropriate techniques to prevent aspiration. Patient and/or caregiver will verbalize potential risk factors for aspiration. | 1. Keep suctioning equipment at the bedside. Patients at an increased risk for aspirating should have functioning suctioning equipment at the bedside for immediate use. 2. Performing suctioning as necessary. Patients with a large amount of secretions or who cannot clear the secretion themselves may require frequent suctioning. 3. Keep the head of the bed elevated after feeding. Whether self-feeding, assisting with feeding, administering medications or tube feedings, the head of the bed should remain elevated for 30 minutes to one hour after oral intake. 4. Implement other feeding techniques. Patients who require assistance with feeding should be fed small bites slowly. Some patients may require coaching to remind them to chew and swallow. Allow rest before feeding times, as this may decrease the patient’s difficulty with swallowing. Do not distract or allow the patient to talk while chewing or swallowing. 5. Consult with speech therapy. If swallowing is impaired, the patient requires further screening. A speech-language pathologist (SLP) can test swallowing with different foods and liquids. They can also teach the patient techniques to reduce swallowing such as the “chin-tuck” maneuver. 6. Follow diet modifications. Use thickening agents as ordered and ensure proper diet modifications such as pureed or mechanical soft foods if these are specified. Thicker foods and liquids are less likely to be aspirated so diet recommendations should be instituted for people at high risk of aspiration. 7. Position properly. Patients with drooling or uncontrolled secretions should be placed side-lying to allow secretions to drain and not pool in their mouths. Patients on continuous tube feeds should always have the head of the bed elevated at least 30 degrees. 8. Educate about conditions that can cause aspiration. Esophageal strictures (narrowing of the esophagus) can trap food. Gastroesophageal reflux disease (GERD) is a condition that causes gastric acid to back up into the esophagus which can cause damage and lead to strictures. Delayed gastric emptying doesn’t empty food as quickly as it should which can cause reflux, vomiting, and other problems. 9. Request medication formulation changes. Patients who cannot swallow pills may need medications to be administered in liquid, IV, or powder form. Some pills cannot be crushed and may not come in other forms. In these situations, the nurse should consult a pharmacist. Some patients may also be able to tolerate swallowing pills by placing the pill in applesauce or pudding. 10. Monitor tube-feeding patients closely. Check residuals as ordered, often every 4 hours. Facility policy will dictate when residuals are too high. Always alert the provider if residuals are increasing, bowel sounds are hypoactive or absent, if there is any vomiting or frequent diarrhea, and if abdominal distention is observed. 11. Provide mouth care. Mouth care prior to meals increases the desire to eat, while oral care following meals removes any residual food that could cause aspiration. | Patient experienced aspiration, as observed by clear lung sounds, unlabored breathing, absence of coughing, and oxygen saturation within normal limits. Patient caregiver demonstrated appropriate techniques to prevent aspiration. Patient caregiver verbalized potential risk factors for aspiration. |
Subjective Data: Verbalizes about risk for falls Objective Data: -Altered glucose levels -Decreased lower extremity strength and balance -Unsafe, cluttered environment -Use of assistive devices -Acute illnesses -Chronic conditions that affect mobility -Older age | Risk for Falls related to decreased lower extremity strength and unsafe, cluttered environment as evidenced by Environmental hazards and disorientation | Patient will remain free of falls. Patient will demonstrate a safe environment free from potential hazards. Patient will verbalize understanding of risk factors for falls. | 1. Incorporate appropriate safety measures. There is a range of fall prevention interventions and the nurse should pick interventions appropriate to the patient’s condition and risk level. An alert and oriented young adult may only require the support of a walker, while an elderly, confused patient may need a bed alarm. Severely confused patients who cannot follow directions may require restraints or 1:1 supervision to keep them safe. However restraints should only be used as a last resort. 2. Provide footwear and encourage use. All hospitalized patients should be encouraged to wear non-slip footwear. Hospitals often have color-coded socks, with yellow socks signifying patients who are at high risk for falls. 3. Use fall risk identification. Fall alert identifiers such as patient wristbands, chart stickers, and wall signs alert all staff members of the high risk for falls when assisting the patient. 4. Keep the patient’s room free of clutter. Remove excess furniture and keep cords and IV lines off the floor to prevent falling. 5. Keep the call button and personal items within reach. Before exiting the room, always ensure the patient has their call button and personal items such as water within reach. This prevents the risk of reaching or attempting to get out of bed alone and potentially falling. 6. Encourage assistance when getting out of bed. Encourage the patient to use their call button and request assistance when going to the bathroom or getting out of bed to promote safety. 7. Keep the bed in the lowest position. Except when the nurse is at the bedside performing a task that requires raising the bed, the bed should always stay in the lowest position to prevent injuries from falling out of bed. 8. Educate the patient on their fall risk factors. Having an open and direct conversation with the patient about the individual risk factors that increase their risk for falls and the safety measures in place will increase adherence to interventions. 9. Coordinate with physiotherapy and occupational therapy. Therapy services should be utilized to assist the patient in increasing their strength and balance and instructing on the proper use of new equipment such as crutches. | Patient remained free of falls. Patient demonstrated a safe environment free from potential hazards. Patient verbalized understanding of risk factors for falls. |
Subjective Data: Verbalizes fear about infection Objective Data: -Loss of limbs -Impaired vision -Hearing impairment – Skin Impairment | Risk for Injury related to Impaired mobility and Medication side effects as evidenced by kin breakdown and skin impairment | Patient will remain free from falls. Patient will engage in safe behavior and take action to reduce chance of injury. Patient will remain free from any form of self-harm. Patient will remain free from any skin breakdown or impairment in skin integrity. | 1. Monitor vital signs. Abnormal vital signs could put the patient at risk of falls resulting in injury due to low blood pressure. 2. Monitor mental status. Altered mental status could increase a patient’s risk of injury as the patient may not be fully aware of their surroundings and what is considered safe. 3. Implement fall precautions as appropriate. Patients at an increased risk of falling are also at an increased risk of injury. By identifying patients at an increased risk of falls, the nurse can implement measures to prevent falls. Measures the nurse can take include utilizing bed and chair alarms, putting fall mats on the floor beside the bed, and applying signage to the patient’s door indicating the risk of falls. 4. Assist patient with frequent position changes. Patients with impaired mobility may be at an increased risk of skin breakdown and skin injury. Assisting with frequent position changes will decrease the potential risk of skin injuries. 5. Provide a safe environment Providing a safe environment for patients will decrease the risk of potential injuries. Safe environments should be personalized to each individual patient and their individual risk factors based on the nursing assessment. 6. Complete hourly rounds and ensure the call light is within reach. This allows the nurse to check on the patient frequently and assist the patient in getting anything that is needed thereby reducing the potential risk of injury. This is particularly important for patients with impaired mobility. 7. Educate patient. Tailor patient education to each individual patient and what measures the patient can take either while hospitalized or at home to prevent accidents or injuries from occurring. | Patient remained free from falls. Patient engaged in safe behavior and take action to reduce chance of injury. Patient remained free from any form of self-harm. Patient remained free from any skin breakdown or impairment in skin integrity. |