Brief History: This is an 84-year-old female admitted two days ago with a diagnosis of Adult Failure to Thrive, dehydration, and weight loss. The patient has dementia/advanced Alzheimer's disease, and dysphagia due to a previous stroke. She was receiving intermittent PEG tube feedings at home, which have continued since her admission. Orders have been written for her to be started on continuous tube feedings today. You are the nurse on the 7a-7p shifts and will be initiating the continuous enteral feedings. Ms. Newton is currently alert, agitated, and oriented times one (person). 02 @2L/min. via nasal cannula is in place. 

 

Questions:

 

1) Patient's Diagnosis: Give a brief summary of the pathophysiology of the patient's medical diagnosis. (rephrase)

 

2) List at least three possible nursing diagnoses for this patient: 

 

3) What are possible nursing interventions you anticipate providing for this patient? 

 

4) Which intervention would be your first priority and why? 

 

5) How do you plan to evaluate the effectiveness of the intervention you deemed to be a priority? 

1. Esophageal Dysphagia

Dysphagia is any disruption in the swallowing process during bolus transport from the oral cavity to the stomach. The swallowing process is divided into four stages: Pre-oral, oral, pharyngeal and esophageal.

Pre-oral phase is when the food is transferred from plate to mouth. The oral phase is completely voluntary and involves the entry of food into the oral cavity and preparation for swallowing. The pharyngeal phase is initiated as the tongue propels the bolus posteriorly and the base of tongue contacts the posterior pharyngeal wall, starting a reflexive action. The soft palate elevates to prevent nasal reflux. The pharyngeal constrictor musculature contracts to push the bolus through the pharynx. The epiglottis inverts to cover the larynx and the vocal folds adduct to prevent aspiration. The esophageal phase is completely involuntary and consists of peristaltic waves

Swallowing is a complex process and many disturbances in oropharyngeal and esophageal physiology including neurologic deficits, obstruction, fibrosis, structural damage or congenital and developmental conditions can result in dysphagia. Breathing difficulties can sometimes affect the ability to swallow.

Damage to the neuromuscular system can interfere with the nerves responsible for starting and controlling swallowing. Most neurological causes of dysphagia is stroke. The most common complications of dysphagia are pulmonary complications, dehydration and malnutrition. Other possible complications, such as social isolation, mental and emotional health issues or intellectual and body development deficit.

2. Nursing diagnosis

Imbalance Nutrition related to inability to swallow food/ dysphagia as evidenced by malnutrition and dehydration

Risk for aspiration related to depressed gag and cough reflex and tube feedings

Risk for infection related to poor nutrition as evidenced by dehydration and malnutrition

3. Priority diagnosis would be;

Of all the 3 diagnosis stated above the priority diagnosis that one should take into consideration first would be the patient risk for aspiration. Aspiration would lead to pneumonia and pneumonia could cause infection this further aggravate the patients condition then follows the problem regarding imbalance nutrition.

Priority Nursing Intervention:

Our main objective would be;

*Maintain patent airway

*Patient's risk of aspiration will decrease as a result of ongoing assessment and early intervention.

Nursing Intervention:

1.Monitor level of consciousness.

Rationale: A decreased level of consciousness is a prime risk factor for aspiration.

2. Assess cough and gag reflex.

R: A depressed cough or gag reflex increases the risk of aspiration.

3. Auscultate bowel sounds to evaluate bowel motility.

R: Decreased gastrointestinal motility increases the risk of aspiration because food or fluids accumulate in the stomach.

4. Keep suction setup available (in both hospital and home setting) and use as needed.

R: To maintain a patent airway.

5. Notify the physician or other health care provider immediately of noted decrease in cough and/or gag reflexes, or difficulty in swallowing.

R: Early intervention protects the patient's airways and prevents aspiration.

6. Position patients who have a decreased level of consciousness on their side.

R: To protect the airway. Proper positioning can decrease the risk of aspiration. Comatose patients need frequent turning to facilitate drainage of secretions.

7. Position patient at 90-degree angle, whether in bed or in a chair or wheelchair. Use cushions or pillows to maintain position.

R: Proper positioning of patients with swallowing difficulties is of primary importance during feeding or eating.

8. Maintain upright position for 30 to 45 minutes after feeding.

R: The upright position facilitates the gravitational flow of food or fluid through the alimentary tract.

9. Instruct on signs and symptoms of aspiration.

R: Aids in appropriately assessing high-risk situations and determining when to call for further evaluation.

How do you plan to evaluate the effectiveness of the intervention you deemed to be a priority? 

Through;

Determining client's behavioral response to nursing interventions.

Comparing that client's response with predetermined outcome criteria are met.

Appraised the extent to which client's goals were attained.

The collaboration of client and health care team members are accomplished.

Identifying that errors in the plan of care are lessened.