Nursing DX Client Outcomes Interventions Rationales Evaluations

Risk for Aspiration for Client will swallow and 1. Monitor respiratory rate 1. Signs of aspiration Client will keep receiving thickened
entry of gastrointestinal digest oral, nasogastric or (normal respiratory rate for should be detected as soon food and fluids during meals. All
secretions, gastric feedings without pediatrics are 20 to 30/min.), as possible to prevent precautions will be repeated during the
oropharyngeal aspiration during meal depth, and effort. Note any further aspiration and to process of meal times and at least an
secretions, solids, or times 3-5 times daily. signs of aspiration such as initiate treatment that can hour afterward. Client has responded
fluids into the dyspnea, cough, cyanosis, be lifesaving. Because of well to interventions and has shown no
tracheobronchial wheezing, or fever (normal laryngeal pooling and new signs of aspiration with
passages r/t impaired temperature for pediatrics is residue in clients with implementing new precautions.
swallowing and 36 to 38 degrees Celsius or dysphagia, silent aspiration
reduced LOC. 96.8 to 100.4 degrees can occur.
Fahrenheit).
Objectively: Client has 2. Clients who aspirate
difficulty swallowing 2. When feeding client, will show early signs of
and chewing solids and watch for signs of impaired difficulty in swallowing.
drinking fluids. All swallowing or aspiration
food and fluids are including coughing, choking, 3. A client with aspiration
thickened before spitting foods, or excessive needs immediate
serving to client. drooling. suctioning and may need
further lifesaving
3. Have a suction machine interventions such as
available when feeding high intubation.
risk clients.
4. Maintaining a sitting
4. Keep head of bed position after meals can
elevated or client ambulated help decrease aspiration
in wheelchair when feeding pneumonia.
and for at least an hour
afterward.
 Nursing DX Patient Outcomes Interventions Rationales Evaluations

Risk for impaired skin Staff members of the 1. Monitor skin condition at 1. Systematic inspection Client skin has been moist with no
integrity r/t client being health care system will least once a day for color or can identify impending breakdown of skin or lesions
immobile due to brain check once a day and texture changes, problems early in an breakdown present. Health care team
traumatic injury at 17 report any altered tissue, dermatological conditions, or immobile client. will keep repeating interventions of
months of age. lesions, or skin integrity. lesions. Determine whether mobilization and monitoring of skin
the client is experiencing loss 2. Implementing an and incontinence plans.
of sensation or pain. incontinence prevention
plan with the use of a skin
Objectively: Client is 2. Implement an protectant or a cleanser
unable to move body incontinence management protectant can significantly
and is 100% dependent plan to prevent exposure to decrease skin breakdown
on staff to be mobilized chemicals in urine and stool
in all daily tasks. that can strip or erode the 3. Turning the client,
skin. (Health care team will mobilizing, and taking
check client’s diapers every precautions will keep skin
2 hours for urine or stools.) integrity intact and have
less breakdown.
3. Turn and position client
every 2 hours. Transfer the
client with care to protect
against the adverse effects of
external mechanical forces.
(pressure, friction, or shear)
 Nursing DX Patient Outcomes Interventions Rationales Evaluations
Risk for Falls r/t client Client will remain free 1. . Make sure side rails of 1. Client will need side Client has remained free from falls
being immobile due to from falls daily and in an bed are kept up and locked to rails of bed up and locked with implementing preventions of falll
brain traumatic injury environment to minimize keep from client falling from into place to keep from risks. Health care team will keep
at the age of 17 the incidence of falls. the bed. falling out of bed implementing procedures and will
months. identify in the future any new
2. Be careful when 2. A very important procedures that should be performed
Objectively: Client is ambulating a client who is preventive measure to will taking care of the client.
unable to move body immobile. Be sure to lock reduce the risk of injurious
and is 100% dependent the wheels on the bed and the falls for nonambulatory
on staff to be mobilized wheelchair, have sufficient clients involves increasing
in all daily tasks. She personnel to protect the safety measures while
does not have any client from falls. transferring, including
control over extremities careful locking of
or ability to keep from equipment such as
falling if left 3. When ambulating client wheelchairs and beds
unattended in a risk into the wheelchair make before moves.
area. sure client is properly .
strapped into the char with 3. Immobile client with
all belts clasped together. To traumatic brain injury
help protect client against should be properly
falling from wheelchair. strapped into a wheelchair
to sustain free from falling
and injuries.