A physical injury risk condition is a condition in which there is a high risk of being impaired due to sensory impairment, physical disability, inability to recognize the danger, or premature age. Physical injury risk conditions include physical trauma, falls / falls, aspiration, and choking.
<Nursing care plan>
Does not cause aspiration
Do not suffocate
Self-management to prevent aspiration and suffocation
1. Vital signs, awareness level
2. Age, cognition, comprehension
3. Respiratory status (lung noise, wheezing, cyanosis, sputum properties, volume)
4. Presence or absence of paralysis or esophageal stricture
5. Condition in the oral cavity
6. Swallowing movement, situation
-Preceding period (cognitive period): Food recognition and selection
-Preparation: Upper limb function, dexterity, openness, lip movement, tongue movement
-Oral stage: Oral and tooth conditions, whether dentures are correct, saliva secretion, intake status, chewing status, tongue status
-Pharynx: swallowing status, presence or absence of swelling
-Esophageal period: presence or absence of stagnation, presence or absence of reflux
7. Bite volume, meal pace
8. Usage of thickeners, etc.
9. Thoughts on food
10. Presence / absence of test, test data (swallowing function test, chest X-ray, WBC, CRP, etc.)
11. Utilization of social support
1. Firmly gudge up and adjust your posture (if necessary, work with ST to determine your posture)
2. When eating food, bend forward to the neck
3. Adjust the shape and hardness of the meal so that it is easy to swallow.
4. Perform throat ice massage and swallowing exercises before meals
5. Encourage fluid intake before meals
6. If you have paralysis, assist with eating so that you can put food on the healthy side.
7. Promptly suck and tap when suffocating
8. Continue to gudge up for about 30 minutes to prevent aspiration
9. Provide an opportunity to receive explanations from dietitians about dietary patterns and cooking methods
10. Introduce and coordinate social support
1. Explain the importance of adjusting your posture
2. Explain that massage and gymnastics before meals promote saliva secretion and make it easier to eat.
3. Explain that by including a small amount of water before meals, dryness is eliminated and it becomes easier to eat.
4. Explain to eat slowly and little by little
5. Explain the dietary patterns that are less likely to cause aspiration and suffocation
6. If you have paralysis, explain to eat on the healthy side.
7. Explain what to do if you swallow
8. Explain what to do if you are suffocated
9. Explain that you can receive an explanation from a nutritionist