Nursing Diagnosis
Aspiration (choking) related to bleeding in the esophagus as evidence by vomiting up blood, shortness of breath, coughing and excessive sweating.
Assessment
Check vital signs for increase in pulse, blood pressure, temperature and oxygen levels
Head to toe assessment looking for pale skin, grimacing and mental awareness
Assess for restlessness and pain
Monitor swallowing ability by assessing for coughing or clearing of the throat after swallowing
Monitor for choking during eating or drinking
Assess respiratory rate for depth, effort and length
Head to toe assessment looking for pale skin, grimacing and mental awareness
Assess for restlessness and pain
Monitor swallowing ability by assessing for coughing or clearing of the throat after swallowing
Monitor for choking during eating or drinking
Assess respiratory rate for depth, effort and length
Smart Plan
By April 30, 2014 at 1700 patient will be free from excessive vomiting and bleeding in the esophagus. Vital Signs will be stable, Respirations will be between 16-18. Patient will be free from choking and swallowing will be easy and painless.
Nursing Interventions
1. Monitor vital signs - to have a baseline data incase of any alteration or change in pulse and blood pressure, capillary refill and oxygen levels.
2. Check level of consciousness - by performing a head to toe assessment
3. Monitor bleeding and vomiting - to have an idea of the state of bleeding and the amount of blood loss
4. Elevate head of bed to semi-fowlers position - to prevent choking and provide effective airway
5. Inform patient to avoid anything that causes strain - to prevent bleeding and further injury and to ensure the health of the patient
6. Offer emotional support and patient teaching - to help the patient cope while providing comfort and trust. Teach the patient about ways to prevent bleeding and aspiration.
2. Check level of consciousness - by performing a head to toe assessment
3. Monitor bleeding and vomiting - to have an idea of the state of bleeding and the amount of blood loss
4. Elevate head of bed to semi-fowlers position - to prevent choking and provide effective airway
5. Inform patient to avoid anything that causes strain - to prevent bleeding and further injury and to ensure the health of the patient
6. Offer emotional support and patient teaching - to help the patient cope while providing comfort and trust. Teach the patient about ways to prevent bleeding and aspiration.
Evaluation
Patient will remain free of bleeding and aspiration and will demonstrate no signs or symptoms. Pulse and Blood pressure remain stable and a well nutritional balanced diet is being maintained. Patient and family teaching and emotional support provided and understood.