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Etiology Disphagya can be found on some of the causes that can cause the condition include: Stroke. Progressive neurological disease. The tube on trachestomy. Paralise or absence of movement of the vocal cords.
Tumors in the mouth. Surgery of the head. Pathophysiology Normally people swallow solid food or drinking liquids and swallow saliva or mucus produced by the body hundreds of times every day. During the oral stage, the tongue pushing food or solids into the back of the mouth, and began to swallow response.
Pharyngeal phase began immediately after food or liquid pass through the pharynx the tube that connects the mouth to the esophagus into the esophagus or gastrointestinal tract.
The last stage is the stage of esophageal, food or liquid pass through the esophagus into the stomach. Although the first and second stages have some control voluntair, stages three and four occur by itself without realizing it. If the swallowing process stalled due to various reasons, will result in difficulty swallowing. Nursing Assessment Nursing assessment needs to be done in patients with swallowing disorders or disphagya include : History of the disease. History of stroke. History of the use of medical devices : tracheostomy, nasogastric tube, mayo tube, ETT, post endoscopy examination.
History surgery laryx blood, pharynx, esophagus, thyroid. Postoperative mouth area. Physical examination : Mouth shape is not symmetrical. Looks an inflammation of the pharynx. Edema of the pharynx. Preterm labor, or induced abortion. Abuse consumption in the mother, such as ; drugs, alcohol, smoking and caffeine. Assessment 1. History of pregnancy. Status of the newborn.
Physical examination head to toe, including : cardiovascular, gastrointestinal, integument, musculoskeletal, neurologic, pulmonary, renal, reproduction.
Supporting data X-ray of the chest and other organs to determine the presence of abnormalities. Ultrasonography to detect abnormalities of organs. Stick glucose to determine glucose levels decrease. Serum calcium levels, decreased levels means there is hypocalcemia.
Bilirubin levels, to identify improvement due to premature are more sensitive to hyperbilirubinemia Electrolyte levels, blood gas analysis, blood type, blood culture, urinalysis, fecal analysis, and so forth. Nursing Diagnosis 1. Risk for respiratory distress related to immaturity of the lungs, with decreased production surfactan that cause hypoxemia and acidosis. Risk for hypothermia or hyperthermia related to prematurity or changes in ambient temperature.
Imbalanced nutrition less than body requirements related to inadequate glycogen reserves, iron, and calcium and loss of glycogen stores due to the high rate of metabolism, inadequate intake of calories, and lose calories. Fluid and Electrolyte imbalances related to immaturity, radiation environment, the effect fototherapy or loss through the skin or lungs. Risk for impaired skin integrity related to immaturity and fragile skin.
Impaired sensory perception : visual, auditory, kinesthetic, gustatory, tactile and olfactory related to less stimulation or excessive in the intensive care environment. Knowledge Deficit family about treatment of the sick infant at home.
In this latest edition of NANDA nursing diagnosis list , eight nursing diagnoses were removed from compared to the old nursing diagnosis list These nursing diagnoses are :. Risk for disproportionate growth Noncompliance Readiness for enhanced fluid balance Readiness for enhanced urinary elimination Risk for impaired cardiovascular function Risk for ineffective gastrointestinal perfusion Risk for ineffective renal perfusion Risk for imbalanced body temperature Approved NANDA Nursing Diagnosis List.
Decreased diversional activity engagement Nursing Care Plan Readiness for enhanced health literacy Sedentary lifestyle Nursing care Plan. Frail elderly syndrome Nursing care Plan Risk for frail elderly syndrome Deficient community health Risk-prone health behaviour Ineffective health maintenance Nursing care Plan Ineffective health management Readiness for enhanced health management Ineffective family health management Ineffective protection.
Imbalanced nutrition: less than body requirements Nursing care Plan Readiness for enhanced nutrition Insufficient breast milk production Ineffective breastfeeding Nursing care Plan Interrupted breastfeeding Nursing care Plan Readiness for enhanced breastfeeding Ineffective adolescent eating dynamics Ineffective child eating dynamics Ineffective infant feeding dynamics Ineffective infant feeding pattern Nursing care Plan Obesity Overweight Risk for overweight Impaired swallowing Nursing care Plan.
Risk for unstable blood glucose level Nursing care Plan Neonatal hyperbilirubinemia Risk for neonatal hyperbilirubinemia Risk for impaired liver function Risk for metabolic imbalance syndrome.
Risk for electrolyte imbalance Risk for imbalanced fluid volume Deficient fluid volume Nursing care Plan Risk for deficient fluid volume Excess fluid volume Nursing care Plan. Impaired urinary elimination Functional urinary incontinence Overflow urinary incontinence Reflex urinary incontinence Stress urinary incontinence Urge urinary incontinence Risk for urge urinary incontinence Urinary retention. Constipation Nursing care Plan Risk for constipation Perceived constipation Chronic functional constipation Risk for chronic functional constipation Diarrhoea Dysfunctional gastrointestinal motility Risk for dysfunctional gastrointestinal motility Bowel incontinence.
Insomnia Sleep deprivation Readiness for enhanced sleep Disturbed sleep pattern.
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