Nurse's Pocket Guide

isk for SUFFOCATION
• Determine client’s/SO’s knowledge of safety factors/hazards
present in the environment.
• Identify level of concern/awareness and motivation of
client/SO(s) to correct safety hazards and improve individual
situation.
• Assess neurological status and note factors that have potential
to compromise airway or affect ability to swallow (e.g., stroke,
cerebral palsy, MS, ALS).
• Determine use of antiepileptics and how well epilepsy is controlled.
• Note reports of sleep disturbance and fatigue; may be indicative
of sleep apnea (airway obstruction).
• Assess for allergies (e.g., medications, foods, environmental)
to which individual could have severe/anaphylactic reaction
resulting in respiratory arrest.
NURSING PRIORITY NO.2.To reverse/correct contributing factors:
• Identify/encourage relevant safety measures (e.g., seizure precautions;
close supervision of toddler; avoiding smoking in
bed, propping baby bottle, or running automobile in closed
garage) to prevent/minimize risk of injury.
• Recommend storing small toys, coins, cords/drawstrings, and
plastic bags out of reach of infants/young children. Avoid use
of plastic mattress or crib covers, comforter, or fluffy pillows
in cribs to reduce risk of accidental suffocation.
• Use proper positioning, suctioning, use of airway adjuncts, as
indicated, for comatose individual or client with swallowing
impairment or obstructive sleep apnea to protect/maintain
airway.
• Provide diet modifications as indicated by specific needs (e.g.,
developmental level, presence/degree of swallowing disability,
impaired cognition) to reduce risk of aspiration.
• Monitor medication regimen (e.g., anticonvulsants, analgesics,
sedatives), noting potential for oversedation.
• Discuss with client/SO(s) identified environmental/
work-related safety hazards and problem solve methods for
resolution.
• Emphasize importance of periodic evaluation and repair of
gas appliances/furnace, automobile exhaust system to prevent
exposure to carbon monoxide.
NURSING PRIORITY NO. 3. To promote wellness (Teaching/
Discharge Considerations):
• Review safety factors identified in individual situation and
methods for remediation.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
664 Cultural Collaborative Community/Home Care