The nurse is completing her documentation after feeding a patient with aspiration precautions. Which of the following items should she document? (Select all that apply.)
a. Episodes of coughing or gagging
b. Hesitation or fear of eating
c. Amount eaten
d. Aspiration protocol used
e. Respiratory status
ANS: A, B, C, D, E
It is important to document thoroughly the patient's experience during the feeding so the other nursing staff will be aware of patient's needs including any episodes of coughing, gagging, or choking; respiratory status; hesitancy or fear of eating; and occurrences of nausea, vomiting, regurgitation, and/or reflux symptoms. The nurse should also document the protocol used, the amount food eaten, and fluid intake.
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