A 6-year-old client with a severe traumatic brain injury is preparing to transfer from the pediatric intensive care unit to an inpatient rehabilitation facility. Upon assessment, the nurse notes the client coughs and sputters when drinking water, and struggles to grasp a spoon due to impaired fine motor control. The client's guardians are visibly distraught, crying, and stating, 'We are completely overwhelmed and do not know how to handle this.' Which collaborative care action should the registered nurse prioritize?
- Coordinate an urgent evaluation with the speech-language pathologist to assess the client's swallowing mechanism and risk for aspiration.Answer
- BInitiate a consultation with the occupational therapist to address the client's fine motor deficits and feeding independence.
- CDirect the unlicensed assistive personnel to strictly monitor the client during meals to ensure safe swallowing.
- DComfort the guardians by telling them, 'Your child is young and will easily bounce back, so please do not worry.'
Answer
The nurse should prioritize collaborating with the speech-language pathologist to address the client's swallowing difficulties and risk for aspiration.
The correct action applies the prioritization framework focused on Airway, Breathing, and Circulation. The client's coughing and sputtering when drinking indicates dysphagia, which poses an immediate risk for aspiration and airway compromise. The speech-language pathologist is the correct interdisciplinary team member to evaluate swallowing function and recommend safe dietary modifications.
Step-by-Step Solution
Key Concept
Prioritization of Interdisciplinary Referrals using the ABC Framework