Aspiration, Risk for
Sue Galanes, RN, MS,
NANDA: The state in which an individual is at risk for entry of
gastrointestinal secretions, oropharyngeal secretions, or solids or fluids into
Both acute and chronic conditions can place patients at risk for
aspiration. Acute conditions, such as postanesthesia effects from surgery or
diagnostic tests, occur predominantly in the acute care setting. Chronic
conditions, including altered consciousness from head injury, spinal cord
injury, neuromuscular weakness, hemiplegia and dysphagia from stroke, use of
tube feedings for nutrition, endotracheal intubation, or mechanical ventilation
may be encountered in the home, rehabilitative, or hospital settings. Elderly
and cognitively impaired patients are at high risk. Aspiration is a common
cause of death in comatose patients.
- Reduced level of consciousness
- Depressed cough and gag reflexes
- Presence of tracheotomy or endotracheal tube
- Presence of gastrointestinal tubes
- Tube feedings
- Anesthesia or medication administration
- Decreased gastrointestinal motility
- Impaired swallowing
- Facial, oral, or neck surgery or trauma
- Situations hindering elevation of upper body
- Patient maintains patent airway.
- Patient's risk of aspiration is decreased as a result of ongoing
assessment and early intervention.
Ongoing Assessment Actions/Interventions/Rationale
- (i) independent
- (i) Monitor level of consciousness.
- A decreased level of consciousness is a prime risk factor for
- (i) Assess cough and gag reflex.
- A depressed cough or gag reflex increases the risk of
- (i) Monitor swallowing ability:
- Assess for coughing or clearing of the throat after a
- Assess for residual food in mouth after eating.
- Pockets of food can be easily aspirated at a later
- Assess for regurgitation of food or fluid through nares.
- Monitor for choking during eating or drinking.
- (i) Auscultate bowel sounds to evaluate bowel
- Decreased gastrointestinal motility increases the risk of
aspiration because food or fluids accumulate in the stomach. The elderly have a
decrease in esophageal motility, which delays esophageal emptying. When
combined with the weaker gag reflex of the elderly, aspiration is a higher
- (i) Assess for presence of nausea or
- (i) Assess pulmonary status for clinical
evidence of aspiration. Auscultate breath sounds for development of crackles
- Aspiration of small amounts can occur without coughing or
sudden onset of respiratory distress, especially in patients with decreased
levels of consciousness.
- (c) In patients with endotracheal or
tracheostomy tubes, monitor the effectiveness of the cuff. Collaborate with the
respiratory therapist, as needed, to determine cuff pressure.
- An ineffective cuff can increase the risk of aspiration.
- (i) independent
- (i) Keep suction setup available (in both
hospital and home setting) and use as needed
- To maintain a patent airway.
- (i) Notify the physician or other health
care provider immediately of noted decrease in cough and/or gag reflexes, or
difficulty in swallowing.
- Early intervention protects the patient's airways and
- (i) Position patients who have a decreased
level of consciousness on their side.
- To protect the airway. Proper positioning can decrease the
risk of aspiration. Comatose patients need frequent turning to facilitate
drainage of secretions.
- (i) Supervise or assist patient with oral
Never give oral fluids to a comatose patient.
- To detect abnormalities early.
- (i) Offer foods with consistency that
patient can swallow.
Use thickening agents as appropriate. Cut foods into
- Semisolid foods like pudding and hot cereal are most easily
swallowed. Liquids and thin foods like creamed soups are most difficult for
patients with dysphagia.
- (i) Encourage patient to chew thoroughly and
eat slowly during meals. Instruct patient not to talk while eating.
- (i) For patients with reduced cognitive
abilities, remove distracting stimuli during mealtimes.
- To facilitate concentration chewing and swallowing.
- (i) Place whole or crushed pills in soft
foods (e.g., custard). Verify with a pharmacist which pills should not be
crushed. Substitute medication in elixir form as indicated.
- (i) Position patient at 90-degree angle,
whether in bed or in a chair or wheelchair. Use cushions or pillows to maintain
- Proper positioning of patients with swallowing difficulties
is of primary importance during feeding or eating.
- (i) Maintain upright position for 30 to 45
minutes after feeding.
- The upright position facilitates the gravitational flow of
food or fluid through the alimentary tract. If the head of bed cannot be
elevated because of patient's condition, use a right side-lying position after
feedings to facilitate passage of stomach contents into the duodenum.
- (i) Provide oral care after meals.
- To remove residuals and to reduce pocketing of food that can
be later aspirated.
- (c) In patients with nasogastric (NG) or
- Check placement before feeding.
- A displaced tube may erroneously deliver tube feeding
into the airway.
- Check residuals before feeding. Hold feedings if residuals are
high and notify the physician.
- High amounts of residual (greater than 50% of previous
hour's intake) indicates delayed gastric emptying and can cause distention of
the stomach leading to reflux emesis.
- Place dye (e.g., methylene blue) in NG feedings.
- Detection of the color in pulmonary secretions would
- Position with head of bed elevated 30 to 45 degrees.
- (c) Use speech pathology consultation as
- A speech pathologist can be consulted to perform a dysphagia
assessment that helps determine the need for video fluoroscopy or barium cookie
Education/Continuity of Care
- (i) independent
- (i) Explain to patient/caregiver the need for
- To decrease the risk of aspiration.
- (i) Instruct on proper feeding
- (i) Instruct on upper-airway suctioning
techniques to prevent accumulation of secretions in the oral cavity.
- (i) Instruct on signs and symptoms of
- Aids in appropriately assessing high-risk situations and
determining when to call for further evaluation.
- (i) Instruct caregiver on what to do in the
event of an emergency.
- (i) Refer to home health nurse,
rehabilitation specialist, or occupational therapist as indicated.
- See also:
Enteral Tube Feeding, Chapter 7,
~ Care Plan Index ~
Outcomes Index ~
~ Care Plan Constructor Home ~