Risk for aspiration
related to impaired swallowing, depressed cough and gag reflexes, and decreased level of consciousness.
|The client will not aspirate secretions or foods/fluids as evidenced by:|
- clear breath sounds
- resonant percussion note over lungs
- absence of cough, tachypnea, and dyspnea.
|Nursing Actions and Selected Purposes/Rationales|
- Assess for and report signs and symptoms of aspiration of secretions or foods/fluids (e.g. rhonchi, dull percussion note over affected lung area, cough, tachypnea, tachycardia, dyspnea, presence of tube feeding in tracheal aspirate, chest x-ray results showing pulmonary infiltrate).
- Implement measures to reduce the risk for aspiration:
- withhold oral foods/fluids and place client in side-lying position if he/she has a depressed or absent gag reflex, severe dysphagia, and/or is not alert
- perform oropharyngeal suctioning, encourage client to use tonsil-tip suction, and provide oral hygiene as often as needed to remove excess secretions
- if client is receiving tube feedings:
- check tube placement before each feeding or on a routine basis if feeding is continuous
- do not increase rate of continuous tube feeding infusion unless ordered; administer intermittent tube feedings slowly
- maintain client in a high Fowler's position during and for at least 30 minutes after feeding unless contraindicated
- stop tube feeding and notify physician if residuals exceed established parameters (usually 75-150 ml)
- if oral intake is allowed:
- perform actions to improve ability to swallow (see Diagnosis 2, action b)
- allow ample time for meals
- instruct client to avoid laughing and talking while eating and drinking
- maintain client in high Fowler's position during and for at least 30 minutes after meals and snacks unless contraindicated
- assist client with oral hygiene after eating to ensure that food particles do not remain in mouth.
- If signs and symptoms of aspiration occur:
- perform tracheal suctioning
- withhold oral intake
- prepare client for chest x-ray.