NURSING DIAGNOSIS: Risk for aspiration

related to impaired swallowing, depressed cough and gag reflexes, and decreased level of consciousness.

Desired Outcome
The client will not aspirate secretions or foods/fluids as evidenced by:
  1. clear breath sounds
  2. resonant percussion note over lungs
  3. absence of cough, tachypnea, and dyspnea.
Nursing Actions and Selected Purposes/Rationales
  1. 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).
  2. Implement measures to reduce the risk for aspiration:
    1. 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
    2. perform oropharyngeal suctioning, encourage client to use tonsil-tip suction, and provide oral hygiene as often as needed to remove excess secretions
    3. if client is receiving tube feedings:
      1. check tube placement before each feeding or on a routine basis if feeding is continuous
      2. do not increase rate of continuous tube feeding infusion unless ordered; administer intermittent tube feedings slowly
      3. maintain client in a high Fowler's position during and for at least 30 minutes after feeding unless contraindicated
      4. stop tube feeding and notify physician if residuals exceed established parameters (usually 75-150 ml)
    4. if oral intake is allowed:
      1. perform actions to improve ability to swallow (see Diagnosis 2, action b)
      2. allow ample time for meals
      3. instruct client to avoid laughing and talking while eating and drinking
      4. maintain client in high Fowler's position during and for at least 30 minutes after meals and snacks unless contraindicated
      5. assist client with oral hygiene after eating to ensure that food particles do not remain in mouth.
  3. If signs and symptoms of aspiration occur:
    1. perform tracheal suctioning
    2. withhold oral intake
    3. prepare client for chest x-ray.