Nursing diagnosis – risk for aspiration

Risk for Aspiration
DEFINITION
At risk for entry of gastrointestinal (GI) secretions, oropharyngeal
secretions, solids, or fluids into the tracheobronchial passages
RISK FACTORS
• RISK FOR ASPIRATION
• Decreased GI motility
• Delayed gastric emptying
• Depressed cough and gag
reflexes
• Feeding or GI tubes
• Impaired swallowing
• Incompetent lower esophageal
sphincter
• Increased gastric residual or
intragastric pressure
• Medication administration
• Reduced level of consciousness
(LOC)
• Situations hindering elevation
of upper body
• Surgery or trauma to face,
mouth, or neck
• Tracheotomy or endotracheal
tube
• Wired jaws
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Elimination
• Neurocognition
• Respiratory function
EXPECTED OUTCOMES
The patients will
• Have clear breath sounds on auscultation.
• Have normal bowel sounds.
• Maintain patent airway.
• Breathe easily, cough effectively, and show no signs of respiratory
distress or infection.
• Demonstrate measures to prevent aspiration.
• Maintain respiratory rate within normal limits for age.
• Describe plan for home care.
SUGGESTED NOC OUTCOMES
Aspiration Prevention; Knowledge: Treatment Procedure(s); Respiratory
Status: Ventilation; Risk Control; Swallowing Status
INTERVENTIONS AND RATIONALES
Determine: Assess for gag and swallowing reflexes. Impaired reflexes
may cause aspiration.
Assess respiratory status at least every 4 hr or according to established
standards; begin cardiopulmonary monitoring to detect signs
of possible aspiration (increased respiratory rate, cough, sputum production,
and diminished breath sounds).
Auscultate bowel sounds every 4 hr and report changes. Delayed
gastric emptying may cause regurgitation of stomach contents.
Elevate the head of the bed or place the patient in Fowler’s position
to aid breathing.
Recognize the progression of airway compromise and report your
findings to detect complications early.
Perform: Help patient turn, cough, and deep breathe every 2–4 hr.
Perform postural drainage, percussion, and vibration every 4 hr, or
as ordered. Suction, as needed, to stimulate cough and clear upper
and lower airways. These measures promote drainage of secretions
and full expansion of lungs.
Perform chest physiotherapy before feeding to decrease the risk of
emesis leading to aspiration.
Elevate patient during feeding, and use an upright position after
feeding. Such positioning uses gravity to prevent regurgitation of
stomach contents and promotes lung expansion.
Place patient in the lateral or prone position and change position
at least every 2 hr to reduce the potential for aspiration by allowing
secretions to drain.
Inform: Instruct patient and family members in home care plan.
They must demonstrate the ability to carry out measures to prevent
or respond to aspiration events to ensure adequate home care before
discharge.
Attend: Encourage fluids within prescribed restrictions. Provide
humidification, as ordered (such as a nebulizer). Fluids and humidification
liquefy secretions.
SUGGESTED NIC INTERVENTIONS
Airway Management; Aspiration Precautions; Feeding; Positioning;
Respiratory Monitoring; Vital Signs Monitoring; Vomiting Management
Reference
Thoyre, S. M., et al. (2005, May–June). The early feeding skills assessment for
preterm infants. Neonatal Network, 24(3), 7–16.

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