Aspiration Precaution Nursing Diagnosis and Nursing Care Plan

Aspiration Precaution Nursing Diagnosis and Nursing Care Plan

This guide is about aspiration precaution, aspiration precaution nursing diagnosis, and aspiration precaution nursing care plan. It can be used to develop aspiration precaution nursing care plans for educational purposes.

Aspiration Precaution Nursing Diagnosis and Nursing Care Plan

Aspiration Precaution

What exactly is aspiration precaution?

Aspiration precaution is breathing in a foreign object such as foods or liquids into the trachea and lungs and happens when protective reflexes are reduced or jeopardized. It can also be simply defined as the inhaling of a liquid or object into the lungs.

An infection that develops after an entry of food, liquid, or vomit into the lungs can result in aspiration pneumonia. Inhaling chemical fumes or breathing in and choking on certain chemicals, even small amounts of gastric acids can damage lung tissue, resulting in chemical pneumonitis.

Many household and industrial chemicals can produce both an acute and a chronic form of inflammation in the lungs which can place patients at risk for aspiration. Acute conditions, like post-anesthesia effects from surgery or diagnostic tests, happen predominantly in the acute care setting. Chronic conditions, like altered consciousness from a head injury, spinal cord injury, neuromuscular weakness, hemiplegia, and dysphagia from stroke, use of tube feedings for nutrition, and artificial airway devices such as tracheostomies, may be experienced in the home, rehabilitative, or hospital setting.

Prevention is the main goal when caring for patients at risk for aspiration. Evidence shows that one of the principal precautionary measures for aspiration is placing at-risk patients in a semirecumbent position. Other measures include compensating for absent reflexes, assessing feeding tube placement, identifying delayed stomach emptying, and managing effects of prolonged intubation.

Summary of the causes of aspiration precaution

What is the cause of aspiration precaution?

Decreased level of awareness due to: traumatic brain (or head) injury, stroke, decreased/absent gag reflex, medical conditions that affect swallowing.
Conditions that affect the food pipe.
Gastroesophageal reflux (GERD).
Any type of surgery that puts you under anesthesia.
Drinking large amounts of alcohol.
Taking medications that cause drowsiness, confusion, or weakness.
Aging.
Dental problems.
Having a feeding tube.

Summary of the signs of aspiration

What are the signs of silent aspiration?

Coughing after swallowing or drinking liquids.
Difficulty breathing: breathing rapidly, or very slow.
Hearing “gurgling” lung sounds when person breaths.
coughing up phlegm: yellow, or green color.
Phlegm that has food on it.
Bad smelling.
change of voice (hoarseness).
change of skin color, skin turns bluish (cyanosis).

Aspiration Precaution Nursing Diagnosis

How do you diagnose aspiration?

Aspiration Precaution Nursing Diagnosis and Nursing Care Plan
Aspiration Precaution Nursing Diagnosis

Assessment is required in order to distinguish possible problems that may have led to aspiration as well as name any episode that may occur during nursing care.

Assessment Rationales
Assess the level of consciousness. The primary risk factor of aspiration is decreased level of consciousness.
Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, or fever. Signs of aspiration should be identified as soon as possible to prevent further aspiration and to initiate treatment that can be life-saving.
Evaluate swallowing ability by assessing for the following: 

  • Coughing, choking, throat clearing, gurgling, or “wet” voice during or after swallowing
  • Residual food in mouth after eating
  • Regurgitation of food or fluid through the nares
Impaired swallowing increases the risk for aspiration. There remains a need for valid and easy-to-use methods to screen for aspiration risk.
Review results of swallowing studies as ordered. For high-risk patients, the performance of a videofluoroscopic swallowing study may be indicated to determine the nature and extent of any swallowing abnormality.
Assess for the presence of nausea or vomiting. Nausea or vomiting places patients at great risk for aspiration, especially if the level of consciousness is compromised. Antiemetics may be required to prevent aspiration of regurgitated gastric contents.
Observe for food particles in tracheal secretions in patients with tracheostomies. Food should never be present in the tracheobronchial passages. It signifies aspirated material.
Auscultate bowel sounds to assess for gastrointestinal motility. Reduced gastrointestinal motility increases the risk of aspiration as fluids and food build up in the stomach. Further, elderly patients have a decrease in esophageal motility, which delays esophageal emptying. When combined with the weaker gag reflex of older patients, aspiration is at higher risk.
Assess pulmonary status for clinical evidence of aspiration. Auscultate breath sounds noting for crackles and rhonchi. Monitor chest x-ray films as ordered. Aspiration of small amounts can happen with sudden onset of respiratory distress or without coughing particularly in patients with diminished levels of consciousness. Pulmonary infiltrates on chest x-ray films indicate some level of aspiration has already occurred.
Monitor the effectiveness of the cuff in patients with endotracheal or tracheostomy tubes. An ineffective cuff can increase the risk of aspiration. Work together with the respiratory therapist, as necessary, to verify cuff pressure.
In patients with nasogastric (NG) or gastrostomy tubes:
  • Check placement before feeding, using tube markings, x-ray study (most accurate), pH of gastric fluid, and color of aspirate as guides.
A displaced tube may erroneously deliver tube feeding into the airway. Chest x-ray verification of accurate tube placement is most reliable. The gastric aspirate is usually green, brown, clear, or colorless, with a pH between 1 and 5.
  • Test sputum with glucose oxidase reagent strips.
Significant amounts of glucose in the sputum may be indicative of aspiration.
  • Check residuals before feeding, or every 4 hours if feeding is continuous. Hold feedings if the amount of residuals is large, and notify the physician.
Large amounts of residuals indicate delayed gastric emptying and can cause distention of the stomach, leading to reflux emesis. The number of residuals may vary depending on the volume and rate of infusion; however, the evaluation can be unreliable. Feedings are often held if the residual volume is greater than 50% of the amount to be delivered in 1 hour.
Assess the patient and family for willingness and cognitive ability to learn and cope with swallowing, feeding, and related disorders. Food and feeding habits may be strongly tied to family cultural values. Acknowledgment and/or adjustment to cultural values can facilitate compliance and successful family coping.

Aspiration Precaution Nursing Care Plan

What is the most effective way of preventing aspiration?

Aspiration Precaution Nursing Diagnosis and Nursing Care Plan
Aspiration Precaution Nursing Care Plan

The following are the therapeutic nursing interventions for aspiration risk:

Nursing Interventions Rationales
Keep suction machines available when feeding high-risk patients. If aspiration does occur, suction immediately. A patient with aspiration needs immediate suctioning and will need further lifesaving interventions such as intubation.
Inform the physician or other health care provider instantly of a noted decrease in cough/gag reflexes or difficulty in swallowing. Early intervention protects the patient’s airway and prevents aspiration. Anyone identified as being at high risk for aspiration should be kept NPO (nothing by mouth) until further evaluation is completed.
Keep head of the bed elevated when feeding and for at least a half-hour afterward. Maintaining a sitting position after meals may help decrease aspiration pneumonia in the elderly.
Position patients with a decreased level of consciousness on their side. This positioning (rescue positioning) decreases the risk for aspiration by promoting the drainage of secretions out of the mouth instead of down the pharynx, where they could be aspirated.
Supervise or aid the patient with oral intake. Never give oral fluids to a comatose patient. Supervision helps identify abnormalities early and allows the implementation of strategies for safe swallowing. Withholding fluids and foods as needed prevents aspiration.
Provide foods with consistency that the patient can swallow. Use thickening agents if recommended by a speech pathologist or dietician. Thickened semisolid foods such as pudding and hot cereal are most easily swallowed and less likely to be aspirated. Liquids and thin foods (e.g., creamed soups) are most difficult for patients with dysphagia.
Allow the patient to chew thoroughly and eat slowly during meals. Well-masticated food is easier to swallow, food cut into small pieces may also be easier to swallow.
Note new onset of abdominal distention or increased rigidity of abdomen. Abdominal distention or rigidity can be associated with paralytic or mechanical obstruction and an increased likelihood of vomiting and aspiration.
For patients with reduced cognitive abilities, eliminate distracting stimuli during mealtimes. Tell the patient not to talk while eating. Concentration must be focused on chewing and swallowing. There is a higher risk for the airway to be opened when talking and eating at the same time.
During enteral feedings, position patient with head of the bed elevated 30 to 40 degrees; maintain for 30 to 45 minutes after feeding. Keeping a patient’s head elevated helps keep food in the stomach and decreases the incidence of aspiration
Place medication and food on the strong side of the mouth when unilateral weakness or paresis is present. Careful food placement promotes chewing and successful swallowing.
Offer liquids after food is eaten. Ingesting food and fluids together increases swallowing difficulties.
Place whole or crushed pills in soft foods (e.g., custard). Verify with a pharmacist which pills should not be crushed. Mixing pills with food helps reduce the risk for aspiration.
Stop continual feeding temporarily when turning or moving patient. When turning or moving a patient, it is difficult to keep the head elevated to prevent regurgitation and possible aspiration.
Provide oral care before and after meals. Oral care before meals reduces bacterial counts in the oral cavity. Oral care after eating removes residual food that could be aspirated at a later time.
In patients with artificial airways:
  • Perform oral suctioning as needed.
Suctioning reduces the volume of oropharyngeal secretions and reduces aspiration risk.
  • Brush teeth twice a day, and swab mouth with sponge applicators every 2 to 4 hours between brushing.
Oral care reduces the risk for ventilator-associated pneumonia by decreasing the number of microorganisms in aspirated oropharyngeal secretions.
In patients with NG or gastrostomy tubes:
  •  If ordered by a physician, put several drops of blue or green food coloring in tube feeding to help indicate aspiration. In addition, test the glucose in tracheobronchial secretions to detect aspiration of enteral feedings.
Colored secretions suctioned or coughed from the respiratory tract indicate aspiration.
  • Elevate the head of the bed to 30 to 45 degrees while feeding the patient and for 30 to 45 minutes afterward if feeding is intermittent. Turn off the feeding before lowering the head of the bed. Patients with continuous feedings should be in an upright position.
Upright positioning reduces aspiration by decreasing reflux of gastric contents.
Consult a speech pathologist, as appropriate. A speech pathologist can be consulted to perform a dysphagia assessment that helps determine the need for videofluoroscopy or modified barium swallow and to establish specific techniques to prevent aspiration in patients with impaired swallowing.
For patients at high risk for aspiration, obtain complete information from the discharging institution regarding institutional management. Continuity of care can prevent unnecessary stress for the patient and family and can facilitate successful management in the home setting.
Establish emergency and contingency plans for the care of patients. Clinical safety of patients between visits is a primary goal of home care nursing.
Educate the patient and family on the need for proper positioning. Upright positioning decreases the risk for aspiration.
Instruct in signs and symptoms of aspiration. The information helps in appropriate assessment of high-risk situations and determination of when to call for further evaluation.
Demonstrate suctioning techniques to prevent the accumulation of secretions in the oral cavity. Respiratory aspiration requires prompt action to maintain the airway and promote effective breathing and gas exchange.
Refer the patient to a home health nurse, rehabilitation specialist, or occupational therapist as indicated. The use of consultants may be required to ensure outcomes are achieved.

Aspiration Precaution Nursing Diagnosis and Nursing Care Plan Examples

Nursing Care Plan 1

Foreign Body Airway Obstruction (FBAO)

Desired Outcome: The patient will be relieved of foreign body that is obstructing his/her airways and aspiration will then be prevented

Interventions Rationales
Assess if the infant/child is conscious or unconscious. The actions to treat FBAO are different depending on the alertness status of the infant/child.
Assess the severity of the situation by checking if it is a severe choking scenario with ineffective coughing, or a mild one with effective coughing. To correctly administer the proper actions to remove the foreign body from the infant/ child.
Conscious Infant (under 1 year old)

Place the infant over your forearm, supported by your thigh. The head should be lower than the torso. Ensure to support the head and neck using your hand.

Use the heel of your hand to deliver up to 5 forceful back blows in between the shoulder blades.

Turn the infant face up, head still lower than torso. Deliver up to 5 chest thrusts by using 2 to 3 fingers to depress the infant’s sternum. Avoid the tip of the sternum.

Repeat back blows and chest thrusts until the foreign body comes out, or until the infant becomes unconscious.

DO NOT attempt blind finger sweep or abdominal thrusts on the infant.

To remove the foreign body and prevent the risk for aspiration.
Unconscious Infant (up to 1 year old)
Shout for help (call 911 in the home/community setting).
Tongue-jaw lift maneuver: Place your thumb inside the infant’s mouth to grasp the lower incisor teeth or gums. If the foreign body is visible, remove it immediately. DO NOT attempt a blind finger sweep (or putting your finger in the mouth hoping to remove the non-visible foreign body).
Perform rescue breathing. Perform back blows and chest thrusts as you would in a conscious infant until foreign body is removed.
If the foreign body is expelled but the infant is still not breathing, perform cardiopulmonary resuscitation (CPR).
To remove the foreign body and prevent the risk for aspiration.
Conscious Adult or Child (over 1 year old)
If the person can breathe, speak, or cough, do not attempt to intervene.
If the person cannot breathe, speak, or cough, perform Heimlich maneuver (abdominal thrusts): – Stand behind the person.
Clench one hand into a fist and grab this with your other hand in a lock under the person’s rib cage. – Sharply pull your fist in a backward and upward direction for 6 to 10 times. –
If the person is obese or is in late pregnancy, do not perform Heimlich maneuver. Do chest thrusts instead.
To remove the foreign body and prevent the risk for aspiration.
Conscious Adult or Child (over 1 year old)
Shout for help (call 911 in the home/community setting). Place the person on his/her back, with arms on the side.
If the object is visible, attempt to remove the foreign body from the mouth through finger sweep method.DO NOT perform a blind finger sweep in a child under 8 years old. Perform a tongue-jaw lift maneuver instead to check if the foreign body is visible and can be removed.
If the person is not breathing, start rescue breathing. If he/she is still unconscious, start Heimlich maneuver (abdominal thrusts):Kneel over the person Place the heel of your hand on his/her abdomen, just above the navel.
Place your other hand on top of the first hand.
Apply pressure in the abdomen using 6 to 10 sharp and upward thrusts.
Continue the sequence of finger sweep, rescue breathing, and Heimlich maneuver until the foreign body is removed.
If the foreign body is expelled but the person is still not breathing, perform cardiopulmonary resuscitation (CPR).

Nursing Care Plan 2

Cerebrovascular Accident (CVA or Stroke)

Nursing Diagnosis: Risk for Aspiration related to decreased ability to swallow secondary to CVA / stroke                                               

Desired Outcome: The patient will be able to avoid any aspiration or develop aspiration pneumonia.

Interventions Rationale
Assess airway patency. Maintaining an open and clear airway is vital to retain airway clearance and reduce the risk for aspiration.
Assess the patient’s ability to cough out secretions. Stroke can cause neuromuscular weakness and may limit the patient’s ability to clear the airway.
Refer the patient for speech and language therapy (SALT) team. Stroke can diminish or reduce the patient’s ability to swallow. The patient can choke, which can cause further airway problems. The SALT team are specialists in assessing the ability to swallow and recommending diet, thickness of liquids to drink, and techniques to improve the ability to swallow.
Encourage a Fowler’s position when the patient is eating/ feeding the patient. To prevent food or liquid to be aspirated into the airways and lungs.
Follow the SALT team’s advice on the appropriate diet of the patient as well as the proper thickness of the drinks. To prevent food or liquid to be aspirated into the airways and lungs.

Aspiration Precaution Nursing Diagnosis and Nursing Care Plan

 

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