- 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’s Diagnosis: –
Date:-
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- maintains patent airway.
- Patient’s risk of aspiration will decrease as a result of ongoing assessment and early intervention.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Monitor level of consciousness. | A decreased level of consciousness is a prime risk factor for aspiration. |
| Assess cough and gag reflex. | A depressed cough or gag reflex increases the risk of aspiration. |
| Auscultate bowel sounds to evaluate bowel motility. | Decreased gastrointestinal motility increases the risk of aspiration because food or fluids accumulate in the stomach. |
| Keep suction setup available (in both hospital and home setting) and use as needed. | To maintain a patent airway. |
| 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 prevents aspiration. |
| 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. |
| For patients with reduced cognitive abilities, remove distracting stimuli during mealtimes. | To facilitate concentration chewing and swallowing. |
| Position patient at 90-degree angle, whether in bed or in a chair or wheelchair. Use cushions or pillows to maintain position. | Proper positioning of patients with swallowing difficulties is of primary importance during feeding or eating. |
| 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. |
| Provide oral care after meals. | To remove residuals and to reduce pocketing of food that can be later aspirated. |
| Instruct on signs and symptoms of aspiration. | Aids in appropriately assessing high-risk situations and determining when to call for further evaluation. |
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