Risk for Aspiration

NURSING DIAGNOSIS:
Risk for Aspiration
Related To: [Check those that apply]
  • 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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Objective/Expected Outcome;The patient will:
  • 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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