NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Risk Control
* Risk Detection
* Respiratory Status: Ventilation
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
* Aspiration Precautions
NANDA Definition: At risk for entry of gastrointestinal secretions, oropharyngeal secretions, or solids or fluids into tracheobronchial passages
Both acute and chronic conditions can place patients at risk for aspiration. Acute conditions, such as postanesthesia effects from surgery or diagnostic tests, occur predominantly in the acute care setting. Chronic conditions, including altered consciousness from head injury, spinal cord injury, neuromuscular weakness, hemiplegia and dysphagia from stroke, use of tube feedings for nutrition, endotracheal intubation, or mechanical ventilation may be encountered in the home, rehabilitative, or hospital settings. Elderly and cognitively impaired patients are at high risk. Aspiration is a common cause of death in comatose patients.
* Risk Factors: Reduced level of consciousness
* Depressed cough and gag reflexes
* Presence of tracheostomy 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
* Expected Outcomes Patient maintains patent airway.
* Patient’s risk of aspiration is decreased as a result of ongoing assessment and early intervention.
* Monitor level of consciousness. A decreased level of consciousness is a prime risk factor for aspiration.
* Assess cough and gag reflexes. A depressed cough or gag reflex increases the risk of aspiration.
* Monitor swallowing ability:
o Assess for coughing or clearing of the throat after a swallow.
o Assess for residual food in mouth after eating. Pockets of food can be easily aspirated at a later time.
o Assess for regurgitation of food or fluid through nares.
o Monitor for choking during eating or drinking. Choking indicates aspiration.
* Auscultate bowel sounds to evaluate bowel motility. Decreased gastrointestinal motility increases the risk of aspiration because food or fluids accumulate in the stomach. Elderly patients have a decrease in esophageal motility, which delays esophageal emptying. When combined with the weaker gag reflex of elderly patients, aspiration is a higher risk.
* Assess for presence of nausea or vomiting.
* Assess pulmonary status for clinical evidence of aspiration. Auscultate breath sounds for development of crackles and/or rhonchi. Aspiration of small amounts can occur without coughing or sudden onset of respiratory distress, especially in patients with decreased levels of consciousness.
* In patients with endotracheal or tracheostomy tubes, monitor the effectiveness of the cuff. Collaborate with the respiratory therapist, as needed, to determine cuff pressure. An ineffective cuff can increase the risk of aspiration.
* Keep suction setup available (in both hospital and home settings) and use as needed. This is necessary 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 airway and prevents aspiration.
* Position patients who have a decreased level of consciousness on their sides. This protects the airway. Proper positioning can decrease the risk of aspiration. Comatose patients need frequent turning to facilitate drainage of secretions.
* Supervise or assist patient with oral intake. Never give oral fluids to a comatose patient. This will help detect abnormalities early.
* Offer foods with consistency that patient can swallow. Use thickening agents as appropriate. Cut foods into small pieces. Semisolid foods like pudding and hot cereal are most easily swallowed. Liquids and thin foods like creamed soups are most difficult for patients with dysphagia.
* Encourage patient to chew thoroughly and eat slowly during meals. Instruct patient not to talk while eating.
* For patients with reduced cognitive abilities, remove distracting stimuli during mealtimes. This facilitates concentration on chewing and swallowing.
* Place whole or crushed pills in soft foods (e.g., custard). Verify with a pharmacist which pills should not be crushed. Substitute medication in elixir form as indicated.
* 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. If the head of the bed cannot be elevated because of the patient’s condition, use a right side-lying position after feedings to facilitate passage of stomach contents into the duodenum.
* Provide oral care after meals. This removes residuals and reduces pocketing of food that can be later aspirated.
* In patients with nasogastric (NG) or gastrostomy tubes:
o Check placement before feeding. A displaced tube may erroneously deliver tube feeding into the airway.
o Check residuals before feeding. Hold feedings if residuals are high and notify the physician. High amounts of residual (>50% of previous hour’s intake) indicate delayed gastric emptying and can cause distention of the stomach leading to reflux emesis.
o Place dye (e.g., methylene blue) in NG feedings. Detection of the color in pulmonary secretions would indicate aspiration.
o Position with head of bed elevated 30 to 45 degrees.
* Use speech pathology consultation as appropriate. A speech pathologist can be consulted to perform a dysphagia assessment that helps determine the need for videofluoroscopy or modified barium swallow.
Education/Continuity of Care
* Explain to patient/caregiver the need for proper positioning. This decreases the risk of aspiration.
* Instruct on proper feeding techniques.
* Instruct on upper-airway suctioning techniques to prevent accumulation of secretions in the oral cavity.
* Instruct on signs and symptoms of aspiration. This aids in appropriately assessing high-risk situations and determining when to call for further evaluation.
* Instruct caregiver on what to do in the event of an emergency.
* Refer to home health nurse, rehabilitation specialist, or occupational therapist as indicated.