RISK FOR ASPIRATION
At risk for entry of gastrointestinal secretions, oropharyngeal secretions, or [exogenous food] solids or fluids into tracheobronchial passages [due to dysfunction or absence of normal protective mechanisms]
- 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
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.
Interventions and Rationales:
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.
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.
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.
Encourage fluids within prescribed restrictions. Provide humidification, as ordered (such as a nebulizer). Fluids and humidification liquefy secretions.
Thoyre, S. M., et al. (2005, May–June). The early feeding skills assessment for preterm infants. Neonatal Network, 24(3), 7–16.