RISK FOR ASPIRATION
Definition:
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]
Risk factors:
- 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
Expected outcomes:
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:
Determine:
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.
Perform:
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.
Inform:
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.
Attend:
Encourage
fluids within prescribed restrictions. Provide humidification, as ordered (such
as a nebulizer). Fluids and humidification liquefy secretions.
Reference:
Thoyre, S. M.,
et al. (2005, May–June). The early feeding skills assessment for preterm
infants. Neonatal Network, 24(3), 7–16.
COMMENTS