Nursing Dx

Taxonomy II: Safety/Protection—Class 2 Physical Injury (00039)
[Diagnostic Division: Respiration]
Submitted 1988
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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]

Reduced level of consciousness
Depressed cough and gag reflexes

Impaired swallowing [owing to inability of the epiglottis and true vocal cords to move to close off trachea]
Facial/oral/neck surgery or trauma; wired jaws Situation hindering elevation of upper body [weakness, paralysis]
Incomplete lower esophageal sphincter [hiatal hernia or other esophageal disease affecting stomach valve function], delayed gastric emptying, decreased gastrointestinal motility, increased intragastric pressure, increased gastric residual
Presence of tracheostomy or endotracheal (ET) tube; [inadequate or overinflation of tracheostomy/ET tube cuff]
[Presence of] gastrointestinal tubes; tube feedings/medication administration

NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes/Evaluation
Criteria—Client Will:
• Experience no aspiration as evidenced by noiseless respirations, clear breath sounds; clear, odorless secretions.
• Identify causative/risk factors.
• Demonstrate techniques to prevent and/or correct aspiration.

Actions/Interventions
NURSING PRIORITY NO.1. To assess causative/contributing factors:
• Note level of consciousness/awareness of surroundings,cognitive impairment.
• Evaluate presence of neuromuscular weakness, noting muscle groups involved, degree of impairment, and whether they are of an acute or progressive nature (e.g., Guillain-Barré,amyotrophic lateral sclerosis—ALS).
• Assess amount and consistency of respiratory secretions and strength of gag/cough reflex.
• Observe for neck and facial edema, for example, client with head/neck surgery, tracheal/bronchial injury (upper torso burns, inhalation/chemical injury).
• Note administration of enteral feedings, being aware of potential for regurgitation and/or misplacement of tube.
• Ascertain lifestyle habits, for instance, use of alcohol, tobacco, and other CNS-suppressant drugs; can affect awareness and muscles of gag/swallow.

NURSING PRIORITY NO.2. To assist in correcting factors that can lead to aspiration:
• Monitor use of oxygen masks in clients at risk for vomiting. Refrain from using oxygen masks for comatose individuals.
• Keep wire cutters/scissors with client at all times when jaws are wired/banded  to facilitate clearing airway in emergency situations.
• Maintain operational suction equipment at bedside/chairside.
• Suction (oral cavity, nose, and ET/tracheostomy tube) as needed to clear secretions. Avoid triggering gag mechanism when performing suction or mouth care.
• Assist with postural drainage  to mobilize thickened secretions that may interfere with swallowing.
• Auscultate lung sounds frequently (especially in client who is coughing frequently or not coughing at all; ventilator client being tube-fed)  to determine presence of secretions/silent aspiration.
• Elevate client to highest or best possible position for eating and drinking and during tube feedings.
• Feed slowly, instruct client to chew slowly and thoroughly.
• Give semisolid foods; avoid pureed foods  (increased risk of aspiration) and mucus-producing foods (milk). Use soft foods that stick together/form a bolus (e.g., casseroles, puddings, stews) to aid swallowing effort.
• Provide very warm or very cold liquids  (activates temperature receptors in the mouth that help to stimulate swallowing). Add thickening agent to liquids as appropriate.
• Avoid washing solids down with liquids.
• Ascertain that feeding tube is in correct position. Measure residuals when appropriate to prevent overfeeding. Add food coloring to feeding to identify regurgitation.
• Determine best position for infant/child (e.g., with the head of bed elevated 30 degrees and infant propped on right side after feeding because upper airway patency is facilitated by upright position and turning to right side decreases likelihood of drainage into trachea).
• Provide oral medications in elixir form or crush, if appropriate.
• Refer to speech therapist for exercises to strengthen muscles and techniques to enhance swallowing.

NURSING PRIORITY NO.3. To promote wellness (Teaching/ Discharge Considerations):
• Review individual risk/potentiating factors.
• Provide information about the effects of aspiration on the lungs.
• Instruct in safety concerns when feeding oral or tube feeding. Refer to ND impaired Swallowing.
• Train client to suction self or train family members in suction techniques (especially if client has constant or copious oral secretions) to enhance safety/self-sufficiency.
• Instruct individual/family member to avoid/limit activities that increase intra-abdominal pressure (straining, strenuous exercise, tight/constrictive clothing), which may slow digestion/increase risk of regurgitation.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings/conditions that could lead to problems of aspiration.
• Verification of tube placement, observations of physical findings.
PLANNING
• Interventions to prevent aspiration or reduce risk factors and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to interventions/teaching and actions performed.
• Foods/fluids client handles with ease/difficulty.
• Amount/frequency of intake.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions to be taken.