Aspiration Nursing Diagnosis & Care Plan

Aspiration is a serious condition where foreign substances such as food, liquid, or stomach contents enter the airway or lungs. This nursing diagnosis is crucial as aspiration can lead to severe respiratory complications, including pneumonia, and can be life-threatening if not addressed promptly and effectively.

Causes (Related to)

Aspiration can result from various conditions compromising a patient’s ability to protect their airway or impair their swallowing mechanism. Common causes include:

• Neurological disorders (stroke, Parkinson’s disease, multiple sclerosis)
• Impaired consciousness (sedation, general anesthesia)
• Structural abnormalities of the throat or esophagus
• Gastroesophageal reflux disease (GERD)
• Dysphagia (difficulty swallowing)
• Presence of artificial airways (endotracheal tubes, tracheostomy)
• Advanced age
• Weakened gag reflex
• Certain medications that affect swallowing or consciousness

Signs and Symptoms (As evidenced by)

Aspiration can manifest with various signs and symptoms. During a physical assessment, a patient at risk for or experiencing aspiration may present with one or more of the following:

Subjective: (Patient reports)

• Difficulty swallowing
• Coughing or choking during meals
• The feeling of food getting stuck in the throat
• Sensation of regurgitation

Objective: (Nurse assesses)

• Coughing or choking during or after meals
• Wet or gurgling breath sounds
• Frequent throat clearing
• Changes in voice quality (wet or gurgly voice)
• Respiratory distress
• Tachypnea
• Decreased oxygen saturation
• Fever (in case of aspiration pneumonia)
• Presence of oral or tracheal secretions
• Food particles in oral secretions
• Drooling or difficulty managing oral secretions

Expected Outcomes

The following are common nursing care planning goals and expected outcomes for aspiration:

• The patient will maintain a patent airway
• The patient will demonstrate improved swallowing ability
• The patient will remain free from signs and symptoms of aspiration
• The patient will maintain oxygen saturation >95% on room air
• The patient will verbalize understanding of aspiration prevention strategies

Nursing Assessment

The first step in nursing care is the assessment, during which the nurse gathers physical, psychosocial, emotional, and diagnostic data. The following section covers subjective and objective data related to aspiration risk.

1. Assess the patient’s level of consciousness and cognitive status.
   Altered mental status increases the risk of aspiration due to impaired protective reflexes.
2. Evaluate the patient’s ability to swallow.
   Perform a bedside swallow assessment or collaborate with a speech therapist for a formal swallowing evaluation.
3. Assess the patient’s gag reflex.
   A weakened or absent gag reflex increases the risk of aspiration.
4. Monitor respiratory status.
   Assess respiratory rate, depth, and pattern. Listen for adventitious breath sounds that may indicate aspiration.
5. Check oxygen saturation levels.
   Use pulse oximetry to monitor oxygen saturation. A sudden drop may indicate aspiration.
6. Assess nutritional status.
   Poor nutrition can weaken muscles involved in swallowing, increasing aspiration risk.
7. Review medication history.
   Certain medications can increase aspiration risk by affecting swallowing or level of consciousness.
8. Evaluate for the presence of gastroesophageal reflux disease (GERD).
   GERD increases the risk of aspiration of stomach contents.
9. Assess for the presence of artificial airways.
   Endotracheal tubes and tracheostomies can increase aspiration risk.
10. Monitor for signs of aspiration pneumonia.
    Assess for fever, increased respiratory rate, and changes in breath sounds.

Nursing Interventions

Nursing interventions are crucial for preventing aspiration and managing patients at risk. The following section outlines possible nursing interventions for a patient with an aspiration nursing diagnosis.

1. Maintain proper positioning.
   Keep the head of the bed elevated at 30-45 degrees, especially during meals and at least 30 minutes after eating.
2. Implement dysphagia precautions as ordered.
   This may include thickened liquids, pureed foods, or NPO (nothing by mouth) status if necessary.
3. Assist with oral care.
   Regular oral hygiene reduces bacterial load in the mouth and minimizes aspiration risk.
4. Educate the patient and family.
   Teach about aspiration risks, prevention strategies, and signs of aspiration to report.
5. Collaborate with the speech therapist.
   Implement recommended swallowing techniques and dietary modifications.
6. Monitor and record intake and output.
   Ensure adequate hydration while adhering to dietary restrictions.
7. Administer medications as ordered.
   This may include proton pump inhibitors for GERD or antibiotics if aspiration pneumonia develops.
8. Suction as needed.
   Clear secretions from the mouth and airway as necessary, using proper technique.
9. Implement feeding tube care if present.
   Ensure proper placement and care of nasogastric or gastrostomy tubes to prevent aspiration.
10. Monitor for signs of aspiration.
    Be vigilant for coughing, choking, or changes in respiratory status during and after meals.

Nursing Care Plans

Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. The following section provides five nursing care plans for aspiration nursing diagnosis.

Care Plan 1: Risk for Aspiration

Nursing Diagnosis Statement: Risk for Aspiration related to impaired swallowing due to stroke.

Related factors/causes:

• Neurological impairment affecting the swallowing mechanism
• Weakened gag reflex
• Altered level of consciousness

Nursing Interventions and Rationales:

1. Perform bedside swallow evaluation before oral intake.
   Rationale: Identifies swallowing difficulties and guides appropriate interventions.
2. Maintain the head of the bed at 30-45 degrees during meals and for 30 minutes after.
   Rationale: Proper positioning reduces the risk of aspiration by using gravity to aid swallowing.
3. Implement a dysphagia diet as recommended by a speech therapist.
   Rationale: Modified food and liquid consistencies can improve safe swallowing and reduce aspiration risk.
4. Provide oral care before and after meals.
   Rationale: Reduces bacterial load in the mouth, minimizing potential complications if aspiration occurs.
5. Educate patient and family on signs of aspiration and prevention strategies.
   Rationale: Increases awareness and promotes early intervention if aspiration occurs.

Desired Outcomes:

• Patient will remain free from signs and symptoms of aspiration throughout hospital stay.
• The patient will demonstrate proper positioning and swallowing techniques during meals.
• Patient will verbalize understanding of aspiration prevention strategies before discharge.

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Care Plan 2: Ineffective Airway Clearance

Nursing Diagnosis Statement: Ineffective Airway Clearance related to presence of artificial airway (endotracheal tube).

Related factors/causes:

• Presence of endotracheal tube
• Impaired cough reflex
• Increased secretion production

Nursing Interventions and Rationales:

1. Endotracheal suctioning is performed as needed, following the sterile technique.
   Rationale: Removes secretions and maintains airway patency, reducing aspiration risk.
2. Monitor cuff pressure of endotracheal tube every 4 hours.
   Rationale: Proper cuff pressure prevents leakage of secretions around the tube, reducing aspiration risk.
3. Provide oral care every 2-4 hours.
   Rationale: Regular oral hygiene reduces bacterial colonization and minimizes risk of ventilator-associated pneumonia.
4. Elevate the head of the bed to 30-45 degrees unless contraindicated.
   Rationale: A semi-recumbent position reduces the risk of aspiration of gastric contents.
5. Assess for signs of ventilator-associated pneumonia (VAP).
   Rationale: Early detection and treatment of VAP can prevent complications.

Desired Outcomes:

• The patient will maintain a patent airway as evidenced by clear breath sounds and oxygen saturation >95%.
• The patient will show no signs of ventilator-associated pneumonia throughout the ICU stay.
• The patient will demonstrate improved secretion clearance with each nursing shift.

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Care Plan 3: Ineffective Airway Clearance

Nursing Diagnosis Statement: Impaired Swallowing related to neuromuscular impairment secondary to Parkinson’s disease.

Related factors/causes:

• A progressive neurological disorder affecting muscle control
• Delayed swallowing reflex
• Reduced oral and pharyngeal muscle strength

Nursing Interventions and Rationales:

1. Collaborate with a speech therapist to implement swallowing exercises.
   Rationale: Strengthens muscles involved in swallowing and improves coordination.
2. Ensure the patient is fully alert and sitting upright before meals.
   Rationale: Maximizes swallowing effectiveness and reduces aspiration risk.
3. Administer medications at optimal times in relation to meals.
   Rationale: Ensures maximum effectiveness of Parkinson’s medications, improving muscle control during meals.
4. Implement the chin tuck technique during swallowing as recommended.
   Rationale: This technique can help protect the airway during swallowing in some patients with Parkinson’s disease.
5. Provide small, frequent meals rather than large meals.
   Rationale: Reduces fatigue during eating and minimizes the risk of aspiration.

Desired Outcomes:

• The patient will demonstrate improved swallowing ability as evidenced by successful completion of meals without choking or coughing.
• The patient will maintain body weight within 5% of baseline over one month.
• The patient will verbalize understanding of safe swallowing techniques before discharge.

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Care Plan 4: Risk for Aspiration

Nursing Diagnosis Statement: Risk for Aspiration related to gastroesophageal reflux disease (GERD).

Related factors/causes:

• Weakened lower esophageal sphincter
• Increased intra-abdominal pressure
• Delayed gastric emptying

Nursing Interventions and Rationales:

1. Administer proton pump inhibitors as ordered.
   Rationale: Reduces gastric acid production, minimizing potential damage if aspiration occurs.
2. Elevate the head of the bed to 30-45 degrees at all times, especially after meals.
   Rationale: Reduces reflux of stomach contents into the esophagus.
3. Teach the patient to avoid lying down for 2-3 hours after meals.
   Rationale: Allows time for gastric emptying, reducing the risk of reflux and potential aspiration.
4. Educate the patient on dietary modifications (e.g., avoiding trigger foods and eating smaller meals).
   Rationale: Reduces symptoms of GERD and minimizes the risk of aspiration.
5. Instruct patient on proper use of prescribed medications and lifestyle modifications.
   Rationale: Promotes self-management of GERD and reduces aspiration risk.

Desired Outcomes:

• The patient will report a reduced frequency of reflux symptoms over one week.
• The patient will demonstrate proper positioning techniques to reduce reflux.
• Patient will verbalize understanding of GERD management strategies before discharge.

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Care Plan 5: Risk for Aspiration

Nursing Diagnosis Statement: Risk for Aspiration related to dysphagia secondary to advanced age.

Related factors/causes:

• Age-related changes in swallowing mechanism
• Decreased saliva production
• Reduced tongue strength and coordination

Nursing Interventions and Rationales:

1. Perform oral care before meals and as needed.
   Rationale: Stimulates saliva production and improves oral hygiene, facilitating safe swallowing.
2. Implement “chin tuck against resistance” (CTAR) exercises as recommended by a speech therapist.
   Rationale: Strengthens suprahyoid muscles involved in swallowing.
3. Ensure dentures (if applicable) fit properly and are in place during meals.
   Rationale: Proper dentition is crucial for effective chewing and swallowing.
4. Encourage small bites and sips, alternating solids and liquids.
   Rationale: Improves control of food and liquid in the mouth, reducing aspiration risk.
5. Provide a quiet, unhurried environment during meals.
   Rationale: Reduces distractions and allows the patient to focus on safe swallowing techniques.

Desired Outcomes:

• The patient will complete meals without signs of aspiration (coughing, choking) throughout the hospital stay.
• Patient will demonstrate proper swallowing techniques during meals.
• The patient will maintain adequate nutrition and hydration as evidenced by stable weight and normal skin turgor.

References

1. Mandell, L. A., & Niederman, M. S. (2019). Aspiration Pneumonia. New England Journal of Medicine, 380(7), 651-663.
2. Rosenbek, J. C., & Jones, H. N. (2020). Dysphagia in Movement Disorders. Plural Publishing.
3. Terré, R., & Mearin, F. (2018). Oropharyngeal dysphagia after the acute phase of stroke: predictors of aspiration. Neurogastroenterology & Motility, 30(4), e13270. https://doi.org/10.1111/nmo.13270
4. Wirth, R., Dziewas, R., Beck, A. M., Clavé, P., Hamdy, S., Heppner, H. J., … & Volkert, D. (2021). Oropharyngeal dysphagia in older persons – from pathophysiology to adequate intervention: a review and summary of an international expert meeting. Clinical Interventions in Aging, 16, 1403-1416. https://doi.org/10.2147/CIA.S223380
5. Metheny, N. A., & Davis-Jackson, J. (2020). Preventing Aspiration in Older Adults with Dysphagia. American Journal of Nursing, 120(11), 52-57. https://doi.org/10.1097/01.NAJ.0000721223.39592.4a
6. Boulanger, J. M., Lindsay, M. P., Gubitz, G., Smith, E. E., Stotts, G., Foley, N., … & Butcher, K. (2018). Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018. International Journal of Stroke, 13(9), 949-984. https://doi.org/10.1177/1747493018786616