Dysphagia or impaired swallowing can be defined as the reduced capacity to swallow solids or liquids related to oral, pharyngeal, or esophageal damage. It is a condition that increases the risk of choking, aspiration, dehydration, and malnutrition.
This is commonly seen in older adults as swallowing muscles weaken. It is an impairment that is prevalent in people that suffer from neurologic damage, such as stroke, head trauma, head and neck cancer, or experience neurological diseases, such as amyotrophic lateral sclerosis, multiple sclerosis, and Parkinson’s disease.
Signs and Symptoms of Dysphagia / Impaired Swallowing
Subjective characteristics a person may have if he/she has dysphagia are refusal to eat, coughing after food or fluid intake, heartburn or epigastric pain, and nighttime awakening.
A person with dysphagia may also be observed as having a weak or hoarse voice. A common condition that may be observed in a client with impaired swallowing is a recurrent pulmonary infection, specifically aspiration pneumonia.
Due to the food entering the trachea instead of the esophagus, or what we call aspiration, the lungs may become infected. In immunocompromised people, this may be fatal.
Diagnosis of Dysphagia / Impaired Swallowing
Dysphagia can be gauged by a tool called the Dysphagia Screening Test. It is minimally invasive and determines the likelihood of a person having impaired swallowing abilities.
This test involves assessing whether the client can be alert, cough on his/her own, swallow at will, raise the tongue, clear the throat, and tolerate swallowing a small amount of water.
The results of the dysphagia screening may evaluate whether the patient can feed normal food, or if the patient would need to be referred for nutrition and hydration.
A more invasive procedure called the fiberoptic endoscopic evaluation of swallowing or FEES test may be indicated by the healthcare provider to determine the extent and etiology of the swallowing disorder.
This test involves the visualization of the swallowing of dyed food with the use of a thin camera passed through the nose.
Factors Related to Dysphagia / Impaired Swallowing
- Upper airway obstruction (i.e., edema, tumor, tracheostomy tube)
- Neuromuscular damage (i.e., weak mastication muscles, decreased/absent gag reflex, paralysis)
- Respiratory disorders
- Behavioral feeding problems
- Failure to thrive
- Anomalies or defects in the nasal, nasopharyngeal, oropharyngeal, upper airway, laryngeal, tracheal, esophageal areas
- Gastroesophageal reflux disease, achalasia
- Trauma, acquired defects, traumatic head injury
- Cranial nerve involvement (vagus or glossopharyngeal)
- Developmental delay
- Cerebral palsy
- Prematurity
Dysphagia Impaired Swallowing Nursing Diagnosis
Dysphagia Impaired Swallowing Nursing Care Plan 1
Head and Neck Cancer
Nursing Diagnosis: Impaired Swallowing related to mechanical obstruction status secondary to head and neck cancer as evidenced by repetitive swallowing, choking, coughing, and gagging.
Desired Outcome: The patient will maintain adequate nutrition and hydration as evidenced by maintained BMI, good skin turgor, moist mucous membranes, and appropriate urine output.
| Nursing Interventions for Impaired Swallowing | Rationale |
| Assess the cause and the degree of impairment by using the dysphagia screening test and by comparing the patient’s previous weight to the current weight. | To provide baseline data and determine the need for hydration and nutritional support. The dysphagia screening test also determines whether the patient has the capacity to feed solids and liquids. |
| Auscultate breath sounds and review laboratory results. | To monitor for aspiration and determine infection by observing the trends in the blood tests. |
| Provide a consistency of food and fluid that is easily swallowed. Avoid dairy products and chocolate. | To reduce the risk of aspiration or choking. Dairy products and chocolate thicken oral secretions and increase the risk of choking. |
| Position client appropriately when feeding and maintain strict aspiration precautions. | Placing the patient upright when feeding minimizes the risk of aspiration, maintaining airway patency. |
| Prepare the patient for possible diagnostic examinations such as the fiberoptic endoscopic evaluation of swallowing, the transnasal or esophageal endoscopy, or the barium swallow. | Diagnostic examinations aid the healthcare team in determining the extent of the swallowing disorder and helps in directing the course of treatment of the patient. |
| Administer tube feeding, parenteral nutrition, or hydration as ordered. | To meet body fluid and nutritional requirements. |
| Refer to the surgeon, gastroenterologist, or oncologist. | For specialized treatment that may improve swallowing ability, such as surgery, medications, and others. |
| Advise patient to avoid eating within 3 hours before sleeping at night and to elevate the head of the bed during sleep. | Eating before sleeping may cause gastric reflux and aspiration. Refraining from eating reduces the risk of this occurring. |
Dysphagia Impaired Swallowing Nursing Care Plan 2
Nursing Diagnosis: Impaired Swallowing related to neuromuscular impairment secondary to Parkinson’s disease as evidenced by choking, drooling, muscle rigidity, food pocketing, and aspiration.
Desired Outcome: The patient will be able to ingest an adequate amount of nutrients and maintain the ideal body weight.
| Dysphagia Nursing Interventions | Rationale |
| Assess the patient’s cognitive and sensory-perceptual status. | Impairment in cognitive or sensory-perceptual status affects the patient’s desire and ability to swallow safely and effectively. |
| Assess the cause and the degree of impairment by using the dysphagia screening test | Swallowing difficulties and choking are common in Parkinson’s disease. Producing baseline data will help in assessing in the future if the patient’s disorder is regressing or progressing. |
| Auscultate breath sounds and review laboratory results. | To monitor for aspiration and determine infection by observing the trends in the blood tests. |
| Note symmetry of facial structures and muscle tone and determine if there is any presence of muscle weakness. Place the food in the functioning side of the patient’s mouth. Modify diet and provide patient-preferred foods that are soft and require little chewing. Avoid thin liquids. | Placing the food in the functioning side of the patient’s mouth allows for sensory stimulation and taste and may trigger swallowing reflexes. Soft foods decrease the potential for choking or aspiration. |
| Cue client to chew and swallow as needed. | This enhances concentration and performance of swallowing. |
| Massage the sides of the trachea and neck. | Massaging these areas will stimulate swallowing. |
| Inspect oral cavity after each bite and have client check around cheeks with tongue for remaining food. | To monitor for food pocketing and minimize the risk of aspiration later on. |
| Keep client seated or upright during feeding and at least 30 minutes post-feeding. | Letting the patient lay down during eating or immediately after intake may cause regurgitation or aspiration. |
| Administer tube feeding, parenteral nutrition, or hydration as ordered. | To achieve adequate nutritional intake, and prevent malnutrition and dehydration. |
| Refer to ENT or speech pathology. | Referral to a specialist will let the patient learn specific techniques to enhance efforts and safety. |
Dysphagia Impaired Swallowing Nursing Care Plan 3
Gastroesophageal Reflux Disease
Nursing Diagnosis: Impaired Swallowing related to acquired pharyngeal/esophageal defects secondary to gastroesophageal reflux disease as evidenced by acidic smelling breath, regurgitation of gastric contents, and vomiting.
Desired Outcome: The patient will pass food and fluid from mouth to stomach safely.
| Nursing Interventions for Impaired Swallowing | Rationale |
| Assess the cause and the degree of impairment. Inspect oropharyngeal cavity for edema, inflammation, altered mucosal integrity. | To determine the exact cause of the swallowing disorder and provide baseline data that may help in the course of the patient’s treatment. |
| Prepare the patient for possible diagnostic examinations such as the fiberoptic endoscopic evaluation of swallowing, the transnasal or esophageal endoscopy, or the barium swallow. | Diagnostic examinations aid the healthcare team in determining the extent of the swallowing disorder and helps in directing the course of treatment of the patient. |
| Position client appropriately when feeding and maintain strict aspiration precautions. | Placing the patient upright when feeding minimizes the risk of aspiration, maintaining airway patency. |
| Provide analgesics prior to feeding, as ordered. | To enhance comfort and decrease pain during swallowing. |
| Instruct client and significant others in emergency measures in the event of choking, such as the Heimlich maneuver. | To prevent aspiration or other serious complications. |
| Keep client seated or upright during feeding and at least 30 minutes post-feeding. | Letting the patient lay down during eating or immediately after intake may cause regurgitation or aspiration. |
| Advise patient to avoid eating within 3 hours before sleeping at night and to elevate the head of the bed during sleep. | Eating before sleeping may cause gastric reflux and aspiration. Refraining from eating reduces the risk of this occurring. |
Dysphagia Impaired Swallowing Nursing Care Plan 4
Nursing Diagnosis: Impaired Swallowing related to dysphagia secondary to stroke
Desired Outcome: The patient will be able to regain swallowing capacity and avoid any aspiration or development of aspiration pneumonia.
| Dysphagia Nursing Interventions | Rationale |
| Assess airway patency. | Maintaining an open and clear airway is vital to retain airway clearance and reduce the risk for aspiration. |
| Assess the patient’s ability to cough out secretions. | Stroke features neuromuscular weakness and may limit the patient’s ability to clear the airway. |
| Refer the patient to SLP or speech and language therapy (SALT) team. | Stroke can diminish or reduce the patient’s ability to swallow. The patient can aspirate, which can cause respiratory problems. The SALT team are specialists in assessing the ability to swallow and recommending diet, thickness of liquids to drink, and techniques to improve the ability to swallow. |
| Encourage a Fowler’s position when the patient is eating/ feeding the patient. | To prevent food or liquid to be aspirated into the airways and lungs. |
| Follow the SLP or SALT team’s advice on the appropriate diet of the patient as well as the proper thickness of the drinks. | To prevent food or liquid to be aspirated into the airways and lungs. |
Dysphagia Impaired Swallowing Nursing Care Plan 5
Malnutrition
Nursing Diagnosis: Risk for Imbalanced Nutrition: Less Than Body Requirements related to dysphagia / impaired swallowing
Desired Outcome: The patient will either regain normal swallowing capacity or be able to improve nutrition by feeding. He/she will also obtain understanding of food options to support nutrition supplementation.
| Dysphagia Nursing Interventions | Rationales |
| Check the patient’s current weight as baseline. Weight the patient daily in the mornings. | Weight loss can be measured accurately with a patient’s actual weight rather than by estimate. The patient’s weight is also an ideal tool in the assessment of a person’s nutritional requirements. |
| Start the patient on a food diary and assess caloric intake. | A record of what the patient eats can help direct treatment. |
| Assess what the patient can safely eat and drink. | Patients with dysphagia and aspiration may be able to tolerate thickened liquids and pureed food. Assessing what the patient can tolerate will help support nutrition and arrange food choices to become available. |
| Promote a semi or full Fowler’s position during feeding. | An upright position or elevating the head to at least 30 degrees aids in swallowing and reduces the risk for aspiration. |
| Refer the patient to the dietitian and/or nutritionist. | A dietitian can help the medical team assess the patient’s nutritional status and recommend food options that will supplement the patient’s nutritional gaps. |
| Refer to speech and language therapy. | Speech and language therapists assess the patient’s ability to swallow safely and can recommend food and food texture that is safe for the patient to eat/drink. |
| Weigh the patient regularly and document readings. | The patient’s weight will help in the evaluation of the patient’s progress. |
| Create a plan with the patient and his/her carer regarding the patient’s nutritional needs. | Understanding the importance of maintaining proper nutrition will encourage the patient to become proactive in adhering to the treatment plan. |
| Discuss the nutritional recommendation of the team, nutritionist, and dietitian to the patient. Follow the recommended type of diet and thickness of fluids. | An explanation of the new food choices and the recommended type of diet and fluids to support the patient’s nutritional requirements will promote compliance to treatment. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
