Risk for Aspiration Nursing Diagnosis and Nursing Care Plan

Risk for Aspiration Nursing Care Plans Diagnosis and Interventions

Risk for Aspiration NCLEX Review and Nursing Care Plans

Aspiration occurs when liquids, foods, or objects are swallowed, but enters the airways and into the lungs.

It is often described by patients as swallowing something that has “gone the wrong way”, since the food or liquid goes into the respiratory tract, rather than the digestive system.

The inhalation of food or liquid can lead to its entry to the lungs, where it may cause an infection known as aspiration pneumonia. 

Gastric acids, vomit, household and industrial chemicals can also cause choking and aspiration.

In such cases, the lung tissue could be damaged, causing chemical pneumonitis.

The after-effects of anesthesia due to surgery or diagnostic procedures may also put the patient at risk for aspiration.

Signs and Symptoms of Aspiration

  • Coughing – this may be ineffective, which could require help from other people such as suctioning, back blows, and other methods
  • Feeling of something stuck in the throat
  • Pain upon swallowing or drinking
  • Gurgling sound when eating or talking
  • Gagging
  • Struggling to breathe or talk
  • Crying (especially in infants or young children)
  • Facial grimace
  • Cyanosis
  • Shortness of breath
  • Dyspnea or difficulty of breathing
  • Heartburn or chest discomfort
  • Excessive salivation
  • Inability to chew

Causes of Aspiration

  • Medical conditions that may affect ability to swallow, such as stroke, neuromuscular disorders, myasthenia gravis, and Parkinson’s disease
  • Foreign body obstruction
  • Use of tube feedings
  • Artificial airway devices such as tracheostomy tubes
  • Acid reflux
  • Post-surgery and use of anesthesia
  • Inhalation or ingestion of household / industrial chemicals

Risk for Aspiration Nursing Diagnosis

Nursing Care Plan for Risk for Aspiration 1

Foreign Body Airway Obstruction (FBAO)

Nursing Diagnosis: Risk for Aspiration related to foreign body airway obstruction

Desired Outcome: The patient will be relieved of foreign body that is obstructing his/her airways and aspiration will then be prevented

Infants and Children

Nursing Interventions for Risk for AspirationRationales
Assess if the infant/child is conscious or unconscious.The actions to treat FBAO are different depending on the alertness status of the infant/child.
Assess the severity of the situation by checking if it is a severe choking scenario with ineffective coughing, or a mild one with effective coughing.To correctly administer the proper actions to remove the foreign body from the infant/ child.
Conscious Infant (under 1 year old)

Place the infant over your forearm, supported by your thigh. The head should be lower than the torso. Ensure to support the head and neck using your hand.

Use the heel of your hand to deliver up to 5 forceful back blows in between the shoulder blades.

Turn the infant face up, head still lower than torso. Deliver up to 5 chest thrusts by using 2 to 3 fingers to depress the infant’s sternum. Avoid the tip of the sternum.

Repeat back blows and chest thrusts until the foreign body comes out, or until the infant becomes unconscious.

DO NOT attempt blind finger sweep or abdominal thrusts on the infant.
To remove the foreign body and prevent the risk for aspiration.
Unconscious Infant (up to 1 year old)
Shout for help (call 911 in the home/community setting).
Tongue-jaw lift maneuver: Place your thumb inside the infant’s mouth to grasp the lower incisor teeth or gums. If the foreign body is visible, remove it immediately. DO NOT attempt a blind finger sweep (or putting your finger in the mouth hoping to remove the non-visible foreign body).
Perform rescue breathing. Perform back blows and chest thrusts as you would in a conscious infant until foreign body is removed.
If the foreign body is expelled but the infant is still not breathing, perform cardiopulmonary resuscitation (CPR).
To remove the foreign body and prevent the risk for aspiration.
Conscious Adult or Child (over 1 year old)
If the person can breathe, speak, or cough, do not attempt to intervene.
If the person cannot breathe, speak, or cough, perform Heimlich maneuver (abdominal thrusts): – Stand behind the person.
Clench one hand into a fist and grab this with your other hand in a lock under the person’s rib cage. – Sharply pull your fist in a backward and upward direction for 6 to 10 times. –
If the person is obese or is in late pregnancy, do not perform Heimlich maneuver. Do chest thrusts instead.
To remove the foreign body and prevent the risk for aspiration.
Conscious Adult or Child (over 1 year old)
Shout for help (call 911 in the home/community setting). Place the person on his/her back, with arms on the side.
If the object is visible, attempt to remove the foreign body from the mouth through finger sweep method.DO NOT perform a blind finger sweep in a child under 8 years old. Perform a tongue-jaw lift maneuver instead to check if the foreign body is visible and can be removed.
If the person is not breathing, start rescue breathing. If he/she is still unconscious, start Heimlich maneuver (abdominal thrusts):Kneel over the person Place the heel of your hand on his/her abdomen, just above the navel.
Place your other hand on top of the first hand.
Apply pressure in the abdomen using 6 to 10 sharp and upward thrusts.
Continue the sequence of finger sweep, rescue breathing, and Heimlich maneuver until the foreign body is removed.
If the foreign body is expelled but the person is still not breathing, perform cardiopulmonary resuscitation (CPR).
 

Nursing Care Plan for Risk for Aspiration 2

Cerebrovascular Accident (CVA or Stroke)

Nursing Diagnosis: Risk for Aspiration related to decreased ability to swallow secondary to CVA / stroke                                               

Desired Outcome: The patient will be able to avoid any aspiration or developing aspiration pneumonia.

Nursing Interventions for Risk for AspirationRationale
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 can cause neuromuscular weakness and may limit the patient’s ability to clear the airway.
Refer the patient for speech and language therapy (SALT) team.Stroke can diminish or reduce the patient’s ability to swallow. The patient can choke, which can cause further airway 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 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.

Nursing Care Plan for Risk for Aspiration 3

Seizures

Nursing Diagnosis: Risk for Aspiration related to neuromuscular impairment secondary to seizures                             

 Desired Outcome: The patient will be able to maintain patent airway and avoid any aspiration or developing aspiration pneumonia.

Nursing Interventions for Risk for AspirationRationale
Assess airway patency.Maintaining an open and clear airway is vital to retain airway clearance and reduce the risk for aspiration. 
If aura begins, ensure that food, liquids, or dentures are removed from the patient’s mouth.To decrease the risk for aspiration in the event of an impending seizure activity.
Advise the patient to avoid sucking lozenges, hard candy, or chewing gum.Seizures could be unpredictable or may occur without any warning. Avoiding chewing gums, hard candies, and lozenges can help reduce the risk of aspiration should a seizure occur.
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.
During seizure activity, suction secretions or small foreign body if the jaw is relaxed.To prevent secretions or small foreign body to be aspirated into the airways and lungs.

Nursing Care Plan for Risk for Aspiration 4

Nursing Care Plan Risk for Aspiration G Tube

Nursing Diagnosis: Risk for Aspiration related to the use of feeding tube for nourishment

Desired Outcome: The patient will be able to maintain patent airway and avoid any aspiration or developing aspiration pneumonia.

Nursing Interventions for Risk for AspirationRationale
Assess the level of consciousness and 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 and to swallow.To assess for any difficulty to clear the airway or any reduced ability to swallow.
Refer the patient for speech and language therapy (SALT) team.The patient can choke, which can cause further airway 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.
Elevate the head of the bed at least 30 degrees when tube feeding the patient. Perform the sameTo prevent food or liquid to regurgitate up the digestive tract and be aspirated into the airways and lungs.
Assess the tube placement before feeding the patient by checking the pH of the gastric fluid, color of the aspirate, and tube markings. Ensure that the patient on NG tube can talk, breathe without difficulty, and is not coughing.
Check the oral cavity for tube coiling.
Ensure that the NG tube is secured appropriately.
If unsure of the tube placement, send the patient for a chest x-ray for verification.
The pH of the gastric fluid should be between 1 and 5, and the aspirate is usually colorless, clear, greenish, or brownish. The tube marking must match the declared marking on the tube insertion document. If unsure, the most reliable verification of accurate tube placement is a chest x-ray.
Follow the 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.

Nursing Care Plan for Risk for Aspiration 5

Dementia

Nursing Diagnosis: Risk for Aspiration secondary to weakness of swallowing muscles secondary to dementia

Desired Outcome: The patient will be able to maintain patent airway and avoid any aspiration or developing aspiration pneumonia.

Nursing Interventions for Risk for AspirationRationale
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.Later stages of dementia may limit the patient’s ability to cough and clear the airway.
Refer the patient for speech and language therapy (SALT) team.Dementia can be accompanied by reduced the patient’s ability to swallow. The patient can choke, which can cause further airway 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.
Follow the 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.
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.
Remove any distracting stimuli that can interrupt the patient’s eating time.Distractions such as too much noise or even watching television may reduce the dementia patient’s focus on eating his/her food, thereby increasing the risk for aspiration.

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

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

Facebookredditpinterest
Photo of author
Author
Anna C. RN, BSN, PHN

Anna C. RN, BSN, PHN
Clinical Nurse Instructor

Emergency Room Registered Nurse
Critical Care Transport Nurse
Clinical Nurse Instructor for LVN and BSN students

Anna began writing extra materials to help her BSN and LVN students with their studies. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process.

Her experience spans almost 30 years in nursing, starting as an LVN in 1993. She received her RN license in 1997. She has worked in Medical-Surgical, Telemetry, ICU and the ER. She found a passion in the ER and has stayed in this department for 30 years.

She is a clinical instructor for LVN and BSN students along with a critical care transport nurse.

Leave a Comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.