IMPAIRED SWALLOWING Nursing Care Plan

You know difficulty in swallowing or impaired swallowing is very disturbing. You can't do your work properly, you can't speak properly, and especially, you can't eat properly. There are different reasons why people experience difficulty of swallowing and most of them are mild cases and non life-threatening. However, a patient having like this kind of discomfort is eager to have a nursing care. Like Mr. Hans who recently undergone radiotheraphy and experiencing esophagitis. Since he is a radio announcer, having impaired swallowing is very disturbing for him. Below is a sample of nursing care plan of impaired swallowing of Mr. Hans.

Assessment:

Subjective: *slurred speech (we are unable to understand Mr. Hans clearly).

Objective:
- Nasal-sounding voice.
- Drooling (unintentional flowing of saliva outside the mouth).
- Irritated
- Uncomfortable
- Pain scale 8/10 when swallowing
- Nausea (wanting to vomit)

Diagnosis:

Impaired swallowing related to esophagitis secondary to radiotheraphy.

Planning:

After 4 hours of nursing intervention, the patient will report improved ability to swallow, as evidenced by describing the cause of impaired swallowing and describe procedures for treatment and its rationale.

Interventions:

- Assess Mr. Hans, the patient, for causative factors. Other nurses must know that the patient has impaired swallowing so you need to notify all the staff.

- Help Mr. Hans about proper way of eating while having impaired swallowing. Assist the the patient with his moving bolus of food from the from area to back part of mouth. Tell Mr. Hans to place food in the back mouth where his swallowing can be ensured. You can use a syringe with short piece of tubing attached or a glossectomy spoon, a spoon that can transport bolus of food to the oropharynx to help Mr. Hans swallow his food. Prepare soft, moist food of a consistency that can be manipulated by the tongue against the pharynx, such as gelatin, custard, or mashed potatoes. You can use artificial saliva papain tablets, these can decrease the patient's thick secretions, just tell Mr. Hans, the patient, to dissolved in mouth for 10  minutes before eating. Apply meat tenderizer made from papaya enzyme applied to oral cavity 10 minutes before eating. Unless contraindicated to him , increase fluid intake to 8 glasses of liquid. Check medications for potential side effects of dry mouth or decreased salivation.

- Since Mr. Hans have difficulty in communication, establish a visual method to communicate the him with staff at bedside.

- Plan meals when Mr. Hans is well rested and ensure that there is reliable suction equipment on hand during meals. Discontinue feeding if the patient is tired. If indicated to him, use modified supraglottic swallow technique. Teach Mr. Hans to hold his breath before and during swallowing in order to close his vocal folds and prevent food to enter in the airway. Position the head of the bed in semi- or high Fowler's position. Make Mr. Hans' neck flexed forward slightly and his chin tilted down. Remember that when you tilted down a patients' chin, it closes airway and preventing food to enter the lungs.

- Instruct the patient to be able to eat effectively, take bolus of food and hold it in his strongest side of mouth for 1-2 seconds, then immediately flex his neck with chin tucked against chest. Without breathing, instruct Mr. Hans to swallow as many times as needed. When mouth is emptied, raise chin and clear throat. Tell the patient to avoid overloading the mouth because this decreases his swallowing effectiveness. Note the consistency of food that is problematic and select consistencies that are easier to swallow like mashed bananas, potatoes, gelatin, and gravy which are highly viscous. Select thick liquids such as milkshakes, slushes, nectar, and cream soups. If bolus of food is pocketed in the affected side, teach Mr. Hans, the patient, how to use tongue to transfer food or apply external finger pressure to cheek to help remove the trapped bolus.

- Drooling is present to Mr. Hans so use a quick-stretch stimulation just before and toward the end of each meal. Digitally apply short, rapid, downward strokes to the edge of his bottom lip, mostly on the affected side. Use a cold washcloth over finger for added stimulation.

- Minimize extraneous stimuli while eating such as television or radio and no verbal stimuli unless directed at task. Have Mr. Hans to concentrate on his task of swallowing to reduce the possibility of aspiration. If you need nursing care plan for aspiration you can check it in risk for aspiration. Before beginning of Mr. Hans feeding, assess that the he is adequately alert and responsive and can control the mouth, that he has gag reflex and he can swallow saliva. Always have suction equipment available and functioning properly. Position the patient sitting upright 60 to 90 degrees in his chair or dangle his feet at side of the bed if possible. Mr. Hans  should assume position 10 to 15 minutes before eating and maintain it for 10 to 15 minutes after finishing eating. Flex the patient's head forward on the midline about 45 degrees to keep esophagus patent.

- If above strategies are unsuccessful to Mr. Hans, consultation with a physician may be necessary for alternative feeding techniques such as tube feedings or parenteral nutrition.

Evaluation:

After 4 hours of nursing intervention, the patient reported improved ability to swallow, as evidenced by describing the cause of impaired swallowing and described procedures for treatment and its rationale.

Related nursing care plan is Imbalanced Nutrition: Less than Body Requirements.
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