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IMPAIRED SWALLOWING Nursing Care Plan

Impaired Swallowing
Abnormal functioning of the swallowing mechanism associated
with deficits in oral, pharyngeal, or esophageal structure or function

Defining Characteristics
Major (Must Be Present, One or More)*
Observed evidence of difficulty in swallowing and/or:
Stasis of food in oral cavity
Coughing before a swallow
Coughing after food or fluid intake
Choking
Gagging
Minor (May Be Present)
Nasal-sounding voice
Drooling*
Slurred speech
Vomiting*
Regurgitation*
Lack of chewing*
Related Factors
Pathophysiologic
Related to decreased/absent gag reflex, mastication difficulties, or decreased
sensations secondary to:
Cerebral palsy*
Muscular dystrophy
Poliomyelitis
Parkinson’s disease
Guillain–Barré syndrome
Myasthenia gravis
Amyotrophic lateral sclerosis
CVA
Neoplastic disease affecting
brain
Right or left hemispheric brain
damage
Vocal cord paralysis
Cranial nerve damage (V, VII,
IX, X, XI)
Related to tracheoesophageal tumors, edema
Related to irritated oropharyngeal cavity
Related to decreased saliva
Treatment Related
Related to surgical reconstruction of the mouth, throat, jaw, or nose
Related to decreased consciousness secondary to anesthesia
Related to mechanical obstruction secondary to tracheostomy tube
Related to esophagitis secondary to radiotherapy
Situational (Personal, Environmental)
Related to fatigue
Related to limited awareness, distractibility
Maturational
Infants/Children
Related to decreased sensations or difficulty with mastication
Related to poor suck/swallow/breathe coordination
Older Adult
Related to reduction in saliva, taste

Goal
The client will report improved ability to swallow, as evidenced by
the following indicators:
• Describe causative factors when known.
• Describe rationale and procedures for treatment.

Interventions
Assess for Causative or Contributing Factors
Refer to Related Factors.
• Consult with a speech therapist for a bedside swallowing
assessment
and recommended plan of care.
• Alert all staff that client has impaired swallowing.
Reduce or Eliminate Causative/Contributing Factors in People With:
Mechanical Impairment of Mouth
• Assist client with moving the bolus of food from the anterior to
the posterior part of mouth. Place food in the posterior mouth,
where swallowing can be ensured, using:
• A syringe with a short piece of tubing attached
• A glossectomy spoon
• Soft, moist food of a consistency that can be manipulated by
the tongue against the pharynx, such as gelatin, custard, or
mashed potatoes.
• Prevent/decrease thick secretions with:
• Artificial saliva Papain tablets dissolved in mouth 10 minutes
before eating
• Meat tenderizer made from papaya enzyme applied to oral
cavity 10 minutes before eating
• Frequent mouth care
• Increase fluid intake to 8 glasses of liquid (unless contraindicated)
• Check medications for potential side effects of dry mouth/
decreased salivation
• Use of Haberman or comparable nipple when bottle feeding
for infant with cleft lip/palate and Möbius syndrome
Muscle Paralysis or Paresis
• Establish a visual method to communicate with staff at bedside
that client is dysphagic.
• Plan meals when client is well rested; ensure that reliable
suction equipment is on hand during meals. Discontinue feeding
if client is tired.
• If indicated, use modified supraglottic swallow technique
(Emick-Herring & Wood, 1990).
• Position the head of the bed in semi- or high Fowler’s position,
with the neck flexed forward slightly and chin tilted down.
• Use cutout cup (remove and round out one third of side of
foam cup).
• Take bolus of food and hold in strongest side of mouth for
1 to 2 seconds, then immediately flex the neck with chin
tucked against chest.
• Without breathing, swallow as many times as needed.
• When mouth is emptied, raise chin and clear throat.
• Note the consistency of food that is problematic. Select
consistencies that are easier to swallow, such as:
• Highly viscous foods (e.g., mashed bananas, potatoes,
gelatin, gravy)
• Thick liquids (e.g., milkshakes, slushes, nectars, cream soups)
• If drooling is present, use a quick-stretch stimulation just before
and toward the end of each meal (Emick-Herring & Wood, 1990):
• Digitally apply short, rapid, downward strokes to edge of
bottom lip, mostly on the affected side.
• Use a cold washcloth over finger for added stimulation.
• If a bolus of food is pocketed in the affected side, teach client
how to use tongue to transfer food or apply external digital
pressure to cheek to help remove the trapped bolus (Emick-
Herring & Wood, 1990).
Impaired Cognition or Awareness
General
• Remove feeding tube during training if increased gag reflex is
present.
• Concentrate on solids rather than liquids because liquids usually
are less well tolerated.
• Minimize extraneous stimuli while eating (e.g., no television or
radio, no verbal stimuli unless directed at task).
• Have client concentrate on task of swallowing.
• Have client sit up in chair with neck slightly flexed.
• Instruct client to hold breath while swallowing.
• Observe for swallowing and check mouth for emptying.
• Avoid overloading mouth because this decreases swallowing
effectiveness.
• Give solids and liquids separately.
• Progress slowly. Limit conversation.
• Provide several small meals to accommodate a short attention
span.
Client With Aphasia or Left Hemispheric Damage
• Demonstrate expected behavior.
• Reinforce behaviors with simple, one-word commands.
Client With Apraxia or Right Hemispheric Damage
• Divide task into smallest units possible.
• Assist through each task with verbal commands.
• Allow to complete one unit fully before giving next command.
• Continue verbal assistance at each eating session until no
longer needed.
• Incorporate written checklist as a reminder to client.
• Note: Client may have both left and right hemispheric damage
and require a combination of the above techniques.
Reduce the Possibility of Aspiration
• Before beginning feeding, assess that the client is adequately
alert and responsive, can control the mouth, has cough/gag
reflex, and can swallow saliva.
• Have suction equipment available and functioning properly.
• Position client correctly:
• Sit client upright (60 to 90 degrees) in chair or dangle his or her
feet at side of bed if possible (prop with pillows if necessary).
• Client should assume this position 10 to 15 minutes before
eating and maintain it for 10 to 15 minutes after finishing
eating.
• Flex client’s head forward on the midline about
45 degrees to keep esophagus patent.
• Keep infant’s head elevated during and immediately after
feedings
• Keep client focused on task by giving directions until he or she
has finished swallowing each mouthful.
• “Take a breath.”
• “Move food to middle of tongue.”
• “Raise tongue to roof of mouth.”
• “Think about swallowing.”
• “Swallow.”
• “Cough to clear airway.”
• Reinforce voluntary action.
• Start with small amounts and progress slowly as client learns to
handle each step:
• Ice chips
• Eyedropper partly filled with water
• Whole eyedropper filled with water
• Juice in place of water
• ¼ teaspoon semisolid food
• ½ teaspoon semisolid food
• 1 teaspoon semisolid food
• Pureed or commercial baby foods
• One half cracker
• Soft diet
• Regular diet; chew food well
• For a client who has had a CVA, place food at back of tongue
and on side of face he or she can control:
• Feed slowly, making certain client has swallowed the
previous
bite.
• Some clients do better with foods that hold together
(e.g., soft-boiled eggs, ground meat and gravy).
• If the above strategies are unsuccessful, consultation with a
physician may be necessary for alternative feeding techniques
such as tube feedings or parenteral nutrition.
Initiate Health Teaching and Referrals, as Indicated
Teach Exercises to Strengthen (Grober, 1984):
Lips and Facial Muscles
• Alternate a tight frown with a broad smile with lips closed.
• Puff out cheeks with air and hold.
• Blow out of pursed lips.
• Practice pronouncing u, m, b, p, w.
• Suck hard on a popsicle.
Tongue
• Lick a popsicle or lollipop.
• Push tip of tongue against roof and floor of mouth.
• Count teeth with tongue.
• Pronounce la, la, la; ta, ta, ta; d; n; z; s.
• See Impaired Oral Mucous Membranes.
• See Imbalanced Nutrition: Less Than Body Requirements.

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