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RISK FOR ASPIRATION Nursing Care Plan

Risk for Aspiration
At risk for entry of gastrointestinal secretions, solids, or fluids into
the tracheobronchial passages

Risk Factors
Pathophysiologic
Related to reduced level of consciousness secondary to:
Presenile dementia
Head injury
Cerebrovascular accident
Parkinson’s disease
Alcohol- or drug-induced
Coma
Seizures
Anesthesia
Related to depressed cough/gag reflexes
Related to increased intragastric pressure secondary to:
Lithotomy position
Ascites
Obesity
Enlarged uterus
Related to impaired swallowing or decreased laryngeal and glottic
reflexes
secondary to:
Achalasia
Cerebrovascular accident
Myasthenia gravis
Catatonia
Muscular dystrophy
Esophageal strictures
Debilitating conditions
Multiple sclerosis
Scleroderma
Parkinson’s disease
Guillain–Barré syndrome
Related to tracheoesophageal fistula
Related to impaired protective reflexes secondary to:
Facial/oral/neck surgery or trauma*
Paraplegia or hemiplegia
Treatment Related
Related to depressed laryngeal and glottic reflexes secondary to:
Tracheostomy/endotracheal tube*
Sedation
Tube feedings
Related to impaired ability to cough secondary to:
Wired jaw*
Imposed prone position
Situational (Personal, Environmental)
Related to inability/impaired ability to elevate upper body
Related to eating when intoxicated
Maturational
Premature
Related to impaired sucking/swallowing reflexes
Neonate
Related to decreased muscle tone of inferior esophageal sphincter
Older Adult
Related to poor dentition

Author's Notes
Risk for Aspiration is a clinically useful diagnosis for people at high risk for
aspiration because of reduced level of consciousness, structural deficits,
mechanical devices, and neurologic and gastrointestinal disorders.
People with swallowing difficulties often are at risk for aspiration; the
nursing diagnosis Impaired Swallowing should be used to describe a client
with difficulty swallowing who is also at risk for aspiration. Risk for
Aspiration should be used to describe people who require nursing interventions
to prevent aspiration, but do not have a swallowing problem.

Goals
The client will not experience aspiration as evidenced by the following
indicators:
• Relate measures to prevent aspiration.
• Name foods or fluids that are high risk for causing aspiration.
The parent will reduce opportunities for aspirations as evidenced
by the following indicators:
• Remove small objects from child’s reach.
• Inspect toys for removable small objects.
• Discourage the child from putting objects in his or her mouth.

Interventions
Assess Causative or Contributing Factors
Refer to Related Factors.
Reduce the Risk of Aspiration in:
Clients With Decreased Strength, Decreased Sensorium,
or Autonomic Disorders
• Maintain a side-lying position if not contraindicated by injury.
• If the client cannot be positioned on the side, open the oropharyngeal
airway by lifting the mandible up and forward and
tilting the head backward. (For a small infant, hyperextension
of the neck may not be effective.)
• Assess for position of the tongue, ensuring it has not dropped
backward, occluding the airway.
• Keep the head of the bed elevated, if not contraindicated by
hypotension or injury.
• Maintain good oral hygiene. Clean teeth and use mouthwash
on cotton swab; apply petroleum jelly to lips; removing encrustations
gently.
• Clear secretions from mouth and throat with a tissue or gentle
suction.
• Reassess frequently for obstructive material in mouth and
throat.
• Reevaluate frequently for good anatomic positioning.
• Maintain side-lying position after feedings.
• Positions are maintained to reduce aspiration.
Clients With Tracheostomy or Endotracheal Tubes
• Inflate cuff:
• During continuous mechanical ventilation
• During and after eating
• During an 1 hour after tube feedings
• During intermittent positive-pressure breathing treatments
• Suction every 1 to 2 hours and PRN and provide oral care.
Clients With Gastrointestinal Tubes and Feedings
• Confirm that tube placement has been verified by radiography
or aspiration of greenish fluid (check hospital/organizational
policy for preferred method).
• Confirm that tube position has not changed since it was inserted
and verified.
• Elevate the head of the bed for 30 to 45 minutes during feeding
periods and 1 hour after to prevent reflux by use of reverse
gravity.
• Aspirate for residual contents before each feeding for tubes
positioned gastrically.
• Administer feeding if residual contents are less than 150 mL
(intermittent), or administer feeding if residual is no greater
than 150 mL at 10% to 20% of hourly rate (continuous).
• Regulate gastric feedings using an intermittent schedule,
allowing periods for stomach emptying between feeding
intervals.
For an Older Adult With Difficulties Chewing and Swallowing
(See Impaired Swallowing)
Initiate Health Teaching and Referrals, as Indicated
• Instruct the client and family on causes and prevention of
aspiration.
• Maintain oral hygiene to prevent pneumonia related to oral
bacteria aspiration.
• Have the family demonstrate tube-feeding technique.
• Refer the family to a community nursing agency for assistance
at home.
• Teach the client about the danger of eating when under the
influence of alcohol.
• Teach the Heimlich or abdominal thrust maneuver to remove
aspirated foreign bodies.
Pediatric Interventions
For Newborns With Cleft Lip, Palate, or Both
• Position infant’s head upright.
• Use a special feeding device for infants with cleft lip/cleft palate
such as a cleft lip/cleft palate nurser, the Haberman feeder,
or a gravity flow nipple.
• If nipple feeding is unsuccessful, use a rubber-tipped syringe to
deposit the formula on the back of the tongue.
• Observe for signs to stop feeding momentarily, such as elevated
eyebrows and wrinkled forehead.
• Do not position the nipple through the cleft.
• Position the nipple so it is compressed by the infant’s tongue
and existing palate.
• Apply gentle counterpressure on the base of the bottle to assist
the infant with tongue and palate control of the milk flow.
• Burp frequently because of excessive air swallowing.

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