# 40

40) Discuss the nursing interventions for clients who are at risk for aspiration.(pg. 93 Nurses pocket guide)
Priority #1: assess causative/contributing factors:
-Note level of consciousness/awareness of surroundings cognitive impairment.
-Evaluate presence of neuromuscular weakness, noting muscle groups involved, degree of impairment and whether they are of an acute or progressive nature ( ALS).
-Assess amount and consistency of respiratory secretions and strength of gag/cough reflexes.
-Observe for neck and facial edema, or example, client with head/neck surgery, tracheal/bronchial injury.
-Note administration of enteral feedings, being aware of potential for regurgitation and/or misplacement of tube.
-Ascertain lifestyle habits, for instance, use of alcohol, tobacco, and other CNS -suppressant drugs; can affect awareness and muscles of gag/swallow.
Nursing priority #2 : to assist in correcting factors that can lead to aspiration:
-Monitor use of oxygen masks in clients ast risk for vomiting. Refrain from using oxygen masks for comatose individuals.
-Keep wire cutters/scissors with client at all times when jaws are wired/banded to facilitate clearing airway in emergency situations
-Maintain operational suction equipment at bedside/chair side.
-Suction ( oral cavity, nose, and ET/tracheostomy tube) as needed to clear secretions. Avoid triggering gag mechanism when performing suction or mouth care.
_Assist with postural drainage to mobilize thickened secretions that may interfere with swallowing.
-Auscultate lung sounds frequently (especially in client who is coughing frequently or not coughing at all; ventilator client being tube-fed) to determine presence of secretions/silent aspiration.
-Elevate client to highest or best possible position for eating and drinking and during tube feedings.
-Feed slowly, instruct client to chew slowly and thoroughly.
-Give semisolid foods; avoid pureed foods(increased risk of aspiration) and mucus-producing foods (milk). Use soft foods that stick together/form a bolus (e.g. casseroles, puddings, stews) to aid swallowing effort.
-Provide very arm or very cold liquids (activates temperature receptors in the mouth that help to simulate swallowing). Add thickening agent to liquids as appropriate.
-Avoid washing solids down with liquids.
-Ascertain that feeding tube is in correct position. Measure residuals when appropriate to prevent overfeeding. Add food coloring to feeding to identify regurgitation.
-Determine best position for infant/child(e.g. with the head of bed elevated 30 degrees and infant propped on right side after feeding because upper airway patency is facilitated by upright position and turning to right side decreases likelihood of drainage into trachea).
-Provide oral medications in elixir form to crush, if appropriate.
-Refer to speech therapist for exercises to strengthen muscles and techniques to enhance swallowing.
Nursing Priority #3: To promote wellness (teaching/discharge considerations):
-Review individual risk/potentiating factors.
-Provide information about the effects of aspiration on the lungs. -Instruct in safety concerns when feeding oral or tube feeding. Refer to ND impaired Swallowing.
-Train client to suction self or train family members in suction techniques(especially if client has constant or copious oral secretions) to enhance safety/self -sufficiency.
-Instruct individual/family member to avoid/limit activities that increase intra-abdominal ressure (straining, strenuous exercise, tight/constrictive clothing), which may slow digestion/increase risk of regurgitation.
Just a quick tip, when answering a question that asks something like which is the best nursing intervention for a client at risk for aspiration, use one of the options from nursing priority # 1 because more than likely there will be an intervention from each of the three priorities.