Student Nurses Community

NURSING CARE PLAN Risk for Aspiration

ASSESSMENT

SUBJECTIVE:
Daughter of
patient states
that patient has
been struggling
with swallowing
and seems to
choke a lot since
her stroke.
OBJECTIVES:
Crackles noted
upon
auscultation
Diagnosis of
stroke and
right sided
paralysis
Pt exhibits
difficulty
swallowing
without
choking.
Orders to have
a speech
therapy
consult

DIAGNOSIS

Risk for
aspiration
related to
impaired
swallowing,
depressed
cough and gag
reflexes
secondary to
stroke

INFERENCE

Chronic condition
(stroke)

multiple areas of
the brain and a
series of voluntary
and involuntary
muscular
contractions are
affected

PLANNING

After 72 hours
of nursing
intervention,
risk for
aspiration will
be decreased
and the
patient will be
able to
maintain a
patent airway
as evidenced
by:

Paralysis of throat
muscles

clear breath
sounds

Impairs swallowing
and gag reflex of
patient (dysphagia)

resonant
percussion
noted over
lungs

Possibility of
material, which a
person is
swallowing to enter

Absence of
cough,
tachypnea,
and
dyspnea.

INTERVENTIONS

Independent:
Assess client's
ability to swallow
and strength of
gag reflex and
evaluate
amount/consisten
cy of secretions

RATIONALE

To determine
presence/effectiv
eness of
protective
mechanisms.
Normally the time
taken for the
bolus to move
from the point at
which the reflex
is triggered to the
esophageal entry
(pharyngeal
transit time) is (1
second). Clients
can aspirate even
if they have an
intact gag reflex

Assess ability to
swallow by
positioning
examiner's thumb
and index finger
on client's
laryngeal
protuberance. Ask
client to swallow;
feel larynx
elevate. Ask client These are all
to cough; test for
signs of
a gag reflex on
swallowing
both sides of
impairment
posterior
To remove excess
pharyngeal wall
secretions while
(lingual surface)

EVALUATION

After 72 hours
of nursing
interventions,
goal met. Clear
breath sounds,
resonant
percussion
over the lungs
are noted.
There is
absence of
cough and the
vital signs are
within normal
limits.

Student Nurses Community

TEMP: 36.5 C

the airway and

lungs

RR: 16 cpm

(Risk for aspiration)

PR: 75 bpm
BP: 110/80 mmHg

with a tongue
blade. Do not rely
on presence of
gag reflex to
determine when
to feed.

reducing
potential for
aspiration of
secretions.
To prevent foreign
aspiration

Observe for signs

To mobilize
associated with
thickened
swallowing
secretions that
problems (e.g.,
may interfere
coughing,
with swallowing.
choking, spitting
of food, drooling,
A noisy
difficulty handling
environment can
oral secretions,
be an aversive
double swallowing
stimulus and can
or major delay in
decrease
swallowing,
effective
watering eyes,
mastication and
nasal discharge,
swallowing.
wet or gurgly
Talking and
voice, decreased
laughing while
ability to move
eating increases
tongue and lips,
the risk of
decreased
aspiration
mastication of
Liquids can be
food, decreased
easily aspirated;
ability to move
thickened liquids
food to the back
form a cohesive
of the pharynx,
bolus that the
slow or scanning
client can
speech).

Student Nurses Community

perform
swallow with
increased
oropharyngeal
efficiency.
suctioning but
avoid triggering of
Food may
gag mechanism,
become pocketed
and provide oral
in the affected
hygiene as often
side and cause
as needed
stomatitis, tooth
Remove any oral
decay, and
possible later
dentures.
aspiration.
Assist in postural
An upright
drainage.
position ensures
Provide meals in a
that food stays in
quiet environment
the stomach until
away from
it has emptied
excessive stimuli
and decreases
such as a
the chance of
community dining
aspiration
room.
following meals
Avoid providing
liquids until client
is able to swallow
effectively.
Check oral cavity
for proper
emptying after
client swallows
and after client
finishes meal.

The presence of
new crackles or
wheezing, an
elevated
temperature or
white blood cell
count, and a
change in sputum
could indicate
aspiration of food

Student Nurses Community

Provide oral care

and even
at end of meal. It
pneumonia.
may be necessary
It is common for
to manually
family members
remove food from
to disregard
client's mouth. If
necessary dietary
this is the case,
restrictions and
use gloves and
give client
keep client's teeth
inappropriate
apart with a
foods that
padded tongue
predispose to
blade.
aspiration
Keep client in an
Feeding a client
upright position
who cannot
for 30 to 45
adequately
minutes after a
swallow results in
meal.
aspiration and
Auscultate lung
possibly death.
sounds after
Enteral feedings
feeding. Note new
via PEG tube are
crackles or
generally
wheezing, and
preferable to
note elevated
nasogastric tube
temperature.
feedings because
Notify physician
studies have
as needed.
demonstrated
that there is
Educate client,
increased
family, and all
nutritional status
caregivers about
and possibly
rationales for food
improved survival

Student Nurses Community

consistency and
choices.

Collaborative
Ensure proper
nutrition by
consulting with
physician for
enteral feedings,
preferably a PEG
tube in most
cases.

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