Impaired Swallowing (Dysphagia) Nursing Care Plan & Management

Utilize this comprehensive nursing care plan and management guide to provide exceptional care for patients with dysphagia or those at impairment in swallowing. This guide equips you with valuable insights into conducting thorough nursing assessments, implementing evidence-based interventions, establishing appropriate goals, and identifying nursing diagnoses related to dysphagia. By utilizing this guide, you will enhance your ability to effectively manage and support patients with dysphagia, ensuring their safety and well-being.

What is dysphagia?

Dysphagia or impairment in swallowing involves more time and effort to transfer food or liquid from the mouth to the stomach. It occurs when the muscles and nerves that help move food through the throat and esophagus are not working right. It can be a temporary or permanent complication that can be fatal.

Aspiration of food or fluid can also occur possibly brought about by a structural problem, interruption or dysfunction of neural pathways, decreased strength or excursion of muscles involved in mastication, facial paralysis, or perceptual impairment. The swallowing muscles can become weak with age or inactivity. It is a common complaint among older adults, in those individuals who have had a stroke, suffered head trauma, have head or neck cancer, or experience progressive neurological diseases as of multiple sclerosis, amyotrophic lateral sclerosis, and Parkinson’s disease. Dysphagia can befall at any age, but it’s more prevalent in older adults.

Dysphagia can befall at any age, but it’s more prevalent in older adults. The causes of swallowing problems vary, and treatment depends on the cause.

Nursing Assessment and Rationales

Assessment is necessary to determine potential problems that may have lead to dysphagia as well as handle any difficulty that may appear during nursing care.

1. Assess the ability to swallow by positioning the examiner’s thumb and index finger on the patient’s laryngeal protuberance. Ask the patient to swallow; feel the larynx elevate. Ask the patient to cough; test for a gag reflex on both sides of the posterior pharyngeal wall (lingual surface) with a tongue blade. Do not rely on the presence of a gag reflex to determine when to feed.
The lungs are usually protected against aspiration by reflexes as cough or gag. When reflexes are depressed, the patient is at increased risk for aspiration.

2. Evaluate the strength of facial muscles.
Cranial nerves VII, IX, X, and XII control motor function in the mouth and pharynx. Coordinated function of muscles innervated by these nerves is necessary to move a bolus of food from the mouth to the posterior pharynx for controlled swallowing.

3. Check for coughing or choking during eating and drinking.
These signs indicate aspiration.

4. Observe for signs associated with swallowing problems (e.g., coughing, choking, spitting of food, drooling, difficulty handling oral secretions, double swallowing or major delay in swallowing, watering eyes, nasal discharge, wet or gurgly voice, decreased ability to move tongue and lips, decreased mastication of food, decreased ability to move food to the back of the pharynx, slow or scanning speech).
These are all signs of swallowing impairment.

5. Assess the ability to swallow a small amount of water.
If aspirated, little or no harm to the patient occurs.

6. Check for residual food in the mouth after eating.
Pocketed food may be easily aspirated at a later time.

7. Check for food or fluid regurgitation through the nares.
Regurgitation indicated the decreased ability to swallow food or fluids and an increased risk for aspiration.

8. Evaluate the results of swallowing studies as ordered.
A video-fluoroscopic swallowing study may be indicated to determine the nature and extent of any oropharyngeal swallowing abnormality, which aids in designing interventions.

9. Determine the patient’s readiness to eat. The patient needs to be alert, able to follow instructions, hold head erect, and able to move the tongue in the mouth.
If one of these factors is missing, it may be desirable to withhold oral feeding and do enteral feeding for nourishment. Cognitive deficits can result in aspiration even if able to swallow adequately.

10. Classify food given to the patient before each spoonful if the patient is being fed.
Knowledge of the consistency of food to expect can prepare the patient for appropriate chewing and swallowing technique.

11. Observe for signs of aspiration and pneumonia. Auscultate lung sounds after feeding. Note new or wheezing, and note the elevated temperature. Notify the physician as needed.
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.

12. Weigh patients weekly.
This is to help evaluate nutritional status.

1. Assess the oral cavity at least once daily and note any discoloration, lesions, edema, bleeding, exudate, or dryness. Refer to a physician or specialist as appropriate.
Oral examination can show signs of oral disease, symptoms of systemic disease, drug side effects, or trauma of the oral cavity.

2. Inspect for any indication of infection, and culture lesions as needed. Refer to a physician, nurse, or specialist as appropriate.
Early evaluation promotes immediate treatment. Specific manifestations direct accurate treatment.

3. Severe mucositis may manifest as any of the following:

•  3.1. Candidiasis
  Fungal infection due to any type of Candida (a type of yeast); cottage cheese-like white or pale yellowish patches on tongue, buccal mucosa, and palate

•  3.2. Herpes simplex
  Common viral infection; painful itching vesicle (typically on upper lips) that ruptures within 12 hours and becomes encrusted with a dried exudate

•  3.3. Gram-positive bacterial infection (staphylococcal and streptococcal infections)
  Dry, raised, wartlike yellowish-brown, round plaques on buccal mucosa

•  3.4. Gram-negative bacterial infections
  Creamy to yellow-white, shiny, nonpurulent patches often seated on painful, red, superficial mucosal ulcers and erosions

•  3.5. Fevers, chills, rigors
  These symptoms are a result of the body’s attempt to increase its internal temperature to fight off infection and inflammation.

4. Evaluate nutritional status.
Malnutrition can be a contributing cause. Oral fluids are needed for moisture to membranes.

5. Observe the ability to eat and drink.
Difficulty or inability to chew or swallow may occur secondary to the pain of inflamed or ulcerated oral and/or oropharyngeal mucous membranes.

6. Note the patient’s oral hygiene practices.
Information gives direction on possible causative factors and guidance for subsequent education.

7. Check for mechanical agents such as ill-fitting dentures or chemical agents such as constant exposure to tobacco that could create or develop trauma to oral mucous membranes.
Irritative and causative agents for stomatitis should be eliminated.

8. Inspect the status of the oral mucosa; including the tongue, lips, gums, saliva, teeth, and mucous membranes.
A well-organized assessment should be performed of the listed sites using a tongue blade to show areas of the oral cavity. This will identify any signs of inflammation, infection, or mucositis. This can also help in the early detection and management of oral health issues, as well as prevent potential complications.

9. Examine after removal of dental appliances. Use a moist, padded tongue blade to gently pull back the cheeks and tongue.
Denture removal is necessary because lesions may be underlying and further irritated by the appliance. Caregivers also need to be informed of the importance of these assessments.

10. Assess the severity of ulcerations involving the intraoral soft tissues, including the palate, tongue, gums, and lips.
Sloughing of the mucosal membrane can progress to ulceration.

11. Monitor the patient’s fluid status to determine if adequate.
Dehydration predisposes patients to impaired oral mucous membranes.

12. Determine the patient’s mental status. If the patient is unable to care for self, oral hygiene must be provided by nursing personnel.
The nursing diagnosis of Bathing/Hygiene Self-care deficit is then also applicable.

Nursing Interventions and Rationales

The following are the therapeutic nursing interventions for impaired swallowing:

1. For hospitalized or home care patients:

• 1.1. Before mealtime, provide adequate rest periods.
  Fatigue can further add to swallowing impairment.
  
• 1.2. Eliminate any environmental stimuli (e.g., TV, radio)
  The patient can more concentrate when external stimuli are removed.
  
• 1.3. Provide oral care before feeding. Clean and insert dentures before each meal.
  Optimal oral care promotes appetite and eating.
  
• 1.4. If the patient has impaired swallowing, consult a speech pathologist for bedside evaluation as soon as possible. Ensure that the patient is seen by a speech pathologist within 72 hours after admission if the patient has had a CVA.
  Speech pathologists specialize in impaired swallowing. Early referral of CVA patients to a speech pathologist, along with early initiation of nutritional support, results in decreased length of hospital stay, shortened recovery time, and reduced overall health costs.
  
• 1.5. For impaired swallowing, use a dysphagia team composed of a rehabilitation nurse, speech pathologist, dietitian, physician, and radiologist who work together.
  The dysphagia team can help the patient learn to swallow safely and maintain a good nutritional status.
  
• 1.6. Place suction equipment at the bedside, and suction as needed.
  With impaired swallowing reflexes, secretions can rapidly accumulate in the posterior pharynx and upper trachea, increasing the risk of aspiration.
  
• 1.7. If the patient has impaired swallowing, do not feed until an appropriate diagnostic workup is completed. Ensure proper nutrition by consulting with a physician for enteral feedings, preferably a PEG tube in most cases.
  Feeding a patient who cannot sufficiently swallow results in aspiration and possibly death. Enteral feedings via PEG tube are generally preferable to nasogastric tube feedings because studies have shown that there is increased nutritional status and possibly improved survival rates.

2. Before feeding, provide the patient a lemon wedge, pickle, or tart-flavored hard candy or use artificial saliva if decreased salivation is a contributing factor.
Moistening and the use of tart flavors stimulate salivation, lubricate food, and improve the ability to swallow.

3. If the patient has an intact swallowing reflex, attempt to feed. Observe the following feeding guidelines:

• 3.1. Position the patient upright at a 90-degree angle with the head flexed forward at a 45-degree angle.
  This position allows the trachea to close and esophagus to open, which makes swallowing easier and reduces the risk of aspiration.

• 3.2. Ensure the patient is awake, alert, and able to follow sequenced directions before attempting to feed.
  As the patient becomes less alert the swallowing response decreases, which increases the risk of aspiration.

• 3.3. Begin by feeding the patient one-third teaspoon of applesauce. Provide sufficient time to masticate and swallow.
  Gravy or sauce added to dry foods facilitates swallowing.

• 3.4. Place food on the unaffected side of the tongue.
  Placing food on the unaffected side, this can help the patient control the movement and direction of the food, decreasing the risk of it entering the airway.

• 3.5. During feeding, give the patient-specific directions (e.g., “Open your mouth, chew the food completely, and when you are ready, tuck your chin to your chest and swallow”).
  Proper instruction and focused concentration on specific steps reduce risks.

4. Maintain the patient in a high-Fowler’s position with the head flexed slightly forward during meals.
Aspiration is less likely to happen in this position.

5. Instruct the patient not to talk while eating. Provide verbal cueing as needed.
Concentration must be focused on the task.

6. Observe for uncoordinated chewing or swallowing; coughing shortly after eating or delayed coughing, which may mean silent aspiration; pocketing of food; wet-sounding voice; sneezing when eating; delay of more than 1 second in swallowing; or a variation in respiratory patterns. If any of these signs are present, put on gloves, eliminate all food from the oral cavity, end feedings, and consult with a speech and language pathologist and a dysphagia team.
These are signs of impaired swallowing and possible aspiration.

7. Reassure the patient to chew completely, eat gently, and swallow frequently, especially if extra saliva is produced. Give the patient direction or reinforcement until he or she has swallowed each mouthful.
Such directions assist in keeping one’s focus on the task.

8. Advance slowly, giving small amounts; whenever possible, alternate servings of liquids and solids.
This technique helps prevent foods from being left in the mouth.

9. Encourage a high-calorie diet that involves all food groups, as appropriate. Avoid milk and milk products.
Dairy products can lead to thickened secretions.

10. If patients pouch food to one side of their mouth, encourage them to turn their heads to the unaffected side and manipulate the tongue to the paralyzed side.
Foods placed on the unaffected side of the mouth promote more complete chewing and movement of food to the back of the mouth, where it can be swallowed. These strategies aid in cleaning out residual food.

11. If the patient tolerates single-textured foods such as pudding, hot cereal, or strained baby food, advance to a soft diet with guidance from the dysphagia team. Avoid foods such as hamburgers, corn, and pasta that are difficult to chew. Also, avoid sticky foods such as peanut butter and white bread.
The dysphagia team should determine the appropriate diet for the patient on the basis of progression in swallowing and ensuring that the patient is nourished and hydrated.

12. If the patient had a stroke, place food in the back of the mouth, on the unaffected side, and gently massage the unaffected side of the throat.
Massage aids stimulate the act of swallowing.

13. Place whole or crushed pills in custard or gelatin. (First, ask a pharmacist which pills should not be crushed.) Substitute medication in an elixir form as indicated.
Mixing some pills with foods helps reduce the risk of aspiration.

14. Encourage the patient to feed self as soon as possible.
With self-feeding, the patient can establish the volume of a food bolus and the timing of each bite to promote effective swallowing.

15. If oral intake is not possible or is inadequate, initiate alternative feedings (e.g., nasogastric feedings, gastrostomy feedings, or hyperalimentation).
Optimal nutrition is a patient’s need.

16. For many adult patients, avoid using straws if recommended by a speech pathologist.
The use of straws can increase the risk of aspiration because straws can result in the spilling of a bolus of fluid in the oral cavity as well as decrease control of the posterior transit of fluid to the pharynx.

17. Praise the patient for successfully following directions and swallowing appropriately.
Praise reinforces the behavior and sets up a positive atmosphere in which learning takes place.

18. Discuss and demonstrate the following to the patient or caregiver:

• Avoidance of certain foods or fluids
• Upright position during eating
• Allowance of time to eat slowly and chew thoroughly
• Provision of high-calorie meals
• Use of fluids to help facilitate the passage of solid foods
• Monitoring of the patient for weight loss or dehydration

Both the patient and caregiver may need to be active participants in implementing the treatment plan to optimize safe nutritional intake.

19. Keep the patient in an upright position for 30 to 45 minutes after a meal.
An upright position guarantees that food stays in the stomach until it has emptied and decreases the chance of aspiration following meals.

20. Discuss the importance of exercise to enhance the muscular strength of the face and tongue to enhance swallowing.
Muscle strengthening can facilitate greater chewing ability and positioning of food in the mouth.

21. Evaluate nutritional status regularly. If not adequately nourished, work with the dysphagia team to determine whether the patient needs to avoid oral intake (NPO) with therapeutic feeding only or needs enteral feedings until the patient can swallow adequately.
Enteral feedings can maintain nutrition if the patient is unable to swallow adequate amounts of food.

22. Educate the patient, family, and all caregivers about rationales for food consistency and choices.
It is common for family members to disregard necessary dietary restrictions and give patients inappropriate foods that predispose to aspiration.

23. Initiate a dietary consultation for calorie count and food preferences.
Dietitians have a greater understanding of the nutritional value of foods and may be helpful in guiding treatment.

1. Plan and implement a meticulous mouth care regimen after each meal regularly and every 4 hours while awake.
Mouth care prevents the formation of oral plaques and bacteria. Patients with oral catheters and oxygen may require additional care.

2. Increase the frequency of oral hygiene by rinsing with one of the suggested solutions between brushings and once during the night especially if signs of mild stomatitis (dryness and burning; mild erythema and edema along mucocutaneous junction) occur.
This will reduce further damage and may promote comfort.

3. Provide systemic or topical analgesics as prescribed.
This will provide comfort and relieve pain.

4. Discontinue flossing if it causes pain.
Increased sensitivity to pain is a result of thinning of the oral mucosal lining.

5. Explain that topical analgesics can be administered as “swish and swallow” or “swish and spit” 15 to 20 minutes before meals, or painted on each lesion immediately before mealtime.
Each treatment must be performed as prescribed for optimal results.

6. Instruct the patient to hold the solution for several minutes before expectoration.
This measure enhances the therapeutic effect.

7. Explain the use of topical protective agents.
A variety of more protective agents are available to coat the lesions and promote healing as prescribed.

• 7.1. Zilactin or Zilactin-B
  This medicated gel contains benzocaine for pain and is painted on the lesion and allowed to dry to form a protective seal and promote the healing of mouth sores.

• 7.2. Gelclair
  This is a bioadherent oral gel that covers the oral cavity and forms a protective barrier to relieve pain.

• 7.3. Substrate of an antacid and kaolin preparation.
  The substance is prepared by allowing the antacid to settle. The pasty residue is swabbed onto the inflamed areas and after 15 to 20 minutes, rinsed with saline or water. The residue remains as a protectant on the lesion.

• 7.4. Palifermin
  This agent decreases the incidence and duration of severe oral mucositis in patients with hematological cancers undergoing high-dose chemotherapy followed by bone marrow transplantation.

8. For severe mucositis infection:

• 8.1. Give local antimicrobial agents as ordered.
  Mycostatin, nystatin, and Mycelex Troche are commonly prescribed.

• 8.2. Stop the use of a toothbrush and flossing.
  Brushing could increase damage to ulcerated tissues. A disposable foam stick (Toothette) or sterile cotton swab is a way to gently apply cleansing solutions.

9. If the patient does not have a bleeding disorder and is capable to swallow, encourage to brush teeth with a soft pediatric-sized toothbrush using fluoride-containing toothpaste after every meal and to floss teeth daily.
The toothbrush is the most important tool for oral care. Brushing the teeth is the most effective method for reducing plaque and controlling periodontal disease.

10. Use tap water or normal saline to provide oral care; do not use commercial mouthwashes containing alcohol or hydrogen peroxide. Also, do not use lemon-glycerin swabs.
Alcohol dries the oral mucous membranes. Hydrogen peroxide can injure oral mucosa and is remarkably foul-tasting to patients. Lemon-glycerin swabs can result in decreased salivary amylase and oral moisture, as well as erosion of tooth enamel.

11. Maintain the use of lubricating ointment on the lips.
Lubrication prevents drying and cracking.

12. For eating problems:

• Encourage a diet high in protein and vitamins.
• Serve foods and fluids lukewarm or cold.
• Serve frequent small meals or snacks spaced throughout the day.
• Encourage soft foods (e.g., mashed potatoes, puddings, custards, creamy cereals).
• Encourage the use of straw.
• Encourage peach, pear, or apricot nectars and fruit drinks instead of citrus juices.

Dietary modifications may be needed to facilitate healing and tissue integrity.

13. Use foam sticks to moisten the oral mucous membranes, clean out debris, and swab out the mouth of the edentulous patient. Do not use to clean the teeth or else the platelet count is very low, and the patient is prone to bleeding gums.
Studies have revealed that foam sticks are apparently not effective for removing plaque from teeth.

14. Maintain the inside of the mouth moist with frequent sips of water and salt water rinses.
Moisture promotes the cleansing effect of saliva and helps avert mucosal drying, which can result in erosions, fissures, or lesions.

15. Provide scrupulous oral care to critically ill patients.
Cultures of the teeth of critically ill patients have produced notable bacterial colonization, which can cause nosocomial pneumonia.

16. If whitish plaques are evident in the mouth or on the tongue and can be rubbed off readily with gauze, leaving a red base that bleeds, suspect a fungal infection and contact the physician for follow-up.
Oral candidiasis (moniliasis) is remarkably common secondary to antibiotic therapy, steroid therapy, HIV infection, diabetes, or immunosuppressive drugs and should be treated with oral or systemic antifungal agents.

15. Instruct patient to avoid alcohol or hydrogen peroxide-based commercial products for mouth care and to avoid other irritants to the oral cavity (e.g., tobacco, spicy foods).
Oral irritants can further break and infect the oral mucosa and increase the patient’s discomfort.

16. For continuity of care, instruct the patient or caregiver to perform the following:

• 16.1. Lightly brush all surfaces of the teeth, gums, and tongue with a soft-bristled nylon or foam brush. Floss smoothly.
  Careful mechanical cleansing and flossing loosens debris, stimulates circulation, and reduces risk of infection.

• 16.2. Brush with a nonabrasive dentifrice like baking soda.
  Baking soda promotes further cleansing of teeth.

• 16.3. Remove and brush dentures properly after meals as necessary.
  Dental care is key to reducing the risk of infection and improving appetite.

• 16.4. Have loose-fitting dentures adjusted.
  Rubbing and irritation from ill-fitting dentures promote breakage and injury of the oral mucosa.

• 16.5. Rinse the mouth thoroughly during and after brushing.
  Removing food particles decreases the risk of infection related to trapped decaying food.

17. Include food items with each meal that require chewing.
Chewing stimulates gingival tissue and promotes circulation.

18. Educate patient on how to inspect the oral cavity and monitor for signs and symptoms of infection, complications, and healing.
Build on patient’s existing knowledge to develop an individualized plan of care.

19. Educate patient on how to implement a personal plan of oral hygiene including a schedule of care.
Encouragement and reinforcement of oral care are significant to oral outcomes.

20. Refer the patient to the dietitian for instructions on the maintenance of a well-balanced diet.
Nutritional expertise may be necessary to optimize the therapeutic diet needed to facilitate healing.

Recommended Resources

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See also

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